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Author: Glenda Gray – Research Professor, Perinatal HIV Research Unit and Chair of the South African Council for Medical Research
Disclosure Statement
Glenda Gray is Vice President of Orange Babies Charity in South Africa, Director of HCRISA, President and CEO of the South African Medical Research Council, and a member of the NRF Board of Directors. She writes this article in a personal capacity.
A United Nations initiative backed by global experts is tackling an ambitious agenda to end the AIDS epidemic by 2030.
The 90-90-90 strategy aims to achieve this goal by achieving three goals: 90% of all HIV-positive people need to know their HIV status, 90% of HIV-positive people need antiretroviral treatment and 90% of people on treatment antiretroviral virally removed. When a person is suppressed virally, it means that the virus in his blood is undetectable. The latter goal is informed by evidence that people with suppressed viral load are less likely to transmit HIV to others.
But there are a few steps to go before these goals can be achieved. The first is a large-scale HIV testing in the community, which is at least an annual screening test. The second is to link tests to care. This is essential because it reduces the gap between the diagnosis of HIV and the start of antiretroviral therapy.
The third step is close surveillance of people taking antiretroviral drugs. The World Health Organization (WHO) recommends testing viral load as the primary method of monitoring antiretroviral therapy in people. Viral load is a measure of the amount of HIV in a person's blood and is used to measure a person's level of response to HIV treatment. The lower the viral load, the better the health outcomes.
The WHO guidelines recommend all patients on antiretroviral therapy to undergo a viral load test every six and twelve months, and then every year if the patient is stable. But very few patients receive this level of care.
The main obstacle is the time required to obtain the results of laboratory tests often located at great distances from clinics. One way to get around the problem is to allow viral load testing to take place at the primary health care level – so-called point-of-care viral load testing. It would be a game changer. The results would be immediately known and health workers could intervene quickly by evaluating antiretroviral therapy in real time. This would improve the results of the treatment.
But for that, you have to innovate. A new approach is being tested. The idea is to check if the monitoring of the viral load at the point of treatment is at hand.
Trial
Surveillance of the viral load of people on antiretroviral therapy is an essential part of HIV management. Viral load tests help doctors determine if a person is taking their medications as prescribed. It also helps to determine if patients are taking the right combination of antiretrovirals.
This is a key part of the HIV arsenal, as research has shown that people who have been killed by a virus are less likely to spread the virus to another person. This makes it a key factor in breaking the transmission cycle.
The most effective way to do this is to use point-of-service test sites. These are based in the community so that patients do not have to travel long distances to get tested and treated. This new model is being tested to provide convenient access to care for patients.
Currently, almost all viral load tests are performed in designated and centralized laboratories. This means that there can be delays in getting results in the field. Patients can wait for weeks.
Laboratory viral load tests are also expensive. Point-of-care testing is also less expensive than viral loadings in the lab: health workers could be tested rather than highly paid technicians.
Small steps have been taken to allow monitoring of viral load at the point of care.
But additional equipment is also needed. Pilots evaluating the viral load tests at the points of service are in progress. A pilot uses a portable test machine – the m-PIMA HIV1 / 2 – which can be installed on a desk and allows an accurate reading of the viral load in less than 70 minutes.
The machine is tested to determine if it meets WHO standards. Once approved by WHO, ministries of health can begin implementation at all sites.
Reduce the gap
All countries still struggling to control the HIV pandemic are committed to achieving the 90-90-90 goals.
South Africa, still home to 7.9 million people living with HIV and still experiencing the largest HIV epidemic in the world, is no exception and is making significant progress.
It is getting closer to the target that 90% of people living with HIV know their status. And the second goal is that 90% of people living with HIV receive treatment.
But he still has a way to do the third. While the country is on track to reach the goal of viral suppression of 90% of people on treatment, progress on this front has not been uniform. Some parts of the country are still lagging behind others. Being able to deploy point-of-care testing would go a long way towards filling those gaps.
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