The Treatment Cascade in Children With Unsuppressed Viral Load—A Reality Check in Rural Lesotho, Southern Africa

Lejone, Thabo Ishmael; Ringera, Isaac; Cheleboi, Molisana; Wagner, Sarah; Muhairwe, Josephine; Klimkait, Thomas; Labhardt, Niklaus Daniel

doi:10.1097/qai.0000000000001597

Cited by 7 publications

(8 citation statements)

References 26 publications

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“…In children from the same cohort, virologic failure rates on bPI were lower than the previously reported 25.4% on a first-line regimen [7]. A pediatric study from a similar cohort in Lesotho reported failure rates (VL �80 copies/mL) of 28% on first-line treatment and, despite counseling, of 49% after switching to bPI [6]. This data indicates key challenges in the management of HIV-infected children such as ART-acceptance and -tolerability, inability to swallow the pills mainly designed for adults, and likely pharmacokinetic issues [20].…”

Section: Discussionmentioning

confidence: 60%

“…Additionally, in young children, a bPI-based treatment is currently started as a first-line therapy [3]. Children have a particularly high risk of virologic failure [6,7], which puts them in jeopardy of having a lack of effective treatment options in the future. Thus far, several studies from SSA found that poor adherence rather than viral resistance is the main driver of failure under bPI treatment [8][9][10].…”

Section: Introductionmentioning

confidence: 99%

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High failure rates of protease inhibitor-based antiretroviral treatment in rural Tanzania – A prospective cohort study

et al. 2020

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Background Poor adherence to antiretroviral drugs and viral resistance are the main drivers of treatment failure in HIV-infected patients. In sub-Saharan Africa, avoidance of treatment failure on second-line protease inhibitor therapy is critical as treatment options are limited. Methods In the prospective observational study of the Kilombero & Ulanga Antiretroviral Cohort in rural Tanzania, we assessed virologic failure (viral load �1,000 copies/mL) and drug resistance mutations in bio-banked plasma samples 6-12 months after initiation of a protease inhibitor-based treatment regimen. Additionally, viral load was measured before start of protease inhibitor, a second time between 1-5 years after start, and at suspected treatment failure in patients with available bio-banked samples. We performed resistance testing if viral load was �1000 copies/ml. Risk factors for virologic failure were analyzed using logistic regression. Results In total, 252 patients were included; of those 56% were female and 21% children. Virologic failure occurred 6-12 months after the start of a protease inhibitor in 26/199 (13.1%) of adults and 7/53 of children (13.2%). The prevalence of virologic failure did not change over time. Nucleoside reverse transcriptase inhibitors drug resistance mutation testing performed at 6-12 months showed a positive signal in only 9/16 adults. No cases of resistance mutations for protease inhibitors were seen at this time. In samples taken between 1-5 years protease inhibitor resistance was demonstrated in 2/7 adults. In adult samples before protease

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Section: Discussionmentioning

confidence: 60%

Section: Introductionmentioning

confidence: 99%

High failure rates of protease inhibitor-based antiretroviral treatment in rural Tanzania – A prospective cohort study

et al. 2020

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“…2,8,10,12,14,[20][21][22][23][24][25][26][27][28] Clinical factors, nutritional status, duration on ART, ART regimen, WHO clinical stage, adherence, initial CD4 count, initial VL, count and EAC sessions completed have also been reported to have significant associations. [7][8][9][10]12,14,[20][21][22][23][24][27][28][29][30][31][32][33][34][35][36][37] Some important variables of potential association (ie, prophylaxis against opportunistic infections and nutritional status) with VL suppression were not considered in previous studies.…”

Section: Introductionmentioning

confidence: 99%

Magnitude of Viral Load Suppression and Associated Factors among Clients on Antiretroviral Therapy in Public Hospitals of Hawassa City Administration, Ethiopia

Anito¹,

Lenjebo²,

Wolka³

et al. 2022

HIV

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Background A majority of clients on first-line antiretroviral therapy with an initial high viral load will resuppress following an adherence intervention. Some sociodemographic and clinical characteristics were found to affect resuppression. Few reports on the outcome of the intervention and its associated factors in our country, with inconsistent results and some missed clinical factors of potential association, have compelled this study. The study aimed to assess the proportion of viral load suppression and associated factors among clients on antiretroviral therapy in public hospitals of Hawassa City Administration, Ethiopia. Methods An institution-based cross-sectional study with retrospective document review was conducted among 342 participants on antiretroviral therapy enrolled for counseling since its start in November 2016. Data were captured using a pretested and structured checklist from all client charts with complete data, entered into EpiData 3.1.0 and exported to SPSS 27 for analysis. The proportion of viral load suppression was determined. Bivariate and multivariate logistic regressions were performed to identify associated factors. Statistical significance was determined at a 95% CI and P <0.05. Results The proportion of viral load suppression was found to be 40.9% (35.7%–46.5%). Nevirapine-based antiretroviral treatment regimens (AOR 0.125, 95% CI 0.034–0.464), malnutrition (AOR 0.565, 95% CI 0.329–0.971), poor adherence (AOR 0.504, 95% CI 0.287–0.886), lower CD4 count (AOR 0.149, 95% CI 0.071, 0.314), and fewer counseling sessions (AOR 0.330, 95% CI 0.149–0.729) were significantly associated with viral load suppression. Conclusion The proportion of viral load suppression is lower than that recommended by the World Health Organization. Nevirapine-based regimens, poor nutritional status, poor adherence, lower CD4 count, and fewer counseling sessions risk a lower proportion of viral load suppression. This calls for the need to devise strategies to address these factors and to revisit program implementation.

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“…Several studies have highlighted the practical challenges of applying this viral load algorithm. Key challenges include ensuring that patients with an elevated viral load receive enhanced adherence counselling and a follow‐up viral load, and those whose viral load remains elevated are switched to a new antiretroviral regimen . This has led to proposals to include HIV drug resistance testing as part of the algorithm, or to switch all patients following an initial elevated viral load .…”

Section: Introductionmentioning

confidence: 99%

HIV viral resuppression following an elevated viral load: a systematic review and meta‐analysis

et al. 2019

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Introduction Guidelines for antiretroviral therapy recommend enhanced adherence counselling be provided to individuals with an initial elevated viral load before making a decision whether to switch antiretroviral regimen. We undertook this systematic review to estimate the proportion of patients with an initial elevated viral load who resuppress following enhanced adherence counselling. Methods Two databases and two conference abstract sites were searched from January 2012 to October 2019 for studies reporting the number of patients with an elevated viral load whose viral load was undetectable when subsequently assessed. Data were pooled using random effects meta‐analysis. Results Fifty‐eight studies reported outcomes of 45,720 viraemic patients, mostly from Africa (48 studies), and among patients on first‐line antiretroviral therapy (43 studies). Almost half (46.1%, 95% CI 42.6% to 49.5%) of patients with an initial elevated viral load resuppressed following an enhanced adherence intervention. Of those on first‐line ART with confirmed virological failure (6280 patients, 21 studies), only 53.4% (40.1% to 66.8%) were appropriately switched to a different regimen. Resuppression was higher among studies that provided details of adherence support. The proportion resuppressing was lower among children (31.2%, 21.1% to 41.3%) and adolescents (40.4%, 15.7% to 65.2%) compared to adults (50.4%, 42.6% to 58.3%). No important differences were observed by date of study publication, gender, viral failure threshold, publication status, time between viral loads or treatment regimen. Information on resistance testing among people with an elevated viral load was inconsistently reported. Conclusions The findings of this review suggest that in settings with limited resources, current guideline recommendations to provide enhanced adherence counselling can result in resuppression of a substantial number of these patients, avoiding unnecessary drug regimen changes. Appropriate action on viral load results is limited across a range of settings, highlighting the importance of viral load cascade analyses to identify gaps and focus quality improvement to ensure that action is taken on the results of viral load testing.

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The Treatment Cascade in Children With Unsuppressed Viral Load—A Reality Check in Rural Lesotho, Southern Africa

Abstract: Only 1 of 5 children with unsuppressed initial VL under ART was retained in care and virally suppressed at 18 months of follow-up. ART programs must increase the focus onto the extremely vulnerable care cascade in children with unsuppressed VL.

Cited by 7 publications

References 26 publications

High failure rates of protease inhibitor-based antiretroviral treatment in rural Tanzania – A prospective cohort study

High failure rates of protease inhibitor-based antiretroviral treatment in rural Tanzania – A prospective cohort study

Magnitude of Viral Load Suppression and Associated Factors among Clients on Antiretroviral Therapy in Public Hospitals of Hawassa City Administration, Ethiopia

HIV viral resuppression following an elevated viral load: a systematic review and meta‐analysis

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