Infectious Disease · Medical Literature
Toward Empowering Women in HIV Care: A Peer-Supported Patient-Initiated Viral Load Testing Cluster-Randomized Trial in Dar es Salaam, Tanzania.
Abstract
BackgroundRoutine viral load testing (VLT) is critical for monitoring HIV treatment effectiveness, yet adherence to annual testing and patient engagement remain suboptimal, particularly among women. We evaluated a peer educator-supported, patient-initiated VLT approach in Dar es Salaam, Tanzania.MethodsIn 2024, a two-arm cluster-randomized trial was conducted across six public HIV clinics. Intervention sites implemented a 4-6-month peer-supported program promoting patient-initiated VLT, while control sites continued routine care. Data from adult PLHIV were analyzed using regression models.ResultsAmong 567 participants, 14.8% had not tested within 12 months, with higher non-testing among men (19.7% vs. 12.2%, p=0.019). Intervention sites showed higher mean numbers tested for men (65 vs. 26) and women (146.4 vs. 57). Although patient-initiated testing was infrequent overall (2.8%), the intervention arm demonstrated higher odds of patient-initiated viral load testing than the control arm (aOR=4.69; 95% CI: 1.30-16.95).ConclusionPeer-supported strategies improved patient-initiated VLT and female engagement but require stronger health system support.
Clinical relevance
Routine viral load testing (VLT) is the cornerstone of HIV treatment monitoring, yet adherence to annual testing remains suboptimal in sub-Saharan Africa, particularly among women on antiretroviral therapy. This cluster-randomized trial addresses a critical implementation gap in Tanzania — a high-burden setting — by evaluating whether peer educator-supported, patient-initiated VLT can meaningfully improve testing uptake and patient engagement. Clinicians and HIV program implementers should take note given the persistent global challenge of achieving UNAIDS 95-95-95 targets, especially the third pillar of viral suppression monitoring.
Key findings
1. Among 567 adult PLHIV across six public HIV clinics in Dar es Salaam, 14.8% had not undergone VLT within the prior 12 months, indicating a significant gap in routine monitoring adherence. 2. Non-testing rates were significantly higher among men than women (19.7% vs. 12.2%, p=0.019), identifying male patients as a higher-risk subgroup for VLT non-adherence. 3. Intervention sites demonstrated substantially higher mean numbers of patients tested for both men (65 vs. 26) and women (146.4 vs. 57) compared to control sites, suggesting a meaningful absolute increase in testing volume. 4. Patient-initiated VLT was infrequent overall, occurring in only 2.8% of the study population, underscoring the nascent state of patient-driven testing behaviors in this context. 5. Despite the low baseline rate, the intervention arm showed significantly higher odds of patient-initiated VLT compared to the control arm (aOR = 4.69; 95% CI: 1.30–16.95), representing a clinically and statistically meaningful effect. 6. The peer-supported program — delivered over 4–6 months — improved both patient-initiated testing and female engagement, though the authors noted that sustained impact requires stronger health system infrastructure.
Practice implications
HIV programs in resource-limited settings should consider integrating trained peer educators into VLT workflows, particularly to activate patient-initiated testing among women, given the nearly 5-fold increase in odds of patient-initiated VLT observed with this low-cost, community-based intervention (aOR 4.69). Clinicians should prioritize targeted outreach and differentiated service delivery for male PLHIV, who demonstrated significantly higher rates of VLT non-adherence (19.7%) and may require distinct engagement strategies beyond peer-support models. Implementation of such programs must be paired with reinforced health system capacity — including reliable reagent supply chains, point-of-care testing availability, and clinical follow-up protocols — to translate improved testing initiation into actionable treatment decisions and sustained viral suppression.