Recently there has been an increase in access to antiretroviral drugs (ARV) in resource poor settings. This has come about due to various factors including access pricing of drugs, generic formulations and ARV roll-out programmes both in the public and private sectors. Important role players in driving these programmes have been non-governmental organisations and faith-based organisations.

Monitoring for virological, immunological and toxic effects of ARV drugs is crucial to the successful delivery of these programmes. An increased number of technologies have been advocated for use in resource poor settings. These technologies relate mainly to CD4 lymphocyte tests, a test which remains a crucial factor in patient evaluation and consequent management decisions.  However, once treatment with ARVs has commenced, viral load testing becomes pivotal in monitoring responses in individual patients and also is vital in the evaluation of the performance of individual programmes. Although technologies remain relatively expensive, it is felt that appropriate, rationalized viral load testing will proof cost-beneficial in the longer term particularly in settings where restricted options exist for ARVs at access pricing. Monitoring for toxic effects of ARVs is equally important because of additional insults to the liver from coinfections, nutritional factors and traditional medicines.

It is felt that a shift in focus should be undertaken to provide ARV management packages, which utilize “best of breed” FDA-approved technologies rather than second best or inferior technologies. These FDA-approved technologies can be operational at all levels of care from the peripheral rural settings, through to regional centres and central reference laboratories. The importance of developing appropriate peripheral laboratory capacity is seen as important in terms of developing peripheral capacity away from central reference laboratories.  The experience has been that important community ownership is derived when these laboratories are operational in resource poor settings. These laboratories can serve an additional function of not only strengthening HIV management care but also would serve to strengthen general medical care in these resource poor settings.

It is important to choose technologies that are robust, reliable and able to scale up as specimen volumes increase. There should be a quality control programme managed from a central reference laboratory, which is based on technologies that do not rely on traditional communication systems. Cellular phone technology, with built-in communication redundancies, is suitable for this. A working model of such a laboratory configuration supporting an ARV roll out programme in a resource poor setting will be presented.