TRAC Plus, Rwanda’s centre for infectious disease control and prevention, recommends every patient on HIV therapy should have a viral load test once a year. This test, which checks the quantity of Human Immunodeficiency Virus (HIV) in a person’s blood, has only been accessible to very few patients.
The National Reference Laboratory (NRL) in Kigali is currently the only site in Rwanda that performs the test. In 2008 roughly 11.5 per cent of HIV patients on antiretroviral therapy had a viral load test. The lab only completed 7,272 tests last year from the 63,149 patients who were on antiretroviral drugs at the end of December, according to TRAC Plus fact-sheets seen by RNA.
In the first six months of 2009 the national lab completed 3,673 tests, with 70,234 people on antiretroviral drugs as of June 2009.
Lab space in Butare University Hospital to accommodate viral load testing is currently under construction. NRL is also in the process of obtaining an instrument that would double the amount of tests performed a day, from 48 to 96.
Testing the level of the virus is gaining momentum in Rwanda, but it’s not yet common-place.
“The picture here is that the viral load testing basically has become crucial throughout the years. In 2005, viral load wasn’t the issue. It was an expensive test and partners could not afford it,” said Richard Nkunda, head of the Molecular Biology Department at NRL.
At that time, CD4 tests seemed to work well enough, Nkunda said. A CD4 test indicates the strength of the immune system, but does not tell the amount of HIV in a patient. “The viral load is a better picture of the work that the antiretroviral is doing,” he explained.
Viral load testing is a clear indicator of treatment failure, where as studies show following a patient’s CD4 count is not.
If a patient is taking an antiretroviral medication correctly and the treatment is working, a patient’s viral load will decrease. But, if a CD4 test shows an HIV patient’s immune system is deteriorating that does not automatically mean the antiretroviral treatment is not working. However, a tracked hit to the immune system of an HIV-positive person can lead to unnecessary, and often expensive, changes in therapy, states research in the August edition of the Clinical Infectious Diseases journal by the Kenya Medical Research Institute/ Walter Reed Project in Kenya and the Perinatal HIV Research Unit of the University of Witwatersrand in South Africa.
Expense is a major factor in creating more viral load testing facilities, Nkunda told RNA. The average cost to conduct one test is $25 (US). The new instrument, needed to double the amount of tests that can be completed in a day, costs $100,000 (US) to buy, Nkunda said. Set-up and operating costs mean labs are not sprouting up in every district in the country. “We can’t manage to build several labs, like for CD4,” he said.
The NRL is funded by PEPFAR and Global Fund. Money is secured for the new equipment and the new lab, but expanding beyond that will require more time, said Nkunda.
In 2004 PEPFAR funds provided $39 million (US) to Rwanda to fight HIV/AIDS. In 2009, the United States emergency plan for AIDS relief gave $122.6 million (US). The first five years of PEPFAR was dedicated to responding to the HIV/AIDS crisis, said Janean Davis, leader of the USAID health team. Starting in 2009, the next five years of PEPFAR are focused on increasing capacity and sustainability.
“Only NRL has the lab capacity to perform [viral load] testing,” Davis discussed with RNA. “That said, we have a direct cooperative agreement to support their capacity. We give funding directly to NRL and with that funding we map out a work plan of where their capacity needs to be strengthened, be it human capacity and training, be it machines and equipment and maintenance, be it longer term planning.”
Testing viral loads requires specific training. Five lab technicians test viral loads for the whole country, but that will change with the new equipment and opening of the second lab.
The new technology will require less hands-on action, but that doesn’t mean less work for lab techs. In fact, work hours for technicians skilled in viral testing may increase as NRL determines whether it is meeting the testing demand.
“We test what we get,” said Nkunda, explaining that whatever samples the lab is given from clinics around the country are tested. Nkunda said the turnaround time for viral load testing is one week. If the operation of the second lab in Butare and the new instruments do not satisfy the testing need NRL will develop more strategies. “If it gets bigger we have to continue and get bigger or increase hours of running.”
The lab in Butare, in addition to providing an extra space, will also aid in decentralization – providing easier access to care for people in rural areas.
Keeping patients on effective HIV treatment is shared between the three national health organizations, TRAC Plus, NRL, and CAMERWA, as well as funding partners, Nkunda pointed out. Doctors, following TRAC Plus guidelines, first request the test to be done. As demand increases, and labs receive more test samples, more test kits are needed. Acquiring test kits is the responsibility of CAMERWA, Rwanda’s national drug procurement and distribution agency.
The ability to test a person’s viral load requires more than the sample in a test tube.