Factors associated with recent unsuppressed viral load in HIV-1-infected patients in care on first-line antiretroviral therapy in South Africa

Abstract

Unsuppressed viral load (VL) in patients on antiretroviral therapy (ART) occurs when treatment fails to suppress a person’s VL and is associated with decreased survival and increased HIV transmission. The objective of this study was to evaluate factors associated with unsuppressed VL (VL > 400 copies/ml) in patients currently in care on first-line ART for ≥ 6 months attending South African public healthcare facilities. We analysed electronic medical records of ART patients with a VL result on record who started ART between January 2004 and April 2016 from 271 public health facilities. We present descriptive and multivariable logistic regression for unsuppressed VL at last visit using a priori variables. We included 244,370 patients (69% female) on first-line ART in April 2016 for ≥ 6 months. Median age at ART start was 33 years (7% were < 15 years old). Median duration on ART was 3.7 years. Adjusting for other variables, factors associated with having an unsuppressed VL at the most recent visit among patients in care included: (1) < 15 years old at ART start (adjusted odds ratio [aOR]=2.58; 95% CI = 2.37, 2.81) versus 15–49 years at ART start, (2) male gender (aOR = 1.29; 95% CI = 1.25, 1.35), (3) 6–12 months on ART versus longer (aOR = 1.34; 95% CI = 1.29, 1.40), (4) on tuberculosis (TB) treatment (aOR = 1.78; 95% CI = 1.48, 2.13), and (5) prior ART exposure versus none (aOR = 1.20; 95% CI = 1.08, 1.32). Approximately 85% of the ART cohort who were in care had achieved viral suppression, though men, youth/adolescents, patients with prior ART exposure, those with short duration of ART, and patients on TB treatment had increased odds of not achieving viral suppression. There is a need to develop and evaluate targeted interventions for ART patients in care who are at high risk of unsuppressed VL.

Keywords

HIV AIDS viral load viral load suppression South Africa antiretroviral therapy 90–90–90

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References

UNAIDS. AIDS by the Numbers, http://www.unaids.org/sites/default/files/media_asset/AIDS-by-the-numbers-2016_en.pdf (2016, accessed 10 January 2017).

Statistics South Africa. Statistical release: mid-year population estimate 2015, https://www.statssa.gov.za/publications/P0302/P03022015.pdf (2015, accessed 10 January 2017).

Shisana

Rehle

Simbayi

et al . South African national HIV prevalence, incidence and behaviour survey, 2012. Cape Town: HSR Press, 2014.

World Health Organization. Consolidated ARV guidelines, 2013. Chapter 7.3: monitoring response to ART and the diagnosis of treatment failure, http://www.who.int/hiv/pub/guidelines/arv2013/art/artmonitoring/en/index3.html (2013, accessed 13 January 2017).

Barth

Tempelman

Moraba

et al . Long-term outcome of an HIV-treatment programme in rural Africa: viral suppression despite early mortality. AIDS Res Treat 2011; 2011: 434375.

Attia

Egger

Muller

et al . Sexual transmission of HIV according to viral load and antiretroviral therapy: systematic review and meta-analysis. AIDS 2009; 23: 1397–1404.

South African National Department of Health. National consolidated guidelines for the Prevention of Mother-to-Child Transmission of HIV (PMTCT) and the management of HIV in children, adolescents and adults, http://www.sahivsoc.org/Files/ART%20Guidelines%2015052015.pdf (2015, accessed 6 November 2017).

Boulle

Van Cutsem

Hilderbrand

et al . Seven-year experience of a primary care antiretroviral treatment programme in Khayelitsha, South Africa. AIDS 2010; 24: 563–572.

Ribaudo

Lennox

Currier

et al. Virologic failure endpoint definition in clinical trials: is using HIV-1 RNA threshold <200 copies/mL better than <50 copies/mL? An analysis of ACTG studies. 16th conference on retroviruses and opportunistic infections, Montreal, Canada, 8–11 February 2009.

10.

Burton

Giddy

J and

Stinson

Prevention of mother-to-child transmission in South Africa: an ever-changing landscape. Obstet Med 2015; 8: 5–12.

11.

Fox

Van Cutsem

Giddy

et al . IeDEA-SA collaboration. Rates and predictors of failure of first-line antiretroviral therapy and switch to second-line ART in South Africa. J Acquir Immune Defic Syndr 2012; 60: 42837.

12.

Datay

Boulle

Mant

et al . Associations with virologic treatment failure in adults on antiretroviral therapy in South Africa. J Acquir Immune Defic Syndr 2010; 54: 48995.

13.

Greig

Du Cros

Mills

et al . Predictors of raised viral load during antiretroviral therapy in patients with and without prior antiretroviral use: a cross-sectional study. PLoS One 2013; 8: e71407.

14.

Bastard

Pinoges

Balkan

et al . Timeliness of clinic attendance is a good predictor of virological response and resistance to antiretroviral drugs in HIV-infected patients. PLoS One 2012; 7: e49091.

15.

El-Khatib

Katzenstein

Marrone

et al . Adherence to drug-refill is a useful early warning indicator of virologic and immunologic failure among HIV patients on first-line ART in South Africa. PLoS One 2011; 6: e17518.

16.

Brennan

Maskew

Sanne

et al . The importance of clinic attendance in the first six months on antiretroviral treatment: a retrospective analysis at a large public sector HIV clinic in South Africa. J Int AIDS Soc 2010; 13: 49.

17.

Aldous

AL and

Haubrich

RH.

Defining treatment failure in resource-rich settings. Curr Opin Hiv AIDS 2009; 4: 459–466.

18.

Dahourou

Gautier-Lafaye

Teasdale

et al . Transition from paediatric to adult care of adolescents living with HIV in sub-Saharan Africa: challenges, youth-friendly models, and outcomes. J Int AIDS Soc 2017; 20: 34–49.

19.

Mark

Armstrong

Andrade

et al . HIV treatment and care services for adolescents: a situational analysis of 218 facilities in 23 sub-Saharan African countries. J Int AIDS Soc 2017; 20: 25–33.

20.

Beghin

Yombi

Ruelle

et al . Moving forward with treatment options for HIV-infected children. Expert Opin Pharmacother. Epub ahead of print 18 September 2017. DOI: 10.1080/14656566.2017.1377181.

21.

Zanoni

Archary

Buchan

et al . Systematic review and meta-analysis of the adolescent HIV continuum of care in South Africa: the cresting wave. BMJ Glob Health 2016; 1: e000004.

22.

Kim

Mazenga

et al . High self-reported non-adherence to antiretroviral therapy amongst adolescents living with HIV in Malawi: barriers and associated factors. J Int AIDS Soc 2017; 20: 1–12.

23.

Flys

Donnell

Mwatha

et al . Persistence of K103N-containing HIV-1 variants after single-dose nevirapine for prevention of HIV-1 mother-to-child transmission. J Infect Dis 2007; 195: 711.

24.

Stringer

JSA

McConnell

Kiarie

et al . Effectiveness of non-nucleoside reverse-transcriptase inhibitor-based antiretroviral therapy in women previously exposed to a single intrapartum dose of nevirapine: a multi-country, prospective cohort study. PLoS Med 2010; 7: e1000233.

25.

Huntington

Thorne

Anderson

et al . UK collaborative HIV cohort (UK CHIC) Study. National Study of HIV in Pregnancy and Childhood (NSHPC). Response to antiretroviral therapy (ART): comparing women with previous use of zidovudine monotherapy (ZDVm) in pregnancy with ART naïve women. BMC Infect Dis 2014; 14: 127.

26.

Lecher

Williams

Fonjungo

et al . Progress with scale-up of HIV viral load monitoring – seven Sub-Saharan African Countries, January 2015–June 2016. MMWR Morb Mortal Wkly Rep 2016; 65: 1332–1335.

27.

Eshleman

Wilson

Zhang

et al . Virologic outcomes in early antiretroviral treatment: HPTN 052. HIV Clin Trials 2017; 18: 100–109.