Share
 
Title
Moving from CD4 counts to Viral load measures; policy, practice and patient experiences in rural Tanzania and Malawi: A mixed-methods case study
Presenter
John Songo
Authors
J. Songo1, J. Renju2, F. Hasan3, E. McLean1, A. Dube1, T. Kalua4, E. Geubbels3, J. Todd5, A. Crampin1, A. Wringe6
Institutions
1Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi, 2London School of Hygine and Tropical Medicine, Moshi, Tanzania, United Republic of, 3Ifakara Health Institute, Dar es Salaam, Tanzania, United Republic of, 4Malawi Ministry of Health, HIV & AIDS Department, Lilongwe, Malawi, 5London School of Hygine and Tropical Medicine, Mwanza, Tanzania, United Republic of, 6London School of Hygine and Tropical Medicine, London, Malawi

Background: In 2014 the WHO suggested a changing role for CD4 monitoring in clinical care, recommending routine viral loads (VL) to monitor adherence, and using CD4 counts to screen for opportunistic infections. However, roll-out VL testing has been slow in many settings and little is known about how the switch from CD4 counts to VL monitoring is taking place in practice. We used mixed methods in Tanzania and Malawi to i) document the evolution of national policies, ii) assess health facility level implementation; and iii) understand health provider and patient perspectives on the utility of these tests.
Methods: Guidance on the use of CD4 and VL were extracted from National HIV policies covering the period 2013-17. A facility survey was conducted in 2017 in health facilities in Malawi (n=5) and Tanzania (n=11) within two health and demographic surveillance sites (HDSS). Eight indicators on CD4 counts and VL testing were extracted. In-depth interviews with 3-6 health workers and 7-11 PLHIV across countries explored understanding and experience of the tests. Interviews were recorded and transcribed. Thematic analysis was conducted and findings compared across settings.
Results: Unlike Tanzania, Malawi did not adopt a policy requiring CD4 testing for ART eligibility. However both countries adopted VL testing in 2014 (Malawi) and 2015 (Tanzania). The frequency for VL testing was well aligned with national policy. Turnaround times for VL testing were longer than government recommendations in both countries (30 days).
(Figure 1).
In-depth interviews suggested that health workers were aware of the guidance for VL testing and recognised its utility to give a “better picture of the health of our patients”. However, in Tanzania health workers preferred CD4 counts, where available, reporting that the turnaround time was quicker. In both countries PLHIV that recalled having undergone tests generally referred to CD4 counts and valued it as a measure of their health status.
Conclusions: Although CD4 counts are being phased out, the coverage of VL testing has not matched national policy. The slow scale up of VL testing and corresponding health worker training and delays in processing test results may undermine PLHIV engagement in HIV care.

Figure 1: Implementation of viral load and CD testing in health facilities serving two health and demographic surveillance sites in Tanzania and Malaw
[Figure 1: Implementation of viral load and CD testing in health facilities serving two health and demographic surveillance sites in Tanzania and Malaw]

Download the e-Poster