Why viral load results do not reach the patient: analysis of a health process

The question

The HIV response is measured against three targets: that 95 % of people living with HIV know their status, that 95 % of those are on treatment, and that 95 % of those on treatment have a suppressed viral load — under one thousand copies per millilitre. An undetectable viral load means treatment is working, and a person who no longer transmits the virus.

It is the third target that resists. In Senegal, according to UNAIDS data for 2020, 71 % of people living with HIV know their status, 98 % of them are on treatment — but only 57 % have a suppressed viral load. Across West and Central Africa, the figure falls to 45 %.

Why? Treatment failure did not explain everything. A more prosaic possibility remained: that the measurement itself never completes. That is what we set out to verify.

How we worked

A descriptive, cross-sectional and entirely qualitative study, conducted across five health facilities in three districts and two regions — two with their own testing platform, three having to transport or refer their samples.

One hundred and eleven people were interviewed in semi-structured interviews: seventy-three people living with HIV, thirteen care providers, nine laboratory technicians, four managers, seven public health officers and five civil society representatives. Collection in November and December 2021.

Analysis followed grounded theory: thematic coding in Atlas.ti, then presentation as flow diagrams. The pathway was broken into four stages — eligibility and patient information, sample collection and transport, analysis and return of the result to the facility, handover to the patient and record update — each examined separately.

Interviews took place in closed rooms, on verbal, free and anonymous consent. We had no access to patient registers, and we deliberately gave up geo-referencing homes, which would have compromised the confidentiality of serological status.

What we found

Patients do not know what is being prescribed

This is the first blockage, and the easiest to lift. Asked what a viral load test is, a large majority of people living with HIV said they did not know. And when asked what information they had been given at the point of prescription, the most frequent answer was: none.

The doctor is the source of information in the great majority of cases where any exists. Counsellors and social services come next — but almost exclusively at the two Mbour sites. Information materials and community channels never appear.

Turnaround times ranging from twenty-four hours to ten months

This is the study's most striking gap. Depending on the site, the average time between sample collection and delivery of the result runs from twenty-four hours to one week where a testing platform is present and the circuit organised, and up to ten months elsewhere.

Stock-outs of consumables, reagents above all, are the main cause of delay against result turnaround deadlines.

One medical region reports having carried out no viral load measurement at all between January and October 2021, for lack of reagents. A community organisation reports January samples analysed in October. Some transported samples went two years without a result.

Nobody funds sample transport

The finding is dismayingly banal. The machines exist, the reagents eventually arrive, the technicians are trained — but transporting samples between facilities is budgeted nowhere. Neither the fuel nor the courier's allowance. One site reports transport delays of up to fifteen days.

Add to that competition from COVID-19 on the same platforms: at the reference laboratory, the flow of COVID samples far exceeded that of viral load tests.

Where it works, social work makes the difference

The two Mbour sites stand out clearly. Patients there are informed, followed up by telephone, told when and where to collect their result. Their transport costs are reimbursed. Neither better equipment nor larger budgets explain the gap: what explains it is a social service that is actually present — a social worker and mediators.

At the Dakar sites, the question "were you told where and when to collect your result?" draws an overwhelmingly negative answer.

A reception that discourages those most exposed

The populations most affected by the epidemic are also those who drop out most. Community actors report that some providers describe themselves as uncomfortable with these groups, which feeds a poor reception and users' reluctance to return. We also observed that some people deliberately attend the facilities furthest from their homes, in order to protect the confidentiality of their status.

What we recommended

1. Inform and educate patients on what a viral load test is and what it is for — the information gap is the easiest blockage to lift
2. Budget for sample transport: fuel and courier allowances
3. Equip sites with testing platforms and sustained reagent supply, and provide for HIV-2 testing where the cohort justifies it
4. Replicate the Mbour social service model at the Dakar sites
5. Train medical staff in reception, listening and availability
6. Make viral load testing accessible at community level, and provide financial support for transport and laboratory work-ups
7. Introduce electronic tracking of results

Out of respect for the confidentiality of those interviewed, this summary names neither the facilities associated with any particular group, nor the individuals quoted in the report.

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