Improving Coverage of Viral Load Testing at USAID-Supported Facilities in Nigeria

To assess viral suppression coverage rates, all eligible PLHIV on ART should receive viral load (VL) testing. Following the adoption of new treatment guidelines by the Federal Ministry of Health in Nigeria in December 2016, the United States President's Emergency Plan for AIDS Relief (PEPFAR) has invested in monitoring PLHIV on ART through an expanded ART "Treat All" approach. According to the World Health Organization's updated treatment guidelines (2021), monitoring PLHIV on ART is essential to ensure successful treatment outcomes. VL testing has been the preferred strategy for treatment monitoring since 2016. VL testing coverage can be assessed by comparing the number of ART patients with a documented VL result in the past 12 months with the total number of PLHIV on ART six months prior. Although progress has been made in conducting VL testing to monitor treatment outcomes in Nigeria, gaps in the provision of this service to all eligible clients remain. Data for Implementation (Data.FI) collaborated with Chemonics and Heartland Alliance Nigeria, two implementing partners supported by the United States Agency for International Development (USAID), to identify the causal factors for VL testing in eight states: Adamawa, Bauchi, Borno, Cross River, Kano, Kebbi, Lagos, and Zamfara. A gap analysis conducted in June 2021 revealed that eight of the 15 states had low VL testing coverage. Further analysis identified 14 high-volume health facilities with low VL testing coverage, with only 66.1% of targeted PLHIV eligible for VL testing services receiving VL testing services. The technical teams from Data.FI Nigeria, Chemonics's Strategic HIV/AIDS and TB Response Program (SHARP) Task Orders 1 and 3, and Heartland Alliance Nigeria's Key Populations Community HIV Services Action and Response (KP-CARE 1) met to discuss the root causes of low performance and propose effective strategies to mitigate the identified causes. The causes included poor turnaround time in testing at PCR centers, poor turnaround time of assayed VL results, inadequate human resources, poor documentation of ART services, frequent breakdown of VL testing machines, inadequate quantity of sample collection boxes, and disparity in drug pickup dates and VL sample collection dates. To address these issues, the technical teams agreed to implement the following strategies: institute and train staff on the use of remote sample login, collaborate with stakeholders to ensure interoperability of the remote sample login for the Laboratory Information Management System (LIMS) and electronic medical records (EMR), engage community health extension workers (CHEWs), ensure that source documents and EMR are updated, reroute VL samples to alternative existing PCR centers, engage with the Third Party Logistics (3PL) team to provide more sample carrier boxes, and realign the client appointment schedule. The IPs began to implement these strategies on July 1, 2021. After six weeks of implementation, another analysis was conducted to assess any changes from baseline. Results from the end-line analysis showed that 80.3% of targeted PLHIV eligible for VL testing had a VL test with the results documented in the clients' folders. VL testing coverage at end-line ranged from 63.6% at the Federal Medical Centre in Kebbi State to 100% at the Ganye General Hospital in Adamawa State. An improvement of 14.2 percentage points was achieved, translating to serving 4,866 additional eligible PLHIV with VL testing.