Less than 2% of pregnant women in Uganda receive timely viral load testing
Low rates of viral load testing among pregnant women highlight need to review care for pregnant women living with HIV.
Public health clinic data from Kampala, Uganda suggests just 43% of women who began HIV treatment as part of pregnancy care in 2015 had a viral load test – and most had to wait more than 12 months to receive it.
In line with World Health Organization (WHO) guidelines, Uganda recommends that women living with HIV who begin antiretroviral treatment (ART) during pregnancy have a viral load test within six months of beginning ART and a second test at 12 months.
Delays in viral load testing for pregnant women may result in late detection of treatment failure, increase maternal and newborn deaths and illness, and lead to HIV drug resistance.
But data from five public health clinics in Kampala on women who began ART in 2015 through the Option B+ initiative to prevent mother-to-child transmission of HIV found only 1.9% received a viral load test within six months.
Around 910 pregnant women began Option B+ and should have been able to access timely viral load monitoring as part of their care. Patient records were only available for two-thirds of these women. Their median age was 24 and around half (52%) were having their first pregnancy.
Among the women enrolled on Option B+ with patient records, a further third were lost to follow up. Of those remaining, just 43% had at least one viral load test after starting ART.
Just 2% of women retained in care had a viral load test within six months. This increased to 11% within nine months and 22% within 12 months.
The median time it took to receive a viral load test after starting ART was 12.7 months. Some had to wait up to 20 months for a viral load test.
Most women (91%) who had a viral load test were virally suppressed.
Only a third of women who were found to have a high viral load (above 1000 copies/ml) during their first test received a second viral load test. The rest received intensive adherence counselling, which lasted beyond six months. This is despite the WHO recommendation that women who are found to have a high viral load in their first test should have a follow-up test within four months.
Overall, 16.5% of women who had a first viral load test went on to have a second one. Among those being tested for a second time, half had a high viral load.
Across the five clinics, factors such as age, gestational stage, marital status and ART adherence were not significantly associated with being offered a viral load test.
Viral load testing processes appeared to vary at different times between the health centres. More research is needed to establish the actual reasons for the differences in testing practices.
In 2018, WHO altered its guidelines for pregnant women living with HIV to recommend mandatory viral load testing when a pregnancy is first registered.
Coverage of viral load testing for pregnant women in Uganda may have improved in response to this, something this study is unable to assess, based as it is on 2015 data. But such low coverage suggests significant delays in viral load testing for pregnant women are still likely to exist. This gap needs to be urgently addressed or the health of women living with HIV, their children and sexual partners will remain at risk.