Viral Load Testing in Malawi

Julio Raoughcancan, from Thyolo, gets a dried blood spot sample drawn by a Health Surveillance Assistant (HSA) at Bvumbwe Health Centre. This sample will be compared with a venous blood sample drawn by a clinician in a validation study to prove that finger prick Dried Blood Spot (DBS) sampling techniques can be task shifted to lower cadres in the Health Centres
Giulio Donini/UNITAID
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Viral load testing shows the amount of HIV in the blood of a person living with the virus. Antiretroviral drugs suppress HIV replication. If a person on ARV treatment has a viral load above a certain point, it indicates that the treatment isn’t working, either because the medicines aren’t being taken correctly, or because HIV has become resistant to the antiretroviral medicines.

In either case, health workers can respond quickly, working with people on treatment to improve adherence to a drug regimen or prescribing advanced "second-line" drugs. These steps can bring viral load down to virtually "undetectable" levels, helping those on treatment stay healthy and benefiting the community by reducing the risk of transmission. Sexual transmission of HIV is 96 percent less likely when viral load is undetectable.

Viral load testing is the gold standard for monitoring the health of people on HIV treatment. But because the equipment can be expensive and requires skilled staff, the test is not widely available in poor countries with limited resources.

Doctors Without Borders/Médecins Sans Frontières (MSF)—thanks to co-funding from UNITAID—is working to develop ways to expand viral load testing in eight countries in sub-Saharan Africa, including MSF sites in the Democratic Republic of Congo, Lesotho, Malawi, Mozambique, South Africa, Swaziland, Uganda, and Zimbabwe. These photographs offer a glimpse of MSF viral load and HIV treatment projects in Malawi, where the HIV adult prevalence is high at about 14–16 percent.

ARV treatment is dispensed at the Bvumbwe Health Centre.
Giulio Donini/UNITAID
Julio Raoughcancan, from Thyolo, gets a dried blood spot sample drawn by a Health Surveillance Assistant (HSA) at Bvumbwe Health Centre. This sample will be compared with a venous blood sample drawn by a clinician in a validation study to prove that finger prick Dried Blood Spot (DBS) sampling techniques can be task shifted to lower cadres in the Health Centres
Giulio Donini/UNITAID
Julio Raoughcancan, from Thyolo, gets a dried blood spot sample drawn by a Health Surveillance Assistant (HSA) at Bvumbwe Health Centre. This sample will be compared with a venous blood sample drawn by a clinician in a validation study to prove that finger prick Dried Blood Spot (DBS) sampling techniques can be task shifted to lower cadres in the Health Centres
Giulio Donini/UNITAID
The laboratory at Thyolo District Hospital. Whole blood and dried blood spot samples are collected from remote sites like Bvumbwe Health Centre, then delivered by motorbike to Thyolo District Hospital to be analysed in a laboratory.
Giulio Donini/UNITAID
Viral Load Laboratory Responsible Anthony Tebulo at work. The lab can process 160 samples a day. Results are sent to HSAs by SMS. “With some machines it takes two days to get a result. Not we get it in two hours,” said Anthony Tebulo.
Giulio Donini/UNITAID
Various shots from a National Association for People Living with HIV/AIDS in Malawi (NAPHAM) support group meeting in the remote village of Chidothe in Thyolo District.. Many of these patients receive their drugs through the Community ART Group (CAG) model of care. Based on a model started by MSF in Mozambique, CAGs are a community-based initiative that bring together ARV patients to take turns on a rotating basis to collect ARVs every month. In Chidothe, the nearest ARV clinic is 5km away. The Chidothe support group also discusses adherence issues and positive living – recently they’ve learned the importance of viral load testing. When a support group leader asked the group how many had received a viral load test recently, practically the entire room raised their hands. In Malawi, “Tizirombo ta HIV” means HIV viral load, using the Chichewa word for “germ” to describe the virus. The group meets every week and they link up with village chiefs to run plays and talk about their status. “Before we started in 2003 people were very worried and there were many AIDS deaths in the community,” one member said. “We decided that if we came together, we could support each other.”
Giulio Donini/UNITAID
Various shots from a National Association for People Living with HIV/AIDS in Malawi (NAPHAM) support group meeting in the remote village of Chidothe in Thyolo District.. Many of these patients receive their drugs through the Community ART Group (CAG) model of care. Based on a model started by MSF in Mozambique, CAGs are a community-based initiative that bring together ARV patients to take turns on a rotating basis to collect ARVs every month. In Chidothe, the nearest ARV clinic is 5km away. The Chidothe support group also discusses adherence issues and positive living – recently they’ve learned the importance of viral load testing. When a support group leader asked the group how many had received a viral load test recently, practically the entire room raised their hands. In Malawi, “Tizirombo ta HIV” means HIV viral load, using the Chichewa word for “germ” to describe the virus. The group meets every week and they link up with village chiefs to run plays and talk about their status. “Before we started in 2003 people were very worried and there were many AIDS deaths in the community,” one member said. “We decided that if we came together, we could support each other.”
Giulio Donini/UNITAID
Namitambo Health Centre in Chiradzulu District, one of the few sites where the first-ever available point-of-care viral load device is being used. Called SAMBA, this platform is simpler to use than other molecular technologies for viral load, requires less staff training and can be rolled out in low healthcare levels like the Namitambo Health Centre. It is the first point-of-care viral load device to be rolled out world-wide and its roll-out is part of the UNITAID grant. Chiradzulu district has one of the highest HIV prevalence rates in the country.
Giulio Donini/UNITAID
SAMBA has been operational at Namitambo Health Centre since the end of Summer 2013 (note: 55-56 is PIMA). 140 tests per month since then and patients get results same day. The machine just indicates if the patient has a viral load above or below 1,000 copies (per ml). Importantly, there is no need for cold storage of reagents. It is electrically powered with a back upbattery to secure power during power-cuts.
Giulio Donini/UNITAID
Mercy Banda, 35, single mother with one child. She came to Namitambo Health Centre to get her ARVs and her first viral load test. She walked 7km to the clinic. She doesn’t understand what a viral load test really means but she understands she needs results during treatment. She also understands the importance of getting results quickly, as before it could take months. Clinicians had suspicions that Mercy was failing treatment. The MSF/UNITAID team had to leave before her result was available, but if her viral load was over 1,000 copies per ml, they would start three months of enhanced adherence counselling.
Giulio Donini/UNITAID