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Impact and Programmatic Implications of Routine Viral Load Monitoring in Swaziland

Jobanputra, Kiran MBChB, MPH, MRCGP*; Parker, Lucy Anne BSc, MPH, PhD*; Azih, Charles MD, MPH; Okello, Velephi MBChB, BSc, MPH; Maphalala, Gugu BSc, MSc; Jouquet, Guillaume MSc*; Kerschberger, Bernhard MD, MSc*; Mekeidje, Calorine MD*; Cyr, Joanne PhD*; Mafikudze, Arnold MBChB, MSc*; Han, Win MD*; Lujan, Johnny MD, MPH§; Teck, Roger MD, MPH§; Antierens, Annick MD, BPH§; van Griensven, Johan MD, PhD; Reid, Tony MD, MSc, FCFP

JAIDS Journal of Acquired Immune Deficiency Syndromes: September 1st, 2014 - Volume 67 - Issue 1 - p 45–51
doi: 10.1097/QAI.0000000000000224
Clinical Science

Objective: To assess the programmatic quality (coverage of testing, counseling, and retesting), cost, and outcomes (viral suppression, treatment decisions) of routine viral load (VL) monitoring in Swaziland.

Design: Retrospective cohort study of patients undergoing routine VL monitoring in Swaziland (October 1, 2012 to March 31, 2013).

Results: Of 5563 patients eligible for routine VL testing monitoring in the period of study, an estimated 4767 patients (86%) underwent testing that year. Of 288 patients with detectable VL, 210 (73%) underwent enhanced adherence counseling and 202 (70%) had a follow-up VL within 6 months. Testing coverage was slightly lower in children, but coverage of retesting was similar between and age groups and sexes. Of those with a follow-up test, 126 (62%) showed viral suppression. The remaining 78 patients had World Health Organization–defined virologic failure; 41 (53%) were referred by the doctor for more adherence counseling, and 13 (15%) were changed to second-line therapy, equating to an estimated rate of 1.2 switches per 100 patient-years. Twenty-four patients (32%) were transferred out, lost to follow-up, or not reviewed by doctor. The “fully loaded” cost of VL monitoring was $35 per patient-year.

Conclusions: Achieving good quality VL monitoring is feasible and affordable in resource-limited settings, although close supervision is needed to ensure good coverage of testing and counseling. The low rate of switch to second-line therapy in patients with World Health Organization–defined virologic failure seems to reflect clinician suspicion of ongoing adherence problems. In our study, the main impact of routine VL monitoring was reinforcing adherence rather than increasing use of second-line therapy.

*Médecins Sans Frontières (Operational Centre Geneva), Mbabane, Swaziland;

Swaziland National AIDS Program, Ministry of Health, Mbabane, Swaziland;

Swaziland National Reference Laboratory, Mbabane, Swaziland;

§Médecins Sans Frontières (Operational Centre Geneva), Geneva, Switzerland;

Institute of Tropical Medicine, Antwerp, Belgium; and

Médecins Sans Frontières (Operational Research Unit, MSF Luxembourg), Luxembourg.

Correspondence to: Kiran Jobanputra, MBChB, MPH, MRCGP, Médecins Sans Frontières (Switzerland), PO Box 572, Nhlangano, Swaziland (e-mail:

Supported by Médecins Sans Frontières—Operational Centre Geneva.

An extract of this data was presented at the Seventh International Francophone Conference on HIV and Hepatitis (AfraVIH), Montpellier, France, April 29, 2014.

The authors have no conflicts of interest to disclose.

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Received February 28, 2014

Accepted May 05, 2014

© 2014 by Lippincott Williams & Wilkins