The viral load monitoring cascade in a resource-limited setting: A prospective multicentre cohort study after introduction of routine viral load monitoring in rural Lesotho

Abstract

Introduction For HIV-positive individuals on antiretroviral therapy (ART), the World Health Organization (WHO) recommends routine viral load (VL) monitoring. We report on the cascade of care in individuals with unsuppressed VL after introduction of routine VL monitoring in a district in Lesotho. Materials and methods In Butha-Buthe district 12 clinics (11 rural, 1 hospital) send samples for VL testing to the district laboratory. We included data from patients aged ≥15 years from Dec 1, 2015 to November 1, 2018. As per WHO guidelines VL <1000 copies/mL are considered suppressed, those ≥1000copies/mL unsuppressed. Patients with unsuppressed VL receive adherence counseling and follow-up VL within 8–12 weeks. Two consecutively unsuppressed VLs should trigger switch to second-line ART. For analysis of the VL monitoring cascade we defined care to be “according to guidelines” if patients with unsuppressed VL received a follow-up VL within <180 days and follow-up VL was either re-suppressed, or again unsuppressed and the individual was switched to second-line within 90 days. Results For 9,949 individuals 24,948 VL tests were available. The majority were female (73%), median age 41 years (interquartile range 33–52), and 58% seen at rural clinics. Overall, 25% (260/1028) of individuals were managed according to guidelines: 40% (410/1028) had a follow-up VL within 180 days of their initial unsuppressed VL and 25% (260/1028) of those either re-suppressed or switched to second-line within 90 days. Female patients were more likely to have a follow-up VL done, (p = 0.015). In rural clinics rates of two consecutively unsuppressed VLs were higher than in the hospital (64% vs. 44%, p<0.001), and rural clinics were less likely to switch these patients to second-line (35% vs. 66%, p<0001). Conclusions Our data show that in a real-life setting availability of routine VL monitoring may not be exploited to its potential. A lack of timely follow-up after a first unsuppressed VL and reluctance to switch patients with confirmed virological failure, reduce the benefit of VL monitoring, i.e. in the rural clinics. Future studies will have to assess models of care which ensure that VL results are met with an action and make use of scalable innovative approaches.

Virological suppression and clinical management in response to viremia in South African HIV treatment program: A multicenter cohort study

“…Confirmatory VL testing after detection of viremia was profoundly delayed. This delay may be due to a variety of provider-driven, patient-related, or health infrastructural factors such as patient nonattendance [27,28]. In contrast, it has been suggested that subsequent delay between confirmation and switching to second-line ART is more likely provider-driven [29].…”

Non-uptake of viral load testing among people receiving HIV treatment in Gomba district, rural Uganda

“…This finding of relatively high non-uptake of VL testing emphasizes the need for governments in resource-limited settings to scale up VL testing in support of “test and treat all” WHO guidelines. However, gaps remain in the VL cascade of care, including missed tests, implementation of enhanced adherence counselling, delays in following up patients with detectable viraemia and delayed switching to second-line treatment after virologic failure is confirmed [ 9 ]. Optimizing the VL cascade and expanding coverage requires addressing challenges to VL implementation in resource-poor settings which include poor adherence to WHO and national guidelines on VL testing, lack of awareness of the benefits of VL testing by clinicians and patients, weak health and laboratory systems, low levels of staff training, poor quality assurance leading to sample rejections, high costs for VL consumables, reagents and tests, and lack of civil society mobilization to improve access to VL testing [ 12 ].…”

“…Viral suppression, i.e., suppression of plasma viral load below the lower limit of detection for commercially available assays (HIV RNA < 50 copies/ml), is the key indicator of HIV treatment success [ 5 – 7 ]. The World Health Organization (WHO) recommends the use of viral load (VL) testing as the gold standard to ensure viral suppression is achieved and sustained [ 8 ], but gaps in the VL cascade of care remain [ 9 ]. During January–June 2016, the proportion of people on ART ever receiving at least one VL test in seven sub-Saharan African countries was 9–91% [ 2 ].…”

HIV viral resuppression following an elevated viral load: a systematic review and meta‐analysis

“…This review also found that only around half of patients on first‐line ART with virological failure confirmed by at least two viral load tests were switched to an alternative regimen. Several studies included in this review documented failure to take action at each step in the viral load cascade from initial viral load test, to adherence counselling and repeat testing, and regimen change in the case of persistent high viral load ; these studies highlight the value of viral load cascade analyses to identify gaps and focus quality improvement to ensure that action is taken on the results of viral load testing.…”