Point-of-Care Viral Load Testing Improves Viral Suppression and Care Retention

Point-of-care viral load testing significantly improved viral suppression and retention in care when compared with standard-of-care testing in a study in South Africa. The investigators found that over a 12-month period, there was a 13.9% increase of retention with viral load suppression among participants who received point-of care testing and same-day counseling.

The results of the study were previewed in a press conference Monday and will be presented in full Tuesday, March 5, 2019, in a late-breaking oral abstract session at the Annual Conference on Retroviruses and Opportunistic Infections (CROI 2019).

For the study, a team of investigators from the University of Washington, University of Oxford, and University of KwaZulu-Natal in Durban, South Africa, set out to determine if point-of-care viral load testing was a viable method to monitor people living with HIV on antiretroviral therapy (ART) in resource-limited settings to work towards achieving UNAIDS’s 90-90-90 targets.

The open-label, randomized, controlled trial was conducted in Durban, and enrolled adults at an urban public clinic over the age of 18 who had been on ART for 6 months.

At point of enrollment, the participants were randomized to receive either point-of-care viral load testing and same day counseling or the standard-of-care, laboratory viral load testing.

In an exclusive interview, Contagion® spoke to study author Paul Drain, MD, MPH, assistant professor at the University of Washington, about the study and the implications (see video).

"In our intervention arm we use point-of-care HIV viral testing, so this is doing the viral load testing within the clinic on the same day that the patient comes in," Dr. Drain said. "If there was a problem with the viral load — meaning if the viral load was high, we could do same-day counseling and try and address the issues or if we needed to switch them on to a second life regimen we could do that in an accelerated fashion."

The study enrolled 390 participants in total, with 195 placed into each treatment arm. The participants’ mean age was 33 years, 235 (60%) were female, and the median CD4 count at enrollment was 468 [IQR 309-666] cells/mm3, the investigators note.

Each participant was followed for a 12-month period and received HIV care according to South African guidelines. Participants visited the clinic every 2 months, submitted to viral load testing at months 6 and 12 following ART initiation, and participated in “consideration for decentralized ART delivery at community pharmacies 1 year after ART initiation.”

The primary outcome of the study was retainment with viral load suppression (<200 copies/mL) after 12 months, with retained defined as collected ART at the study clinic between 44-56 weeks after enrollment.

After 12 months of monitoring, 175 (89.7%) participants in the point-of-care arm and 148 participants (75.9%) in the standard-of-care arm were retained with viral load suppression, an increase of 13.9% (95% CI 6.4-21.2, p = 0.0004) among participants in the point-of-care arm.

The investigators note that when disaggregated, the point-of-care virologic testing increased viral load suppression by 10.3% from 83.1% to 93.3% (p = 0.03). Additionally, “when restricted to those with a viral load result at exit, the proportion with viral load suppression increased by 5.3% from 91.0% to 96.3% (p = 0.05) in the point-of-care arm,” the investigators write.

During the study period, 99.5% of participants in the point-of-care arm received their viral load results on the same day as testing, while 74.7% of standard-of-care participants received a viral load result a median of 41 days [IQR 28-69 days] after blood draw.

The study also found that participants in the point-of-care arm had a 3.4-fold (95% CI 2.5-4.8) higher rate of entry into decentralized ART delivery.

The investigators conclude that participants who received point-of-care viral load testing had improved viral suppression and retention in care, which could be attributed to the rapid receipt of viral load results to people living with HIV and their providers. Based on these findings, the investigators are hopeful that increasing access to point-of-care viral load testing could help to achieve the 90-90-90 targets, especially in resource-limited areas such as South Africa.

The study, “Point-of-Care Viral Load Testing Improves HIV Viral Suppression and Retention in Care,” was announced in a press conference previewing a presentation on Tuesday, March 5, 2019 at CROI 2019 in Seattle, Washington.