HIV viral resuppression following an elevated viral load: a systematic review and meta‐analysis

Abstract

Introduction Guidelines for antiretroviral therapy recommend enhanced adherence counselling be provided to individuals with an initial elevated viral load before making a decision whether to switch antiretroviral regimen. We undertook this systematic review to estimate the proportion of patients with an initial elevated viral load who resuppress following enhanced adherence counselling. Methods Two databases and two conference abstract sites were searched from January 2012 to October 2019 for studies reporting the number of patients with an elevated viral load whose viral load was undetectable when subsequently assessed. Data were pooled using random effects meta‐analysis. Results Fifty‐eight studies reported outcomes of 45,720 viraemic patients, mostly from Africa (48 studies), and among patients on first‐line antiretroviral therapy (43 studies). Almost half (46.1%, 95% CI 42.6% to 49.5%) of patients with an initial elevated viral load resuppressed following an enhanced adherence intervention. Of those on first‐line ART with confirmed virological failure (6280 patients, 21 studies), only 53.4% (40.1% to 66.8%) were appropriately switched to a different regimen. Resuppression was higher among studies that provided details of adherence support. The proportion resuppressing was lower among children (31.2%, 21.1% to 41.3%) and adolescents (40.4%, 15.7% to 65.2%) compared to adults (50.4%, 42.6% to 58.3%). No important differences were observed by date of study publication, gender, viral failure threshold, publication status, time between viral loads or treatment regimen. Information on resistance testing among people with an elevated viral load was inconsistently reported. Conclusions The findings of this review suggest that in settings with limited resources, current guideline recommendations to provide enhanced adherence counselling can result in resuppression of a substantial number of these patients, avoiding unnecessary drug regimen changes. Appropriate action on viral load results is limited across a range of settings, highlighting the importance of viral load cascade analyses to identify gaps and focus quality improvement to ensure that action is taken on the results of viral load testing.

Evaluating HIV Viral Rebound Among Persons on Suppressive Antiretroviral Treatment in the Era of “Undetectable Equals Untransmittable (U = U)”

“…Overall, our rate of viral rebound was lower than that of the UK CHIC Study (7.8 per 100 person-years; 95% CI, 7.6–8.0), though there were important differences in study design, including a much earlier and longer period of eligibility (1998–2013), and definitions of viral rebound [ 11 ]. With adequate viral monitoring and adherence counseling, many patients experiencing rebound can expect to return to suppression without regimen switch [ 27 , 28 ]. The majority of persons in our study who experienced viral rebound subsequently achieved suppression, providing additional reassurance in the context of U = U.…”

Predictors of Virological Failure after Adherence-Enhancement Counseling among First-Line Adults Living with HIV/AIDS in Kombolcha Town, Northeast Ethiopia

“…The current systematic review and meta-analysis shows that viral resuppression is >53% in patients with initial high viral loads. 10 Globally, virological failure after adherence-enhancement counseling is a public health problem, as >50% of antiretroviral users fail to achieve it. 11 Even local reports of virological failure after adherence-enhancement counseling show higher failure rates than global reports, though there has been limited reports on a national level.…”

Protocol for a randomised feasibility study of Point-Of-care HIV viral load testing to Enhance Re-suppression in South Africa: the POwER study

“… 5 Similar delays have been reported in a large analysis of South African laboratory data; among 260 323 patients with viraemia, the median time to a repeat viral load was 6.2 months, (IQR 4.0–11.1) 25 . Third, among people with confirmed viral failure, a systematic review, 26 and more recent individual studies, 4 27–29 have found that only 30%–60% are switched to second-line ART. Even among patients who are switched, this can take a further 3–12 months, 27–29 with delays of even a few months being associated with increased risk of opportunistic infections and mortality, particularly among people with low CD4 counts.…”