Viral load testing: room for improvement in Namibia’s antiretroviral treatment services

This approach emphasizes offering antiretroviral therapy (ART) to anyone diagnosed with HIV. Project SOAR is assessing the impact of this policy on key service outcomes, per-patient costs, and contextual factors affecting its success. Baseline data collection revealed that less than two-thirds of patient health records contained viral load (VL) results from the previous 12 months. This suggests a low VL rate or issues with recording VL test results. In response, the study team examined VL testing practices and challenges. Qualitative findings from patients and health providers aim to explain low rates of VL testing. The data on VL testing practices were collected during the endline phase of a broader assessment of Namibia's national rollout of "treat all" at 10 health facilities in 6 districts in northern Namibia. The selected facilities have received technical assistance for HIV clinical services from IntraHealth International since 2015. Between June and July 2018, the study team conducted 10 focus group discussions with ART providers, 2 in-depth interviews with laboratory officers, and 22 in-depth interviews with patients who had no VL test results recorded in their health passports in the past 12 months or whose most recent VL test results were indicative of an unsuppressed level of VL. Most patients lack basic knowledge of viral load testing. When the interviewer explained that ART patients should receive a VL test every 12 months to monitor the effectiveness of HIV treatment, nine patients said they had heard of VL testing, and ten said they had not. Only a few patients (5 of 22) could describe the purpose of the test in sufficient terms. While nearly every patient knew approximately how frequently their blood was drawn, very few said they had been told how often they should be tested for VL. Key messages from the study include: few patients understand the purpose of viral load testing nor the role it plays in their treatment; VL testing may be done, but results are often not communicated to patients, nor is meaningful counseling provided even when patients are in treatment failure; despite lack of patient familiarity with VL testing, some providers expect patients to monitor and manage their own VL testing schedule; and strengthening providers' knowledge and skills in HIV care and VL testing, and their ability to comprehensively counsel patients about their VL results is critical. Patient counseling by providers often fell short of conveying a thorough understanding of VL testing. The counseling patients received was generally non-specific, with several participants saying their results were described in relative terms or that they had simply been told their results were "fine." Participants expressed a desire to better understand VL as well as the relationship between VL results and their relative health and prognosis.