HIV targets held back by lab services shortfalls

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World Health Organisation study found that insufficient capacity to perform laboratory tests used in monitoring HIV infection, and under-utilisation of existing testing capacity, are limiting the ability to meet the Joint UN Programme on HIV and AIDS (UNAIDS) 90-90-90 targets.

The Joint UN Programme on HIV and AIDS (UNAIDS) 90-90-90 targets call for 90% of all people living with HIV to know their HIV status, 90% of all people diagnosed with HIV infection to receive antiretroviral therapy (ART), and 90% of those receiving ART to achieve durable viral suppression by the year 2020.

The researchers analysed responses to annual surveys sent to WHO offices from 127 countries between 2012 and 2014. Respondents each reported on the capacity and usage of CD4 testing, HIV viral load (VL) testing, and early infant diagnosis in their country. The researchers found that the capacity of available CD4 instruments was sufficient to meet the demand of all people living with HIV/Aids (PLWHA), irrespective of treatment status, but VL capacity was inadequate to cover needs in most reporting countries. Even when capacity was sufficient, machines were being under-utilised; only 13.7% of existing CD4 capacity and only 36.5% of existing VL capacity were utilised across reporting countries in 2013.

Habiyambere and colleagues note that the responses were limited to national programmes and did not include testing capacity in the private sector, and that incomplete responses or non-response to surveys limit the comprehensiveness of the survey data. However, they note that these findings identify shortfalls in VL testing capacity and under-utilisation of CD4 and VL technologies that will need to be addressed to reach the UNAIDS targets.

They say: “With laboratory systems in reporting countries expanding, a national laboratory strategic plan to strengthen services must be developed, implemented, and monitored by governments and their national and international partners. The focus of international community, to ensure optimal use of laboratory technologies, should be on those countries where interventions for scaling up access to HIV diagnostic technologies are most needed.”

In an accompanying Perspective, Peter Kilmarx and Ravia Simbi discuss the practical challenges of achieving high capacity and efficiency in all stages of HIV care and note that moving forward, “strong leadership, resources, planning, and management are needed to scale up laboratory services. Continuing monitoring efforts, like those of Habiyambere and colleagues, are essential.”

Background: The Joint United Nations Programme on HIV and AIDS (UNAIDS) 90-90-90 targets have reinforced the importance of functioning laboratory services to ensure prompt diagnosis and to assess treatment efficacy. We surveyed the availability and utilization of technologies for HIV treatment monitoring and early infant diagnosis (EID) in World Health Organization (WHO) Member States.
Methods and Findings: The survey questionnaire included 14 structured questions focusing on HIV testing, cluster of differentiation 4 (CD4) testing, HIV viral load (VL) testing, and EID and was administered annually from 2012 to 2014 through WHO country offices, with each survey covering the previous 12-mo period. Across 127 targeted countries, survey response rates were 60% in 2012, 67% in 2013, and 78% in 2014. There were encouraging trends towards increased procurement of CD4 and VL/EID instruments in reporting countries. Globally, the capacity of available CD4 instruments was sufficient to meet the demand of all people living with HIV/AIDS (PLWHA), irrespective of treatment status (4.62 theoretical tests per PLWHA in 2013 [median 7.33; interquartile range (IQR) 3.44–17.75; median absolute deviation (MAD) 4.35]). The capacity of VL instruments was inadequate to cover all PLWHA in many reporting countries (0.44 tests per PLWHA in 2013 [median 0.90; IQR 0.30–2.40; MAD 0.74]). Of concern, only 13.7% of existing CD4 capacity (median 4.3%; IQR 1.1%–12.1%; MAD 3.8%) and only 36.5% of existing VL capacity (median 9.4%; IQR 2.3%–28.9%; MAD 8.2%) was being utilized across reporting countries in 2013. By the end of 2013, 7.4% of all CD4 instruments (5.8% CD4 conventional instruments and 11.0% of CD4 point of care [POC]) and 10% of VL/EID instruments were reportedly not in use because of lack of reagents, the equipment not being installed or deployed, maintenance, and staff training requirements. Major limitations of this survey included under-reporting and/or incomplete reporting in some national programmes and noncoverage of the private sector.
Conclusion: This is the first attempt to comprehensively gather information on HIV testing technology coverage in WHO Member States. The survey results suggest that major operational changes will need to be implemented, particularly in low- and middle-income countries, if the 90-90-90 targets are to be met.

Vincent Habiyambere, Nathan Ford, Daniel Low-Beer, John Nkengasong, Anita Sands, Mercedes Pérez González, Paula Fernandes, Ekaterina Milgotina

PLOS material PLOS Medicine abstract PLOS Medicine perspective

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