Monday 11 March 2019 - Updated on Thursday 21 January 2021
Important advances have been made, but the problem is very far from solved.

Globally 37 million people live with HIV, 70% of them live in Africa: Since the start of the epidemic in the 1980s 77 million people have become infected with HIV.Important advances have been made in recent years. In 2017 close to a million people died from AIDS related diseases, 50% fewer than at the height of the epidemic in 2004. In 2017, 2 million new HIV infections were recorded; that is 47% less than in 1996. The widespread availability of anti-retroviral (ARV) therapy over the past decade has made a dramatic difference in the survival and transmission rates. Following the global scale-up an estimated 59% of people living with HIV now receive ARV therapy. In 2014, UNAIDS and partners launched the 90–90–90 targets; the target is to diagnose 90% of all HIV-positive persons, provide ARV therapy for 90% of those diagnosed, and achieve viral suppression for 90% of those treated by 2020. 

Current ARV therapies involve life-long treatment with a minimum of 3 drugs. This is a challenge on the personal patient level, but also at the level of health systems. 

Médecins Sans Frontières (MSF) has been treating people infected with HIV since 2000. Alongside MSF, Epicentre has contributed by conducting research projects that demonstrate to the Ministries of Health, donors and the scientific community the feasibility of treating high number of patients in resource-limited settings. 

Speeding up access to test results, speeding up start of treatment.

Point of Care (POC) viral load monitoring in Malawi; Early Infant Diagnosis (EID) in Uganda

To reduce the number of new HIV infections early detection and the prescription of effective treatments is important, especially among HIV-infected mothers and their new-borns. In addition, it is important to monitor the treatments effectiveness; an ineffective treatment should be detected early so that the combination of drugs can be adjusted, i.e a switch to 2nd or 3rd line treatment. This detection is best not based on a sole clinical assessment of a patient’s condition as this is often too late. The current gold standard tool to monitor the treatment effectiveness is to measure the HIV viral load. A suppressed viral load indicates that the regimen prescribed is working well and that virus cannot be transmitted. 

A pregnant mother is being tested for HIV and receives counselling.
A pregnant mother is being tested for HIV and receives counselling.

Measuring viral load involves complex equipment capable of performing so-called PCR tests, whereby copies of the virus can be quantified. Operating this equipment required high-level infrastructure and qualified technicians, which is why in low- and middle-income countries these are typically located in centralized laboratories. This is an impediment to rapid access to results for patients and clinicians alike.

In recent years, Point-Of-Care (POC) devices have been developed and are proving to be a good tool in settings where complex technology is not easy to implement. POC devices permit a same day result opposed to several weeks, sometimes months. This same day result allows prompt action, such as adherence counselling, switch to 2nd or 3rd line regimen. 

In Malawi and Uganda Epicentre has had research projects with SAMBA (Simple Amplification Based Assay), one such recent POC method that can detect and monitor early HIV infection in newborns exposed to HIV through their mothers during pregnancy. Early Infant Diagnosis (EID) test results can be made available within a day and treatment, such as ARV initiation, can be started promptly. Viral load measurement through this method also helps to monitor the effectiveness of the ART regimen so that adjustments can be made if necessary.

Directing patients to the optimal treatment regimen

Research into viral load and drug susceptibility testing (DST)

By measuring viral load, the effectiveness of ARV treatment can be assessed. If it becomes clear the patient’s virus is resistant to the ARV regimen, and treatment is failing, it is essential to change the drug combination that make up the treatment, in part or in whole. However, in the settings where MSF works, the number of ARV drugs available is limited, and consequently, so are the number of combinations. Epicentre has conducted several cohort and cross-sectional studies that demonstrate the need for simpler and more accessible Drug Sensitivity Testing techniques to identify effective ARV drugs and providing the evidence base for MSF's advocacy on this issue and highlighting the difficulty of accessing in particular 3rd line ARV drugs.

Improving adherence to treatment

Targeting particular age groups such as adolescents

Adolescent HIV project, in Malawi. Dance to start the 'six-months-meeting day' to welcome new members and monitor all the girls and boys who already joined the programme.
Adolescent HIV project, in Malawi. Dance to start the 'six-months-meeting day' to welcome new members and monitor all the girls and boys who already joined the programme.

ARV therapy is a lifelong treatment consisting of at least 3 drugs and is sometimes accompanied by short and/ or long-term side effects. To avoid development and spread of drug-resistant HIV, it is crucial that patients strictly comply with the treatment requirements. This is why HIV management programs need to support patients, because, although patients understand the importance of regular treatment, it is often hard to continue to adhere to a treatment that can have such severe constraints. Epicentre conducted qualitative studies highlighting these constraints faced by patients. The focus has been particularly on adolescents for whom adherence is especially difficult and who are even more susceptible to wanting to avoid the social stigma of HIV and on long-term ART patients who may face similar and other difficulties. 

The aim is to reduce non-compliance that contributes to the emergence of drug-resistance requiring a switch to more expensive 2nd or 3rd line treatments, or, even worse run out of treatment options altogether. These studies have contributed to reveal reasons for poor compliance and helped MSF programs to address these issues

Assessing Cascade of Care

Population level studies on prevalence and incidence

Epicentre has conducted population level studies to assess ART programs after several years. Several questions can be addressed with such studies: HIV prevalence and incidence, level of awareness HIV status of the population, linkage to care, viral load suppression at population level. These are key indicators to assess the so-called cascade of care. Progress can be measured of the different steps in HIV treatment and care, gaps can be identified, and goals can be formulated.

In some cases Epicentre has been able to conduct surveys before and after an MSF intervention so that results can be measured. 

Selected resources

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Viral load monitoring with samba-1_Uganda_Poster_Epicentre-MSF_IAS2017_Nicolas S

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Understanding virological failure in adolescents living with HIV in Chiradzulu District, Malawi: evidence from a cross-sectional assessment and a qualitative study - Schramm B - Video 2017

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Virological failure, drug resistance and third-line regimen requirements among patients receiving second-line ART in 3 HIV-programs in Kenya, Malawi and Mozambique - Schramm B - Video 2016

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Increasing access to routine viral load with nearly point-of-care SAMBA_Poster_AIDSConf2016_Nicolas S

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Cross-sectional assessment of virological failure, drug resistance and third-line regimen requirements among patients receiving second-line ART in 3 in Kenya, Malawi and Mozambique_Poster_AIDSconf2016_Schramm B

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Selected publications

HIV-1 drug resistance testing at second-line regimen failure in Arua, Uganda: avoiding unnecessary switch to an empiric third-line.

Journal Reference: Tropical medicine & international health : TM & IH 2018 Oct ; 23(10); 1075-1083. doi: 10.1111/tmi.13131. Epub 2018 10 02

Progress towards the UNAIDS 90-90-90 goals by age and gender in a rural area of KwaZulu-Natal, South Africa: a household-based community cross-sectional survey.

Journal Reference: BMC public health 2018 03 02; 18(1); 303. doi: 10.1186/s12889-018-5208-0. Epub 2018 03 02

Cascade of HIV care and population viral suppression in a high-burden region of Kenya.

Journal Reference: AIDS (London, England) 2015 Jul 31; 29(12); 1557-65. doi: 10.1097/QAD.0000000000000741. Epub 2016 04 26

Closer to 90-90-90. The cascade of care after 10 years of ART scale-up in rural Malawi: a population study.

Journal Reference: Journal of the International AIDS Society 2016 ; 19(1); 20673. doi: 10.7448/IAS.19.1.20673. Epub 2016 02 15

Factors associated with HIV status awareness and Linkage to Care following home based testing in rural Malawi.

Journal Reference: Tropical medicine & international health : TM & IH 2016 Nov ; 21(11); 1442-1451. doi: 10.1111/tmi.12772. Epub 2016 10 07

Who Needs to Be Targeted for HIV Testing and Treatment in KwaZulu-Natal? Results From a Population-Based Survey.

Journal Reference: Journal of acquired immune deficiency syndromes (1999) 2016 Dec 01; 73(4); 411-418. doi: 10.1097/QAI.0000000000001081. Epub 2017 06 05
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Recent activities

Towards a better and more effective treatment of AIDS-associated Kaposi sarcoma in Mozambique

A study conducted in Mozambique by MSF, Hôpitaux Universitaires de Genève, the Mozambique Ministry of Health and Epicentre shows p...

Survey to measure HIV positive status awareness among female sex workers in Nsanje, Malawi

Start of study understanding the experience of female sex workers.

New HIV first-line treatment study launched in Malawi

Epicentre and MSF have started a study to data on the new WHO-recommended first-line treatment in Malawi.

HIV-status awareness study Kenya

Data collection has been completed for a cross-sectional population study in Ndhiwa sub-County, Homa Bay County, Kenya.