The African Society for Laboratory Medicine (ASLM) warmly welcomes a special issue of the Journal of the International AIDS Society (JIAS) summarizing a workshop focused on viral load scale-up that took place from 27 to 30 June 2016 in Swaziland. The workshop, entitled ‘Reaching the Third 90: Implementing High Quality Viral Load Monitoring at Scale,’ was attended by 150 participants from 16 sub-Saharan African countries, including individuals from diverse backgrounds reflecting key elements of the viral load continuum, such as clinical providers, civil society representatives, laboratorians, programme managers, policy makers, researchers and funders.

This special edition contains 10 papers, in which key opinion leaders in the field of HIV/AIDS, including Ambassador Deborah L Birx of the US President’s Emergency Plan for AIDS Relief (PEPFAR), Dr John Nkengasong of the Africa Centres for Disease Control and Prevention, Dr Wafaa El-Sadr of ICAP at Columbia University and Dr Ali Elbireer of the African Society for Laboratory Medicine (ASLM), participated. They shared their insight and experience on what is needed to make routine viral load monitoring achieve its full potential, such as reaching the third 90% of the UNAIDS 90-90-90 treatment target, enabling early infant diagnosis, facilitating prevention of mother-to-child transmission of HIV, supporting the delivery of differentiated HIV care, and ultimately, preventing onward transmission of HIV for an HIV-free world.

In order to ensure that the scale up of viral load testing results in improved clinical management, Wafaa El-Sadr et al proposed conceptualizing routine viral load monitoring as a continuum: a series of must-follow steps from demand creation to specimen collection, sample transportation, viral load testing, and utilization of the test results. Only fulfilment of these steps will guarantee improved coverage, better quality and utilization of test results for the greatest impact.

To create demand, the International Treatment Preparedness Coalition (ITPC) introduced a new model called the Community Demand Creation Model (CDCM). This new initiative could be used to mobilize the whole ‘HIV community’ for routine viral load monitoring. According to Peter et al, the important lessons that we gained from the initial roll out of CD4 testing and early infant diagnosis scale up could also be used to scale up routine viral load monitoring in resource-limited settings.

‘Implementation of testing in the developing health systems of resource-limited countries is always challenging,’ said Dr Ali Elbireer, CEO of ASLM and co-author on the paper. ‘It’s important to examine past efforts on the ground and take forward the lessons learned into the next endeavour.’

Return and utilization of viral load test results is another key component along the entire testing cascade. A Population-based HIV Impact Assessment conducted by Saito and colleagues demonstrated the feasibility of returning test results to patients within a reasonable time period. However, they also found that only specimen tracking through a strong laboratory data management system or adoption of the point-of-care testing would reduce turn-around times considerably.

Ellman et al offered a discussion of the benefits of simplifying the routine viral load testing threshold to <1000 RNA copies/mL. In their view, this would optimize monitoring of individual patient health, as well as the assessment of public health impacts.

Another issue raised is the great potential of routine viral load monitoring in the prevention of mother-to-child transmission of HIV. In a simulation model, Lesosky et al suggested that a single viral load measurement at 36 weeks gestation could benefit current prevention of mother-to-child transmission programmes. They propose using point-of-care viral load testing to mitigate the prolonged turn-around times associated with centralized viral load testing.

An additional important issue addressed was the use of routine viral load monitoring in key segments of the population with a high risk of virological failure: infants, children, and adolescents. Arpadi et al and Marcus et al  emphasized that these groups should be prioritized for routine viral load monitoring to guide clinical care and to overcome challenges related to treatment adherence.

The importance of routine viral load monitoring among other key populations, including sex workers, men who have sex with men, and injection drug users, was underscored by Schwartz et al. In this context, routine viral load monitoring can be used not only as a health surveillance tool but also as an advocacy tool for human rights and for equitable access to proper HIV care for the entire community.

To realize the aforementioned great potential of routine viral load monitoring, cost-effectiveness is frequently questioned in resource-limited settings where there are several other competing priorities in already weak healthcare delivery systems. In a systematic review, Barnabas et al, explain that routine viral load monitoring could be cost-effective, if it is delivered as part of differentiated HIV care. This is really good news for resource-limited settings in the process of adopting viral load-informed differentiated care models.

Finally, ASLM joins JIAS in calling for ‘The Right to Viral Load Testing’ for better HIV care and strong impact.

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