Are you taking antiretroviral (ARV) drugs and want to know how well you're doing? If you live in a wealthy country, chances are that your progress is regularly checked using the "gold standard" - a viral load test. If you're in a developing country, where more people are on ARV medication and the need is greater, the expensive and complex test is hard to find, making it even more difficult to monitor whether your treatment is failing and you need to change your medication.
But as the number of people receiving HIV treatment rises, and more people become eligible for treatment, the prohibitive cost of viral load tests will have to come down, and donors should use their purchasing power to push for better prices, said medical charity Médecins Sans Frontières (MSF) in a report released at the 17th International AIDS Conference on AIDS and STIs in Africa. Almost 10 million people are on ARVs in developing countries, and an estimated 18 million more need the medication.
The World Health Organization (WHO) recommends routine viral load monitoring six months after starting the drugs, and then once a year to make sure the treatment is working, and to find treatment failures that must be switched to a different regimen, or to identify recipients who need support to stick to their medication. However, an MSF survey of 23 resource-limited countries found that the test was available in only four of them, while virtually all countries included viral load monitoring in their treatment guidelines.
The test measures how well the virus is being suppressed by the ARVs. An increased viral load - the amount of virus in the blood - indicates that a patient has developed resistance to one or more ARV drugs. The goal of taking HIV treatment is to strengthen your immune system to the point where there are undetectable levels of virus in your blood, and the risk of transmitting HIV is very low. Viral load testing is much more accurate and can identify problems sooner than CD4 testing, which is currently used by countries without viral load tests.
There are growing fears that national treatment programmes are missing a large number of treatment failures, which could lead to the development of widespread resistance. At the conference MSF presented study findings from Zimbabwe, Malawi and Kenya, where 10 percent of patients had high, viral loads despite most of them showing no signs clinically or when their CD4 counts were tested.
"The treatment wasn't working for them, and we didn't know it. We would have had to wait till they get sick, or their immune system drops, to help them," Sharonann Lynch, HIV Policy Advisor for MSF's Access Campaign, told IRIN. The study also found that patients were being switched to pricier second-line regimens unnecessarily.
When one looks at the overall cost of implementing a viral load test, including human resources, laboratories and transporting samples, the reagents - substances that produce a chemical reaction - used to run each test accounted for as much as 75 percent of the outlay. Most countries are paying more than US$20 for reagents per test, but the price could be lower than $10. In South Africa, the government is rethinking the use of CD4-count tests for monitoring patients on treatment, and now pays less than $15 per test for reagents.
"There is no reason to be paying more than $10 [for each test] in 2014," Lynch noted. There were opportunities for countries and donors such as the Global Fund to fight AIDS, Tuberculosis and Malaria, and the US Presidents Emergency Plan for AIDS Relief (PEPFAR), to slash prices by pooling their resources and buying the test materials in bigger quantities.
The Global Fund has no "ideological objections" to teaming up to buy commodities at a lower price if it makes sense, Mark Edington, head of grant management at the Global Fund, told IRIN, but the proposal would have to be looked at by the Fund's technical teams before any decisions would be taken.
The Fund has already worked with the UK Department for International Development (DFID) and the US government's President's Malaria Initiative (PMI) to purchase insecticide-treated bednets at a lower price; it is currently looking to work with PEPFAR on getting male circumcision devices cheaply.
Cost can longer be viewed as a barrier to implementing viral load testing. MSF has suggested innovative strategies such as the use of dried blood spot samples and the pooling of viral load samples to cut prices even further. At their HIV treatment sites in Malawi, for instance, MSF would test five different samples at the same time and were able to cut costs by a third, Lynch said.
She believes the benefits of viral load testing are best summed up by the "undetectable club". The members are women who have started a support group in South Africa's KwaZulu-Natal province to help each other keep their viral loads undetectable. "We're entering a new era of HIV treatment... People are [becoming] proud that they are on treatment,” Lynch says. “It also helps for them to know that they are responsible for suppressing the virus...This is a life-long commitment, it helps greatly to have proof that treatment is working and the virus is suppressed."