By : M Chilufya, J Musonda, B H Mutale, V Kamanga
Citation Style For This Article: Chilufya M, Musonda J, Mutale BH, et al. An HIV Free Nation.Health Press Zambia Bull. 2021; 05(02); pp 3.
Key Messages
- Zambia National Health Strategic Plan 2017 – 2021 goal is to reduce new HIV infections and mortality by 75%.1
- The main aim was to reduce new HIV infections to less than 18,000 by 2020
- Causes of new HIV infections: unknown HIV status, known status not on ART and high viral load PLWHIV.
The Problem
- Zambia has made great strides in attaining 95-95-95: HIV new case identification at 95%; of HIV infected people initiated on treatment at 94.5%; and of those initiated on ART 94.2% with viral load suppression.. However, despite these efforts, the country continues to record high number of new HIV infections (48,000) with 17,000 HIV related deaths attributed to high viral load2. There are approximately 67,762 patients on ART with high viral load in Zambia3.
- A high viral load increases the risk of HIV transmission threefold to their sexual partner4:
-When viral load is
exceptionally high the risk
is sevenfold4
-Advanced HIV disease the
risk is six fold4
Problem Visualization
Based on information from high viral load registers from selected facilities in Lusaka and Western Provinces of Zambia5, illustrated that not all patients with high viral load were enrolled on Enhanced Adherence Counseling (EAC) i.e. 92% of which only 54% completed EAC giving an attrition of 3,328 not Completed EAC and while only 50% proceeded to have a repeat viral load done5.
April 13 2021: For more information contact: Justin Musonda, Mwelwa Chilufya, Bwalya Helena Mutale and Vikwato Kamanga on 0977849383 and 0974389250
*Unless specialized interventions to reduce new HIV Infections are made an integral part of HIV care, there will still be virally unsuppressed PLWHIV transmitting new infections and deaths resulting from poor management
Literature shows that.
- High viral load in patients is associated with decreased survival and increased HIV transmission
- HIV transmission is much higher among partners of patients with high viral load compared to those with suppressed viral load.6,7
Policy Options
For Zambia to avert new HIV infections and reduce mortality among patients with high viral load below are the proposed policy options
- Maintain Status Quo (Standard of Care) of offering routine ART Services through use of already existing SOPs and guidelines on the management of High VL patients.
What: This option relies on the already existing service delivery based on the current Zambia Consolidated Guidelines (ZCGs).
Why: According to data for high viral load index testing in selected facilities in Lusaka, Chongwe and selected districts in western province it depicts 18% HIV positivity among contacts for index case with high viral load9
Feasibility: High.
- Enhance high viral load clinics (Viremia Clinics)
What: Build on status quo according to the Zambia Consolidated Guidelines (ZCGs)
- Leverage on existing ART infrastructure and incorporate viremia clinics
- Integration of Peadiatric and Adult mental health screening tools including treatment of identified disorders
Why: In Zimbabwe, following the scale up of viremia clinics, the percentage of patients completing EAC increased from 46% to 78%, while patients having a repeat viral load after EAC also increased from 34% to 84%.10
Feasibility: High. This strategy is highlighted in the ZCG but requires reinforcement through capacity building and allocation of dedicated personnel.
- Scale up Viremia clinics, strengthen Mental Health service provision alongside incorporating high viral load Monitoring and Evaluation (M&E) system in ART
What:
- Build on status quo according to the Zambia Consolidated Guidelines (ZCGs)
- Leverage on existing ART infrastructure and incorporate viremia clinics integration of Peadiatric and Adult mental health screening tools including treatment of identified disorders
- Develop and standardize high viral load M&E system
Why:
- Common mental disorders is among the most prevalent condition with the prevalence of over 30% among PLHIV reported across studies in some Low to Medium Income Countries (LMIC), particularly for depression. 6,7
- In Zambia there are no reporting tools for the unsuppressed cascade (including mental health assessments and treatment among PLWHIV), WHO 2019 highly recommends its adoption. 15
Feasibility: High.
This strategy will build on the current status quo by integrating mental health screening and treatment, creating a routine HVL surveillance system.
Recommendations
Scaling up routine Viraemia clinics with mental health incorporation; through introduction of Peadiatric and Adult mental health screening tools in EAC .
Enhanced care for patients with high viral load will reduce new HIV transmissions and AIDS related deaths
Action Required
Scale up Viremia clinics to all ART facilities; through
– Allocation of dedicated personnel, training and mentorship
– Develop Peadiatric and Adult mental health screening tools integrated in EAC
– Develop and adopt a monitoring and evaluation high viral load cascade framework and reporting system.
References/ Resources
Ministry of Health, Zambia National Health Strategic Plan 2017-2021, Zambia. Source: http://www.moh.gov.zm/docs/ZambiaNHSP.pdf
UNAIDS DATA (2020).
Ministry of Health (2020), Zambia Consolidated Guidelines for Treatment and Prevention of HIV infection, Zambia.
Roger Pebody, May 2020, The biology of HIV transmission; Estimated HIV risk per exposure. https://www.aidsmap.com/about-hiv/estimated-hiv-risk-exposure
Lesley Odendal, 2019, Leakages in ART treatment cascades in West Africa and Zambia
HIV/AIDS and mental health research in sub-Saharan Africa: A systematic review. June 2011African Journal of AIDS Research 10(2):101-122 https://www.researchgate.net/publication/233064944_HIVAIDS_and_mental_health_research_in_sub-Saharan_Africa_A_systematic_review
Saag etal 2018, Mental health service utilization is associated with retention in care among persons living with HIV at a university-affiliated HIV clinic. Available at https://aidsrestherapy.biomedcentral.com/articles/10.1186/s12981-018-0188-9
Glass etal, 2019, The viral load monitoring cascade in a resource-limited setting: A prospective multicenter cohort study after introduction of routine viral load monitoring in rural Lesotho. Available at https://doi.org/10.1371/journal.pone.0220337.
Smart Care Data
Management of PLHIV with viremia: Experiences from a High-Volume Referral. ART Clinics in Zimbabwe. (2020) https://cquin.icap.columbia.edu/wp-content/uploads/2020/07/CQUIN-Presentation_AHD-2020_Viremia-Clinic_Tafadzwa_Zimbabwe-21July2020.pdf.
Global HIV/AIDS Overview Report. Available at https://www.hiv.gov/federal-response/pepfar-global-aids/global-hiv-aids-overview. Accessed on 19/08/2020.
Davey etal 2018, Factors associated with recent unsuppressed viral load in HIV-1-infected patients in care on first-line antiretroviral therapy in South Africa. https://www.researchgate.net/publication/322528087_Factors_associated_with_recent_unsuppressed_viral_load_in_HIV-1-infected_patients_in_care_on_first-line_antiretroviral_therapy_in_South_Africa. Accessed on 26/08/2020.
University of Maryland , Baltimore, Viremia clinics in Kenya: Enhanced monitoring and management of HIV-positive individuals on antiretroviral treatment with high viral load. https://static1.squarespace.com/static/5a29b53af9a61e9d04a1cb10/t/5beed8cfcd836634a26fd535/1542379729840/Viremia+Clinics_long+form_11.16.pdf Accessed on 18th March 2021.
Prevalence and correlates of common mental disorder among HIV patients attending antiretroviral therapy clinics in Hawassa City, Ethiopia. https://annals-general-psychiatry.biomedcentral.com/articles/10.1186/s12991-019-0241-7 Accessed
WHO (2019), Considerations for developing a monitoring and evaluation framework for viral load testing.