Who’s slipping through the cracks? A comprehensive individual, clinical and health system characterization of people with virological failure on first‐line HIV treatment in Uganda and South Africa

Abstract

Objectives: HIV virological failure remains a major threat to programme success in sub-Saharan Africa. While HIV drug resistance (HIVDR) and inadequate adherence are the main drivers of virological failure, the individual, clinical and health system characteristics that lead to poor outcomes are not well understood.The objective of this paper is to identify those characteristics among people failing first-line antiretroviral therapy (ART). Methods:We enrolled a cohort of adults in HIV care experiencing virological failure on first-line ART at five sites and used standard statistical methods to characterize them with a focus on three domains: individual/demographic, clinical, and health system, and compared each by country of enrolment. Results: Of 840 participants, 51% were women, the median duration on ART was 3.2 years [interquartile range (IQR) 1.1, 6.4 years] and the median CD4 cell count prior to failure was 281 cells/µL (IQR 121, 457 cells/µL). More than half of participants [53%; 95% confidence interval (CI) 49-56%] stated that they had > 90% adherence and 75% (95% CI 72-77%) took their ART on time all or most of the time. Conversely, the vast majority (90%; 95% CI 86-92%) with a completed genotypic drug resistance test had any HIV drug resistance. This population had high health system use, reporting a median of 3 (IQR 2.6) health care visits and a median of 1 (IQR 1.1) hospitalization in the preceding 6 months.Conclusions: Patients failing first-line ART in sub-Saharan Africa generally report high rates of adherence to ART, have extremely high rates of HIV drug

Temporal dynamics and drivers of durable HIV viral load suppression and persistent high‐ and low‐level viraemia during Universal Test and Treat scale‐up in Uganda: a population‐based study

“…A noteworthy fraction (∼20%) of persistent high-level viraemia was observed in individuals self-reporting ART use for ≥12 months, which could reflect unaddressed virologic failure and/or suboptimal ART adherence in this population. Factors associated with persistent viraemia among persons on ART reported elsewhere include HIV drug resistance, delayed switching to second-or third-line ART regimens, viral load monitoring gaps and poor care quality [35][36][37]. Point-of-care viral load monitoring may reduce delays in detecting and responding to virologic failure among persons on ART exhibiting viraemia for >12 months [38].…”

Temporal dynamics and drivers of durable HIV viral load suppression and persistent high- and low-level viremia during Universal Test and Treat scale-up in Uganda: a population-based study

“…Factors associated with persistent viremia among persons on ART reported elsewhere include HIV drug resistance, delayed switching to second-or third-line ART regimens, viral load monitoring gaps, and poor care quality. [33][34][35] Point-of-care viral load monitoring may reduce delays in detecting and responding to virologic failure among persons on ART exhibiting viremia for >12 months. 36 Furthermore, persistently viremic men were significantly more likely than women to have never initiated ART, which could reflect gendered patterns in anticipated/enacted HIV stigma, masculine norms surrounding care-seeking, and perceptions that health facilities are predominantly femaleoriented spaces.…”

Determinants of health-related quality of life in people with Human Immunodeficiency Virus, failing first-line treatment in Africa

“…Data for this analysis were derived from the REVAMP clinical trial (NCT02787499). The design and primary results of the trial have been previously described [ 18 , 19 ]. In summary, REVAMP was a pragmatic clinical trial, designed to investigate the impact of adopting resistance testing to improve management of virological failure for PWH on first-line ART in sub-Saharan Africa.…”