Alarming rates of virological failure and HIV-1 drug resistance amongst adolescents living with perinatal HIV in both urban and rural settings: evidence from the EDCTP READY-study in Cameroon

Viral suppression and adherence in adolescents living with HIV in rural Tanzania

BACKGROUND

Adolescents living with HIV (ALHIV) in sub-Saharan Africa are affected by poor treatment outcomes, likely a consequence of poor adherence.

OBJECTIVES

To assess viral suppression rates and evaluate factors associated with achieving viral suppression and maintaining treatment adherence among ALHIV in rural Tanzania.

METHODS

Cross-sectional analysis of data from the Kilombero and Ulanga Antiretroviral Cohort in Ifakara, Tanzania, including adolescents aged 10-19 years on antiretroviral treatment (ART) ≥6 months at the time point of their first viral load (VL) measurement after implementation of routine VL testing from August 2017 through December 2023. VL ≥1000 copies/ml was considered unsuppressed. We assessed agreement between adherence measures (self-report, pill box return, pill count and visual analogy scale) and viral suppression. Logistic regression was used to determine factors associated with viral suppression.

RESULTS

Of 319 included adolescents, 159 (50%) were male, 143 (45%) aged 10-13 years, 213 (74%) had disclosed their HIV status, 72 (23%) lived ≥50 kilometers from the clinic, 161 (55%) had a WHO stage III/IV and 80 (33%) had CD4 cell counts <500 cells/mm3. Overall, 249 (78%) adolescents were virally suppressed. Factors associated with viral suppression were having a CD4 cell count ≥500 cells/mm3 (adjusted Odds Ratio (aOR) 3.48; 95% CI 1.49-8.13) versus those with a CD4 cell count <500 cells/mm3, being on a dolutegravir-based regimen (aOR 12.6; 95% CI 2.50-68.7) versus those on a NNRTI based regimen. Female gender was associated with lower odds of having viral suppression (aOR 0.41; 95%CI 0.18-0.93). There was a weak to moderate agreement between adherence measures and VL suppression.

CONCLUSION

Adolescents in this rural cohort remain far behind the UNAIDS 95% viral suppression target with only 78% being virally suppressed. The weak to moderate associations between adherence assessment and viral suppression. Adolescents' HIV care models need to be strengthened in order to achieve viral suppression goals in this population.

Outcomes of HIV-infected children on antiretroviral therapy for at least 10 years at the Essos Hospital Centre, Cameroon: contributing to the elimination of paediatric AIDS in tropical settings

Evidence on long-term outcomes of children receiving antiretroviral therapy (ART) in low- and middle-income countries (LMICs) is of utmost importance to optimize current and future therapeutic strategies for HIV. We sought to ascertain the long-term responses among ART-experienced children and their potential implications. A retrospective, observational, facility-based cohort study was conducted among 136 ART-experienced children monitored for 10 years (2007-2017) at the Essos Hospital Centre in Yaoundé, Cameroon. Primary outcomes were good clinical response defined as the World Health Organization (WHO) clinical stage 1/2, immune restoration as CD4 >500 cells/mm3, viral suppression (VS) as viral load (VL) <1000, or viral undetectability as VL <40 copies/ml at the last follow-up and their predictors (P < .05). At ART initiation among the 90 eligible children, median (interquartile range) age was 29.5 (11-60) months, 53.3% were males, 34.5% were at WHO clinical stage 1/2, median-CD4 was 497 cells/mm3, and initial ART-regimens were mainly zidovudine-lamivudine-nevirapine (85.5%) and zidovudine-lamivudine-efavirenz (12.2%). After 10 years of follow-up, 36.7% were switched to protease-based ART regimens, those at WHO clinical stage 1/2 improved to 75.5%; median-CD4 increased to 854 cells/mm3; 83.3% achieved VS, while only 10% achieved viral undetectability. Following multivariate analysis, no predictor of VS or immune recovery was identified (P > .05). In this LMIC, long-term outcomes of children on ART appear encouraging, characterized by moderate VS rate and immune recovery. However, challenges in achieving viral undetectability indicate continuous viral replication and risks of drug resistance emergence that may jeopardize effectiveness of future paediatric ART strategies.

The Long-Term Health Outcomes of People Living with Perinatal Human Immunodeficiency Virus: A Scoping Review

Since the first reported cases of perinatally acquired human immunodeficiency virus (HIV) in 1982, a generation born with HIV has reached adulthood. The authors conducted a scoping review of PubMed and Google Scholar for articles published between January 2000 and June 2023 to assess the long-term, multisystem health outcomes of this population. Long-term health outcomes studied in this population pertain to the effects of perinatal HIV (PHIV) infection and life-long antiretroviral therapy on the endocrine, reproductive, psychosocial, neurobehavioral, immunologic, and cardiovascular systems. Holistic health of all body systems should be considered in the long-term care of people with PHIV.

Adolescents and young adults with HIV and unsuppressed viral load: where do we go from here?

PURPOSE OF REVIEW

Adolescents and youth living with HIV (AYLHIV) have worse outcomes at all stages of the care cascade when compared with adults, yet adolescents and youth with unsuppressed viral load are typically excluded from phase 3 studies of novel HIV therapeutic agents and emerging strategies. Long-acting agents have the potential to radically change outcomes for young people struggling with adherence to daily oral HIV medications.

RECENT FINDINGS

1.5 million children aged less than 15 years live with HIV and more than 100 000 acquire HIV perinatally every year. Adolescents and youth aged 10-24 years comprise ∼40% of global incident HIV infections. Rates of viral suppression among AYLHIV vary markedly from 44 to 88%, resulting in morbidity and risks of transmission to partners and infants. Virological failure is mostly due to poor adherence, and AYLHIV express high levels of interest and acceptability of alternatives to oral daily medications, such as long-acting antiretroviral formulations. Emerging data regarding their use in populations with unsuppressed viral load are encouraging.

SUMMARY

AYLHIV, including populations without virologic suppression, must be prioritized for the programmatic implementation and research of long-acting HIV drugs and other therapeutic strategies to prevent morbidity and mortality and to ultimately end the HIV epidemic.

Empowering adolescents living with perinatally-acquired HIV: tailored CD4+ count assessment for optimized care, the EDCTP READY-study

Background

The elevated rate of AIDS-related mortality in Sub-Saharan Africa among adolescents living with HIV (ALHIV) is influenced by various factors, notably immunosuppression, within a framework of limited therapeutic alternatives. We aimed to enhance the management of pediatric HIV by assessing the immune response and associated factors in perinatally-infected ALHIV on antiretroviral therapy (ART) in Cameroon.

Methods

A cohort study was conducted from 2018-2020 among 271 ART-experienced ALHIV in Cameroon. Sociodemographic data, immunological (CD4), and virological (plasma viral load, PVL) responses were measured at enrolment (T0), 6-months (T1), and 12-months (T2) using PIMA CD4 (Abbott/Pantech (Pty) Ltd) and Abbott Applied Biosystem platform (Real-Time PCR m2000RT) respectively. Immunological failure (IF) was defined as absolute CD4 < 250 cells/mm3, and Virological failure (VF) as PVL ≥ 1,000 copies/ml. A linear mixed-effects model with R version 4.4.1 was used to estimate both fixed and random effects, with significance set at p < 0.05.

Results

Of the 271 perinatally-infected ALHIV enrolled over three phases, females were predominant (55.7, 55.1, and 56.0%); median age was 14 (IQR: 12-17); majority of the participants were followed-up in urban areas (77.5, 74.5, and 78.6%); and the age distribution favored older adolescents (48.7, 61.2, and 58.5%). Most participants achieved clinical success (93.1, 89.7, 88.9%), predominantly on first-line ART (80.8, 66.2, and 53.0%), with good adherence (64.2, 58.9, and 64.5%). Most participants had secondary education (67.2, 70.1, and 67.5%). Median CD4+ counts fluctuated overtime, with values of 563 (IQR: 249.0-845.0), 502 (IQR: 319.0-783.5), and 628 (IQR: 427.5-817.5), respectively. Of note, being male was linked to a reduction in CD4+ count compared to females, [-200.63 (-379.32 to -21.95), p = 0.028]. Similarly, late adolescence was associated with lower CD4+ counts compared to early adolescence, [-181.08 (-301.08 to -61.09), p = 0.003]. Moreover, participants experiencing VF showed significantly lower CD4+ counts compared to those with undetectable viral loads, [-353.08 (-465.81 to -240.36), p < 0.001]. Additionally, there was a marginally significant interaction between male gender and secondary educational level, [209.78 (-6.94-426.51), p = 0.058].

Conclusion

Among perinatally-infected ALHIV, age, gender, educational level, and virological status are key factors influencing their immune health and treatment outcomes. Prioritizing targeted interventions and close monitoring within these subgroups is crucial for optimal management, employing holistic care strategies that consider not only medical interventions but also psychosocial support and education.

Evaluation of Viral Suppression in Paediatric Populations: Implications for the Transition to Dolutegravir-Based Regimens in Cameroon: The CIPHER-ADOLA Study

Mortality in children accounts for 15% of all AIDS-related deaths globally, with a higher burden among Cameroonian children (25%), likely driven by poor virological response. We sought to evaluate viral suppression (VS) and its determinants in a nationally representative paediatric and young adult population receiving antiretroviral therapy (ART). A cross-sectional and multicentric study was conducted among Cameroonian children (<10 years), adolescents (10-19 years) and young adults (20-24 years). Data were collected from the databases of nine reference laboratories from December 2023 to March 2024. A conditional backward stepwise regression model was built to assess the predictors of VS, defined as a viral load (VL) <1000 HIV-RNA copies/mL. Overall, 7558 individuals (females: 73.2%) were analysed. Regarding the ART regimen, 17% of children, 80% of adolescents and 83% of young adults transitioned to dolutegravir (DTG)-based regimens. Overall VS was 82.3%, with 67.3% (<10 years), 80.5% (10-19 years) and 86.5% (20-24 years), and p < 0.001. VS was 85.1% on a DTG-based regimen versus 80.0% on efavirenz/nevirapine and 65.6% on lopinavir/ritonavir or atazanavir/ritonavir. VS was higher in females versus males (85.8% versus 78.2%, p < 0.001). The VS rate remained stable around 85% at 12 and 24 months but dropped to about 80% at 36 months after ART initiation, p < 0.009. Independent predictors of non-VS were younger age, longer ART duration (>36 months), backbone drug (non-TDF/3TC) and anchor drug (non-DTG based). In this Cameroonian paediatric population with varying levels of transition to DTG, overall VS remains below the 95% targets. Predictors of non-VS are younger age, non-TDF/3TC- and non-DTG-based regimens. Thus, efforts toward eliminating paediatric AIDS should prioritise the transition to a DTG-based regimen in this new ART era.

Combating antimicrobial resistance in malaria, HIV and tuberculosis

Antimicrobial resistance poses a significant threat to the sustainability of effective treatments against the three most prevalent infectious diseases: malaria, human immunodeficiency virus (HIV) infection and tuberculosis. Therefore, there is an urgent need to develop novel drugs and treatment protocols capable of reducing the emergence of resistance and combating it when it does occur. In this Review, we present an overview of the status and underlying molecular mechanisms of drug resistance in these three diseases. We also discuss current strategies to address resistance during the research and development of next-generation therapies. These strategies vary depending on the infectious agent and the array of resistance mechanisms involved. Furthermore, we explore the potential for cross-fertilization of knowledge and technology among these diseases to create innovative approaches for minimizing drug resistance and advancing the discovery and development of new anti-infective treatments. In conclusion, we advocate for the implementation of well-defined strategies to effectively mitigate and manage resistance in all interventions against infectious diseases.

Prevalence and factors associated with viral non-suppression in people living with HIV receiving antiretroviral therapy in sub-Saharan Africa: A systematic review and meta-analysis

Despite advances in HIV treatment, the burden of viral non-suppression (VNS) remains a treatment success concern, particularly in Sub-Saharan African (SSA) countries. We determined the prevalence and factors associated with VNS for people living with HIV (PLHIV) receiving antiretroviral therapy (ART). This review, registered with PROSPERO (CRD42023470234), conducted an extensive search for evidence, focusing on PLHIV living in SSA on ART from the year 2000 to 19th October 2023, across databases including PubMed/MEDLINE, Embase, Web of Science, and Scopus. A total of 2357 articles were screened, from which 32 studies met the criteria for the final analysis, involving 756,620 PLHIV of all ages. The pooled prevalance for VNS was found to be 20.0% (95% CI: 15.43%-25.52%, I2 = 100%, p-value <0.01) Children and adolescents demonstrated the highest prevalence of VNS (viral load ≥1000 copies/mL) at 27.98% (95% CI: 21.91%-34.97%, I2 = 94%, p-value <0.01). The study revealed various factors associated with increased odds (risk) of VNS, p-value <0.05. These factors encompassed socio-demographics such as sex, age, education level, and marital status. Additionally, aspects related to HIV care, such as the facility attended, HIV status disclosure and adherence exhibited higher odds of VNS. Suboptimal ART adherence, longer duration on ART, socio-economic factors, lack of family and social support, presence of co-morbidities, advanced WHO HIV clinical stage, ART regimens, lower CD4+ count, abnormal body mass index, history of treatment interruptions, and progression of HIV illness were associated with VNS. Furthermore, behavioural/psychological factors including depression, substance use, negative perceptions towards ART, experiences of abuse, alcohol use, stigma, and certain patterns of sexual behaviour were also identified as factors for VNS. The occurrence of two VNS to every ten PLHIV on ART poses a threat to the progress made towards reaching the third 95% UNAIDS target in SSA. Additionally, these findings highlight the intricate interplay of various factors, encompassing patient characteristics, behavioural patterns, sociocultural influences, and pharmacological factors, all impacting VNS among PLHIV. Recognising its multifaceted nature, we recommend designing and implementing high impact interventions to effectively address VNS in SSA.

Determinants of survival of adolescents receiving antiretroviral therapy in the Centre Region of Cameroon: a multi-centered cohort-analysis

BACKGROUND

In spite of the global decreasing mortality associated with HIV, adolescents living with HIV (ADLHIV) in sub-Saharan Africa still experience about 50% mortality rate. We sought to evaluate survival rates and determinants of mortality amongst ADLHIV receiving antiretroviral therapy (ART) in urban and rural settings.

METHODS

A multi-centered, 10-year retrospective, cohort-study including ADLHIV on ART ≥ 6 months in the urban and rural settings of the Centre Region of Cameroon. Socio-demographic, clinical, biological, and therapeutic data were collected from files of ADLHIV. The Kaplan-Meier method was used to estimate survival probability after ART initiation; the log rank test used to compare survival curves between groups of variables; and the Cox proportional hazard model was used to identify the determinants of mortality.

RESULTS

A total of 403 adolescents' records were retained; 340 (84%) were from the urban and 63 (16%) from the rural settings. The female to male ratio was 7:5; mean age (Standard deviation) was 14.1 (2.6) years; at baseline, 64.4% were at WHO clinical stages I/II, 34.9% had ≥ 500 CD4 cells/mm3, 91.1% were anemic, and the median [Inter Quartile Range] duration on ART was5.3 [0.5-16] years. The survival rate at 1, 5 and 10 years on ART was respectively 97.0%, 55.9% and 8.7%; with mean survival time of 5.8 years (95% CI 5.5-6.1). In bivariate analysis, living in the rural setting, non-disclosed HIV status, baseline CD4 count < 500 cells/mm3, not being exposed to nevirapine prophylaxis at birth and being horizontally infected were found to be the determinants of higher mortality with poor retention in care slightly associated with mortality. In multivariate analysis, living in rural settings, poor retention in care and anemia were independent predictors of mortality (p < 0.05).

CONCLUSION

Although ADLHIV have good survival rate on ART after 1 year, we observe poor survival rates after 5 years and especially 10 years of treatment experience. Mitigating measures against poor survival should target those living in rural settings, anemic at baseline, or experiencing poor retention in care.

Prevalence of HIV drug resistance among adolescents receiving ART in Cameroon with low- or high-level viraemia

OBJECTIVES

To characterize HIV drug resistance (HIVDR) below and above the WHO threshold of 1000 copies/mL, considered for the definition of HIV ART failure in resource-limited settings.

METHODS

From a cohort of 280 adolescents (aged 10-19 years) receiving ART for at least 6 months, genotypic resistance testing (GRT) was attempted for two groups of participants: participants with low-level viraemia [LLV; viral load (VL) 200-999 copies/mL] and those in virological failure (VF; confirmed VL ≥1000 copies/mL) using an in-house method. The Stanford HIValg Program was used to identify relevant HIVDR mutations and predict the efficacy of the newly introduced tenofovir-lamivudine-dolutegravir combination.

RESULTS

GRT was successfully performed in 54/58 (93.1%) eligible participants, of which 28/31 (90.3%) were in VF and 26/27 (96.3%) had LLV. A high level of resistance was found both in adolescents with LLV and those in VF, with respectively 84.6% (22/26) and 75.0% (21/28) of participants harbouring at least one HIVDR mutation. NRTIs and NNRTIs were the most affected drug classes in both population groups. In contrast, PIs were not significantly affected and dolutegravir was expected to be active for all participants tested. However, for the newly introduced dolutegravir-based combination, functional monotherapy (dolutegravir only) was potentially possible for 22.7% (5/22) of the participants with LLV.

CONCLUSIONS

Our findings show that the 1000 copies/mL threshold is not an indicator of virological success and we call for a revision of the current WHO definition of VF in resource-limited countries.

Genotypic resistance testing improves antiretroviral treatment outcomes in a cohort of adolescents in Cameroon: Implications in the dolutegravir-era

Acquired drug resistance (ADR) is common among adolescents living with perinatal HIV (APHI) in sub-Saharan Africa (SSA). Personalized management has the potential to improve pediatric antiretroviral therapy (ART), even in the presence of long-term treatment and HIV-1 subtype diversity. We sought to evaluate the effect of HIV-1 mutational profiling on immuno-virological response and ADR among APHI. A cohort-study was conducted from 2018-2020 among 311 APHI receiving ART in Cameroon. Clinical, immunological and virological responses were measured at enrolment (T1), 6-months (T2) and 12-months (T3). Immunological failure (IF: CD4 #x003C;250 cells/mm3), VF (viremia ≥1,000 copies/ml), and ADR were analyzed, with P#x003C;0.05 considered significant. Mean age was 15(±3) years; male-female ratio was 1:1; median [IQR] ART-duration was 36[21-81] months. At T1, T2, and T3 respectively, adherence-level was 66.4, 58.3 and 66.5%; 14 viral clades were found, driven by CRF02_AG (58.6%); ADR-mutations favored increased switch to second-line ART (16.1, 31.2, and 41.9%, P#x003C;0.0001). From T1-T3 respectively, there were declining rates of IF (25.5, 18.9, and 9.83%, P#x003C;0.0001), VF (39.7, 39.9, and 28.2%, P=0.007), and HIVDR (96.4, 91.7, and 85.0%, P=0.099). Predictors of ADR were being on first-line ART (P=0.045), high viremia at enrolment (AOR=12.56, P=0.059), and IF (AOR=5.86, P=0.010). Of note, optimized ART guided by mutational profile (AOR=0.05, P=0.002) was protective. Moreover, full Tenofovir+Lamivudine+Dolutegravir efficacy was predicted in 77 and 62% of APHI respectively after first- and second-line failure. Among APHI in this SSA setting, viral mutational profiling prompts the use of optimized Dolutegravir-based ART regimens, leading to improved immuno-virological response and declining ADR burdens. Thus, implementing personalized HIV medicine in this vulnerable population would substantially improve ART response and the achievement of the 95-95-95 goals in these underserved populations.

HIV-1 subtype diversity and immuno-virological outcomes among adolescents failing antiretroviral therapy in Cameroon: A cohort study

OBJECTIVE

We sought to evaluate the variability of HIV-1 and its effect on immuno-virological response among adolescents living with perinatally acquired HIV (APHI).

METHODS

A cohort study was conducted from 2018-2020 among 311 APHI receiving antiretroviral therapy (ART) in Cameroon. Sequencing of protease and reverse transcriptase regions was performed for participants experiencing virological failure, VF, (Plasma viral load, PVL ≥ 1000 RNA copies/ml). HIV-1 subtypes were inferred by phylogeny; immuno-virological responses were monitored at 3-time points (T1-T3). Cox regression modeling was used to estimate adjusted hazard ratios (aHRs) of progression to: CD4 < 250, and PVL > 5log10, adjusted for acquired drug resistance, gender, ART line, adherence, and duration on treatment; p < 0.05 was considered statistically significant.

RESULTS

Of the 141 participants in VF enrolled, the male-female ratio was 1:1; mean age was 15 (±3) years; and median [IQR] duration on ART was 51 [46-60] months. In all phases, 17 viral clades were found with a predominant CRF02_AG (58.2%, 59.4%, and 58.3%). From T1-T3 respectively, there was an increasing CD4 count (213 [154-313], 366 [309-469], and 438 [364-569] cells/mm3) and decline log10 PVL (5.23, 4.43, and 4.43), similar across subtypes. Among participants with CRF02_AG infection, duration of treatment was significantly associated with both rates of progression to CD4 < 250, and PVL > 5log10, aHR = 0.02 (0.001-0.52), and aHR = 0.05 (0.01-0.47) respectively. Moreover, four potential new HIV-1 recombinants were identified (CRF02_AG/02D, CRF02_AG/02A1F2, D/CRF02_AG, and AF2/CRF02_AG), indicating a wide viral diversity.

CONCLUSION

Among APHI in settings like Cameroon, there is a wide genetic diversity of HIV-1, driven by CRF02_AG and with potential novel clades due to ongoing recombination events. Duration of treatment significantly reduces the risk of disease progression.

High risk of virologic failure among HIV-infected children and adolescents routinely followed-up in Littoral region of Cameroon

Virological response to antiretroviral therapy (ART) remains a challenge for HIV-infected children and adolescents due to non-optimization of pediatric ART for resource-limited settings. In this study, we aimed to investigate factors associated with virologic failure (VF) in HIV-infected-children and adolescents on ART in Cameroon. A prospective patient-based cohort study was conducted among HIV-infected children (0-9 years) and adolescents (10-19 years) followed-up between November 2018 and October 2019 in 38 healthcare centers located in the Littoral region of Cameroon. The 1st viral load (VL) was assessed after 6 months of ART initiation and the 2nd VL between 3 and 6 six months later in patients with VL ≥1000 copies/ml in accordance with the national algorithm using Abbott Real-Time HIV-1 Viral Load Assay. Multivariate analyses were performed to identify the determinants of higher risk of VF. Of 1,029 HIV-infected children and adolescents (393 children and 636 adolescents), 801 (77.8%) cumulatively presented with VL <1000 copies/mL within 12 months on ART. Adolescents were more likely to have VF than children (24.5% vs 18.3%, OR: 1.39; 95%CI: 1.00-1.93; p = 0.047). Patients followed-up in decentralized care units were significantly more likely to have VF compared to those attending the accredited treatment centers (26.1% vs 16.6%, OR: 1.88, 95%CI: 1.37-2.58; p<0.001). Our findings show a high rate of VL suppression (VLS, 77.8%) among HIV-infected children and adolescents, albeit lower than the established target of 90%. Being adolescent and patients followed in the decentralized care units are high risk factors for VF, thereby necessitating routine therapeutic education of patients and guardians in resource limited countries to improve VLS.

Viral load suppression in HIV-infected adolescents in cameroon: towards achieving the UNAIDS 95% viral suppression target

BACKGROUND

Achieving the UNAIDS 95% sustained viral suppression (VS) rate requires considerable global efforts, particularly among adolescents living with HIV (ALHIV) who are often associated with high rates of virological failure (VF). In this study, we prospectively assessed the rate of VS, and the factors associated with VF in a cohort of adolescents followed up according to the WHO guidelines in Cameroon.

METHODS

A cross-sectional study was carried out in 2021 among adolescents (aged 10-19 years) receiving ART in the national program in Cameroon. Socio-demographic and clinical data were collected using patients' medical files and a brief interview with the participant and/or his guardian. Thereafter, a first viral load test (VL1) was performed using the ABBOTT Platform. For adolescents with VL1 > 1000 copies/ml, adherence-enhancing interventions were routinely performed each month for 3 consecutive months, after which a second viral load (VL2) was measured. Adolescents with VL2 > 1000 copies/ml were considered in VF.

RESULTS

Overall, 280 adolescents were enrolled, of whom 89.3% (250/280) acquired HIV infection via mother-to-child transmission. The median age was 16.0 (IQR: 13.0-18.0) years and the median duration on ART was 9.8 (IQR: 5.1-12.8) years. Females and males were almost equally represented, as 52.1% (146/280) were female, while 47.9% (134/280) were males (p = 0.47). The VS rate was 88.2% (CI: 83.8-91.7%) overall; 89.0% (CI: 82.0-93.1%) and 88.7% (CI: 81.2-93.0%) in females and males, respectively. Being on second or third-line ART, self-declared suboptimal adherence, and a history of past VF were independently associated with VF.

CONCLUSION

The high rate of VS we report in this study is welcome in the era of the 95/95/95 UNAIDS goals, and indicates that improving treatment outcomes in this specific and fragile population that represent adolescents in Sub-Saharan Africa is achievable.

TRIAL REGISTRATION

20/10/2020 NCT04593979 ( https://clinicaltrials.gov/ct2/show/NCT04593979 ).

Evaluation of Circulating and Archived HIV-1 Integrase Drug-Resistance Variants among Patients on Third-Line ART in Cameroon: Implications for Dolutegravir-Containing Regimens in Resource-Limited Settings

To ensure the long-term efficacy of dolutegravir (DTG), we evaluated the genotypic profile in viral reservoirs among patients on third-line (3L) antiretroviral therapy (ART) in Cameroon, according to prior exposure to raltegravir (RAL). A facility-based study was conducted from May through December 2021 among patients on 3L ART from HIV treatment centers in Yaoundé and Douala. Viral load was measured, and genotyping was performed on plasma RNA and proviral DNA. HIV-1 drug resistance mutations were interpreted using HIVdb.v9.1 and phylogeny analysis was performed using MEGA.v7, with P < 0.05 considered significant. Of the 12,093 patients on ART, 53 fully met our inclusion criteria. The median (IQR) age was 51 years (40 to 55 years), and the male/female ratio was 4/5. The median duration on integrase strand-transfer inhibitors (INSTI)-containing regimens was 18 months (12 to 32 months), and 15.09% (8/53) were exposed to RAL. The most administered 3L ART was TDF+3TC+DTG+DRV/r (33.96%, 18/53). Only 5.66% (3/53) had unsuppressed viremia (>1000 copies/mL). Resistance testing in proviral DNA was successful for 18/22 participants and revealed 1/18 patients (5.56%, in the RAL-arm) with archived mutations at major resistance positions (G140R and G163R). Five subtypes were identified, CRF02_AG (12/18), CRF22_01AE (3/18), A1 (1/18), G (1/18), and F2 (1/18). In Cameroon, 3L-experienced patients had a good virological response with a low level of archived mutations in the integrase. This finding underscored the use of DTG-containing ART for heavily treated patients in similar programmatic settings. However, patients with prior exposure to RAL should be closely monitored following a stratified or personalized approach to mitigate risks of INSTI-resistance, alongside pharmacovigilance. IMPORTANCE We described the analysis of the genotypes of the population within third-line antiviral therapy in Cameroon, with a focus on defining the effects of prior raltegravir (RAL) treatment and resistance mutations for current dolutegravir (DTG) treatment. While supporting the current transition to DTG-containing ART in resource-limited settings toward the achievement of the UNAIDS' goal of HIV elimination by 2030, our findings suggested that RAL-exposed patients may need a specific monitoring approach either in a stratified or personalized model of third-line ART to ensure the long-term success of DTG-containing regimens.

Rate of virological failure and HIV-1 drug resistance among HIV-infected adolescents in routine follow-up on health facilities in Cameroon

The objective of this study was to determine the rates of virological failure (VF) and HIV drug resistance (HIVDR) amongst adolescents on antiretroviral Therapy (ART). A retrospectively designed study was conducted in 10 healthcare centers for adolescents living with HIV (ALHIV) in the two main cities of Cameroon (Yaoundé and Douala), from November 2018 to May 2019. Sociodemographic, clinical, therapeutic and laboratory parameters were collected from medical records. All enrolled ALHIV had viral load (VL) measurements following the national guidelines. All patients with a VL ≥ 1000 copies/ml were called to perform genotyping tests. The chi-square test was used to determine the factors associated with VF. Out of the 1316 medical records of ALHIV, we included 1083 ALHIV having a VL result. Among them, 276 (25.5%) were experiencing VF, and VF was significantly higher in ALHIV with suboptimal adherence (p<0.001), older adolescents (p<0.05), those who lived outside the city where they were receiving ART (p<0.006), severely immunocompromised (p<0.01) and started ART at infancy (p<0.02). Among the 45/276 (16.3%) participants with an available genotyping resistance testing (GRT) result, the overall rate of HIVDR was 93.3% (42/45). The most common mutations were K103N (n = 21/42, 52.3%) resulting in high-level resistance to Efavirenz and Nevirapine, followed by M184V (n = 20/42, 47.6%) and thymidine analog mutations (n = 15/42, 35.7%) associated with high-level resistance to Lamivudine and Zidovudine respectively. The high rate of VF and HIVDR among ALHIV regularly followed in health facilities in Cameroon highlights the need to develop interventions adapted to an adolescent-centered approach to preserve future ART options.

Adolescent support club attendance and self-efficacy associated with HIV treatment outcomes in Tanzania

HIV treatment outcomes may be improved by ameliorating psychosocial challenges adolescents living with HIV (ALHIV) face. This analysis describes participation in existing facility-based adolescent clubs and the associations between club attendance, adolescent well-being and HIV treatment outcomes. Data were collected through interviews with a sub-sample of adolescents age 10-19 years and medical record abstraction of all adolescents attending HIV services at seven clinics in Tanzania. Independent variables included adolescent club attendance, self-esteem, self-efficacy, mental distress, social capital and other health utilization or HIV experience characteristics. Study outcomes included visit adherence, viral suppression (<1000 cp/ml), and retention. Of 645 adolescents attending HIV services, 75% attended clubs at least once with a median of eight club sessions attended over a two-year period. Mental distress was prevalent, with 67% of the adolescents scoring above a recognized cut-off of ≥5. Adolescents who attended 10 or more clubs, compared to those not attending any clubs over a two-year period were at an almost three-fold increased odds of having good visit adherence (odds ratio [OR] 2.72, 95% confidence interval [CI]: 1.25, 5.94). Club attendance was also associated with sustained retention in the following year: adolescents who attended some clubs (1-9) had three-times the odds of being retained (OR 3.01; 95%CI: 1.86, 4.87) while those who attended 10+ had over seven-times the odds (OR 7.29; 95%CI: 4.34, 12.22). Among the 154 adolescents who were interviewed, being in the top self-efficacy tertile was positively associated with viral suppression (OR 3.04, 95%CI: 1.08, 8.60) and retention (OR 4.44, 95%CI: 1.19, 17.40). Attending the HIV clinic with a guardian/treatment supporter (OR 3.29, 95%CI: 1.17, 9.22) was also associated with viral suppression. Self-efficacy, social capital and treatment support are associated with better health outcomes among adolescents. However, many ALHIV either never attended or did not regularly attend clubs.

Archiving of mutations in HIV-1 cellular reservoirs among vertically infected adolescents is contingent with clinical stages and plasma viral load: Evidence from the EDCTP-READY study

INTRODUCTION

Globally, HIV-related adolescent deaths have increased about 50%, especially for those who are vertically infected. This could be driven by archived drug resistance mutations (DRMs) as children grow up, which might jeopardize antiretroviral therapy (ART). Our objective was to compare HIV-1 genotypic variation between plasma RNA and proviral DNA of vertically infected adolescents (aged 10-19 years) failing ART.

METHODS

A comparative study was conducted in 2019 among 296 adolescents with perinatal HIV infection (ALPHI) failing ART in health facilities of the Centre Region of Cameroon. The WHO clinical stage, CD4 count and plasma viral load (PVL) were measured. For those failing ART (PVL ≥ 1000 copies/mL), RNA (plasma) and proviral DNA (buffy coat) were sequenced in the pol gene at Chantal BIYA International Reference Centre (CIRCB), Yaoundé, Cameroon. HIV-1 subtypes and DRMs were interpreted using Stanford HIVdb v.8.8 and MEGA-X.

RESULTS

Of the 30% (89/296) failing ART, 81 had both RNA and DNA sequences generated and three were excluded for APOBEC mutations: the mean age was 16 ± 3 years; female-to-male ratio was 3:5; median PVL was 46 856 copies/mL [interquartile range (IQR): 19 898-271 410]; median CD4 count was 264 cells/μL (IQR: 131-574); and 42% were at WHO clinical stage 3/4. Subtype concordance between RNA and DNA viral strains was 100%, with CRF02_AG being predominant (65%) and two potential new recombinants found (A1/G/K; F1/G). Adolescents with DRMs were significantly higher in plasma than in proviral DNA (92% vs. 86%, p < 0.0001). Prevalent DRMs by drug class (RNA vs. DNA respectively) were at position M184 (74% vs. 67%) for nucleoside reverse transcriptase inhibitors (NRTIs), K103 (63% vs. 59%) for non-NRTIs, and V82, L76 and M46 (2% vs. 2%) for protease inhibitors. A total of 35% (27/78) of adolescents had concordant DRM profiles in RNA and DNA, while 27% (21/78) had DRMs only in proviral DNA. The presence of archived DRMs was associated with advanced clinical stage 3/4 (OR = 0.14, p = 0.0003) and PVL < 5 Log (Copies/mL) (OR: 4.88, p = 0.006).

CONCLUSIONS

Although plasma RNA remains more sensitive for detecting HIV-1 DRMs, about a quarter of ALPHI experiencing ART failure in an African setting might have archived DRMs in viral reservoirs, indicating clinically occult resistance. Thus, to ensure effective ART success, proviral DNA profiling (alongside RNA genotyping) would provide additional DRMs for adolescents with advanced clinical stages and/or moderate PVL.