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Tackling next challenge in HIV/Aids treatment

By Flavia Nassaka

Experts call for shift from CD4 to Viral load testing, suppression

The biggest challenge HIV/AIDS treatment providers face today is achieving and maintaining undetectable levels of HIV in the blood of patients. Dr. Williams Moullado, the HIV monitoring officer at Medecins San Forentieres (MSF), an international medical humanitarian organization, revealed this to the Independent on Sept.22. The same day, stakeholders held the 2015 HIV/AIDS review meeting at Hotel Africana in Kampala.

Moullado said maintaining undetectable levels of HIV in patients’ blood is an indicator that the virus is suppressed and can no longer attack the body’s immune system.

The HIV/AIDS review meeting held annually brings together all stakeholders to discuss ways of preventing more people from getting infected and ensuring improved quality of life for those already infected.

The Uganda AIDS Commission (UAC) has a Shs13 billion plan for this job, according to its Director General, Dr. Christine Ondoa. She told the meeting, however,the money will go towards ensuring that more people access Antiretroviral (ARV) therapy.

This sparked concerns that the effort might go to waste with absence of an effective system to monitor patients’ response to the drugs.

Gold standard missing

Moullado said unfortunately in Uganda monitoring patients’ adherence to drugs is largely done using a CD4 count, a test that cannot show whether the virus has been reduced but only reveals how one’s immune system is responding by showing the number of CD4(a type of white blood cells that fight infection) in the sample of blood.

In the developed world, progress on ARVs is regularly checked using a gold standard – the viral load test. This test reveals the amount of HIV in one’s blood.

In 2013, the World Health Organization (WHO) ARV guideline recommended scaling up viral load testing. It recommended a viral load test to be done six months after starting treatment and then once a year to make sure the treatment is working, and to find other issues such as treatment resistance that one needs a change in medication, or to identify patients who need support to stick to their medication.

Moullado says some people can have high viral loads without affecting their CD4 or showing any clinical signs that one cannot tell that they are not responding to treatment until their immune system drops and they start getting opportunistic infections.

On the contrary, viral load is a direct measure.  When the virus are below 1000 copies per ml, it indicates they have been suppressed and when they exceed 1000, it means there’s non-suppression which may be caused by either failure to take drugs as recommended or the virus is resistant to the drug.

Doctors say when response to drugs is not monitored effectively, it can lead to shifting people to second line or third line drugs unnecessarily yet these are more expensive tripling the price of first line drugs.  This could stall efforts to expand treatment access or cause personal harm to the patient.

“Since the CD count doesn’t fall immediately when drugs are resisted, the patient may continue taking the drugs and if this resistant virus is transmitted to another patient, this particular drug will not work for the next patient,” said Dr. Charles Kiyaga of the Central Public Health Laboratories.

He added: “We don’t have many options when it comes to drugs. If our first line drugs are predominantly resisted by the strain of virus that we have then we are headed for a bigger problem that we will not be able to get drugs that will sufficiently suppress the virus”.

Although the Ministry of Health included viral load as a preferred monitoring approach  to the national antiretroviral treatment guidelines in January last year, Kiyaga who doubles as the Viral Load Coordinator at the ministry said its still expensive and cannot be accessed by all.

Its use in remote areas is limited and time-consuming since tests have to be conducted in hospital or health center laboratories with appropriate equipment to store the samples. Kiyaga has previously told The Independent that funding was available to test a few patients for viral load when they are diagnosed as acutely failing on treatment.  He said a viral load test goes for about $15 having reduced from about $30.

“The government needs to shift funding from CD4 to viral load. This test identifies problems sooner”, he said adding that funding is exclusively by donors, especially the United States President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria.

Although plasma, the liquid part of blood is the most preferred and accurate in measuring the amount of the virus in a particular blood sample, Kiyaga’s team has resorted to using Dry Blood Spot (DBS) because it’s cheaper to store and transport samples since such tests are only conducted at the central public health laboratories.

They have since set up hubs across the country to collect blood to be transported to the central public health laboratories in Kampala. The team has capacity to do close to 500,000 tests a year, but lack staff.

Kiyaga said the labs work 24/7 yet most of the work is done by volunteers. By August this year, they had done 132 viral load tests from 87 districts yet they receive up to 5,000 samples every day from hubs countrywide.

When asked what they are doing about incorporating viral load in the new plan, Prof. Vinand Nantulya, the Chairman of UAC said their mandate does not cover that. He said ensuring that everyone gets access to viral load tests requires a huge investment in laboratory equipment and other infrastructure yet the government is still grappling with initiating everyone on treatment. Currently more than 250,000 people who need the ARV drugs have no access to them. Some experts say, instead of retaining patients on ARVs, the government should work on retaining them when their viral load has been assessed and reduced.

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