Viral load detection and management on first line ART in rural Rwanda

BackgroundTo achieve the ambitious 90-90-90 UNAIDS targets, access to routine viral load (VL) is critical. To measure VL, Rwanda has relied on a national reference laboratory for years. In 2014, a VL testing platform was implemented in a rural District in the Northern Province. Here we analyze the uptake of VL testing, identification of risks for detectable VL (1000 copies/ml), and the management of patients with a detectable VL.MethodsA retrospective cohort study of patients who started ART between July 2012 and June 2015 and followed until end December 2016. Using descriptive statistics, we describe the VL cascade, from VL uptake to the start of second-line ART in patients diagnosed with virological failure. We estimate predictors of having a detectable VL using logistic regression.ResultsThe uptake of VL testing increased progressively between 2013 and 2016, raising from 25.6% (39/152) in 2013 up to 93.2% (510/547) in 2016.In 2016, 88.5% (n=451) of patients tested, had a suppressed VL. Predictors of having a detectable VL included being male (aOR 2.1; 95%CI 1.12-4.02; p=0.02), being a sex worker (aOR 6.4; 95%CI 1.1-36.0; p=0.04), having a WHO clinical stage IV when starting ART (aOR 8.8; 95%CI 1.8-43.0; p<0.001), having had a previous detectable VL (aOR 7.2; 95%CI 3.5-14.5; p<0.001), and having had no VL before 2016 (aOR 3.1; 95%CI 1.2-8.1; p=0.02). Among patients with initial detectable VL between 2013 and 2016, 88% (n=103) had a follow-up VL, of whom 60.2% (n=62) suppressed their VL below 1000 copies/ml. The median time between the initial and follow-up VL was of 12.5months (IQR: 8.7-19.0). Among patients with confirmed treatment failure, 63.4% (n=26) started second-line ART within the study period.ConclusionVL uptake increased after decentralizing VL testing in rural Rwanda. Virological suppression was high. An individualized follow up of patients at risk of non-suppression and a prompt management of patients with detectable VL may help to achieve and sustain the third global UNAIDS target: virological suppression in 90% of patients on ART.