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.