By Madlen Nash & Madhukar Pai
World AIDS Day is dedicated to raising awareness about HIV/AIDS and mourning the loss of those who have died of the disease. Since its establishment in 1988, massive strides have been made in improving prognosis for those living with HIV. These include safer, cheaper and more effective anti-retroviral drugs; development of rapid diagnostics; and the introduction of pre-exposure prophylaxis (PrEP). Despite these innovations and advances, HIV/AIDS remains the second-leading infectious disease killer in the world.
While HIV mortality has been reduced, there is still a long way to go towards achieving the UNAIDS 90-90-90 targets for diagnosis, treatment and viral suppression; and serious donor fatigue threatens to reverse the progress that has already been made. Only 70% of people with HIV know their status; a mere 54% of adult and 42% of children living with HIV are receiving lifesaving therapy (ART); and one million people lost their lives due to HIV-related causes in 2016.
Source: UNAIDS, 2017 (http://www.unaids.org/en/resources/infographics/measures-progress-909090)
Interventions such as HIV self-testing have great potential to close the initial diagnostic gap, and they are already being scaled-up in many settings. WHO now endorses the use of HIV self-testing and there are several products on the market, along with innovative mobile apps and tools to increase uptake.
HIV self-testing is feasible, accurate, acceptable to people, and successful in increasing the uptake of testing (Source: Dr Nitika Pant Pai, McGill University)
Viral load testing is critical. Lack of access to viral load testing is a key impediment to improving quality of care for those living with HIV and reducing HIV-related mortality. A quick and accurate detection of treatment failure depends on access to a viral load test. Despite the necessity, only 2 in 5 people on treatment have ever had a viral load test (graph above).
New point-of-care technologies, such as the Xpert HIV-1 Viral Load Assay (Cepheid Inc) and Alere Q NAT POC (Abbott Rapid Diagnostics) have the potential to be game changers. Previously, scale up of viral load testing in high burden countries was severely hampered by the infrastructure demands of the older tests. The low-complexity nature of POC technologies, coupled with their ability to deliver same day test results make these technologies particularly well suited for use in resource constrained settings, where point-of-care VL testing is most needed.
Xpert HIV -1 VL, based on the GeneXpert technology, performs well in comparison with current reference tests. The minimal training and infrastructure requirements for the Xpert HIV-1 VL assay make it attractive for use in resource constrained settings (Source: Madlen Nash & Madhu Pai)
The GeneXpert platform, used to run the Xpert HIV viral load assay, is already widely available in many LMICs for tuberculosis testing. In fact, there are over 6600 GeneXpert instruments (with over 29,000 modules) in 130 countries, purchased for TB testing. Clearly, we need to find ways to leverage this platform for making HIV VL testing more accessible. Indeed, we have shown this to be a feasible strategy in India. WHO now encourages countries to use multidisease platforms for testing of HIV, TB and hepatitis as much as possible and feasible.
But technologies alone are not sufficient to close the innovation gap. Financial and political commitments at the country level are necessary. High burden HIV countries need to invest in scaling up technologies such as self-tests, viral loads and ARVs, and aim to improve the cascade of care in HIV. Only then will we end the HIV epidemic for good.
Madlen Nash (@madlennash) is a graduate student at McGill International TB Centre & Department of Epidemiology & Biostatistics, McGill University, Montreal. Her research is focused on tuberculosis & HIV, and she has evaluated novel HIV viral load technologies.
Madhukar Pai (@paimadhu) is a Canada Research Chair in Epidemiology & Global Health at McGill University, Montreal. He is the Director of McGill Global Health Programs, and Associate Director of the McGill International TB Centre.