Continuous viral load monitoring for HIV-positive patients is essential

By Aisha Naava and Lilian Nuwabaine

Of recent, we received a client with several opportunistic infections which were life-threatening. We went ahead to carry out a thorough assessment, examination and laboratory investigations which included HIV among others. It was discovered that the client was HIV positive. Since pre-test counselling was done, it was easy for us to break the news to the client who reacted like he was not aware of his serostatus. 

However, during the process of linkage to care, the client disclosed that he was receiving care from a different health facility. We went ahead and contacted the said facility and inquired about the most recent viral load results. Feedback from the facility showed that this client was overdue for viral load for over 2 years.

Upon our interaction with the client further, he confessed that actually, he always went for viral loading testing, and health workers would give him requests for the tests to which he hid always. We probed further to know why he always did such. He further confessed that he thought it was not necessary since his last viral load results over 2 years back were good and he was complying to treatment. Unfortunately, with fellow health workers, we always thought that probably his blood sample or results were misplaced which was not the case. 

So, the question to us health workers: Do our clients understand the meaning and importance of routine viral load testing?

When a person is tested several months after they start treatment and their viral load is undetectable, it’s one of the biggest motivators for a patient to keep taking their medicines. A viral load test measures the number of HIV viral particles per millilitre of blood. A low viral load indicates that treatment is effective. A high viral load in a person on treatment indicates either that the medication is not being taken properly or that the virus is becoming resistant to the medication.

An elevated viral load suggests treatment provision needs attention, including offering adherence support, such as community-based adherence support services. Although viral load testing can signal adherence problems so that adherence support can be offered, or drug resistance where medications need to be changed, it cannot distinguish between the two. Repeatedly high viral loads despite adherence support can be an indication to change the treatment medication.

During care and treatment, if we run the test and find a patient with a detectable viral load, we know something is wrong. It can mean one of two things: either the patient is not taking their drugs, or there is drug resistance, which means the medicines are not working.

The goal of antiretroviral therapy is viral suppression that is; viral load that is so low that it cannot be detected by viral load tests. Viral load testing is the gold standard for HIV treatment monitoring, therefore, periodic viral load tests are the most accurate way of determining whether antiretroviral therapy is working to suppress replication of the virus.

The goal target of zero HIV/AIDs by 2030 is also contributed to by routine viral load testing because HIV transmission by people living with HIV with undetectable viral loads is rare. Additionally, attaining this target would mean that, by 2025, 73% of all people living with HIV will have suppressed viral loads. 

In 2013, the World Health Organization (WHO) recommended viral load testing as the preferred monitoring tool for diagnosing and confirming antiretroviral therapy failure, WHO recommends viral load monitoring 6 and 12 months after initiating antiretroviral therapy and annually thereafter for people who are stable. In people for whom viral load tests suggest treatment failure, WHO recommends enhanced adherence counselling, followed by an additional viral load test to establish suppression or to confirm treatment failure and a switch to an alternative regimen.

Following the 2013 WHO recommendation, Uganda initiated her efforts to scale up HIV viral load testing, to monitor the efficacy of antiretroviral therapy (ART) for all eligible People Living with HIV on ART in 2014. Since then, there has been a steady increase in the number of viral load tests done annually from 16,411 tests in 2014 to 1,332,335 tests in 2020, and viral load testing is now accessible in all health facilities offering ART services in Uganda. The national viral load testing algorithm stipulates that all People Living with HIV who have been on ART for 6 months should be offered the first VL test.

Therefore, viral load tests improve treatment quality and individual health outcomes for people living with HIV, contribute to prevention and potentially reduce resource needs for costly second and third-line HIV medicines. It also ensures that people living with HIV on suboptimal antiretroviral therapy with high viral loads are identified early can therefore help prevent HIV transmission to infants (in utero and breastfeeding) and sexual and drug injecting partners. 

Conclusively, greatly expanded access to routine viral load testing will be a game-changer in the global response to HIV/AIDS. However, HIV-positive clients should be sensitized about the importance of having routine viral load tests.

The authors are; Ms Aisha Naava, a Nursing officer at Kawolo Hospital and Ms Lilian Nuwabaine Luyima; BSc Nurse & MSN-Midwife & Women’s Health Specialist