Lack of effectiveness of adherence counselling in reversing virological failure among patients on long‐term antiretroviral therapy in rural Uganda

Abstract

ObjectivesThe current World Health Organization and Uganda Ministry of Health HIV treatment guidelines recommend that asymptomatic patients who have a viral load (VL) ≥ 1000 HIV‐1 RNA copies/mL should receive adherence counselling and repeat VL testing before switching to second‐line therapy. We evaluated the effectiveness of this strategy in a large HIV treatment programme of The AIDS Support Organisation Jinja in Jinja, Uganda.MethodsWe measured the HIV VL at enrolment, and for participants with VL ≥ 1000 copies/mL we informed them of their result, offered enhanced adherence counselling and repeated the VL measurement after 3 months. All blood samples with VL ≥ 1000 copies/mL were sequenced in the polymerase (pol) region, a 1257‐bp fragment spanning the protease and reverse transcriptase genes.ResultsOne thousand and ninety‐one participants were enrolled in the study; 74.7% were female and the median age was 44 years [interquartile range (IQR) 39–50 years]. The median time on antiretroviral therapy (ART) at enrolment was 6.75 years (IQR 5.3–7.6 years) and the median CD4 cell count was 494 cells/μL (IQR 351–691 cells/μL). A total of 113 participants (10.4%) had VLs ≥ 1000 copies/mL and were informed of the VL result and its implications and given adherence counselling. Of these 113 participants, 102 completed 3 months of follow‐up and 93 (91%) still had VLs ≥ 1000 copies/mL. We successfully genotyped HIV for 105 patients (93%) and found that 103 (98%) had at least one mutation: eight (7.6%) had only one mutation, 94 (89.5%) had two mutations and one sample (1%) had three mutations.ConclusionsIn this study, enhanced adherence counselling was not effective in reversing virologically defined treatment failure for patients on long‐term ART who had not previously had a VL test.

Durability of non-nucleotide reverse transcriptase inhibitor-based first-line ART regimens after 7 years of treatment in rural Uganda

“…Most of those with failure had only 1 drug resistance mutation (largely NNRTI mutations) and 10 of the 12 participants with virologic had no TAMs, the mutations which are of most concern in terms of their effects on second-line therapy. These are in stark contrast to the patients who we found to have virologic failure during enrollment, [ 12 ] where we found that 83% had 2 or more mutations and 45% had ≥2 TAMs.…”

“…We also enrolled participants with VL measurements of ≥1000 copies/mL but report on these elsewhere. [ 12 , 13 ] Study participants received an honorarium of 20,000 Ugandan shillings (approximately $5 US) to offset travel costs and a meal at each study visit. This study was approved by the Research Ethics Board of the University of British Columbia, the Uganda Virus Research Institute and the Uganda National Council for Science and Technology.…”

A Cascade of Interventions to Promote Adherence to Antiretroviral Therapy in African Countries

“…Patients' treatment buddies were also contacted when possible, although what transpired when they were contacted was not described. This approach was not found to be effective in this study, as 91% of participants remained unsuppressed with a VL > 1000 copies/mL after 3 months [61].…”

Linkage to intensive adherence counselling among HIV-positive persons on ART with detectable viral load in Gomba district, rural Uganda

“…IAC is also known as enhanced adherence counselling (EAC) elsewhere in sub-Saharan Africa where it is standard of care for patients failing first- or second-line ART. A study in Uganda found that IAC was ineffective, with 91% of persons on first-line ART remaining virologically unsuppressed (VL > 1000 copies/ml) after 3 months [ 24 ]. In contrast, a study in South Africa found that enhanced adherence counselling was effective for patients unsuppressed on second-line ART [ 25 ].…”