Predictors of virological failure among people living with HIV receiving first line antiretroviral treatment in Myanmar: retrospective cohort analysis

Abstract

Background Progress toward the global target for 95% virological suppression among those on antiretroviral treatment (ART) is still suboptimal. We describe the viral load (VL) cascade, the incidence of virological failure and associated risk factors among people living with HIV receiving first-line ART in an HIV cohort in Myanmar treated by the Médecins Sans Frontières in collaboration with the Ministry of Health and Sports Myanmar. Methods We conducted a retrospective cohort study, including adult patients with at least one HIV viral load test result and having received of at least 6 months’ standard first-line ART. The incidence rate of virological failure (HIV viral load ≥ 1000 copies/mL) was calculated. Multivariable Cox’s regression was performed to identify risk factors for virological failure. Results We included 25,260 patients with a median age of 33.1 years (interquartile range, IQR 28.0–39.1) and a median observation time of 5.4 years (IQR 3.7–7.9). Virological failure was documented in 3,579 (14.2%) participants, resulting in an overall incidence rate for failure of 2.5 per 100 person-years of follow-up. Among those who had a follow-up viral load result, 1,258 (57.1%) had confirmed virological failure, of which 836 (66.5%) were switched to second-line treatment. An increased hazard for failure was associated with age ≤ 19 years (adjusted hazard ratio, aHR 1.51; 95% confidence intervals, CI 1.20–1.89; p < 0.001), baseline tuberculosis (aHR 1.39; 95% CI 1.14–1.49; p < 0.001), a history of low-level viremia (aHR 1.60; 95% CI 1.42–1.81; p < 0.001), or a history of loss-to-follow-up (aHR 1.24; 95% CI 1.41–1.52; p = 0.041) and being on the same regimen (aHR 1.37; 95% CI 1.07–1.76; p < 0.001). Cumulative appointment delay was not significantly associated with failure after controlling for covariates. Conclusions VL monitoring is an important tool to improve programme outcomes, however limited coverage of VL testing and acting on test results hampers its full potential. In our cohort children and adolescents, PLHIV with history of loss-to-follow-up or those with low-viremia are at the highest risk of virological failure and might require more frequent virological monitoring than is currently recommended.

Near point-of-care HIV viral load testing: Uptake and utilization in suburban Yangon, Myanmar

“…Despite the long waiting time for a first VL, 95% of patients who had a first VL done had a VL below1000 copies/ml. This is also high compared to other reports in resource-limited settings in Africa and Asia, including Myanmar, in which suppression rates were found between 72 and 91% [4,9,[25][26][27][28][29]. As treatment adherence was probably good in our cohort, the long delay in VL testing did not have a large negative impact on viral load results.…”

“…If the second VL is also above 1000 copies/mL despite EAC, virological failure is confirmed and prompt switch to a second-line regimen is indicated [3]. Though VL is regularly measured in developed countries, access to VL tests is still very limited in many low resource settings and this leads to delayed switching to second-line ART [4][5][6][7][8]. The mostly centralized VL testing demands sophisticated and expensive facilities, equipment, and skilled technicians, making it difficult and impractical to scale up.…”

Higher Risk of Mortality and Virologic Failure in HIV-Infected Patients With High Viral Load at Antiretroviral Therapy Initiation: An Observational Cohort Study in Chongqing, China

“…A study in Henan region of China showed that long-term second-line ART was effective (31). Another study in Myanmar showed that 66.5% patients with virologic failure were switched to a second-line ART regimen within 6 months after confirmed virologic failure (32). We found that secondline ART was useful for reducing the overall cohort mortality rate, and that among patients on second-line ART regimens, the mortality rates did not differ significantly according to the baseline VL.…”

Virologic failure in people living with HIV in 1st line ART: A 10-year Mexican population-based study

“…This is because VF is the result of multiple and complex factors that go beyond treatment efficacy such as poor adherence, inadequate care or access to healthcare, and other sociodemographic factors and contextual variables. 16 – 18 …”

“…This is because VF is the result of multiple and complex factors that go beyond treatment efficacy such as poor adherence, inadequate care or access to healthcare, and other sociodemographic factors and contextual variables. [16][17][18] While an early study conducted in a third-level hospital in Mexico City in 2010 found that the probability of VF was 20% at 48 months after ART initiation and was higher among youth (individuals younger than 30 years old), 14 this study was published before the 2014 changes in clinical guidelines. In addition, the determinants of VF have not been explored in Mexico and the 2014 policy changes have not been evaluated.…”