A multipronged strategy to improve viral load testing coverage in Liberia

BACKGROUND: Liberia has an estimated 40,000 persons living with HIV (PLHIV), 16,000 of whom are on antiretroviral therapy (ART). The national viral load (VL) testing coverage rate was below 35% in 2019, and the viral suppression rate among those tested was only 66%. To improve VL monitoring, the USAID/PEPFAR-funded EpiC project introduced a VL coverage acceleration plan across 17 ART facilities where 70% of the country's PLHIV receive ART services.
DESCRIPTION: From February to March 2020, EpiC engaged government, and civil society partners to introduce specific strategies to address VL testing supply and demand issues. A hub-and-spoke system to link facilities to the 20 GeneXpert machines available in the country for processing VL samples was designed to better distribute testing volume according to lab capacity. In addition, volunteers from a network of PLHIV with physician and nursing assistance qualification were selected and equipped to facilitate pre-clinic health talks and adherence counseling with VL-focused information, education, and communication (IEC) materials; conduct VL sample collection and transport to VL labs for processing; return results for quick clinical decision making; track and provide intensive support to PLHIV with non-suppressed VL through home visits and phone calls.
LESSONS LEARNED: National VL testing coverage increased from 1,314 tests in the quarter preceding the intervention (October'December 2019) to 3,057 in the quarter afterwards (April'June 2020). The increase in testing coverage also corresponded with an improved viral suppression rate during the same timeframe, from 66% to 75%. Demand for VL testing increased among PLHIV and, with better VL coverage and results utilization, more PLHIV have been transitioned to more convenient differentiated ART services.
CONCLUSIONS: PLHIV who are health workers can play a critical role in improving VL monitoring by bridging logistical gaps between the ART clinic and VL labs, providing effective adherence counseling, and offering targeted, client-centered support for those who are virally unsuppressed. A hub-and-spoke system helped distribute VL workload between limited labs to ensure effective coverage. Pre-clinic adherence counseling and VL-focused IEC materials generated demand for VL testing among PLHIV. These strategies will be scaled to other facilities to optimize and sustain national VL monitoring in Liberia.