Viral load monitoring: how do HIV-positive patients interpret and understand their results? *Shona Horter1, Lobenguni Simelane-Mahlinza2, Velibanti Dlamini2, Tatiana Kourline2, Bernhard Kerschberger2, Beverley Stringer1, Barbara Rusch3 1 Médecins Sans Frontières (MSF), London, UK; 2MSF, Nhlangano, Swaziland; 3MSF, Geneva, Switzerland *shona.horter@london.msf.org Introduction Viral load (VL) monitoring can reinforce antiretroviral therapy (ART) adherence support and prevent treatment failure through identification of second-line treatment need. The potential disinhibitory effect of known undetectable VL is of concern. Routine VL monitoring for patients on ART has been implemented across Shiselweni, Swaziland, by MSF and the Ministry of Health (MoH), including stepped-up counselling for those with detectable VL. This qualitative study aimed to examine the views and experiences of patients participating in a VL monitoring study within an MSF/MoH HIV/tuberculosis programme. Methods 22 participants were recruited purposively from the 2369 patients who received a VL test result in October–December 2013. VL statuses were: undetectable (n=6), persistently detectable (n=8), and re-suppressed (n=8). Semi-structured interviews were conducted (n=22) based on topic guides, and transcripts analysed thematically to identify emergent codes, patterns (including deviances from majority themes), and concepts, using Nvivo 10 as an analytic aid. Ethics approval was obtained from the Swaziland Scientific and Ethics Committee and the MSF Ethics Review Board. Results Participants identified VL increase as resulting from perceived ineffective treatment, gaps in treatment-taking, and emotional difficulties. Several received limited information about VL during clinic visits and had greater familiarity with CD4 monitoring. Health practitioner attitudes were often described as accusatory and judgemental, with assumed patient non-compliance. This perceived judgement and blame added to confusion over the meaning of VL changes and undermined supportive relationships and the ability to mention potential challenges. An undetectable VL result was seen as positive affirmation that treatment was working, with participants feeling happy and that “they are doing things right”. However, detectable results could cause feelings of upset and despondence. VL monitoring reportedly motivated condom use through reminders of its importance, with undetectable VL not described as increasing riskier sexual practices. However, females reported limited influence in condom negotiation. Conclusions Our findings suggest that VL monitoring has a positive impact on adherence and potentially on treatment outcomes. While patients accept VL monitoring, there is a need for greater information to maximise its potential benefits and care to avoid reinforcement of hierarchical practitioner-patient relationships. Careful training of health practitioners on communication is essential before roll-out and consideration should be paid to VL support and messaging, for example to avoid detectable VL results causing patients to feel hopeless.