As Zimbabwe scales up life-saving anti-retroviral therapy (ART) for people living with HIV, concerns are rife that the absence of mass routine viral load testing will hamper extending treatment to those who need it. People living with HIV bemoan the lack of viral load testing machines at hospitals to enable them to measure the amount of virus in their blood.
However, due to limited funds, Zimbabwe is presently providing repeat CD4 count checks which are considerably cheaper than viral load testing. World Health Organisation (WHO) recommends viral load monitoring at six months after starting ART and every 12 months thereafter. A viral load test, though routine in wealthy countries, is scarce and expensive in Zimbabwe.
The test helps keep people on first-line ARVs, which cost a fraction of the second and third line treatments. The National Aids Council (NAC) 2015 report reveals that there are 15 337 people on second line treatment, an increase from 13 036 recorded in 2014. While having people living with HIV on second line treatment is proving to be expensive for Zimbabwe, quite a sizeable number are failing on it and these have to be put on third line treatment.
The University of Zimbabwe Clinical Research Centre (UZ-CRC) had eight patients on third line ARVs as of September 2012 with an anticipation of not more than 100 people on third line in the country. Speaking during a media tour conducted by National Aids Council, Zimbabwe National Network of People Living with HIV (ZNNP+) Manicaland provincial co-ordinator Mr Lloyd Dembure said the lack of equipment is a dent on the country’s efforts of providing quality care and treatment.
“We would want a situation where our members can go for viral load testing after six months as prescribed by the WHO and get their results instantly,” he said.
“Some of our members reveal that they go for viral load testing at clinics and hospitals in the province but get frustrated and go back home empty-handed and may not come back to collect their results given that they travel long distances.
“We would like our constituency to access the facility for quality care and therapy so that we reduce the numbers of HIV clients lost to follow up,” he said.
Viral load testing, the gold standard in ART monitoring, is used to measure HIV levels in the blood, an indicator of the drugs’ success.
In 2013, WHO recommended viral load testing as the preferred monitoring tool for diagnosing and confirming ART failure. Although routine viral load testing is the standard of care for people living with HIV on ART in developed countries, the cost and complexity of currently available technologies limit availability in resource-poor settings.
Many low and middle income countries conduct viral load tests in only a small number of central laboratories. In Zimbabwe, viral load testing is done in Harare, Bulawayo and Mutare. Blood samples must be collected at local clinics and hospitals and sent to central laboratories for analysis, which can cause lengthy delays in receiving results in the treatment cascade.
Namie Clinic sister-in-charge, Sister Kudzai Marongedza, said people have to wait for close to a month after their blood samples are taken before they can know the amount of the virus in their bodies.
“We draw blood for viral load testing but clients have to wait for the results for close to a month as the blood samples are sent to Mutare General Hospital and this leaves people living with HIV in the dark concerning the amount of HIV in their bodies,” said Sister Marongedza.
The HIV viral load may also be used to help determine whether the virus infecting a person has become drug-resistant. If a person does not respond well to treatment and the amount of virus continues to increase, then the virus may be resistant to that particular ARV.
Despite showing how effective the ART is in suppressing the virus, viral load testing gives room for treatment to be modified to suit one’s genetic make-up. The Aids and TB unit director in the Ministry of Health and Child Care, Dr Owen Mugurungi, said due to financial constraints, Government strives to strike a balance between initiating people on ART and providing viral load machines.
“As a country we are being forced to rely on CD4 counts for HIV treatment monitoring due to the financial constraints that we are facing,” Dr Mugurungi said.
“WHO recommendations require us to monitor the viral load of HIV clients, but we don’t have the funds. We require at least $50 million to procure viral load machines that will cover the whole country adequately.
“However, we have to strike a balance because the average viral load check costs between $20 and $30 and that’s the amount needed for a month’s supply of ARVs. Treating people remains a high priority for Zimbabwe.”
Zimbabwe is yet to achieve the Abuja Declaration which recommends that 15 percent of a nation’s budget be allocated to health. WHO no longer recommends routine CD4 monitoring for people living with HIV who are stable on ART for several reasons — it is a variable and unstable measure that does not determine care outcomes, it is not applicable to infants or breastfed children and CD4 counts typically remain stable in people with sustained undetectable viral loads.
Sister Marongedza added that monitoring the effectiveness of ART over time becomes difficult when there are no viral load tests.
“Improvements in treatment delivery are needed at several stages along the treatment cascade, including significantly expanding the availability and use of routine viral load testing,” said Sister Marongedza.
The 90-90-90 treatment targets having 90 percent of people living with HIV knowing their status, 90 percent of people who know their HIV positive status accessing treatment and 90 percent on treatment having suppressed viral loads. Some resource limited countries have drastically reduced CD4 monitoring in favour of increased viral load testing.
For instance, South Africa discontinued routine CD4 monitoring, a shift that is expected to save $68 million between 2013 and 2017.
Cameroon, Kenya, Malawi, Namibia, Swaziland, Thailand and Uganda also no longer recommend routine CD4 testing, unless viral load testing is unavailable. To help address the problem, the Government has allowed non-governmental organisations with the capacity to scale up viral load testing in the country. Dr Mugurungi is of the view that viral load point-of-care machines will solve Zimbabwe’s challenge.
“The way forward will be that of having at least viral load point-of-care machines at initiating sites just like we did with CD4 count machines,” he explained.
Despite the absence of viral load machines at most ART initiating sites, the problem of defective CD4 count machines is forcing some health institutions to revert back to using the WHO clinical staging method when initiating people living with HIV on life-long anti-retroviral drugs.
The WHO clinical staging method was being relied on when there were few CD4 count machines. This approach can reverse the gains achieved in the fight against HIV in the country. Government, through its partners, is ensuring that the country moves away from that method.
Dr Mugurungi said shortage of CD4 count machines in hospitals is attributed to mismanagement.
“The shortage of CD4 count machines is mainly an issue of management. CD4 count machines distributed across the country’s hospitals are under service contract(s) which means that whenever a CD4 machine malfunctions, the hospital management has to contact a local agent of the supplier of those machines and get it fixed,” he said.