Scaling up HIV viral load – lessons from the large‐scale implementation of HIV early infant diagnosis and CD4 testing

Abstract

IntroductionThe scale‐up of effective HIV viral load (VL) testing is an urgent public health priority. Implementation of testing is supported by the availability of accurate, nucleic acid based laboratory and point‐of‐care (POC) VL technologies and strong WHO guidance recommending routine testing to identify treatment failure. However, test implementation faces challenges related to the developing health systems in many low‐resource countries. The purpose of this commentary is to review the challenges and solutions from the large‐scale implementation of other diagnostic tests, namely nucleic‐acid based early infant HIV diagnosis (EID) and CD4 testing, and identify key lessons to inform the scale‐up of VL.DiscussionExperience with EID and CD4 testing provides many key lessons to inform VL implementation and may enable more effective and rapid scale‐up. The primary lessons from earlier implementation efforts are to strengthen linkage to clinical care after testing, and to improve the efficiency of testing. Opportunities to improve linkage include data systems to support the follow‐up of patients through the cascade of care and test delivery, rapid sample referral networks, and POC tests. Opportunities to increase testing efficiency include improvements to procurement and supply chain practices, well connected tiered laboratory networks with rational deployment of test capacity across different levels of health services, routine resource mapping and mobilization to ensure adequate resources for testing programs, and improved operational and quality management of testing services. If applied to VL testing programs, these approaches could help improve the impact of VL on ART failure management and patient outcomes, reduce overall costs and help ensure the sustainable access to reduced pricing for test commodities, as well as improve supportive health systems such as efficient, and more rigorous quality assurance. These lessons draw from traditional laboratory practices as well as fields such as logistics, operations management and business.ConclusionsThe lessons and innovations from large‐scale EID and CD4 programs described here can be adapted to inform more effective scale‐up approaches for VL. They demonstrate that an integrated approach to health system strengthening focusing on key levers for test access such as data systems, supply efficiencies and network management. They also highlight the challenges with implementation and the need for more innovative approaches and effective partnerships to achieve equitable and cost‐effective test access.

Implementation of “Treat‐all” at adult HIV care and treatment sites in the Global IeDEA Consortium: results from the Site Assessment Survey

“…While almost all sites reported universal HIV treatment as the standard of care, we found considerable variation in site‐level practices related to rapid ART initiation, with private sector sites and sites in high‐resource settings more likely to report longer times to treatment initiation. Consistent with other research , we also found considerable variation in capacity for viral load monitoring, and almost one‐third of the sites implementing Treat All indicated that they could not routinely request or perform viral load testing. Such gaps were particularly prevalent among sites located in rural areas and in low‐income countries, as well as in countries where Treat All was adopted more recently.…”

Point‐of‐care viral load monitoring: outcomes from a decentralized HIV programme in Malawi

“…Monitoring systems with performance indicators should be implemented, ideally with integrated, automated systems that identify patients in need of VL-testing [67]. Creating demand for VL among clinicians and patients will be critical [20,21,35,56,[68][69][70][71]. A recent modelling study predicted that switching patients on efavirenz-based first-line after only one high VL will significantly decrease mortality related to delayed switch [72], POC-VL and same day results would further support this concept.…”

Realizing the potential of routine viral load testing in sub‐Saharan Africa

“…Peter et al . describe the lessons learned from scale‐up of other laboratory tests, such as EID and CD4+ cell count assays, which can inform scale‐up of viral load testing . Ellman et al .…”