Near-point-of-care viral load testing during pregnancy and viremia at delivery

Abstract

Objectives:Assess whether near-point-of-care (POC) viral load testing at the first antenatal care visit (ANC1) increased the proportion of women taking antiretroviral therapy who were virally suppressed at delivery through expedited clinical action.Design:Difference-in-difference analysis.Methods:At 20 public sector facilities in Zimbabwe, 10 implemented near-POC viral load testing at ANC1 (August 2019 to November 2020) and 10 used centralized viral load testing at ANC1. Study endpoints included time to result received, clinical action, and unsuppressed viral load (UVL; >1000 copies/ml) at delivery.Results:Of 1782 women, only 46% came for ANC1 before their third trimester. Preimplementation, 28% of women received viral load testing at ANC1, increasing to 86% during implementation. In the near-POC viral load arm, women were more likely to receive their result within 30 days of ANC1 sample collection compared with the centralized laboratory arm [54 versus 14%, relative risk (RR): 4.17, 95% confidence interval (CI) 1.82–9.55], as well as receive clinical action among those with UVL (63 versus 8%, RR 7.88; 95% CI 1.53–40.47). However, we did not observe significant changes in risk of UVL at delivery with near-POC viral load (RR 1.02, 95% CI 0.95–1.10).Conclusion:ANC1 viral load coverage was initially low. Near-POC viral load testing at ANC1 dramatically improved the timeliness of result receipt by patients and clinical action for those with an UVL. Although we did not observe a significant impact of provision of near-POC viral load at ANC1 on re-suppression at delivery, potentially because of late presentation for ANC1, continued near-POC viral load testing during pregnancy and delivery may reduce UVL and mother-to-child transmission risk.

“It Soothes Your Heart”: A Multimethod Study Exploring Acceptability of Point-of-Care Viral Load Testing among Ugandan Pregnant and Postpartum Women Living with HIV

“…Two qualitative studies, one from South Africa [ 19 ] and another from Kenya [ 12 ], interviewed clients and providers who noted clear practical benefits of implementing POC VL testing, namely, faster turnaround times, fewer clinical encounters, and reduced burden on clients and providers. POC VL testing among PWLHIV has been found to significantly increase ART initiation in pregnancy and reduce the risk of vertical HIV transmission [ 20 ]. Women in our study described how their POC VL results served as an important marker of how well they were adhering to their antiretroviral medications and as an indicator of the level of risk of transmitting HIV to their infants during pregnancy or breastfeeding.…”

“…This was attributable to the faster turnaround time of results and counseling and faster clinical actions taken in the event of viral failure [ 14 , 21 ]. Similarly, an observational cohort study found Zimbabwean PWLHIV who received POC VL testing had a significantly higher likelihood of receiving clinical action (e.g., changed ART regimen, drug resistance testing, and closer follow-up and counseling) than PWLHIV who received SOC VL testing [ 20 ].…”