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Viral load pilot study shows roll-out will depend on an educated workforce
Keith Alcorn, 2016-07-22 07:20:00
For viral load testing to prevent treatment failure, drug
resistance and onward transmission, treatment programmes will need to invest in
better record-keeping and clinic procedures, human resources, demand creation
and decentralisation of second-line treatment provision, a large pilot study of
viral load provision in southern Africa has found.
Findings from the study, funded by UNITAID, the
international drug and diagnostic purchase fund and carried out in seven
countries by MSF, were presented this week at the 21st International
AIDS Conference in Durban, South Africa.
Routine implementation of viral load testing in treatment
programmes is essential for identifying viral load rebound and treatment
failure. Early identification of viral load rebound minimises the risk of
developing drug resistance, so preserving future treatment options.
Maintaining viral suppression also minimises the risk of
onward transmission and the monitoring of viral suppression rates gives some
idea of the potential for HIV incidence in the population. Measurement of viral load is essential at a programmatic level in order to measure facility, district and national performance in achieving the last of the 90-90-90 targets - 90% of people on treatment virally suppressed.
Until recently viral load testing was largely unavailable
outside large urban hospitals or research settings in low and middle-income
countries, but recent reductions in the cost of viral load testing, coupled
with World Health Organization guidance recommending the use of viral load in
preference to CD4 counts as the primary laboratory monitoring test for HIV
treatment, are leading to the rapid expansion of viral load testing in
sub-Saharan Africa and other settings where it was once considered unsuitable
PEPFAR has already funded rapid scale up of viral load
testing in six countries and plans to use the lessons learned to support `Test
and Start` activities in other PEPFAR focus countries, using routine viral load
testing. At the same time the cost of viral load testing is falling: following
negotiations between manufacturer Roche and the Diagnostic Access Initiative,
the company announced a price reduction to $9.40 per test for lower- and
Further price reductions are plausible: speaking at the UN 90-90-90 Target Workshop preceding the conference, Trevor Peter of the Diagnostic Access Initiative said that demand for viral load is forecast to rise from 5-10 million tests to at least 22 million by 2020. The 2015 price reduction enabled 1.5 million extra tests in the past year, he added.
Despite the rapid progress towards availability of viral
load testing, there is still little information available on how viral load is
being implemented in practice, and on what challenges implementers face as they
adopt viral load testing.