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Community Viral Load: A New Way to Measure our Progress

Ronald Valdiserri

Dr. Ronald Valdiserri

We know that when persons are infected with HIV and have not been diagnosed, the virus replicates silently in their bodies for several years. During this time, their immune systems are being damaged and they are very likely to spread the virus to others since they are unaware of their infection. That is why the National HIV AIDS Strategy has identified a specific target for increasing the number of persons who have their HIV infection diagnosed in a timely manner: “By 2015, increase from 79% to 90% the percentage of people living with HIV who know their serostatus (from 948,000 to 1,080,000).”

If you are diagnosed with HIV, your health care provider will evaluate the state of your infection by ordering a number of laboratory tests, including a viral load (VL) test. Viral load is the clinical laboratory test that gauges the level of viral replication by measuring the actual amount of viral genetic material present in a person’s bloodstream. When the viral load is high, it indicates that the virus is actively reproducing—not a good thing. Generally speaking, the higher the viral load, the greater the potential damage to the immune system—and the greater the likelihood of transmitting the virus through unsafe sex or needle-sharing activities. But persons who are on effective antiretroviral (ARV) treatment will have very low viral loads—often so low that they are “undetectable” at the current level of testing sensitivity. Because having an undetectable viral load is one important measure of quality HIV care, it, too, has been identified in the NHAS as a target. Under the goal of “Reducing HIV-Related Disparities,” we are asked to increase, by 20%, the proportion of HIV-diagnosed gay and bisexual men, Blacks, and Latinos who have undetectable viral loads.


Without a doubt, viral load is a very important tool in the clinical management of HIV disease. But now, there is a newly emerging way to use viral load as a population measure: community viral load (CVL). Here’s how it works. We can group individual viral load measurements from various groups who have been diagnosed and are receiving HIV care, for example, African American women, Latino men who have sex with men, transgender women, or White injection drug users. Then we can compare the average viral load for each of these groups to identify disparities across the groups. Since the goal is for all persons who are under HIV care to have an undetectable viral load, if a neighborhood or a community or a particular group has a higher CVL, it indicates a need to intervene. An elevated CVL can mean that persons are being diagnosed very late in the course of their infection, or that they are not receiving timely referral into medical care or even that they might require additional adherence counseling in order to maintain consistent ARV use.

Given its emerging importance as an aggregate measure of HIV programmatic efforts, we are seeing more and more references to CVL. At this week's CROI meeting in Boston, researchers from New York, San Francisco, Baltimore, and Washington, DC all shared information about how they are using CVL to monitor access to diagnosis, care and treatment for HIV infection. In San Francisco, reductions in community viral load have even been associated with decreases in newly diagnosed and reported HIV infections. Public health leaders at the CDC and elsewhere are working to improve the capacity of state and local health departments to be able to monitor this increasingly useful population measure.

Comments

  1. “An elevated CVL can mean that persons are being diagnosed very late in the course of their infection, or that they are not receiving timely referral into medical care or even that they might require additional adherence counseling in order to maintain consistent ARV use.”
    Or that they’re on an ADAP waiting list!
    (over 6,000 people)

  2. Is community viral load a new way to gate keep monies and redirect them to target areas of high density HIV clients demographically – case load mixing of community groups

  3. “An elevated CVL can mean that persons are being diagnosed very late in the course of their infection, or that they are not receiving timely referral into medical care or even that they might require additional adherence counseling in order to maintain consistent ARV use.”
    Or that they’re on an ADAP waiting list!
    (over 6,000 people)
    Best and most truthful comment EVER! Let’s see…most states can’t even handle getting meds to HIV positive people now and despite ‘National AIDS Strategy’ rhetoric, HIV care and prevention funding continues to drop well below the documented need. SO HOW are we supposed to be able to monitor our CVLs if we can’t even treat the individual cases?
    We’re tired of talk from the administration and PACHA, we’d like to have our meds so we can stop dying. Too much to ask?

  4. Are there ways in which local ASOs and other organizations can support or help streamline public health departments in more closely monitoring community viral load? Or is it just a waiting game until PDHs get up to speed from the CDC?

  5. Jim Dickinson says:

    A problem that I see with this approach: it works best in places where the majority of those identified with HIV are in treatment. How does a large lost-to-care population influence this approach? How we would obtain the needed data from those in private care, if the private doc is not routinely ordering viral load testing.
    And while the write-up suggests several reasons for a possible disparity among ethnic, racial and sexual orientation strata, it avoids one of the most obvious: the treatment simply isn’t working, despite access, quality care, etc. How do we account for this variable and what can we do about it?
    Also, if a particular population is entering the system already AIDS defined and with extremely damaged immune function (i.e. ‘natural’ low viral load due to a lack of T-cells for HIV to replicate in) wouldn’t we need to have a mechanism for handling that data differently? Otherwise, it could give a false impression that the population is accessing care and in successful treatment when the reality is that they simply did not test until very late stage disease.
    While I get the concept, it may simply be another researchers’ novelty of the week and I would have to know, of course, that it actually provides something different and useful beyond what we already do before considering investment.

  6. I have some questions about this approach.
    1) Viral load distributions are usually very skewed, aren’t they? If so, the mean isn’t an appropriate statistic. Are the vl’s first log-transformed?
    2) Is there a similar index of community CD4?
    3) What defines a “community”? Would all the PLWHA served by my organization constitute a community?
    Any insights into these issues?
    thanks – warren.

  7. I love this concept of CVL. I do not live in the US. But people must understand the fact that theories are meant to explain things, make sense of the reality. They might not be perfect but they are explanatory. Let’s assume you move in a population P1 where there is no one with HIV, thus having a CVL of 0 and happen to be in intimate unprotected sexual contact with an individual there, chances of getting the virus is 0. Let’s take a second population P2 in which every one is infected and no one on treatment, the same contact will bear significantly higher risks of infection. Most of our populations are in between. By treating everyone who needs to be treated, risks of infections to partners become negligible. Of course this works on a population level, not forcibly on an individual level as each one is responsible not to transmit the virus and not to be infected.

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