Same-Day Antiretroviral Therapy Initiation as a Predictor of Loss to Follow-up and Viral Suppression Among People With Human Immunodeficiency Virus in Sub-Saharan Africa

Ross, Jonathan; Brazier, Ellen; Fatti, Geoffrey; Jaquet, Antoine; Tanon, Aristophane; Haas, Andreas D; Diero, Lameck; Castelnuovo, Barbara; Yiannoutsos, Constantin T.; Nash, Denis; Anastos, Kathryn; Yotebieng, Marcel

doi:10.1093/cid/ciac759

Cited by 11 publications

(7 citation statements)

References 30 publications

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“…Therefore, we were not able to assess adherence or other clinical or sociodemographic factors contributing to an unsuppressed VL. Third, similar to other cohorts in sub-Sahara Africa [ 20 , 21 ], there was a considerable amount of loss to follow-up that was similar for both the NNRTI and dolutegravir group. Fourth, per national guidelines, VL tests are routinely done once per year only, making the differentiation between viral blips and LLV impossible.…”

Section: Discussionsupporting

confidence: 75%

Clinical Relevance of Human Immunodeficiency Virus Low-level Viremia in the Dolutegravir era: Data From the Viral Load Cohort North-East Lesotho (VICONEL)

Kohler,

Brown,

Tschumi

et al. 2024

Open Forum Infectious Diseases

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Background HIV low-level viremia (LLV) is associated with subsequent treatment failure at least with non-nucleoside reverse transcriptase inhibitor (NNRTI)-containing antiretroviral therapy (ART). Data on implications of LLV occurring under dolutegravir, which has largely replaced NNRTIs in Africa, are, however, scarce. Methods We included adult persons with HIV in Lesotho who had ≥2 viral loads (VLs) taken after ≥6 months of NNRTI- or dolutegravir-based ART. Within VL pairs, we assessed the association of viral suppression (<50 copies/mL), low- and high-range LLV (50-199 and 200-999 copies/mL, respectively) with virological failure (≥1000 copies/mL) using a mixed-effects regression model. Participants could contribute VLs to the NNRTI and the dolutegravir group. Results Among 18,550 participants, 12,216 (65.9%) were female and median age at first VL included was 41.2 years (interquartile range 33.4-51.5). In both groups, compared to a suppressed VL, odds of subsequent virological failure were higher for low-range LLV (NNRTI: adjusted odds ratio (aOR); 95% confidence interval (CI): 1.9; 1.4-2.4 and dolutegravir: 2.1; 1.3-3.6) and high-range LLV (aOR; 95% CI: 4.2; 3.1-5.7 and 4.4; 2.4-7.9). Conclusion In the dolutegravir era, LLV remains associated with virological failure, endorsing the need for close clinical and laboratory monitoring of persons with a VL ≥50 copies/mL.

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Section: Discussionsupporting

confidence: 75%

Clinical Relevance of Human Immunodeficiency Virus Low-level Viremia in the Dolutegravir era: Data From the Viral Load Cohort North-East Lesotho (VICONEL)

Kohler,

Brown,

Tschumi

et al. 2024

Open Forum Infectious Diseases

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“…We found several other publications that reported the rate of same-day initiation in various countries in sub-Saharan Africa, mostly at earlier time periods than our study, which was conducted between 2018 and 2020. A multi-country cohort study using data from the IeDEA Network through 2018, including South Africa but not Malawi or Zambia, reported an overall rate of SDI of 64%[9]. Three studies from South Africa were all completed roughly one year earlier than our study, in 2017-2018.…”

Section: Discussionmentioning

confidence: 84%

Uptake of same-day initiation of HIV treatment in Malawi, South Africa, and Zambia: the SPRINT retrospective cohort study

Huber

Hirasen

Brennan

et al. 2022

Preprint

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Introduction: Since 2017 global guidelines have recommended same-day initiation (SDI) of antiretroviral treatment (ART) for patients considered ready for treatment on the day of HIV diagnosis. Many countries in sub-Saharan Africa have incorporated a SDI option into national guidelines, but uptake of SDI is not well documented. We estimated average time to ART initiation at 12 public healthcare facilities in Malawi, 5 in South Africa, and 12 in Zambia. Methods: We sequentially enrolled patients who were eligible to start ART between January 2018 and June 2019 and reviewed their medical records from the point of HIV treatment eligibility (HIV diagnosis or first HIV-related interaction with the clinic) to the earlier of treatment initiation or 6 months. We estimated the proportion of patients initiating ART at their original healthcare facilities on the same day or within 7, 14, 30, or 180 days of baseline, stratified by country and gender. Results: We enrolled 826 patients in Malawi, 534 in South Africa, and 1,984 in Zambia. 88% of patients in Malawi, 57% in South Africa, and 91% in Zambia were offered and accepted SDI. In Malawi, most patients who did not receive SDI had also not initiated ART ≤6 months. In South Africa, an additional 13% of patients initiated ≤1 week, but 21% still had no record of initiation ≤6 months. Among those who did initiate within 6 months in Zambia, most started ≤1 week. There were no major differences by gender. Both WHO Stage III/IV and tuberculosis symptoms were associated with delays in ART initiation. Discussion: As of 2020, uptake of same-day ART initiation was widespread, if not nearly universal, in Malawi and Zambia but was considerably less common in South Africa. Limitations of the study include pre-COVID-19 data that do not reflect pandemic adaptations and potentially missing data for Zambia. South Africa may be able to increase overall ART coverage by reducing numbers of patients who do not initiate ≤6 months.

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“…Other analyses have shown that patients entering HIV care in the era of universal treatment initiate treatment more rapidly [ 4 , 5 ] and that the expansion of HIV treatment eligibility criteria has resulted in the treatment of patients with earlier stage HIV disease [ 38 ]. While earlier treatment initiation is associated with improved clinical outcomes and reduced onward HIV transmission, rapid initiation of treatment after enrollment in HIV care is also associated with lower retention in care [ 39 , 40 ], and qualitative research has suggested that distress and uncertainty about HIV diagnosis, concerns about stigma, fear of lifelong medication, and other patient-level factors may contribute to attrition and lower treatment adherence among those rapidly initiating treatment, particularly among patients with early stage disease who do not feel unwell [ 41 , 42 ]. Our observed decreases in retention after ART initiation in the era of universal treatment may reflect the fact that some patients, who would have been LTC prior to ART initiation before guideline adoption, initiated ART more rapidly.…”

Section: Discussionmentioning

confidence: 99%

Long-term HIV care outcomes under universal HIV treatment guidelines: A retrospective cohort study in 25 countries

Brazier,

Tymejczyk,

Wools-Kaloustian

et al. 2024

PLoS Med

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Background While national adoption of universal HIV treatment guidelines has led to improved, timely uptake of antiretroviral therapy (ART), longer-term care outcomes are understudied. There is little data from real-world service delivery settings on patient attrition, viral load (VL) monitoring, and viral suppression (VS) at 24 and 36 months after HIV treatment initiation. Methods and findings For this retrospective cohort analysis, we used observational data from 25 countries in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium’s Asia-Pacific, Central Africa, East Africa, Central/South America, and North America regions for patients who were ART naïve and aged ≥15 years at care enrollment between 24 months before and 12 months after national adoption of universal treatment guidelines, occurring 2012 to 2018. We estimated crude cumulative incidence of loss-to-clinic (CI-LTC) at 12, 24, and 36 months after enrollment among patients enrolling in care before and after guideline adoption using competing risks regression. Guideline change–associated hazard ratios of LTC at each time point after enrollment were estimated via cause-specific Cox proportional hazards regression models. Modified Poisson regression was used to estimate relative risks of retention, VL monitoring, and VS at 12, 24, and 36 months after ART initiation. There were 66,963 patients enrolling in HIV care at 109 clinics with ≥12 months of follow-up time after enrollment (46,484 [69.4%] enrolling before guideline adoption and 20,479 [30.6%] enrolling afterwards). More than half (54.9%) were females, and median age was 34 years (interquartile range [IQR]: 27 to 43). Mean follow-up time was 51 months (standard deviation: 17 months; range: 12, 110 months). Among patients enrolling before guideline adoption, crude CI-LTC was 23.8% (95% confidence interval [95% CI] 23.4, 24.2) at 12 months, 31.0% (95% CI [30.6, 31.5]) at 24 months, and 37.2% (95% [CI 36.8, 37.7]) at 36 months after enrollment. Adjusting for sex, age group, enrollment CD4, clinic location and type, and country income level, enrolling in care and initiating ART after guideline adoption was associated with increased hazard of LTC at 12 months (adjusted hazard ratio [aHR] 1.25 [95% CI 1.08, 1.44]; p = 0.003); 24 months (aHR 1.38 [95% CI 1.19, 1.59]; p < .001); and 36 months (aHR 1.34 [95% CI 1.18, 1.53], p < .001) compared with enrollment before guideline adoption, with no before–after differences among patients with no record of ART initiation by end of follow-up. Among patients retained after ART initiation, VL monitoring was low, with marginal improvements associated with guideline adoption only at 12 months after ART initiation. Among those with VL monitoring, VS was high at each time point among patients enrolling before guideline adoption (86.0% to 88.8%) and afterwards (86.2% to 90.3%), with no substantive difference associated with guideline adoption. Study limitations include lags in and potential underascertainment of care outcomes in real-world service delivery data and potential lack of generalizability beyond IeDEA sites and regions included in this analysis. Conclusions In this study, adoption of universal HIV treatment guidelines was associated with lower retention after ART initiation out to 36 months of follow-up, with little change in VL monitoring or VS among retained patients. Monitoring long-term HIV care outcomes remains critical to identify and address causes of attrition and gaps in HIV care quality.

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Same-Day Antiretroviral Therapy Initiation as a Predictor of Loss to Follow-up and Viral Suppression Among People With Human Immunodeficiency Virus in Sub-Saharan Africa

Cited by 11 publications

References 30 publications

Clinical Relevance of Human Immunodeficiency Virus Low-level Viremia in the Dolutegravir era: Data From the Viral Load Cohort North-East Lesotho (VICONEL)

Clinical Relevance of Human Immunodeficiency Virus Low-level Viremia in the Dolutegravir era: Data From the Viral Load Cohort North-East Lesotho (VICONEL)

Uptake of same-day initiation of HIV treatment in Malawi, South Africa, and Zambia: the SPRINT retrospective cohort study

Long-term HIV care outcomes under universal HIV treatment guidelines: A retrospective cohort study in 25 countries

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