Profile of HIV-infected patients receiving second-line antiretroviral therapy in a resource-limited setting in Nigeria

The viral load monitoring cascade in HIV treatment programmes in sub-Saharan Africa: a systematic review

BACKGROUND

The United Nations' 95-95-95 (95% of people with HIV being aware of their diagnosis, 95% of those aware of their diagnosis being on treatment and 95% achieving viral suppression) target aims to reduce morbidity and mortality of HIV. However, with 60% of new HIV infections occurring in sub-Saharan Africa (SSA), achieving this target in the region is challenging. Viral load (VL) monitoring is the gold-standard approach of assessing treatment efficacy, and its implementation into national health systems is a global health priority if elimination of HIV as a public health threat is to be achieved by 2030. This systematic review aims to investigate VL monitoring outcomes in SSA, and to identify gaps and possible interventions to help nations meet their 2030 targets.

METHODS

A literature search of three electronic platforms (MEDLINE, EMBASE and Global Health) was undertaken from 1 January to 9 August 2024 to identify studies published in English and conducted in SSA. The primary outcome was the proportion of people living with HIV (PLHIV) on antiretroviral therapy (ART) with routine VL monitoring at the recommended time points (initially, 6 months, 12 months and annually). Secondary outcomes reported proportions of PLHIV who received routine VL monitoring who went on to complete the cascade of care after identified virological failure [enhanced adherence counselling (EAC), switch to second-line ART, and finally viral suppression].

RESULTS

The initial search identified 342 papers, of which 35 studies were included for narrative synthesis. Included studies reported on findings from 14 African countries and demonstrated extensive variation in rates of VL monitoring (range: 24.3-99.7%, mean: 63.8%). Results were more unfavourable in the latter steps of the viral load monitoring cascade, with a range of 0-88%, and a switch to second-line ART mean of 42% (range: 4.4-93%). Studies with additional support, and those with community-based models of care, had higher rates of VL testing and viral suppression.

CONCLUSIONS

VL monitoring and management of virological failure are suboptimal in many SSA countries due to individual and health system-related challenges. Health system strengthening is vital to ensure the sustainability of HIV treatment programmes and the achievement of 95-95-95 targets by 2030.

Disengagement From HIV Care and Failure of Second-Line Therapy in Nigeria: A Retrospective Cohort Study, 2005-2017

BACKGROUND

Understanding the correlates of disengagement from HIV care and treatment failure during second-line antiretroviral therapy (ART) could inform interventions to improve clinical outcomes among people living with HIV (PLHIV).

METHODS

We conducted a retrospective cohort study of PLHIV aged >15 years who started second-line ART at a tertiary center in Nigeria between 2005 and 2017. Participants were considered to have disengaged from care if they had not returned within a year after each clinic visit. Cox proportional hazard models were used to investigate factors associated with: (1) viral failure (HIV-1 RNA >1000 copies/mL), (2) immunologic failure (CD4 count decrease or <100 cells/mm3), and (3) severe weight loss (>10% of bodyweight), after >6 months of second-line ART.

RESULTS

Among 1031 participants, 33% (341) disengaged from care during a median follow-up of 6.9 years (interquartile range 3.7-8.5). Of these, 26% (89/341) subsequently reentered care. Disengagement was associated with male gender, age <30 years, lower education level, and low CD4 count at second-line ART initiation. Among participants with endpoint assessments available, 20% (112/565) experienced viral failure, 32% (257/809) experienced immunologic failure, and 23% (190/831) experienced weight loss. A lower risk of viral failure was associated with professional occupations compared with elementary: adjusted hazard ratio 0.17 (95% confidence interval 0.04 to 0.70).

CONCLUSION

Adverse outcomes were common during second-line ART. However, reengagement is possible and resources should be allocated to focus on retaining PLHIV in care and providing services to trace and reengage those who have disengaged from care.

Towards the elimination of mother-to-child transmission of HIV in Nigeria: a health system perspective of the achievements and challenges

Despite its scaled-up response for prevention of mother-to-child transmission of HIV (PMTCT), Nigeria still contributes the greatest number of infants infected with HIV worldwide. Drawing on our knowledge, and review of policy documents and research papers, we explored the achievements and challenges in the elimination of mother-to-child transmission of HIV in Nigeria using the WHO's health systems framework. We found that Nigeria has increased the number of PMTCT sites, decentralized and integrated PMTCT care for expanded service delivery, adopted task-shifting to address the shortage of skilled healthcare providers, explored alternative sources of domestic funding to bridge the funding gap and harmonized the health management information system to improve data quality. Some of the challenges we identified included: difficulty in identifying HIV-infected pregnant women because of low uptake of antenatal care; interrupted supplies of medical commodities; knowledge gaps among healthcare workers; and lack of a national unique identifying system to enhance data quality. While there have been some achievements in the PMTCT program, gaps still exist in the different blocks of the health system. Elimination of mother-to-child transmission of HIV in Nigeria will require the implementation of feasible, culturally acceptable and sustainable interventions to address the health system-related challenges.

Second-line HIV treatment failure in sub-Saharan Africa: A systematic review and meta-analysis

BACKGROUND

Increased second-line antiretroviral therapy (ART) failure rate narrows future options for HIV/AIDS treatment. It has critical implications in resource-limited settings; including sub-Saharan Africa (SSA) where the burden of HIV-infection is immense. Hence, pooled estimate for second-line HIV treatment failure is relevant to suggest valid recommendations that optimize ART outcomes in SSA.

METHODS

We retrieved literature systematically from PUBMED/MEDLINE, EMBASE, CINAHL, Google Scholar, and AJOL. The retrieved studies were screened and assessed for eligibility. We also assessed the eligible studies for their methodological quality using the Joanna Briggs Institute's appraisal checklist. The pooled estimates for second-line HIV treatment failure and its associated factors were determined using STATA, version 15.0 and MEDCALC, version 18.11.3, respectively. We assessed publication bias using Comprehensive Meta-analysis software, version 3. Detailed study protocol for this review/meta-analysis is registered and found on PROSPERO (ID: CRD42018118959).

RESULTS

A total of 33 studies with the overall 18,550 participants and 19,988.45 person-years (PYs) of follow-up were included in the review. The pooled second-line HIV treatment failure rate was 15.0 per 100 PYs (95% CI: 13.0-18.0). It was slightly higher at 12-18 months of follow-up (19.0/100 PYs; 95% CI: 15.0-22.0), in children (19.0/100 PYs; 95% CI: 14.0-23.0) and in southern SSA (18.0/100 PYs; 95% CI: 14.0-23.0). Baseline values (high viral load (OR: 5.67; 95% CI: 13.40-9.45); advanced clinical stage (OR: 3.27; 95% CI: 2.07-5.19); and low CD4 counts (OR: 2.80; 95% CI: 1.83-4.29)) and suboptimal adherence to therapy (OR: 1.92; 95% CI: 1.28-2.86) were the factors associated with increased failure rates.

CONCLUSION

Second-line HIV treatment failure has become highly prevalent in SSA with alarming rates during the 12-18 month period of treatment start; in children; and southern SSA. Therefore, the second-line HIV treatment approach in SSA should critically consider excellent adherence to therapy, aggressive viral load suppression, and rapid immune recovery.

Switching to second-line ART in relation to mortality in a large Tanzanian HIV cohort

Objectives

In a large cohort of HIV-infected Tanzanians, we assessed: (i) rates of first-line treatment failure and switches to second-line ART; (ii) the effect of switching to second-line ART on death and loss to follow-up; and (iii) treatment outcomes on second-line ART by regimen.

Methods

HIV-1-infected adults (≥15 years) initiated on first-line ART between November 2004 and September 2012, and who remained on initial therapy for at least 24 weeks before switching, were studied. Survival analyses were conducted to examine the effect of second-line ART on mortality and loss to follow-up in: (i) the whole cohort; (ii) all patients eligible for second-line ART by immunological failure (IF) and/or virological failure (VF) criteria; and (iii) patients eligible by VF criteria.

Results

In total, 47 296 HIV-infected patients [mean age 37.5 (SD 9.5) years, CD4 175 (SD 158) cells/mm 3 , 71% female] were included in the analyses. Of these, 1760 (3.7%) patients switched to second-line ART (incidence rate = 1.7/100 person-years). Higher rates of mortality were observed in switchers versus non-switchers in all patients and patients with ART failure using IF/VF criteria. Switching only protected against mortality in patients with ART failure defined virologically and with the highest level of adherence [switching versus non-switching; >95% adherence; adjusted HR = 0.50 (95% CI = 0.26-0.93); P  =   0.03].

Conclusions

Switching patients to second-line ART may only be beneficial in a select group of patients who are virologically monitored and demonstrate good adherence. Our data emphasize the need for routine viral load monitoring and aggressive adherence interventions in HIV programmes in sub-Saharan Africa.

Treatment outcomes of over 1000 patients on second-line, protease inhibitor-based antiretroviral therapy from four public-sector HIV treatment facilities across Johannesburg, South Africa

Objectives

To report predictors of outcomes of second‐line ART for HIV treatment in a resource‐limited setting.

Methods

All adult ART‐naïve patients who initiated standard first‐line treatment between April 2004 and February 2012 at four public‐sector health facilities in Johannesburg, South Africa, experienced virologic failure and initiated standard second‐line therapy were included. We assessed predictors of attrition (death and loss to follow‐up [≥3 months late for a scheduled visit]) using Cox proportional hazards regression and predictors of virologic suppression (viral load <400 copies/ml ≥3 months after switch) using modified Poisson regression with robust error estimation at 1 year and ever after second‐line ART initiation.

Results

A total of 1236 patients switched to second‐line treatment in a median (IQR) of 1.9 (0.9‐4.6) months after first‐line virologic failure. Approximately 13% and 45% of patients were no longer in care at 1 year and at the end of follow‐up, respectively. Patients with low CD4 counts (<50 vs. ≥200, aHR: 1.85; 95% CI: 1.03–3.32) at second‐line switch were at greater risk for attrition by the end of follow‐up. About 75% of patients suppressed by 1 year, and 85% had ever suppressed by the end of follow‐up.

Conclusions

Patients with poor immune status at switch to second‐line ART were at greater risk of attrition and were less likely to suppress. Additional adherence support after switch may improve outcomes.

Pretreatment HIV drug resistance increases regimen switches in sub-Saharan Africa

BACKGROUND

After the scale-up of antiretroviral therapy (ART) for human immunodeficiency virus (HIV) infection in Africa, increasing numbers of patients have pretreatment drug resistance.

METHODS

In a large multicountry cohort of patients starting standard first-line ART in six African countries, pol genotyping was retrospectively performed if viral load (VL) ≥1000 cps/mL. Pretreatment drug resistance was defined as a decreased susceptibility to ≥1 prescribed drug. We assessed the effect of pretreatment drug resistance on all-cause mortality, new AIDS events and switch to second-line ART due to presumed treatment failure, using Cox models.

RESULTS

Among 2579 participants for whom a pretreatment genotype was available, 5.5% had pretreatment drug resistance. Pretreatment drug resistance was associated with an increased risk of regimen switch (adjusted hazard ratio [aHR] 3.80; 95% confidence interval [CI], 1.49-9.68; P = .005) but was not associated with mortality (aHR 0.75, 95% CI, .24-2.35; P = .617) or new AIDS events (aHR 1.06, 95% CI, .68-1.64; P = .807). During three years of follow up, 106 (4.1%) participants switched to second-line, of whom 18 (17.0%) switched with VL < 1000 cps/mL, 7 (6.6%) with VL ≥ 1000 cps/mL and no drug resistance mutations (DRMs), 46 (43.4%) with VL ≥ 1000 cps/mL and ≥1 DRMs; no HIV RNA data was available for 32 (30.2%) participants.

CONCLUSIONS

Given rising pretreatment HIV drug resistance levels in sub-Saharan Africa, these findings underscore the need for expanded access to second-line ART. VL monitoring can improve the accuracy of failure detection and efficiency of switching practices.