Point-of-care HIV viral load testing improves health outcomes
Giving patients their viral load test results on the same day improves viral load suppression rates and motivates patients to remain healthy.
People living with HIV in South Africa who received a point-of-care (POC) viral load test were 13.9% more likely to be virally suppressed and retained in care after one year, compared to those who received a laboratory viral load test.
Presented at the Conference on Retroviruses and Opportunistic Infections (CROI 2019) last week in Seattle, this is the first randomised controlled implementation trial of point-of-care HIV viral load testing with task-shifting to nurses.
Viral load monitoring is critical for managing HIV in patients and identifying those with treatment failure. But rolling-out viral load testing is a major challenge in low-resourced settings where there is limited laboratory capacity to carry-out these tests.
In South Africa, 75% of people living with HIV have had at least one viral load test, but in Kenya this falls to 38%, while in Uganda this falls to just 10%. Point-of-care viral load assays have the potential to alleviate this burden and improve clinical management by providing results while patients are still at the clinic. It can also support a task-sharing care model, whereby community health workers can manage those who are doing well, and advanced practitioners can manage those who need further support.
The STREAM (Simplifying HIV TREAtment and Monitoring) study was conducted at an urban clinic in Durban, South Africa. Adults who were stable and on antiretroviral treatment (ART) for at least six months were randomised to receive either POC monitoring and potential task shifting to enrolled nurses, or lab-based viral load monitoring – the standard of care (SOC) arm. The primary outcome was retention in care and viral suppression at 12 months from enrolment, defined as <200 copies/ml.
390 patients were included in the final analysis. Their mean age was 33 and most (60%) were female. After 12 months, 175 (89.7%) participants in the POC arm and 148 (75.9%) in the SOC arm stayed in care and had achieved viral load suppression. They also tested the intervention at a lower viral suppression threshold (<50 copies/ml), and it remained statistically significant.
For those in the POC arm, their test result was delivered in a matter of hours and most were motivated to stay and receive the result. In patient interviews, one participant said: “What is good about POC testing is that you leave knowing that you have to fix that issue, if there is anything to fix.” In the SOC arm, the median wait time was 28 days for their viral load test results.
In the POC arm, follow-up care and treatment was also markedly faster. Including, where needed, switching to second-line ART and referral into community-based ART programmes.
They also found that healthcare utilisation – including total clinic visits per patient and visits with a professional nurse per patient – were less in the POC arm compared to the SOC arm. Clinic visits with a community nurse, and the number of viral load tests carried-out per patient, were slightly increased in the POC arm compared to the SOC arm.
A cost analysis revealed that the cost per viral load test in the POC model was around $22, while for the SOC model it was $26 for centralised lab results. The total cost comparing the models over five years was also in favour of the POC model.
“Point of care testing can simplify health care and improve outcomes for HIV-positive adults receiving ART,” said lead author Paul K. Drain in his concluding statements. “Increasing access to point-of-care HIV viral load testing could help to achieve 90-90-90 targets.”
The STREAM project was a collaboration between the University of Washington, CAPRISA and the South African Department of Health.