Scale-up of HIV Viral Load Monitoring — Seven Sub-Saharan African Countries

Abstract

To achieve global targets for universal treatment set forth by the Joint United Nations Programme on human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) (UNAIDS), viral load monitoring for HIV-infected persons receiving antiretroviral therapy (ART) must become the standard of care in low- and middle-income countries (LMIC) (1). CDC and other U.S. government agencies, as part of the President's Emergency Plan for AIDS Relief, are supporting multiple countries in sub-Saharan Africa to change from the use of CD4 cell counts for monitoring of clinical response to ART to the use of viral load monitoring, which is the standard of care in developed countries. Viral load monitoring is the preferred method for immunologic monitoring because it enables earlier and more accurate detection of treatment failure before immunologic decline. This report highlights the initial successes and challenges of viral load monitoring in seven countries that have chosen to scale up viral load testing as a national monitoring strategy for patients on ART in response to World Health Organization (WHO) recommendations. Countries initiating viral load scale-up in 2014 observed increases in coverage after scale-up, and countries initiating in 2015 are anticipating similar trends. However, in six of the seven countries, viral load testing coverage in 2015 remained below target levels. Inefficient specimen transport, need for training, delays in procurement and distribution, and limited financial resources to support scale-up hindered progress. Country commitment and effective partnerships are essential to address the financial, operational, technical, and policy challenges of the rising demand for viral load monitoring.

HIV Viral Load Suppression in Adults and Children Receiving Antiretroviral Therapy—Results From the IeDEA Collaboration

“…Some countries in the Asia-Pacific region, including Cambodia and Vietnam, also did not perform routine VL testing. The WHO 2 guidelines have recently recommended that VL testing be the preferred method of detecting treatment failure, and many countries have adopted this recommendation and are scaling up their VL monitoring capacity 11,12 . Studies have shown that the WHO's immunologic and clinical failure criteria have performed poorly in predicting virological treatment failure leading to unnecessary switch to second-line ART during periods of VL suppression, or delayed switch due to the misclassification of treatment failure 13-15 .…”

The 90 90 90 strategy to end the HIV Pandemic by 2030: Can the supply chain handle it?

“…In sub-Saharan Africa, less than half of persons living with HIV infection have access to VL testing [16], and only two of seven countries reported more than 40% of patients receiving one or more VL tests [17]. The good news is that the major manufacturers of VL equipment have anticipated the need to monitor 30+ million patients per annum and are bringing new models to market with the requisite manufacturing capacity.…”

Progress with Scale-Up of HIV Viral Load Monitoring — Seven Sub-Saharan African Countries, January 2015–June 2016

“…Challenges to viral load testing scale-up have been identified, including weaknesses in sample transport and laboratory workflow; finance and procurement; human resources (i.e., staffing shortages); laboratory equipment maintenance; and laboratoryclinic interfaces (5,6). To address these barriers and increase access to viral load testing, the Diagnostic Access Initiative (which includes representatives from the U.S. President's Emergency Plan for AIDS Relief [PEPFAR], UNAIDS, WHO, and others), was launched to increase laboratory capacity and reduce pricing from manufacturers for better access to viral load testing (7).…”

“…CDC provides technical expertise in support of viral load testing, and the United States Agency for International Development (USAID) focuses on supply chain management, working with manufacturers for procurement and maintenance of viral load testing platforms. A previous evaluation found that countries were at various stages of implementation and that scale-up of viral load testing was feasible (6).…”