Challenges and opportunities for the implementation of virological testing in resource‐limited settings

Abstract

Though the advantages of routine virological monitoring for patients on anti-retroviral therapy have been established, cost and complexity limit its full implementation. Monitoring is important for diagnosing virological failure early on, before the development of drug resistance mutations, and to trigger early adherence interventions. Simple and cost-effective viral load tests that facilitate simplification and decentralization of testing and strategies, such as the use of dried blood spots and pooled sample testing, which further aid simplification, are becoming available. In addition, replacing immunological monitoring with virological monitoring in non-viremic patients in a phased manner will reduce the costs associated with dual immuno-virological monitoring. Going forward, the simplification of testing paired with price reducing strategies that will allow for healthy competition between multiple manufacturers will enable the implementation of viral load testing in resource-poor settings. It is important that future HIV and AIDS treatment guidelines provide clear recommendations for routine virological monitoring and that governments and donors fund the implementation of accurate and operationally proven testing platforms in a comprehensive manner.

Prospective Evaluation of Diagnostic Accuracy of Dried Blood Spots from Finger Prick Samples for Determination of HIV-1 Load with the NucliSENS Easy-Q HIV-1 Version 2.0 Assay in Malawi

“…The use of DBS samples for VL monitoring needs to be coupled with strategies such as pooled sample testing to further reduce the price of VL testing and to support full implementation of VL monitoring in resource-constrained settings (9,34). Another recent study that was also conducted in the Thyolo District using the same VL laboratory (35) found that FP-DBS in combination with pooling is feasible, produces accurate results, and can reduce the cost of testing substantially, with cost savings varying depending on the prevalence of a raised VL in the patient population and the VL cut point used.…”

“…Despite the clinical utility of routine VL monitoring, it is generally not accessible in resource-constrained settings due to a combination of limited capacity for sample transport, a lack of laboratory capacity, and high cost (7)(8)(9).…”

Antiretroviral Treatment and Resistance Patterns in HIV-Infected Children

“…Resource-limited countries often times limit recommended DR genotyping investigations for children who are on failing second-line therapy regimens due to cost and other logistical issues [23]. On the account of the limited data, a review explored the knowledge and summary of HIVDR, transmitted HIVDR (TDR) and DRM rates of the three main classes of ARVs in both treatment naïve and pre-treated children in different settings.…”

Provision of Antiretroviral Therapy in South Africa: The Nuts and Bolts

“…Viral load monitoring of ART enabling earlier detection of adherence problems and treatment failure continues to be performed in centralized laboratories due to its technical complexity and expense [110]. Consequently, national guidelines make provision for a single annual viral load assessment per patient on ART [111]. Alternative ways such as the use of DBS, pooling samples, POC viral load tests and the increase in testing volumes to drive prices down will be essential in the scale-up of routine viral load monitoring [112,113].…”