Determinants of Survival of HIV Patients Receiving Dolutegravir: A Prospective Cohort Study in Conflict-Affected Bunia, Democratic Republic of Congo

Abstract

This study aims to determine the factors influencing HIV-related mortality in settings experiencing continuous armed conflict atrocities. In such settings, people living with HIV (PLHIV), and the partners of those affected may encounter specific difficulties regarding adherence to antiretroviral therapy (ART), and retention in HIV prevention, treatment, and care programs. Between July 2019 and July 2021, we conducted an observational prospective cohort study of 468 PLHIV patients treated with Dolutegravir at all the ART facilities in Bunia. The probability of death being the primary outcome, as a function of time of inclusion in the cohort, was determined using Kaplan–Meier plots. We used the log-rank test to compare survival curves and Cox proportional hazard modeling to determine mortality predictors from the baseline to 31 July 2021 (endpoint). The total number of person-months (p-m) was 3435, with a death rate of 6.70 per 1000 p-m. Compared with the 35-year-old reference group, older patients had a higher mortality risk. ART-naïve participants at the time of enrollment had a higher mortality risk than those already using ART. Patients with a high baseline viral load (≥1000 copies/mL) had a higher mortality risk compared with the reference group (adjusted hazard ratio = 6.04; 95% CI: 1.78–20.43). One-fourth of deaths in the cohort were direct victims of armed conflict, with an estimated excess death of 35.6%. Improving baseline viral load monitoring, starting ART early in individuals with high baseline viral loads, the proper tailoring of ART regimens and optimizing long-term ART, and care to manage non-AIDS-related chronic complications are recommended actions to reduce mortality. Not least, fostering women’s inclusion, justice, peace, and security in conflict zones is critical in preventing premature deaths in the general population as well as among PLHIV.

Prior exposure to antiretroviral therapy among adult patients presenting for HIV treatment initiation or reinitiation in sub-Saharan Africa: a systematic review

“…Some apparent reinitiators may in fact reflect unrecorded (‘silent’) transfers from one facility to another, without a medication interruption in between. This phenomenon may help explain the high proportion of ‘initiating’ patients who already have viral suppression in Buju et al 22, for example.…”

“…Similarly, Kunzweiler et al 15 and Dorward et al 21 excluded patients who were lost to follow-up before 6 months after ART initiation, and thus may have underestimated the proportion reinitiating if non-naïve patients are more likely than naïve patients to drop out of care. Study participants were also drawn from diverse populations of individuals with HIV, including those identified in a community campaign (Lebelonyane 2020)12, in a household survey as part of a randomised trial (Sithole 202120), or as routine, walk-in presenters at clinics (Buju 202222, Maskew 202016, and Rosen 201917).…”

“…Sithole et al 20 , which excluded a priori anyone self-reporting prior utilisation, reported that 32% of patients had evidence of prior use based on being virally suppressed. Buju et al 22 and Kunzweiler et al 15 reported that 52% and 30%, respectively, of patients presenting for initiation already had suppressed viral loads, suggesting prior ARV use. Mavhandu-Ramarumo (2019), which also excluded a priori anyone admitting prior utilisation, using the most rigorous methodology with both blood and hair samples, estimated 53% of patients had prior ART exposure.…”

“…We assessed Kunzweiler et al 15 , Genet (2021) et al 23 , Buju(2022) 22 and Pry et al 13 as observational studies. Kunzweiler et al 15 used snowball sampling, as is frequently done among key populations at high risk of stigma.…”

Prior exposure to antiretroviral therapy among adult patients presenting for HIV treatment initiation or re-initiation in sub- Saharan Africa: a systematic review

“…Similarly, Kunzweiler 2018 and Dorward 2020 excluded patients lost to follow up before 6 months after ART initiation, and thus may have underestimated the proportion re-initiating if non-naïve patients are more likely than naïve patients to drop out of care. Study participants were also drawn from diverse populations of individuals with HIV, including those identified in a community campaign(Lebelonyane 2020), in a household survey as part of a randomized trial (Sithole 2021), or as routine, walk-in presenters at clinics(Buju 2022, Maskew 2020, Rosen 2019). partner who was HIV positive (44% compared to 37%; adj OR 1.94 (95% CI 0.95-3.96)).…”