NEAR POINT OF CARE HIV VIRAL LOAD: TARGETED TESTING AT LARGE FACILITIES.

INTRODUCTION Point-of-care (POC) technologies in resource-limited settings can circumvent challenges of centralized laboratory testing, improving clinical management. However, higher device costs and uncertain indications for use, have inhibited scaling-up POC modalities. To address this gap, we investigated the feasibility and cost of targeted near-POC viral load (VL) testing in two large HIV clinics in Lilongwe, Malawi. METHODS VL testing using GeneXpert was targeted for patients suspected of treatment failure or returning to care following a previously elevated VL (>1,000 copies/ml). Descriptive analysis of retrospective clinical and cost data are presented. RESULTS 2813 near-POC VL tests were conducted. 1511 (54%) tests were for patients for whom results and reason for test were documented: 57% (794/1389) of tests were to confirm a previously high VL, and 33% (462/1389) were due to clinical indications. 61% (926/1511) of patients had a high VL, of whom 78% (719/926) had a recorded clinical action: 77% (557/719) switched to second line ART and 15% (194/719) were referred for intensive adherence counseling. 82% (567/687) of patients received a clinical action on the same day as testing. The 'all-in' cost was $33[BULLET OPERATOR]71 for a valid POC VL test, compared to an international benchmark for a centralized VL test of $28[BULLET OPERATOR]62. CONCLUSION Targeted, near-POC VL testing was feasible and consistently enabled prompt clinical action. The difference between the 'all in' cost of near-POC VL and centralized testing of $5[BULLET OPERATOR]09 could be further reduced in an optimized national program by combining targeted near-POC testing and centralized testing.