HIV virologic failure and its predictors among HIV-infected adults on antiretroviral therapy in the African Cohort Study

Abstract

IntroductionThe 2016 WHO consolidated guidelines on the use of antiretroviral drugs defines HIV virologic failure for low and middle income countries (LMIC) as plasma HIV-RNA ≥ 1000 copies/mL. We evaluated virologic failure and predictors in four African countries.Materials and methodsWe included HIV-infected participants on a WHO recommended antiretroviral therapy (ART) regimen and enrolled in the African Cohort Study between January 2013 and October 2017. Studied outcomes were virologic failure (plasma HIV-RNA ≥ 1000 copies/mL at the most recent visit), viraemia (plasma HIV-RNA ≥ 50 copies/mL at the most recent visit); and persistent viraemia (plasma HIV-RNA ≥ 50 copies/mL at two consecutive visits). Generalized linear models were used to estimate relative risks with their 95% confidence intervals.Results2054 participants were included in this analysis. Viraemia, persistent viraemia and virologic failure were observed in 396 (19.3%), 160 (7.8%) and 184 (9%) participants respectively. Of the participants with persistent viraemia, only 57.5% (92/160) had confirmed virologic failure. In the multivariate analysis, attending clinical care site other than the Uganda sitebeing on 2nd line ART (aRR 1.8, 95% CI 1·28–2·66); other ART combinations not first line and not second line (aRR 3.8, 95% CI 1.18–11.9), a history of fever in the past week (aRR 3.7, 95% CI 1.69–8.05), low CD4 count (aRR 6.9, 95% CI 4.7–10.2) and missing any day of ART (aRR 1·8, 95% CI 1·27–2.57) increased the risk of virologic failure. Being on 2nd line therapy, the site where one receives care and CD4 count < 500 predicted viraemia, persistent viraemia and virologic failure.ConclusionIn conclusion, these findings demonstrate that HIV-infected patients established on ART for more than six months in the African setting frequently experienced viraemia while continuing to be on ART. The findings also show that being on second line, low CD4 count, missing any day of ART and history of fever in the past week remain important predictors of virologic failure that should trigger intensified adherence counselling especially in the absence of reliable or readily available viral load monitoring. Finally, clinical care sites are different calling for further analyses to elucidate on the unique features of these sites.

Predictors of first-line antiretroviral therapy failure among adults and adolescents living with HIV/AIDS in a large prevention and treatment program in Nigeria

“…Consistent with our findings, data from a large cohort study conducted in East Africa and Nigeria showed that younger age, single marital status and female gender were independently associated with virologic failure and immunologic failure [ 25 ]. In addition, at a tertiary hospital such as UATH, the clinicians who manage patients are largely resident doctors who rotate through various departments, including the HIV treatment clinic, with variable supervision.…”

“…Although some studies have examined predictors of immunologic failure among patients failing first-line regimens, there is a paucity of data from sub-Saharan Africa [ 20 – 25 ]. In a retrospective multi-site study evaluating long-term outcomes of patients receiving ART in a treatment program in Nigeria, authors indicated that older age, ART regimen, lower CD4 count, higher VL and inadequate adherence were predictors of virologic failure, while female sex and lower baseline CD4 were predictive of immunologic failure [ 14 ].…”

HIV virological non-suppression and factors associated with non-suppression among adolescents and adults on antiretroviral therapy in northern Ethiopia: a retrospective study

“…An elevated VL indicates poor adherence or resistance [26–28]. The overall proportion of non-suppression was higher compared to the study conducted in Uganda 11% [20], Systematic review on viral non suppression rate in low or middle-income countries of the pooled estimate had 16% [29], African cohort 9% [30], Nepal 9.92% [31] and Ethiopia 10.4% (self-report) [6] and 19% [1] and 11.5% in Mekelle public hospitals, Tigray, Ethiopia [22]. However, there is a slight agreement with a report from Tigray region, Ethiopia which was 29.8% [6].…”

“…Patients who were poorly adherent to the ART drugs were 2.56 times (AOR = 2.56, 95% CI: 1.97, 3.33) more likely to have viral non suppression as compared with patients with good adherence. Other studies have also reported that poor adherence to treatment is positively associated with virological treatment failure [30, 44, 46]. This is because, as the drug concentration decreases in the blood, HIV RNAs might not be suppressed which in turn leads to increase in viral load.…”

Reassessing the Ethics of Molecular HIV Surveillance in the Era of Cluster Detection and Response: Toward HIV Data Justice

“…Some people living with HIV refuse, delay, or interrupt treatment on a variety of bases, and for periods that vary (Persson et al 2016). Others cannot sustain viral suppression even when taking antiretroviral therapies (Kiweewa et al 2019). In the era of treatment as prevention, these groups are being pushed further to the margins of respectability in HIV discourse (Cormier McSwiggin 2017;Lloyd 2018); they should be included in HIV data justice-oriented conversations.…”