Taking a blood sample to check HIV levels at a clinic in Bvumbwe, Malawi.
Image source: Guilio Donini/Unitaid via TheGuardian.com
Margaret Chiyabwa sits behind a wooden desk, piled with papers and packets of antiretroviral drugs (ARVs). She is filling in a green patient card. It's raining outside and the room at Bvumbve health centre in rural Thyolo, a district in southern Malawi, is crowded and stuffy. Men, women and children queue along the wall, waiting for a check-up, or to collect medicine. Outside, more people squeeze under the roof of a brick walkway connecting two of the health centre's buildings to shelter from the showers. It's not yet 9am.
This is a quiet morning, says Chiyabwa, a Médecins Sans Frontières (MSF) nurse, as she assesses whether the patient sitting in front of her, who is HIV-positive, should have her viral load (VL) tested.
Around 35,000 people are on ARVs in Thyolo, which has an HIV prevalence rate of more than 14%, higher than the national average of around 10%. By the end of June, 14 of the 27 health facilities in the district, supporting around 75% of ARV patients, were offering VL testing.
"After six months on treatment, we will be asking to test patients' viral load," says Chiyabwa. "It's a good thing because those with a high viral load, we are able to assess if they should go on second-line treatment, before it's too late for them."
Unlike CD4 cell counts, which monitor immunity levels, VL testing detects the level of the HIV virus in the blood, which indicates the extent to which treatment is working. This information allow doctors to determine whether to change treatment if levels are too high, before a patient's condition gets too serious – moving them from first-line to stronger second- or third-line drugs, for example – and also stops patients being put on more expensive drugs unnecessarily.
While the cost of first-line drugs has fallen significantly, from about $10,000 (£6,100) per person, per year in 2000, to about $140, second-line treatment is more than double that amount, at about $300, while third-line treatment is more than £2,000.
VL testing is being heralded as the gold standard in monitoring the virus. This year the World Health Organisation recommended its use to monitor HIV at six and 12 months after the start of treatment, then at least every 12 months after that. However, high costs and the difficulty of introducing the VL technology in poor, rural settings, means this is not an option in many developing countries. According to MSF, laboratory-based tests can cost up to $72 per test result, out of reach of many government budgets.
In an MSF survey of 23 developing countries last year, viral load testing was widely available in only four. MSF said there was an urgent need for simple and affordable viral load technologies that can be used in district laboratories, clinics and communities. There are also calls for more HIV funding to be used to develop new tools and treatments for local health facilities.
Getting tested
At Bvumbve, up to 30 people a day are having their viral loads tested as part of a three-year MSF project funded by Unitaid, a global health initiative funded in part by levies on airline tickets.
The MSF project is evaluating the effectiveness of different viral load and CD4 testing technologies in seven African countries with high rates of HIV – Lesotho, Malawi, Mozambique, South Africa, Swaziland, Uganda and Zimbabwe – to see what works best in poorer settings.
Madalitso Nkumbi, 33, a mother of two, is waiting for a blood test. She discovered she was HIV-positive in 2008, after attending an antenatal clinic when she was pregnant with her second child. She's been living well on ARVs ever since, but is pleased to be offered the viral load testing.
Nkumbi's husband left her when he discovered she was HIV-positive, so she needs to keep well to look after her children, she says. "Since I started getting ARVs, I feel OK, and with the viral monitoring I'm so happy because I know if the drugs are working."
Nkumbi's blood is taken from a finger prick and blotted on to absorbent paper. It will be taken by motorbike to the district hospital for testing. The collection of dried blood samples is being trialled by MSF at Bvumbve. If this method proves effective, it will ease storage and transportation, as samples taken in this way do not need to be kept in a fridge. It should also ease the workload of medical staff, as tests can be taken by healthcare assistants.
Nkumbi should get the results in a week. If her VL is low or "undetectable", she can continue on her one tablet a day regime. But if levels are high, she will receive counselling for three months before a second test is taken to see if any change has occurred – sometimes lack of nutritious food or a short illness can cause a temporary blip in VL levels. If after three months high levels are still recorded, she may need to switch drugs.
"Viral load is a strike in HIV management," says Arthur Mateyu, technical supervisor for eight health centres in Thyolo. He predicts more people will be put on second-line treatment as a result of the VL rollout. "What we're seeing is a lot of clients who were supposed to be on second-line, but were still on first-line drugs. People were dying, nothing could be done because of treatment failure. But viral load testing is helping us to monitor adherence to ARVs."
Malawi is considered a success story in reducing HIV infection rates, passing the tipping point – when the number of people starting treatment exceeds the number of new infections. According to UN figures, between 2001 and 2011, the rate of new HIV infections dropped by 73%. This was helped in part by the introduction of ARVs in 2003, which have slashed death tolls from 92,400 to 45,600 over the past decade.
But, with an HIV prevalence of about 10% among people aged 15 to 49, Malawi has the ninth highest HIV rate in sub-Saharan Africa, according to UNAids estimates. And more than 40% of new infections are among 10- to 19-year-olds. The country is heavily reliant on support from international donors to fund its national HIV and Aids programmes. Any increase in the number of people on second-line treatment could exacerbate the problem.
Stigma still surrounds the condition, but things are improving, says Chiyabwa. "People are opening up and feel free to come to the clinic. This year we have had more patients collecting ARVs because patients are opening up and are free from stigma," she explains.
Establishing HIV support groups has helped. The Chidothe village support group, about three miles from the clinic, meets every Monday afternoon to talk through any concerns they have about treatment or other aspects of living with HIV.
Ennet Manda, 49, from Nanthereza village, is a member. She suspects her husband passed on HIV to her because he died of unknown causes in 2002. Discovering she was HIV-positive was a relief, she says. She recently had her VL tested and her levels came back as "undetected", which means she has a very low chance of transmission and, crucially, that the drugs are working.
Manda adds: "I never worried. I accepted it [the result]. I wasn't shocked. I was happy that I finally knew my status. I started to take drugs and I've got my life back."
Currently based in New York, Dr. Paul Frymoyer has also spent some time practicing medicine in Malawi, Africa. Visit this blog to read more about his experiences as a travelling physician.
