Viral-load point-of-care technologies to achieve an AIDS-free generation

New point-of-care (POC) technology to detect HIV viral load promises to be a game changer in the diagnosis and monitoring of HIV infection. Poverty and distance from healthcare facilities often place people infected with HIV beyond the reach of life-saving care. Viral-load POC testing brings diagnosis and monitoring of antiretroviral therapy (ART) treatment closer to the patient, even in remote regions of sub-Saharan Africa where HIV prevalence is high and resources are scarce. The value of POC testing is underscored by UNAIDS suggesting the possible end to the AIDS epidemic by 2030 if three 90-90-90 ambitious targets are achieved by 2020: 90% of all individuals living with HIV know their status; 90% of all individuals diagnosed with HIV receive sustained ART and 90% of all individuals receiving ART have viral suppression. Achieving the third target requires universal access to viral-load testing, which is in line with the most recent WHO ART guidelines. The WHO defines treatment failure as a persistently detectable viral load exceeding 1000 copies/ml during two consecutive viral-load measurements, within a 3-month interval and after at least 6 months of using ART. High-income countries already use routine viral-load monitoring to detect early treatment failure and inform decisions on switching patients to second-line ART. By contrast, in resource-limited settings, treatment failure is still defined by clinical criteria and CD4 cell counts, parameters that are poorly correlated with viral load. Without access to viral-load testing, individuals may be unnecessarily switched to more expensive second- and third-line treatments. Simple and affordable POC technologies to detect viral load are in development, expanding access to critical diagnostic services and optimizing treatment monitoring for individuals living with HIV. Conventional laboratory testing for viral load, which typically occurs at a central facility to which all tests from a particular region are sent for processing, has certain advantages. Collecting and batching tests produce economies of scale that reduce the cost per test. However, in settings where healthcare infrastructure and transportation are poor, conventional testing can result in large numbers of patients lost to follow-up. Avoiding losing patients to follow-up and maintaining their viral load at undetectable levels is critical not only to avoid treatment failure in the patient but also to reduce the risk of transmission at the individual and the community level. Measuring viral load can also inform public health officials on the risk of transmission at the community level. Community viral load (CVL) is a metric aggregating the viral load for a community. The central hypothesis underlying the use of CVL is that as ART coverage increases, greater numbers of HIV-infected persons will be virologically suppressed, leading to reduced CVL and consequently, reduced incidence of HIV infection in the general population. WHO recommends that all newborns exposed to HIV receive early infant diagnostic screening within the first 2 months of life. However, only half of newborns exposed to HIV receive this screening, contributing to a major gap in HIV treatment access.