Spotlight on Lesotho Viral Load Testing: World AIDS Day 2022

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This World AIDS Day, we are sharing "sneak peeks" of soon-to-be-published updates to the guide A Network Approach to Scaling Up Laboratory Services, including this case study from Lesotho. This story includes impressive data to demonstrate the impact of diagnostic network optimization on patient access to viral load, early infant diagnosis and tuberculosis testing. 

In Lesotho, the Ministry of Health embarked on an ambitious diagnostic network optimization program, with support from USAID, CDC, and implementing partners.

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Person in laboratory in Lesotho organizes test tubes containing samples for testing.
Person in laboratory in Lesotho organizes test tubes containing samples for testing.
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Lab technician in Lesotho organizes samples for testing. Photo Credit: GHSC-PSM
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In 2019, although Lesotho had five viral load (VL) laboratories, its goal of universal VL monitoring was hindered by barriers and delays. In the third quarter of 2019, more than one of every four people living with HIV/AIDS still lacked access to VL testing services.

Aiming to provide coverage to all people living with HIV/AIDS — and with the support of the Ministry of Health (MOH), U.S. Agency for International Development (USAID), and U.S. Centers for Disease Control and Prevention (CDC) — implementing partners banded together to implement an ambitious diagnostic network optimization (DNO) program. 

The program began with a workshop in September 2019, at which participants mapped an optimized diagnostic network for HIV VL testing, early-infant diagnosis (EID), and tuberculosis diagnosis. The network was comprised of a mix of large and small laboratory sites around the country, including 13 minilabs.

The MOH’s head of infectious disease control and the laboratory director joined forces and formed a task force to lead implementation, leveraging each participating organization’s expertise to define clear roles.

The task force prioritized point-of-care VL testing for pregnant and breastfeeding women to provide faster identification and access to care for preventing mother-to-child transmission. A pilot program launched in February 2020 at five central “hub” sites, with eventual full rollout of the program in March 2021 to additional “spoke” sites.

Despite challenges related to COVID-19, which forced some training programs to happen virtually, more than 400 health facility staff received training in the skills needed to implement DNO.

As a result of the DNO, the time required from laboratory sample collection to delivery of results at facilities dropped from a range of 13 to 43 days to less than 24 hours. Health care providers reported a marked increase in patient satisfaction, including among pregnant and breastfeeding women.

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Further scale-up of VL testing to points of care

In 2020–2021, the country scaled up VL testing services further at the point of care (POC) to improve coverage for people living with HIV/AIDS. This scale-up focused on several approaches:

  • VL testing was integrated into existing GeneXpert platforms in 16 POC sites. GeneXperts had previously been used only for EID.
  • Access to POC VL testing was expanded beyond pregnant and breastfeeding women to include infants and teenagers.
  • Three Cobas 4800 (C4800) machines were also placed in Berea and Mafeteng districts and at Ntsekhe Hospital to expand VL testing.

The figures below show the trend of increasing numbers of VL and EID tests across POC GeneXpert and m-PIMA machines between September 2021 and August 2022.

Figure 1. Number of VL and EID tests on GeneXpert and m-Pima platforms, September 2021–August 2022
 

Tests

Sep 21

Oct 21

Nov 21

Dec 21

Jan 22

Feb 22

Mar 22

Apr 22

May 22

Jun 22

Jul 22

Aug 22

GeneXpert VL test

179

367

436

627

386

574

699

650

1006

1219

1108

1364

GeneXpert EID tests

211

8

172

660

605

628

571

534

482

703

672

842

m-PIMA EID tests

53

44

90

171

305

284

343

269

199

286

196

258


Figure 2. Trend of increasing VL and EID testing numbers on POC GeneXpert and m-Pima platforms, September 2021–August 2022



The work in Lesotho continues, with partners providing ongoing training, supervision, and mentorship of health personnel. Next steps also include plans to reach patients with unsuppressed VL and with advanced HIV disease.