Scaling Up Access to Quality Assured Viral Load Testing to Increase the Fraction of PLHIV who Sustain Effective Highly Suppressive Treatment

The Challenge

Identifying people who have HIV is only one part of preventing HIV transmission. Maintaining suppressed viral loads in people living with HIV (PLHIV) is also essential, and a key part of this is getting accurate viral load (VL) test results and responding accordingly.

Objectives and Overview

The project, also called “Quality Improvement Collaborative to Improve Access to and Use of Quality Assured Viral Load Test Results at District and Site Level in Malawi” or “Collaborative to Improve Access to and Use of Quality Assured Viral Load Test Results in Malawi” worked in four districts in Malawi – Mchinji, Karonga, Dedza, and Balaka – to define, share, and ensure that HIV viral load testing is improving care of PLHIV.

The Quality Improvement Collaborative provided technical support to public health facilities to improve patient-centered care through scaling up access to quality viral load testing for PLHIV and increasing the link between laboratory data and clinical care.


The collaborative established quality improvement teams (QITs) at the facility and district levels to champion and implement quality improvement projects (QIPs). The project provided regular mentorship/coaching and technical assistance to the QITs in the targeted districts and facilitates sharing of best practices and achievements between participating QI teams to spread and sustain successful improvement practices.

The collaborative tracked key indicators related to viral load testing – including rejection rates and turnaround times – as well as the improved use of laboratory data for HIV patient care and management.

Twenty QITs are functional in all project-supported districts, with 45 QIPs implemented as of July 2018. The collaborative has implemented key change ideas and process improvements, including:

  • Intensified mentorship and supportive supervision of various antiretroviral (ART) clinic personnel;
  • Regular audits of patient cards and registers and use of high VL registers;
  • Assigning specific responsibilities to staff for patient notification and management;
  • Use of color-coded cards to identify and track intensive adherence counseling clients to completion;
  • Engaging ART expert patients for advocacy, education and promotion of VL testing;
  • Reinforcement of monthly ART supply for all clients unless identified as eligible for multi-month prescription; and
  • Frequent QI meetings to review progress and adjust as required.

Following development and implementation of novel data management solutions and systems, data quality for VL and early infant diagnosis programming has greatly improved and facilities have noted increased VL testing and utilization of VL results. For example:

  • VL results documentation increased from 20 percent in November 2017 to 100 percent in March 2018 at Chilumba Health Center in Karonga District, thanks in part to the provision of targeted mentorship and supportive supervision coupled with assigning specific staff the task of updating master cards and registers daily; and
  • VL sample collection increased from 60 percent in July 2017 to 99 percent in February 2018 at Mchinji District Hospital after staff began reviewing ART master cards to identify patients due for VL testing and increasing the frequency and content of health talks that emphasize the importance of VL testing.

The Change Package document outlines the successful interventions tested to date through the Quality Improvement Collaborative project aimed at improving access to and use of quality assured laboratory data for the management of patients living with HIV/AIDS in Malawi.

It provides an overview of the continuous quality improvement approach used and key indicators tracked to measure performance across the viral load (VL) and early infant diagnosis (EID) testing cascades. It also describes successful change ideas, or quality improvement interventions, identified and tested during the project that could be scaled up and spread to improve access to and use of quality assured viral load and EID testing for patient management within and outside of Malawi.




HIV/AIDS and Quality Health Systems

Bill & Melinda Gates Foundation