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

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.

In 2014, UNAIDS launched "90-90-90" goals to increase to 90% by 2020 the proportion of persons living with HIV infection who know their status, the proportion of persons living with HIV infection receiving ART, and the proportion of persons living with HIV infection on ART who have achieved viral suppression (defined as HIV RNA concentration below the threshold needed for detection on a viral load assay) (1). Increasing viral load monitoring for ART patients will require lowering costs associated with viral load testing and improving access in LMIC. A global diagnostic access initiative was launched in 2014 by UNAIDS, which challenged the global community to work with manufacturers to provide reasonably priced viral load testing, reducing the price of test kits to as low as $10 per test (2)....

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