The Suboptimal Pediatric HIV Viral Load Cascade

Abstract

Background: Children living with HIV and taking antiretroviral therapy (ART) are a priority group for routine viral load (VL) monitoring. As per Lesotho guidelines, a VL ≥1000 copies/mL ("unsuppressed") should trigger adherence counseling and a follow-up VL; 2 consecutive unsuppressed VLs ("virologic failure") qualify for switching to second-line ART, with some exceptions. Here, we describe the pediatric VL cascade in Lesotho. Methods:In a prospective open cohort study comprising routine VL results from 22 clinics in Lesotho, we assessed outcomes along the VL cascade for children who had at least 1 VL test from January 2016 through June 2020. Data were censored on February 10, 2021. Results: In total, 1215 children received 5443 VL tests. The median age was 10 years (interquartile range 7-13) and 627/1215 (52%) were female; 362/1215 (30%) had at least 1 unsuppressed VL. A follow-up VL was available for 325/362 (90%), although only for 159/362 (44%) within 6 months of the first unsuppressed VL. Of those with a follow-up VL, 172/329 (53%) had virologic failure and 123/329 (37%) qualified for switching to second-line ART. Of these, 55/123 (45%) were ever switched, although only 9/123 (7%) were switched within 12 weeks of the follow-up VL. Delays were more pronounced in rural facilities. Overall, 100/362 (28%) children with an unsuppressed VL received a timely follow-up VL and, if required, a timely regimen switch. Conclusions: Despite access to VL monitoring, clinical management was suboptimal. HIV programs should prioritize timely clinical action to maximize the benefits of VL monitoring.

HIV viral suppression in children and adolescents 2 years after transition to dolutegravir: a multicentre cohort study

“…VICONEL has been described in more detail elsewhere [ 29 , 30 ]. The present analysis includes VICONEL participants from 3 hospitals and 18 health centres run by the Ministry of Health or the Christian Health Association of Lesotho.…”

Cohort profile: the Viral load Cohort North-East Lesotho (VICONEL) from 2016 to 2022 – cohort description, test volumes, predictors of viraemia, and the road ahead

“…The former is achieved in part through a dashboard for clinicians and automated reports flagging persons with incident or repeated viraemia to facilitate clinical followup. Scientific evidence is generated through analysis of routine data [4][5][6][7][8], as well as nested observational [9][10][11][12] and interventional studies [13].…”

“…VICONEL covers two of the ten districts in the country with a combined population of around 220'000 people [16]. Previous analyses within the cohort have demonstrated serious gaps along the viral load care cascade for children and adults with HIV in this setting [4,5].…”

“…First, management of viraemia -i.e., timely follow-up viral load testing with switching to second-line ART if indicated -was assessed among children [5] and adults [4], demonstrating major gaps in the viral load care cascade. Among children and adults with a viral load ≥1,000 copies/mL, only 28% and 25%, respectively, were considered to be managed in a timely manner according to guidelines.…”

“…Starting in 2015, a consortium consisting of the Ministry of Health of Lesotho, the District Health Management Here, we report on cohort composition, test numbers, treatment outcomes, and factors associated with viraemia from the first seven years of the cohort (2016 to 2022), review the cohort's broader scientific findings so far, and outline the road ahead. [4][5][6][7][8], as well as nested observational [9][10][11][12] and interventional studies [13].…”