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Opinion: The silver bullet of indicators?

The Treatment Action Campaign’s Marcus Low writes why HIV viral load testing may be the most important HIV indicator. Now, if we could only monitor it.

Until we have a cure or an effective vaccine, viral suppression is the best we can do. Surely we must measure it, argues Marcus Low

Until we have a cure or an effective vaccine, viral suppression is the best we can do. Surely we must measure it, argues Marcus Low

Every few months we are confronted with new AIDS statistics in newspaper headlines. Some of these tell an important story, other less so. Yet, there is one statistic that could easily be reported on, but that somehow never makes it onto the front pages.

Our current measuring sticks         

The scale-up of antiretroviral therapy in the public sector is one of government’s most impressive achievements of recent years. More than 2.4 million people have started treatment in the public sector.

However, as reported in previous issues of NSP Review, this 2.4 million figure might be an under or over-estimate. In addition, knowing how many people started treatment doesn’t tell us anything about how those people are doing now and whether they are still taking treatment.

The silver bullet of indicators?

There is no good reason why…viral suppression rates cannot become a standard part of how we track our progress

The closest thing we have to a cure for HIV is viral suppression. Many patients who are stable on antiretroviral treatment have what is called an ‘undetectable viral load’. This does not mean that there is no virus in the patient’s body, but that there is so little virus that standard tests cannot detect it. Such a low viral load means that a person is very unlikely to transmit HIV to his or her sexual partners.

If we were to measure what percentage of treatment-eligible patients are virally suppressed, we would get a clearer picture of how well these people are actually doing:

  • We would know whether people are still in care. Since HIV-positive people in the public sector should receive at least one viral load test per year, counting the number of people receiving viral load tests would provide an indication of how many people are in the system.
  • We would know how well HIV-positive people are doing. A high rate of viral suppression would tell us that our interventions are working. Lower rates of viral suppression could help us figure out where things are going wrong – especially if rates are reported by facility or district.
  • Viral load suppression rates reported by district might help uncover underlying problems in the health system. For example, if a district has a low viral suppression rate, the reasons for that low rate could be investigated and might uncover problems like stock-outs of essential medicines or long distances between the clinic and where people live in that district.

Everything is in place

There is no good reason why the national, provincial and district viral suppression rates cannot become a standard part of how we track our progress against the HIV epidemic in South Africa. According to current treatment guidelines, all public sector HIV patients must have at least one viral load test per year. The blood samples used in these tests are analysed by the National Health Laboratory Service (NHLS). The NHLS collates these figures and reports on them to the National Department of Health. However, currently these figures are not reported publically.

While raw data that would compromise patient privacy can obviously not be reported, anonymised data broken down to district or clinic level could be reported with no risk to confidentiality. The NSP Review has written to the Department of Health to request that viral load suppression rates nationally, provincially, and on district level should be published on a regular basis.

When we set new NSP targets

“We strongly advocate for universal viral suppression to be included as a new NSP target.

One of the key targets of the National Strategic Plan (NSP) for HIV and AIDS, TB and STIs is that 80 percent of treatment-eligible patients in South Africa must have access to treatment by 2016. This 80 percent threshold is considered to constitute universal coverage.

This is a good target and we appear to be on course to reach it.

However, when the current NSP comes to an end, new targets will have to be set. While universal coverage set at 90 or 100 percent may be a good target, we strongly advocate for universal viral suppression, which is defined as 80 percent of treatment-eligible patients with undetectable viral loads, to be included as a new target. Rather than just telling us how many people are receiving treatment, this measure will tell us whether these people are still in care and how they are doing. As our wider focus shifts from simply providing more people with treatment to ensuring those on treatment are retained on treatment, our monitoring tools must evolve to keep up.

Similarly, when new targets are set to replace the Millennium Development Goals, the most important HIV—related target must be to achieve universal viral suppression.

Until we have a cure or an effective vaccine, viral suppression is the best we can do. Surely we must measure it.

This opinion piece was originally published in the Treatment Action Campaign and Section27 joint publication, the NSP Review.

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