Box 10.3: Key implementation considerations for programme managers: scaling up viral load testing

Consolidated ARV guidelines, June 2013

Consider the various diagnostic options. Several strategies exist to increase access to viral load testing, including the use of dried blood spots (DBS) and, in the near future, point-of-care technologies. Programme managers need to consider the optimal choice in light of multiple factors, such as the availability of existing infrastructure and the number of people receiving services at different levels of care (such as centralized versus peripheral sites).

Review the use of viral load monitoring in the context of alternative patient monitoring strategies. The relative benefit of CD4 monitoring in a context of greater viral load availability may need to be reassessed considering the different specificity profiles of these technologies as markers of treatment failure, their cost and technical requirements for implementation. For example, programmes may consider reducing the number of CD4 tests done for people whose viral load is being routinely measured. CD4 testing is still required to determine ART eligibility.

Provide adherence support. An important proportion of people receiving ARV drugs develop detectable viral load because of inadequate adherence to treatment and can return to undetectable levels if adequate counselling is in place, avoiding unnecessary switching to second-line regimens.

Develop treatment literacy on the use of viral load. As most programmes in low- and middle-income countries have historically relied on CD4 monitoring, people receiving ARV drugs and health care providers may not be familiar with the concept and importance of viral load. Counselling should be provided so that people receiving ARV drugs and health care providers understand the meaning and implications of having a detectable or undetectable viral load and its relation to adherence.

Ensure an adequate supply of second-line ARV drugs. People whose viral load remains detectable following adherence support have probably developed drug resistance and may need to switch regimens. Programme managers should be prepared to offer alternative regimens, including second-line ARV combinations, to address these situations.

Implement quality assurance strategies. As viral load testing is scaled up, its quality must be assured. Centralized systems should be enrolled in external quality assurance programmes, while new quality assurance approaches are needed for decentralized and point-of-care systems.