Availability and Use of HIV Monitoring and Early Infant Diagnosis Technologies in WHO Member States in 2011-2013: Analysis of Annual Surveys at the Facility Level

Abstract

Background: The Joint United Nations Programme on HIV and AIDS (UNAIDS) 90-90-90 targets have reinforced the importance of functioning laboratory services to ensure prompt diagnosis and to assess treatment efficacy. We surveyed the availability and utilization of technologies for HIV treatment monitoring and early infant diagnosis (EID) in World Health Organization (WHO) Member States.

Methods and findings: The survey questionnaire included 14 structured questions focusing on HIV testing, cluster of differentiation 4 (CD4) testing, HIV viral load (VL) testing, and EID and was administered annually from 2012 to 2014 through WHO country offices, with each survey covering the previous 12-mo period. Across 127 targeted countries, survey response rates were 60% in 2012, 67% in 2013, and 78% in 2014. There were encouraging trends towards increased procurement of CD4 and VL/EID instruments in reporting countries. Globally, the capacity of available CD4 instruments was sufficient to meet the demand of all people living with HIV/AIDS (PLWHA), irrespective of treatment status (4.62 theoretical tests per PLWHA in 2013 [median 7.33; interquartile range (IQR) 3.44-17.75; median absolute deviation (MAD) 4.35]). The capacity of VL instruments was inadequate to cover all PLWHA in many reporting countries (0.44 tests per PLWHA in 2013 [median 0.90; IQR 0.30-2.40; MAD 0.74]). Of concern, only 13.7% of existing CD4 capacity (median 4.3%; IQR 1.1%-12.1%; MAD 3.8%) and only 36.5% of existing VL capacity (median 9.4%; IQR 2.3%-28.9%; MAD 8.2%) was being utilized across reporting countries in 2013. By the end of 2013, 7.4% of all CD4 instruments (5.8% CD4 conventional instruments and 11.0% of CD4 point of care [POC]) and 10% of VL/EID instruments were reportedly not in use because of lack of reagents, the equipment not being installed or deployed, maintenance, and staff training requirements. Major limitations of this survey included under-reporting and/or incomplete reporting in some national programmes and noncoverage of the private sector.

Conclusion: This is the first attempt to comprehensively gather information on HIV testing technology coverage in WHO Member States. The survey results suggest that major operational changes will need to be implemented, particularly in low- and middle-income countries, if the 90-90-90 targets are to be met.

Fig 1. Increase in the number of CD4 instruments reported by 40 countries providing data for 3 consecutive y.

Data labels indicate the number of reported instruments. POC, point of care.

Fig 2. Increase in the theoretical CD4 capacity per people living with HIV/AIDS (PLWHA) across 39 countries providing data for 3 consecutive y.

The upper panel shows the number of PLWHA and the theoretical CD4 capacity. The lower panel shows the CD4 capacity per PLWHA. The number of theoretical CD4 tests per PLWHA was calculated for 39 countries, because the number of PLWHA was not available for 1 country.

Fig 3. CD4 capacity per people living with HIV/AIDS (PLWHA), for all reporting countries.

The upper panel shows the number of PLWHA and the theoretical CD4 capacity for the 66, 71, and 68 countries with data available for number of instruments and number of PLWHA in 2011, 2012, and 2013, respectively. The lower panel shows the CD4 capacity per PLWHA.

Fig 4. Utilization of CD4 capacity, for all reporting countries.

The upper panel displays the number of CD4 tests performed and the theoretical CD4 capacity for countries reporting data on the number of tests performed and the number of CD4 instruments (51, 45, and 50 countries reporting for 2011, 2012, and 2013). The lower panel displays the percentage of CD4 capacity utilized during the reporting period.

Fig 5. Nonutilization of CD4 instrumentation in reporting countries by survey year and CD4 platform (conventional CD4 versus point of care (POC) CD4).

Data labels indicate percentage from the number of all reported CD4 instruments, from CD4 POC, or from CD4 conventional instruments in a particular year.

Fig 6. Reasons provided for nonutilization of CD4 instrumentation, for all reporting countries, disaggregated by platform.

Data labels indicate the percentage from total number of reported CD4 point of care (POC) or conventional instruments in a particular year.

Fig 7. Percentage of CD4 instruments with maintenance contracts (upper panel) and/or serviced (lower panel) in the survey year, disaggregated by CD4 platform, for all reporting countries.

Fig 8. Theoretical viral load (VL) capacity per patient on ART and per PLWHA.

Data labels indicate numbers of theoretical tests per year per patient on ART or per PLWHA.

Fig 9. Utilization of viral load (VL)/early infant diagnosis (EID) capacity for all responding countries.

The upper panel shows the number of VL/EID tests performed and the theoretical VL/EID capacity. The lower panel shows the percentage of VL/EID capacity utilized during the reporting period.

Fig 10. The number of early infant diagnosis (EID) tests performed per infant born to an HIV-positive mother per year for all reporting countries.

The upper panel displays the numbers of EID tests performed and the number of infants born to HIV-positive mothers. The lower panel displays the number of EID tests performed per infant born to an HIV-positive mother.

Fig 11. The main reasons for nonutilization of viral load (VL)/early infant diagnosis (EID) instrumentation for all reporting countries.

Data labels indicate the percentage from total number of reported instruments in a particular year.