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Violette LR, Thomas KK, Dorward J, Quame-Amaglo J, Garrett N, Drain PK. Early HIV viral suppression associated with subsequent 12-month treatment success among people living with HIV in South Africa. HIV Med 2024; 25:759-765. [PMID: 38488308 DOI: 10.1111/hiv.13633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 03/02/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND We analyzed the STREAM (Simplifying HIV TREAtment and Monitoring) study to determine risk factors associated with HIV viraemia and poor retention 18 months after initiation of antiretroviral therapy (ART). METHODS The STREAM study was an open-label randomized controlled trial in Durban, South Africa, that enrolled 390 people living with HIV presenting for their first HIV viral load measurement ~6 months after ART initiation. We used modified Poisson regression with robust standard errors to describe associations between baseline characteristics and three HIV outcomes 18 months after ART initiation: HIV viraemia (>50 copies/mL), poor retention in HIV care, and a composite outcome of poor retention in care and/or HIV viraemia. RESULTS Approximately 18 months after ART initiation, 45 (11.5%) participants were no longer retained in care and 43 (11.8%) had viraemia. People with CD4 counts <200 and those with viraemia 6 months after ART initiation were significantly more likely to have viraemia 18 months after ART initiation (adjusted relative risk [aRR] 4.0; 95% confidence interval [CI] 2.1-7.5 and aRR 5.5; 95% CI 3.3-9.0, respectively). People who did not disclose their HIV status and had viraemia after ART initiation were more likely to not be retained in care 12 months later (aRR 2.6; 95% CI 1.1-6.1 and aRR 2.2; 95% CI 1.0-4.8). People with a CD4 count <200 and those with viraemia were more likely to not achieve the composite outcome 18 months after ART initiation. CONCLUSIONS Viraemia after ART initiation was the strongest predictor of subsequent viraemia and poor care retention. Understanding early indicators can help target our interventions to better engage people who may be more likely to experience persistent viraemia or disengage from HIV care.
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Affiliation(s)
- Lauren R Violette
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Katherine K Thomas
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Jienchi Dorward
- Centre for the AIDS Program of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Nigel Garrett
- Centre for the AIDS Program of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Paul K Drain
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
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Haeri Mazanderani A, Radebe L, Sherman GG. Attrition Rates in HIV Viral Load Monitoring and Factors Associated With Overdue Testing Among Children Within South Africa's Antiretroviral Treatment Program: Retrospective Descriptive Analysis. JMIR Public Health Surveill 2024; 10:e40796. [PMID: 38743934 PMCID: PMC11134236 DOI: 10.2196/40796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 12/25/2023] [Accepted: 02/27/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Numerous studies in South Africa have reported low HIV viral load (VL) suppression and high attrition rates within the pediatric HIV treatment program. OBJECTIVE Using routine laboratory data, we evaluated HIV VL monitoring, including mobility and overdue VL (OVL) testing, within 5 priority districts in South Africa. METHODS We performed a retrospective descriptive analysis of National Health Laboratory Service (NHLS) data for children and adolescents aged 1-15 years having undergone HIV VL testing between May 1, 2019, and April 30, 2020, from 152 facilities within the City of Johannesburg, City of Tshwane, eThekwini, uMgungundlovu, and Zululand. HIV VL test-level data were deduplicated to patient-level data using the NHLS CDW (Corporate Data Warehouse) probabilistic record-linking algorithm and then further manually deduplicated. An OVL was defined as no subsequent VL determined within 18 months of the last test. Variables associated with the last VL test, including age, sex, VL findings, district type, and facility type, are described. A multivariate logistic regression analysis was performed to identify variables associated with an OVL test. RESULTS Among 21,338 children and adolescents aged 1-15 years who had an HIV VL test, 72.70% (n=15,512) had a follow-up VL test within 18 months. Furthermore, 13.33% (n=2194) of them were followed up at a different facility, of whom 3.79% (n=624) were in a different district and 1.71% (n=281) were in a different province. Among patients with a VL of ≥1000 RNA copies/mL of plasma, the median time to subsequent testing was 6 (IQR 4-10) months. The younger the age of the patient, the greater the proportion with an OVL, ranging from a peak of 52% among 1-year-olds to a trough of 21% among 14-year-olds. On multivariate analysis, 2 consecutive HIV VL findings of ≥1000 RNA copies/mL of plasma were associated with an increased adjusted odds ratio (AOR) of having an OVL (AOR 2.07, 95% CI 1.71-2.51). Conversely, patients examined at a hospital (AOR 0.86, 95% CI 0.77-0.96), those with ≥2 previous tests (AOR 0.78, 95% CI 0.70-0.86), those examined in a rural district (AOR 0.63, 95% CI 0.54-0.73), and older age groups of 5-9 years (AOR 0.56, 95% CI 0.47-0.65) and 10-14 years (AOR 0.51, 95% CI 0.44-0.59) compared to 1-4 years were associated with a significantly decreased odds of having an OVL test. CONCLUSIONS Considerable attrition occurs within South Africa's pediatric HIV treatment program, with over one-fourth of children having an OVL test 18 months subsequent to their previous test. In particular, younger children and those with virological failure were found to be at increased risk of having an OVL test. Improved HIV VL monitoring is essential for improving outcomes within South Africa's pediatric antiretroviral treatment program.
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Affiliation(s)
- Ahmad Haeri Mazanderani
- Centre for HIV & STIs, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
- Department of Paediatrics & Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Paediatric HIV Diagnostics Division, Wits Health Consortium, University of the Witwatersrand, Johannesburg, South Africa
| | - Lebohang Radebe
- Centre for HIV & STIs, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
- Paediatric HIV Diagnostics Division, Wits Health Consortium, University of the Witwatersrand, Johannesburg, South Africa
| | - Gayle G Sherman
- Centre for HIV & STIs, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
- Department of Paediatrics & Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Paediatric HIV Diagnostics Division, Wits Health Consortium, University of the Witwatersrand, Johannesburg, South Africa
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Lao X, Zhang H, Deng M, Li Q, Xiao Q, He L, Ma L, Song A, Liang X, Yu F, Zhao H, Zhang F. Incidence of low-level viremia and its impact on virologic failure among people living with HIV who started an integrase strand transfer inhibitors: a longitudinal cohort study. BMC Infect Dis 2024; 24:8. [PMID: 38166689 PMCID: PMC10759638 DOI: 10.1186/s12879-023-08906-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/13/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Low-level viremia (LLV) has been identified as a potential precursor to virologic failure (VF), yet its clinical implications, particularly within the context of Integrase Strand Transfer Inhibitors (INSTIs)-based regimens, remain insufficiently explored. The study aimed to investigate the relationship between LLV and VF within ART-naïve patients on INSTIs-based regimens in China. METHODS A longitudinal cohort study was conducted with ART-naïve patients aged ≥ 18 years at Beijing Ditan Hospital, under the Chinese National Free Antiretroviral Treatment Program (NFATP). The LLV was defined as a viral load (VL) ranging from 50 to 199 copies/mL after six months of ART initiation, and VF as a VL ≥ 200 copies/mL. Sensitive analyses were also performed, defining LLV as 50-999 copies/mL and VF as exceeding 1000 copies/mL. Multivariate logistic regression, Kaplan-Meier (KM) curve, and Generalized Estimating Equation (GEE) models were used to evaluate the risk factors associated with LLV and VF events. RESULTS The study involved 830 ART-naïve patients, comprising 600 in the INSTIs group and 230 in the protease inhibitors (PIs) group. LLV events were observed in 10.4% of patients on PIs-based regimens and and 3.2% on INSTIs-based regimens (P < 0.001). INSTIs-based regimens demonstrated a protective effect against LLV events (aHR = 0.27, 95% CI 0.137-0.532). VF events occurred in 10.9% of patients on PIs-based regimens and 2.0% on INSTIs-based regimens, respectively (P < 0.001). The occurrence of LLV events significantly increased the risk of VF by 123.5% (95% CI 7.5%-364.4%), while the integrase inhibitors were associated with a 76.9% (95% CI 59.1%-86.9%) reduction in VF risk. CONCLUSION Our findings indicate that INSTIs-based regimens are critical protective factors against LLV and subsequent VF. These results underscore the importance of HIV viral load monitoring to ensuring effective treatment outcomes, highlighting the necessity for prompt and precise monitoring to refine HIV treatment methodologies.
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Affiliation(s)
- Xiaojie Lao
- Department of Infectious Disease, Beijing Ditan Hospital Capital Medical University, Beijing, 100015, China
| | - Hanxi Zhang
- WHO Collaborating Centre for Comprehensive Management of HIV Treatment and Care, Beijing Ditan Hospital Capital Medical University, Beijing, 100015, China
| | - Meiju Deng
- Clinical Center for HIV/AIDS, Beijing Ditan Hospital Capital Medical University, Beijing, 100015, China
| | - Qun Li
- Department of Infectious Disease, Beijing Ditan Hospital Capital Medical University, Beijing, 100015, China
| | - Qing Xiao
- Department of Infectious Disease, Beijing Ditan Hospital Capital Medical University, Beijing, 100015, China
| | - Lin He
- State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, 102206, China
| | - Liying Ma
- State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, 102206, China
| | - Aqian Song
- Department of Gastroenterology, Beijing Ditan Hospital Capital Medical University, Beijing, 100015, China
| | - Xuelei Liang
- Department of Infectious Disease, Beijing Ditan Hospital Capital Medical University, Beijing, 100015, China
| | - Fengting Yu
- Department of Infectious Disease, Beijing Ditan Hospital Capital Medical University, Beijing, 100015, China
| | - Hongxin Zhao
- Clinical Center for HIV/AIDS, Beijing Ditan Hospital Capital Medical University, Beijing, 100015, China
| | - Fujie Zhang
- Department of Infectious Disease, Beijing Ditan Hospital Capital Medical University, Beijing, 100015, China.
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Gumede SB, Wensing AMJ, Lalla-Edward ST, de Wit JBF, Francois Venter WD, Tempelman HA, Hermans LE. Predictors of Treatment Adherence and Virological Failure Among People Living with HIV Receiving Antiretroviral Therapy in a South African Rural Community: A Sub-study of the ITREMA Randomised Clinical Trial. AIDS Behav 2023; 27:3863-3885. [PMID: 37382825 PMCID: PMC10598166 DOI: 10.1007/s10461-023-04103-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2023] [Indexed: 06/30/2023]
Abstract
A large proportion of people living with HIV (PLHIV) in sub-Saharan Africa reside in rural areas. Knowledge of enablers and barriers of adherence to antiretroviral treatment (ART) in these populations is limited. We conducted a cohort study of 501 adult PLHIV on ART at a rural South African treatment facility as a sub-study of a clinical trial (ClinicalTrials.gov NCT03357588). Socio-economic, psychosocial and behavioral characteristics were assessed as covariates of self-reported adherence difficulties, suboptimal pill count adherence and virological failure during 96 weeks of follow-up. Male gender was an independent risk factor for all outcomes. Food insecurity was associated with virological failure in males. Depressive symptoms were independently associated with virological failure in both males and females. Household income and task-oriented coping score were protective against suboptimal pill-count adherence. These results underscore the impact of low household income, food insecurity and depression on outcomes of ART in rural settings and confirm other previously described risk factors. Recognition of these factors and targeted adherence support strategies may improve patient health and treatment outcomes.
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Affiliation(s)
- Siphamandla B Gumede
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa.
- Department of Interdisciplinary Social Science, Utrecht University, Utrecht, The Netherlands.
| | - Annemarie M J Wensing
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
- Ndlovu Research Consortium, Elandsdoorn, South Africa
| | - Samanta T Lalla-Edward
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa
| | - John B F de Wit
- Department of Interdisciplinary Social Science, Utrecht University, Utrecht, The Netherlands
- Centre for Social Research in Health, UNSW, Sydney, Australia
| | - W D Francois Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa
| | - Hugo A Tempelman
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa
- Ndlovu Research Consortium, Elandsdoorn, South Africa
| | - Lucas E Hermans
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
- Ndlovu Research Consortium, Elandsdoorn, South Africa
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Veenstra S, Porter M, Thwala B, Pillay N, Panieri M, van der Westhuizen J, Phillips E, Meintjes G, Dlamini S, Lehloenya R, Peter J. Long-term HIV and tuberculosis outcomes in patients hospitalised with severe cutaneous adverse reactions. J Clin Tuberc Other Mycobact Dis 2023; 32:100374. [PMID: 37214159 PMCID: PMC10196841 DOI: 10.1016/j.jctube.2023.100374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023] Open
Abstract
Background Treatment-limiting severe cutaneous adverse reactions (SCAR) occur more commonly amongst persons with HIV-associated tuberculosis (TB). The impact of SCAR on long-term HIV/TB outcomes is unknown. Methods Patients with TB and/or HIV admitted to Groote Schuur Hospital, Cape Town, South Africa with SCAR between 1/10/2018 and 30/09/2021 were eligible. Follow-up data was collected for 6- and 12-month outcomes: mortality, TB and antiretroviral therapy (ART) regimen changes, TB treatment completion, and CD4 count recovery. Results Forty-eight SCAR admissions included: 34, 11, and 3 HIV-associated TB, HIV-only and TB-only patients with 32, 13 and 3 cases of drug reaction with eosinophilia and systemic symptoms, Stevens-Johnson syndrome/toxic epidermal necrolysis and generalised bullous fixed-drug eruption respectively. Nine (19%), all HIV-positive (eight co-infected with TB), were deceased at 12-months, and 12(25%) were lost to follow-up. Amongst TB-SCAR patients, seven (21%) were discharged on all four first-line anti-TB drugs (FLTD), while 12(33%) had regimens with no FLTDs; 24/37(65%) completed TB treatment. Amongst HIV-SCAR patients, 10/31(32%) changed ART regimen. If retained in care (24/36), median (IQR) CD4 counts increased at 12-months post-SCAR (115(62-175) vs. 319(134-439) cells/uL). Conclusion SCAR admission amongst patients with HIV-associated TB results in substantial mortality, and considerable treatment complexity. However, if retained in care, TB regimens are successfully completed, and immune recovery is good despite SCAR.
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Affiliation(s)
- S. Veenstra
- Department of Medicine, University of Cape Town, Groote Schuur Hospital, Observatory, Cape Town, South Africa
| | - M.N. Porter
- Division of Allergy and Clinical Immunology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - B.N. Thwala
- Division of Allergy and Clinical Immunology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - N. Pillay
- Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - M.A. Panieri
- Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | | | - E.J. Phillips
- Centre for Drug Safety and Immunology, Departments of Medicine, Dermatology, Pharmacology and Pathology, Microbiology & Immunology, Vanderbilt University Medical Centre, Nashville, TN, USA
| | - G. Meintjes
- Department of Medicine and Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - S. Dlamini
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - R.J. Lehloenya
- Division of Dermatology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - J. Peter
- Division of Allergy and Clinical Immunology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
- Allergy and Immunology Unit, University of Cape Town Lung Institute, Cape Town, South Africa
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Mayasi Ngongo N, Kamangu Ntambwe E, Situakibanza Nani-Tuma H, Mbula Mambimbi M, Mandina Ndona M, Longokolo Mashi M, Bepouka Izizag B, Lukiana T, Odio Ossam J, Mangala Sonzi D, Maes N, Moutschen M, El Moussaoui M, Darcis G. Human Immunodeficiency Virus Viral Load Monitoring and Rate of Virologic Suppression Among Patients Receiving Antiretroviral Therapy in Democratic Republic of the Congo, 2013-2020. Open Forum Infect Dis 2023; 10:ofad242. [PMID: 37363052 PMCID: PMC10287095 DOI: 10.1093/ofid/ofad242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/02/2023] [Indexed: 06/28/2023] Open
Abstract
Background Antiretroviral therapy (ART) expansion and viral load as a treatment monitoring approach have increased the demand for viral load testing. Many hurdles affect the coverage, quality, and use of viral load results. Estimates of viral load monitoring and viral suppression rates are needed to assess the performance of ART programs and improve human immunodeficiency virus (HIV) management outcomes. Methods People with HIV (PWH) viral load monitoring data were routinely collected in 84 health facilities in Kinshasa, Democratic Republic of the Congo (DRC), between 2013 and 2020. The number of PWH under ART, the number of participants with at least 1 viral load test result, the rate of viral suppression (defined as ≤1000 HIV ribonucleic acid copies per mL), and the mean turnaround time from sample collection to release of viral load test results were collected together with clinical data. Results A total of 14 057 PWH were included in the analysis. People with HIV were mainly enrolled after the "test and treat" implementation. The patients were followed for a median period of 27 months. The proportion of PWH with at least 1 available viral load largely increased in recent years. The delay from sample collection to release of viral load test results decreased overtime, from 35 days in 2018 to 16 days in 2020. Pregnancy and advanced HIV disease were associated with a lower chance of viral suppression. Conclusions There has been considerable success in increasing viral load access for all PWH under therapy in DRC. Nevertheless, viral load testing should be intensified with a particular effort to be made in groups at higher risk of viral failure.
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Affiliation(s)
- Nadine Mayasi Ngongo
- Correspondence: Gilles Darcis, MD, PhD, Avenue de l’hôpital 1, 4000 Liège, Belgium (); Nadine Mayasi Ngongo, MD, PhD, Avenue de l’hôpital 1, 4000 Liège, Belgium (nadiamayas02@gmail)
| | - Erick Kamangu Ntambwe
- Department of Molecular Biology of Basic Sciences, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Hippolyte Situakibanza Nani-Tuma
- Department of Internal Medicine, Infectious and Tropical Diseases, University Hospital of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Marcel Mbula Mambimbi
- Department of Internal Medicine, Infectious and Tropical Diseases, University Hospital of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Madone Mandina Ndona
- Department of Internal Medicine, Infectious and Tropical Diseases, University Hospital of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Murielle Longokolo Mashi
- Department of Internal Medicine, Infectious and Tropical Diseases, University Hospital of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Ben Bepouka Izizag
- Department of Internal Medicine, Infectious and Tropical Diseases, University Hospital of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Tuna Lukiana
- Department of Internal Medicine, Infectious and Tropical Diseases, University Hospital of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Jérôme Odio Ossam
- Department of Internal Medicine, Infectious and Tropical Diseases, University Hospital of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Donatien Mangala Sonzi
- Department of Internal Medicine, Infectious and Tropical Diseases, University Hospital of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Nathalie Maes
- Biostatistics and Research Method Center (B-STAT), University Hospital of Liège, Liège, Belgium
| | - Michel Moutschen
- Department of Internal Medicine and Infectious Diseases, Liège University Hospital, Liège, Belgium
- AIDS Reference Laboratory, University of Liège, Liège, Belgium
| | - Majdouline El Moussaoui
- Department of Internal Medicine and Infectious Diseases, Liège University Hospital, Liège, Belgium
| | - Gilles Darcis
- Correspondence: Gilles Darcis, MD, PhD, Avenue de l’hôpital 1, 4000 Liège, Belgium (); Nadine Mayasi Ngongo, MD, PhD, Avenue de l’hôpital 1, 4000 Liège, Belgium (nadiamayas02@gmail)
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Boakye P, Safowaa A. Prevalence and predictors of viral load suppression in adults living with HIV in the western region of Ghana: A cross-sectional study. AIMS Public Health 2023; 10:469-479. [PMID: 37304596 PMCID: PMC10251059 DOI: 10.3934/publichealth.2023033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 05/05/2023] [Accepted: 05/23/2023] [Indexed: 06/13/2023] Open
Abstract
Background Although antiretroviral therapy is beneficial and available free of cost to patients, several roadblocks still prevent patients from reaching viral suppression. This research aimed to determine the prevalence rate of viral suppression among people living with HIV in the western region of Ghana and identify the factors contributing to viral non-suppression. Methods A cross-sectional study was conducted on 7199 HIV-positive adults. All data from the Sekondi Public Health Laboratory database was exported to Microsoft Excel and then verified and filtered before being exported to STATA 16.1. Viral non-suppression was modeled statistically using logistic regression. Results Viral load suppression was achieved in 5465 (75.91%) study participants who received antiretroviral treatment. However, 1734 participants (24.0%) did not achieve viral suppression. Patients with poor adherence to ARV (AOR 0.30; 95% CI 0.16, 0.58) and fair adherence to ARV (AOR 0.23; 95% CI 0.12, 0.45) were associated with a lower odd of viral non-suppression. Patients with six (6) months to two (2) years of treatment before viral load testing (AOR 0.67; 95% CI 0.46, 0.98) were also associated with a lower likelihood of viral non-suppression. Conclusions The rate of non-suppression was high, and the suppression rate fell short of the UNAIDS target. Poor ARV adherence, fair ARV adherence, and a treatment duration of six (6) months to two (2) years before viral load testing appear to be obstacles to viral load suppression. The research findings seem to suggest that viral load testing supports viral non-suppression. Therefore, using viral load tests to monitor medication's effects on health can motivate patients to adhere to their prescribed medication regimen. More research is needed to determine whether viral load testing can improve adherence. Given the high rate of virologic failure, the study highlights the importance of identifying antiretroviral resistance patterns.
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Affiliation(s)
- Philip Boakye
- Department of Epidemiology and Biostatistics, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- Department of Research in Epidemiology, Biostatistics and Informatics, Koachie Health Systems, Accra, Ghana
| | - Adwoa Safowaa
- Department of Epidemiology and Biostatistics, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- Faculty of Health and Medical Sciences, Presbyterian University, Agogo, Ghana
- Department of Research in Epidemiology, Biostatistics and Informatics, Koachie Health Systems, Accra, Ghana
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Steegen K, Chandiwana N, Sokhela S, Venter WD, Hans L. Impact of rilpivirine cross-resistance on long-acting cabotegravir-rilpivirine in low and middle-income countries. AIDS 2023; 37:1009-1011. [PMID: 36779485 PMCID: PMC10090297 DOI: 10.1097/qad.0000000000003505] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 01/31/2023] [Indexed: 02/14/2023]
Abstract
Baseline rilpivirine drug resistance mutations (DRMs) are a risk factor for virological failure in patients treated with long-acting cabotegravir and rilpivirine (CAB/RPV LA). We investigated rilpivirine cross-resistance in treatment-naive and experienced patients in South Africa. One in 10 treatment-naive patients and 74.5% of patients failing treatment presented with rilpivirine DRMs. Our data suggest targeted genotyping may be required for patients initiating CAB/RPV LA, which significantly complicates the currently used public health approach.
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Affiliation(s)
- Kim Steegen
- Department of Haematology and Molecular Medicine, National Health Laboratory Services
- Department of Haematology and Molecular Medicine
| | - Nomathemba Chandiwana
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Simiso Sokhela
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Willem D.F. Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lucia Hans
- Department of Haematology and Molecular Medicine, National Health Laboratory Services
- Department of Haematology and Molecular Medicine
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Musanhu CCC, Takarinda KC, Shea J, Chitsike I, Eley B. Viral load testing among pregnant women living with HIV in Mutare district of Manicaland province, Zimbabwe. AIDS Res Ther 2022; 19:52. [PMID: 36384677 PMCID: PMC9667426 DOI: 10.1186/s12981-022-00480-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 10/07/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Viral load (VL) monitoring of pregnant women living with HIV (PWLHIV) and antiretroviral therapy (ART) may contribute to lowering the risk of vertical transmission of HIV. The aims of this study were to assess the uptake of HIV VL testing among PWLHIV at entry to the prevention-of-mother-to-child transmission (PMTCT) services and identify facilitatory factors and barriers to HIV VL access. METHODS A retrospective, cross-sectional study was conducted at 15 health facilities in Mutare district, Manicaland Province, Zimbabwe from January to December 2018. This analysis was complemented by prospective interviews with PWLHIV and health care providers between October 2019 and March 2020. Quantitative data were analysed using descriptive and inferential statistical methods. Risk factors were evaluated using multivariate logistic regression. Open-ended questions were analysed and recurring and shared experiences and perceptions of PWLHIV and health care providers identified. RESULTS Among 383 PWLHIV, enrolled in antenatal care (ANC) and receiving ART, only 121 (31.6%) had a VL sample collected and 106 (88%) received their results. Among these 106 women, 93 (87.7%) had a VL < 1000 copies/mL and 77 (73%) a VL < 50 copies/mL. The overall median duration from ANC booking to VL sample collection was 87 (IQR, 7-215) days. The median time interval for the return of VL results from date of sample collection was 14 days (IQR, 7-30). There was no significant difference when this variable was stratified by time of ART initiation. VL samples were significantly less likely to be collected at local authority compared to government facilities (aOR = 0.28; 95% CI 0.16-0.48). Barriers to VL testing included staff shortages, non-availability of consumables and sub-optimal sample transportation. Turnaround time was prolonged by the manual results feedback system. CONCLUSIONS AND RECOMMENDATION The low rate of HIV VL testing among PWLHIV in Mutare district is a cause for concern. To reverse this situation, the Ministry of Health should consider interventions such as disseminating antiretroviral guidelines and policies electronically, conducting regular PMTCT mentorship for clinical staff members, and utilising point of care testing and telecommunication devices like mHealth to increase uptake of VL testing and improve results turnaround time.
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Affiliation(s)
- Christine Chiedza Chakanyuka Musanhu
- World Health Organization Country Office, Highlands, P.O.Box HG 430, Harare, Zimbabwe ,grid.415818.1AIDS & TB Department, Ministry of Health and Child Care, Harare, Zimbabwe ,grid.7836.a0000 0004 1937 1151Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | | | - Jawaya Shea
- grid.7836.a0000 0004 1937 1151Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Inam Chitsike
- grid.13001.330000 0004 0572 0760College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Brian Eley
- grid.7836.a0000 0004 1937 1151Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa ,grid.415742.10000 0001 2296 3850Paediatric Infectious Diseases Unit, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
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10
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Hermans LE, Ter Heine R, Schuurman R, Tempelman HA, Burger DM, Vervoort SC, Deville WL, De Jong D, Venter WD, Nijhuis M, Wensing AM. A randomized study of intensified antiretroviral treatment monitoring versus standard-of-care for prevention of drug resistance and antiretroviral treatment switch. AIDS 2022; 36:1959-1968. [PMID: 35950949 PMCID: PMC9612712 DOI: 10.1097/qad.0000000000003349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/19/2022] [Accepted: 07/23/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Standard-of-care antiretroviral treatment (ART) monitoring in low and middle-income countries consists of annual determination of HIV-RNA viral load with confirmatory viral load testing in case of viral rebound. We evaluated an intensified monitoring strategy of three-monthly viral load testing with additional drug exposure and drug resistance testing in case of viral rebound. METHODS We performed an open-label randomized controlled trial (RCT) at a rural South African healthcare clinic, enrolling adults already receiving or newly initiating first-line ART. During 96 weeks follow-up, intervention participants received three-monthly viral load testing and sequential point-of-care drug exposure testing and DBS-based drug resistance testing in case of rebound above 1000 copies/ml. Control participants received standard-of-care monitoring according to the WHO guidelines. RESULTS Five hundred one participants were included, of whom 416 (83.0%) were randomized at 24 weeks. Four hundred one participants were available for intention-to-treat analysis. Viral rebound occurred in 9.0% (18/199) of intervention participants and in 11.9% (24/202) of controls ( P = 0.445). Time to detection of rebound was 375 days [interquartile range (IQR): 348-515] in intervention participants and 360 days [IQR: 338-464] in controls [hazard ratio: 0.88 (95% confidence interval (95% CI): 0.46-1.66]; P = 0.683]. Duration of viral rebound was 87 days [IQR: 70-110] in intervention participants and 101 days [IQR: 78-213] in controls ( P = 0.423). In the control arm, three patients with confirmed failure were switched to second-line ART. In the intervention arm, of three patients with confirmed failure, switch could initially be avoided in two cases. CONCLUSION Three-monthly viral load testing did not significantly reduce the duration of viraemia when compared with standard-of-care annual viral load testing, providing randomized trial evidence in support of annual viral load monitoring.
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Affiliation(s)
- Lucas E. Hermans
- Virology, Department of Medical Microbiology, University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
- Ezintsha, University of Witwatersrand, Johannesburg
- Infectious Diseases & HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Rob Ter Heine
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Rob Schuurman
- Virology, Department of Medical Microbiology, University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
| | - Hugo A. Tempelman
- Ezintsha, University of Witwatersrand, Johannesburg
- Ndlovu Research Consortium, Elandsdoorn, South Africa
| | - David M. Burger
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Walter L.J.M. Deville
- Ndlovu Research Consortium, Elandsdoorn, South Africa
- Julius Global Health, The Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - Dorien De Jong
- Virology, Department of Medical Microbiology, University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
| | - Willem D.F. Venter
- Ezintsha, University of Witwatersrand, Johannesburg
- Ndlovu Research Consortium, Elandsdoorn, South Africa
| | - Monique Nijhuis
- Virology, Department of Medical Microbiology, University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
- Ndlovu Research Consortium, Elandsdoorn, South Africa
- HIV Pathogenesis Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Annemarie M.J. Wensing
- Virology, Department of Medical Microbiology, University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
- Ezintsha, University of Witwatersrand, Johannesburg
- Ndlovu Research Consortium, Elandsdoorn, South Africa
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11
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Shah GH, Etheredge GD, Smallwood SW, Maluantesa L, Waterfield KC, Ikhile O, Ditekemena J, Engetele E, Ayangunna E, Mulenga A, Bossiky B. HIV viral load suppression before and after COVID-19 in Kinshasa and Haut Katanga, Democratic Republic of the Congo. South Afr J HIV Med 2022; 23:1421. [PMCID: PMC9634654 DOI: 10.4102/sajhivmed.v23i1.1421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 08/23/2022] [Indexed: 11/07/2022] Open
Abstract
Background The coronavirus disease 2019 (COVID-19) pandemic resulted in unique programmatic opportunities to test hypotheses related to the initiation of antiretroviral treatment (ART) and viral load (VL) suppression during a global health crisis, which would not otherwise have been possible. Objectives To generate practice-relevant evidence on the impact of initiating ART pre-COVID-19 versus during the COVID-19 pandemic on HIV VL. Method Logistic regression was performed on data covering 6596 persons with HIV whose VL data were available, out of 36 585 persons who were initiated on ART between 01 April 2019 and 30 March 2021. Results After controlling for covariates such as age, gender, duration on ART, tuberculosis status at the time of the last visit, and rural vs urban status, the odds of having a VL < 1000 copies/mL were significantly higher for clients who started ART during the COVID-19 pandemic than the year before COVID-19 (adjusted odds ratio [AOR]: 2.50; confidence interval [CI]: 1.55–4.01; P < 0.001). Odds of having a VL < 1000 copies/mL were also significantly higher among female participants than male (AOR: 1.23; CI: 1.02–1.48), among patients attending rural clinics compared to those attending urban clinics (AOR: 1.83; CI: 1.47–2.28), and in clients who were 15 years or older at the time of their last visit (AOR: 1.50; CI: 1.07–2.11). Conclusion Viral loads did not deteriorate despite pandemic-induced changes in HIV services such as the expansion of multi-month dispensing (MMD), which may have played a protective role regardless of the general negative impacts of response to the COVID-19 crises on communities and individuals. What this study adds This research capitalises on the natural experiment of COVID-19-related changes in HIV services and provides new practice-relevant research evidence.
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Affiliation(s)
- Gulzar H. Shah
- Department of Health Policy and Community Health, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, United States of America
| | | | - Stacy W. Smallwood
- Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, United States of America
| | | | - Kristie C. Waterfield
- Department of Health Policy and Community Health, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, United States of America
| | - Osaremhen Ikhile
- Department of Health Policy and Community Health, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, United States of America
| | | | | | - Elizabeth Ayangunna
- Department of Health Policy and Community Health, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, United States of America
| | | | - Bernard Bossiky
- National Multisectoral HIV/AIDS program (PNMLS), HIV Program, Presidency of DRC, Democratic Republic of the Congo
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12
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Hermans LE, Umunnakwe CN, Lalla-Edward ST, Hebel SK, Tempelman HA, Nijhuis M, Venter WDF, Wensing AMJ. Point-of-Care Tenofovir Urine Testing for the Prediction of Treatment Failure and Drug Resistance During Initial Treatment for Human Immunodeficiency Virus Type 1 (HIV-1) Infection. Clin Infect Dis 2022; 76:e553-e560. [PMID: 36136811 PMCID: PMC9907515 DOI: 10.1093/cid/ciac755] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 08/25/2022] [Accepted: 08/30/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Viral rebound during antiretroviral treatment (ART) is most often driven by suboptimal adherence in the absence of drug resistance. We assessed the diagnostic performance of point-of-care (POC) tenofovir (TFV) detection in urine for the prediction of viral rebound and drug resistance during ART. METHODS We performed a nested case-control study within the ADVANCE randomized clinical trial (NCT03122262) in Johannesburg, South Africa. Adults with human immunodeficiency virus (HIV) and newly initiating ART were randomized to receive either dolutegravir or efavirenz, tenofovir disoproxil fumarate or alafenamide, and emtricitabine. All participants with rebound ≥200 copies/mL between 24 and 96 weeks of follow-up were selected as cases and matched to controls with virological suppression <50 copies/mL. Rapid POC urine-TFV detection was performed retrospectively. RESULTS We included 281 samples from 198 participants. Urine-TFV was detectable in 30.7% (70/228) of cases and in 100% (53/53) of controls. Undetectable urine-TFV predicted rebound with a sensitivity of 69% [95% confidence interval {CI}: 63-75] and specificity of 100% [93-100]. In cases with virological failure and sequencing data (n = 42), NRTI drug resistance was detected in 50% (10/20) of cases with detectable urine-TFV versus in 8.3% (2/24) of cases with undetectable urine-TFV. Detectable urine-TFV predicted NRTI resistance (odds ratio [OR] 10.4 [1.8-114.4] P = .005) with a sensitivity of 83% [52-98] and specificity of 69% [50-84]. CONCLUSIONS POC objective adherence testing using a urine-TFV test predicted viral rebound with high specificity. In participants with rebound, urine-TFV testing predicted the selection of drug resistance. Objective adherence testing may be used to rapidly provide insight into adherence, suppression, and drug resistance during ART.
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Affiliation(s)
- Lucas E Hermans
- Correspondence: L. E. Hermans, ward G26, Groote Schuur Hospital, Anzio Rd, Observatory, 7925, Cape Town, South Africa ()
| | | | - Samanta T Lalla-Edward
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Shane K Hebel
- OraSure Technologies Inc., Bethlehem, Pennsylvania, USA
| | | | - Monique Nijhuis
- Department of Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands,HIV Pathogenesis Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Willem D F Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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13
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Teeraananchai S, Law M, Boettiger D, Mata NDL, Gupte N, Chan YTL, Pham TN, Chaiwarith R, Ly PS, Chan YJ, Kiertiburanakul S, Khusuwan S, Zhang F, Yunihastuti E, Kumarasamy N, Pujari S, Azwa I, Somia IKA, Tanuma J, Ditangco R, Choi JY, Ng OT, Do CD, Gani Y, Ross J, Jiamsakul A. Virological failure and treatment switch after ART initiation among people living with HIV with and without routine viral load monitoring in Asia. J Int AIDS Soc 2022; 25:e25989. [PMID: 36028921 PMCID: PMC9418417 DOI: 10.1002/jia2.25989] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 08/01/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction Viral load (VL) testing is still challenging to monitor treatment responses of antiretroviral therapy (ART) for HIV treatment programme in Asia. We assessed the association between routine VL testing and virological failure (VF) and determine factors associated with switching to second‐line regimen. Methods Among 21 sites from the TREAT Asia HIV Observational Database (TAHOD), people living with HIV (PLHIV) aged ≥18 years initiating ART from 2003 to 2021 were included. We calculated the average number of VL tests per patient per year between the date of ART initiation and the most recent visit. If the median average number of VL tests was ≥ 0.80 per patient per year, the site was classified as a routine VL site. A site with a median < 0.80 was classified into the non‐routine VL sites. VF was defined as VL ≥1000 copies/ml during first‐line therapy. Factors associated with VF were analysed using generalized estimating equations with Poisson distribution. Results Of 6277 PLHIV starting ART after 2003, 3030 (48%) were from 11 routine VL testing sites and 3247 (52%) were from 10 non‐routine VL testing sites. The median follow‐up was 9 years (IQR 5–13). The median age was 35 (30–42) years; 68% were male and 5729 (91%) started non‐nucleoside reverse‐transcriptase inhibitor‐based regimen. The median pre‐ART CD4 count in PLHIV from routine VL sites was lower compared to non‐routine VL sites (144 vs. 156 cells/mm3, p <0.001). Overall, 1021 subsequent VF at a rate of 2.15 (95% CI 2.02–2.29) per 100 person‐years (PY). VF was more frequent at non‐routine VL sites (adjusted incidence rate ratio 2.85 [95% CI 2.27–3.59]) compared to routine VL sites. Other factors associated with an increased rate of VF were age <50 years and CD4 count <350 cells/mm3. A total of 817 (13%) patients switched to second‐line regimen at a rate of 1.44 (95% CI 1.35–1.54) per 100 PY. PLHIV at routine VL monitoring sites were at higher risk of switching than those at non‐routine VL sites (adjusted sub‐hazard ratio 1.78 95% CI [1.17–2.71]). Conclusions PLHIV from non‐routine VL sites had a higher incidence of persistent VF and a low switching regimen rate, reflecting possible under‐utilized VL testing.
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Affiliation(s)
- Sirinya Teeraananchai
- Department of Statistics, Faculty of Science, Kasetsart University, Bangkok, Thailand.,HIV-NAT, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Matthew Law
- The Kirby Institute, UNSW, Sydney, New South Wales, Australia
| | - David Boettiger
- The Kirby Institute, UNSW, Sydney, New South Wales, Australia
| | - Nicole De La Mata
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Nikhil Gupte
- BJ Government Medical College and Sassoon General Hospital, Pune, India
| | | | | | - Romanee Chaiwarith
- Chiang Mai University - Research Institute for Health Sciences, Chiang Mai, Thailand.,Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Penh Sun Ly
- National Center for HIV/AIDS, Dermatology & STDs, Phnom Penh, Cambodia
| | - Yu-Jiun Chan
- Taipei Veterans General Hospital, Taipei, Taiwan
| | | | | | - Fujie Zhang
- Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Evy Yunihastuti
- Faculty of Medicine, Universitas Indonesia - Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Nagalingeswaran Kumarasamy
- Chennai Antiviral Research and Treatment Clinical Research Site (CART CRS), VHS-Infectious Diseases Medical Centre, VHS, Chennai, India
| | | | - Iskandar Azwa
- University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - I Ketut Agus Somia
- Faculty of Medicine, Udayana University & Sanglah Hospital, Bali, Indonesia
| | - Junko Tanuma
- National Center for Global Health and Medicine, Tokyo, Japan
| | - Rossana Ditangco
- Research Institute for Tropical Medicine, Muntinlupa City, Philippines
| | - Jun Yong Choi
- Division of Infectious Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | | | | | - Yasmin Gani
- Hospital Sungai Buloh, Sungai Buloh, Malaysia
| | - Jeremy Ross
- TREAT Asia, amfAR - The Foundation for AIDS Research, Bangkok, Thailand
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- Department of Statistics, Faculty of Science, Kasetsart University, Bangkok, Thailand
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14
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Bernabé KJ, Siedner M, Tsai AC, Marconi VC, Murphy RA. Detection of HIV Virologic Failure and Switch to Second-Line Therapy: A Systematic Review and Meta-analysis of Data From Sub-Saharan Africa. Open Forum Infect Dis 2022; 9:ofac121. [PMID: 35434173 PMCID: PMC9007921 DOI: 10.1093/ofid/ofac121] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/06/2022] [Indexed: 11/12/2022] Open
Abstract
Background The late recognition of virologic failure (VF) places persons with HIV in Sub-Saharan Africa at risk for HIV transmission, disease progression, and death. We conducted a systematic review and meta-analysis to determine if the recognition and response to VF in the region has improved. Methods We searched for studies reporting CD4 count at confirmed VF or at switch to second-line antiretroviral therapy (ART). Using a random-effects metaregression model, we analyzed temporal trends in CD4 count at VF-or at second-line ART switch-over time. We also explored temporal trends in delay between VF and switch to second-line ART. Results We identified 26 studies enrolling patients with VF and 10 enrolling patients at second-line ART switch. For studies that enrolled patients at VF, pooled mean CD4 cell count at failure was 187 cells/mm3 (95% CI, 111 to 263). There was no significant change in CD4 count at confirmed failure over time (+4 cells/year; 95% CI, -7 to 15). Among studies that enrolled patients at second-line switch, the pooled mean CD4 count was 108 cells/mm3 (95% CI, 63 to 154). CD4 count at switch increased slightly over time (+10 CD4 cells/year; 95% CI, 2 to 19). During the same period, the mean delay between confirmation of VF and switch was 530 days, with no significant decline over time (-14 days/year; 95% CI, -58 to 52). Conclusions VF in Africa remains an event recognized late in HIV infection, a problem compounded by ongoing delays between VF and second-line switch.
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Affiliation(s)
- Kerlly J Bernabé
- Department of Tropical Medicine, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA
| | - Mark Siedner
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Alexander C Tsai
- Harvard Medical School, Boston, Massachusetts, USA
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Vincent C Marconi
- Emory University School of Medicine and Rollins School of Public Health, Atlanta, Georgia, USA
- Emory University Vaccine Center, Atlanta, Georgia, USA
- Atlanta Veterans Affairs Medical Center, Decatur, Georgia, USA
| | - Richard A Murphy
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Veterans Affairs Medical Center, White River Junction, Vermont, USA
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15
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Gumede SB, Venter F, de Wit J, Wensing A, Lalla-Edward ST. Antiretroviral therapy uptake and predictors of virological failure in patients with HIV receiving first-line and second-line regimens in Johannesburg, South Africa: a retrospective cohort data analysis. BMJ Open 2022; 12:e054019. [PMID: 35428623 PMCID: PMC9013990 DOI: 10.1136/bmjopen-2021-054019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE This study described the demographics, treatment information and identified characteristics associated with virological failure and being lost to follow-up (LTFU) for patients with HIV on first-line and second-line antiretroviral therapy (ART) regimens in a large South African cohort. DESIGN A quantitative retrospective cohort study using secondary data analysis. SETTING Seven Johannesburg inner city facilities. PARTICIPANTS Unique records of 123 002 people with HIV receiving ART at any point in the period 1 April 2004 to 29 February 2020 were included. MEASURES Demographic characteristics, ART status, CD4 count information and retention status were collected and analysed as covariates of outcomes (viral load (VL) and LTFU). RESULTS Of the total study patients, 95% (n=1 17 260) were on a first-line regimen and 5% (n=5742) were on a second-line regimen. Almost two-thirds were female (64%, n=79 226). Most patients (60%, n=72 430) were initiated on an efavirenz-based, tenofovir disoproxil fumarate-based and emtricitabine-based regimen (fixed-dose combination). 91% (n=76 737) achieved viral suppression at least once since initiating on ART and 60% (n=57 981) remained in care as at the end of February 2020. Patients from the community health centre and primary healthcare clinics were not only more likely to be virally suppressed but also more likely to be LTFU. Patients on second-line regimens were less likely to reach viral suppression (adjusted OR (aOR)=0.26, CI=0.23 to 0.28) and more likely to be LTFU (aOR=1.21, CI=1.09 to 1.35). Being older (≥25 years) and having a recent CD4 cell count≥100 cells/µL were predictors of viral suppression and retention in patients on ART. CONCLUSION Patients on first-line regimens had higher VL suppression rates and were more likely to remain in care than those on a second-line regimen. Being younger and having low CD4 cell counts were associated with poor outcomes, suggesting priority groups for ART adherence support.
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Affiliation(s)
- Siphamandla Bonga Gumede
- Department of Interdisciplinary Social Science, Utrecht University, Utrecht, the Netherlands
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Francois Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - John de Wit
- Department of Interdisciplinary Social Science, Utrecht University, Utrecht, the Netherlands
| | - Annemarie Wensing
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands
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16
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Nardell MF, Adeoti O, Peters C, Kakuhikire B, Govathson-Mandimika C, Long L, Pascoe S, Tsai AC, Katz IT. Men missing from the HIV care continuum in sub-Saharan Africa: a meta-analysis and meta-synthesis. J Int AIDS Soc 2022; 25:e25889. [PMID: 35324089 PMCID: PMC8944222 DOI: 10.1002/jia2.25889] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 02/01/2022] [Indexed: 02/03/2023] Open
Abstract
Introduction Men are missing along the HIV care continuum. However, the estimated proportions of men in sub‐Saharan Africa meeting the UNAIDS 95‐95‐95 goals vary substantially between studies. We sought to estimate proportions of men meeting each of the 95‐95‐95 goals across studies in sub‐Saharan Africa, describe heterogeneity, and summarize qualitative evidence on factors influencing care engagement. Methods We systematically searched PubMed and Embase for peer‐reviewed articles published between 1 January 2014 and 16 October 2020. We included studies involving men ≥15 years old, with data from 2009 onward, reporting on at least one 95‐95‐95 goal in sub‐Saharan Africa. We estimated pooled proportions of men meeting these goals using DerSimonion‐Laird random effects models, stratifying by study population (e.g. studies focusing exclusively on men who have sex with men vs. studies that did not), facility setting (healthcare vs. community site), region (eastern/southern Africa vs. western/central Africa), outcome measurement (e.g. threshold for viral load suppression), median year of data collection (before vs. during or after 2017) and quality criteria. Data from qualitative studies exploring barriers to men's HIV care engagement were summarized using meta‐synthesis. Results and discussion We screened 14,896 studies and included 129 studies in the meta‐analysis, compiling data over the data collection period. Forty‐seven studies reported data on knowledge of serostatus, 43 studies reported on antiretroviral therapy use and 74 studies reported on viral suppression. Approximately half of men with HIV reported not knowing their status (0.49 [95% CI, 0.41–0.58; range, 0.09–0.97]) or not being on treatment (0.58 [95% CI, 0.51–0.65; range, 0.07–0.97]), while over three‐quarters of men achieved viral suppression on treatment (0.79 [95% CI, 0.77–0.81; range, 0.39–0.97]. Heterogeneity was high, with variation in estimates across study populations, settings and outcomes. The meta‐synthesis of 40 studies identified three primary domains in which men described risks associated with engagement in HIV care: perceived social norms, health system challenges and poverty. Conclusions Psychosocial and systems‐level interventions that change men's perceptions of social norms, improve trust in and accessibility of the health system, and address costs of accessing care are needed to better engage men, especially in HIV testing and treatment.
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Affiliation(s)
- Maria F Nardell
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Oluwatomi Adeoti
- Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Carson Peters
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Bernard Kakuhikire
- Faculty of Business and Management Sciences, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Caroline Govathson-Mandimika
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa.,Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence Long
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa.,Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa.,Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Sophie Pascoe
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa.,Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Alexander C Tsai
- Harvard Medical School, Boston, Massachusetts, USA.,Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, USA.,Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ingrid T Katz
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Global Health Institute, Cambridge, Massachusetts, USA
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17
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Siedner MJ, Moosa MYS, McCluskey S, Gilbert RF, Pillay S, Aturinda I, Ard K, Muyindike W, Musinguzi N, Masette G, Pillay M, Moodley P, Brijkumar J, Rautenberg T, George G, Gandhi RT, Johnson BA, Sunpath H, Bwana MB, Marconi VC. Resistance Testing for Management of HIV Virologic Failure in Sub-Saharan Africa : An Unblinded Randomized Controlled Trial. Ann Intern Med 2021; 174:1683-1692. [PMID: 34698502 PMCID: PMC8688215 DOI: 10.7326/m21-2229] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Virologic failure in HIV predicts the development of drug resistance and mortality. Genotypic resistance testing (GRT), which is the standard of care after virologic failure in high-income settings, is rarely implemented in sub-Saharan Africa. OBJECTIVE To estimate the effectiveness of GRT for improving virologic suppression rates among people with HIV in sub-Saharan Africa for whom first-line therapy fails. DESIGN Pragmatic, unblinded, randomized controlled trial. (ClinicalTrials.gov: NCT02787499). SETTING Ambulatory HIV clinics in the public sector in Uganda and South Africa. PATIENTS Adults receiving first-line antiretroviral therapy with a recent HIV RNA viral load of 1000 copies/mL or higher. INTERVENTION Participants were randomly assigned to receive standard of care (SOC), including adherence counseling sessions and repeated viral load testing, or immediate GRT. MEASUREMENTS The primary outcome of interest was achievement of an HIV RNA viral load below 200 copies/mL 9 months after enrollment. RESULTS The trial enrolled 840 persons, divided equally between countries. Approximately half (51%) were women. Most (72%) were receiving a regimen of tenofovir, emtricitabine, and efavirenz at enrollment. The rate of virologic suppression did not differ 9 months after enrollment between the GRT group (63% [263 of 417]) and SOC group (61% [256 of 423]; odds ratio [OR], 1.11 [95% CI, 0.83 to 1.49]; P = 0.46). Among participants with persistent failure (HIV RNA viral load ≥1000 copies/mL) at 9 months, the prevalence of drug resistance was higher in the SOC group (76% [78 of 103] vs. 59% [48 of 82]; OR, 2.30 [CI, 1.22 to 4.35]; P = 0.014). Other secondary outcomes, including 9-month survival and retention in care, were similar between groups. LIMITATION Participants were receiving nonnucleoside reverse transcriptase inhibitor-based therapy at enrollment, limiting the generalizability of the findings. CONCLUSION The addition of GRT to routine care after first-line virologic failure in Uganda and South Africa did not improve rates of resuppression. PRIMARY FUNDING SOURCE The President's Emergency Plan for AIDS Relief and the National Institute of Allergy and Infectious Diseases.
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Affiliation(s)
- Mark J Siedner
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, Mbarara University of Science and Technology, Mbarara, Uganda, Africa Health Research Institute, KwaZulu-Natal, South Africa, and University of KwaZulu-Natal, Durban, South Africa (M.J.S.)
| | | | - Suzanne McCluskey
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (S.M., K.A., R.T.G.)
| | | | - Selvan Pillay
- University of KwaZulu-Natal, Durban, South Africa (M.S.M., S.P., J.B., G.G., H.S.)
| | - Isaac Aturinda
- Mbarara University of Science and Technology, Mbarara, Uganda (I.A., W.M., N.M., G.M., M.B.B.)
| | - Kevin Ard
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (S.M., K.A., R.T.G.)
| | - Winnie Muyindike
- Mbarara University of Science and Technology, Mbarara, Uganda (I.A., W.M., N.M., G.M., M.B.B.)
| | - Nicholas Musinguzi
- Mbarara University of Science and Technology, Mbarara, Uganda (I.A., W.M., N.M., G.M., M.B.B.)
| | - Godfrey Masette
- Mbarara University of Science and Technology, Mbarara, Uganda (I.A., W.M., N.M., G.M., M.B.B.)
| | - Melendhran Pillay
- National Health Laboratory Service, Durban, South Africa (M.P., P.M.)
| | | | - Jaysingh Brijkumar
- University of KwaZulu-Natal, Durban, South Africa (M.S.M., S.P., J.B., G.G., H.S.)
| | | | - Gavin George
- University of KwaZulu-Natal, Durban, South Africa (M.S.M., S.P., J.B., G.G., H.S.)
| | - Rajesh T Gandhi
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (S.M., K.A., R.T.G.)
| | | | - Henry Sunpath
- University of KwaZulu-Natal, Durban, South Africa (M.S.M., S.P., J.B., G.G., H.S.)
| | - Mwebesa B Bwana
- Mbarara University of Science and Technology, Mbarara, Uganda (I.A., W.M., N.M., G.M., M.B.B.)
| | - Vincent C Marconi
- Emory University School of Medicine and Rollins School of Public Health, Atlanta, Georgia (V.C.M.)
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18
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Reynolds Z, McCluskey SM, Moosa MYS, Gilbert RF, Pillay S, Aturinda I, Ard KL, Muyindike W, Musinguzi N, Masette G, Moodley P, Brijkumar J, Rautenberg T, George G, Johnson BA, Gandhi RT, Sunpath H, Marconi VC, Bwana MB, Siedner MJ. 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. HIV Med 2021; 23:474-484. [PMID: 34755438 PMCID: PMC9010349 DOI: 10.1111/hiv.13203] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 10/18/2021] [Indexed: 11/29/2022]
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 resistance and utilize significant health care resources. Health systems interventions to promptly detect and manage treatment failure will be a prerequisite to establishing control of the HIV epidemic.
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Affiliation(s)
| | - Suzanne M McCluskey
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | | | | | - Isaac Aturinda
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Kevin L Ard
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | | | - Godfrey Masette
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Pravi Moodley
- University of KwaZulu-Natal, Durban, South Africa.,National Health Laboratory Service, KwaZulu-Natal, Durban, South Africa
| | | | | | - Gavin George
- University of KwaZulu-Natal, Durban, South Africa
| | - Brent A Johnson
- Department of Biostatistics and Computation Biology, University of Rochester, Rochester, NY, USA
| | - Rajesh T Gandhi
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | - Vincent C Marconi
- Emory University School of Medicine, Atlanta, GA, USA.,Department of Global Health, Emory University, Atlanta, GA, USA.,Emory Vaccine Center, Atlanta, GA, USA
| | | | - Mark J Siedner
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,University of KwaZulu-Natal, Durban, South Africa.,Mbarara University of Science and Technology, Mbarara, Uganda.,Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa
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19
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Ortíz DW, Roberts-Sano O, Marroquin HE, Larson L, Franco KB, Spec A, Melendez JR, Pinzón R, Samayoa AJ, Mejia-Chew C, O Halloran JA. Factors associated with viremia in people living with HIV on antiretroviral therapy in Guatemala. AIDS Res Ther 2021; 18:79. [PMID: 34706742 PMCID: PMC8554948 DOI: 10.1186/s12981-021-00400-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 10/06/2021] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Viral suppression prevents HIV transmission and disease progression, but socio-economic and clinical factors can hinder the goal of suppression. We evaluated factors associated with viral non suppression (VNS) and persistent viremia (PV) in people living with HIV (PLHIV) receiving antiretroviral therapy (ART) in Guatemala. METHODS We conducted a cross sectional analysis using data from an ongoing cohort of PLHIV attending the largest HIV clinic in Guatemala. Univariable and multivariable analyses were conducted between PLHIV with viral suppression and detectable viremia. VNS was defined as most recent HIV RNA ≥ 200 copies/ml and PV as two consecutive HIV RNA ≥ 200 copies/ml. RESULTS Of 664 participants, 13.3% had VNS and 7.1% had PV. In univariable analysis disaggregated by gender, low income, poor education, perceived difficulty attending healthcare, and alcohol use were associated with VNS in men while low CD4 at diagnosis, multiple prior ART regimens and treatment interruptions were significant in both genders. Multiple prior ART regimens (adjusted Odds Ratio (aOR) 2.82, [95% confidence interval (CI) 1.59, 4.99], p < 0.01), treatment interruptions (aOR 4.51, [95% CI 2.13, 9.58], p < 0.01), excessive alcohol consumption (aOR 2.56, [95% CI 1.18, 5.54], p < 0.05) perceived difficulty attending healthcare (aOR 2.07, [ 95% CI 1.25, 3.42], p < 0.01) and low CD4 at diagnosis (aOR 2.34, 95% [CI 1.30, 4.20], p < 0.01) were independently associated with VNS on multivariable regression. CONCLUSIONS We conclude that socio-economic and clinical factors influence viral suppression in our cohort and vary between men and women. Gender specific approaches are necessary to achieve the 90% suppression goal.
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Affiliation(s)
- Dean W Ortíz
- Unidad de Atención Integral del VIH e Infecciones Crónicas del Hospital Roosevelt "Dr. Carlos Rodolfo Mejía Villatoro", Calzada Roosevelt, 5ta. Calle, zona 11, Guatemala City, Guatemala.
| | - Olivia Roberts-Sano
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, USA
| | - Hugo E Marroquin
- Unidad de Atención Integral del VIH e Infecciones Crónicas del Hospital Roosevelt "Dr. Carlos Rodolfo Mejía Villatoro", Calzada Roosevelt, 5ta. Calle, zona 11, Guatemala City, Guatemala
| | - Lindsey Larson
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, USA
| | - Katherine B Franco
- Unidad de Atención Integral del VIH e Infecciones Crónicas del Hospital Roosevelt "Dr. Carlos Rodolfo Mejía Villatoro", Calzada Roosevelt, 5ta. Calle, zona 11, Guatemala City, Guatemala
| | - Andrej Spec
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, USA
| | - Johanna R Melendez
- Unidad de Atención Integral del VIH e Infecciones Crónicas del Hospital Roosevelt "Dr. Carlos Rodolfo Mejía Villatoro", Calzada Roosevelt, 5ta. Calle, zona 11, Guatemala City, Guatemala
| | - Rodolfo Pinzón
- Unidad de Atención Integral del VIH e Infecciones Crónicas del Hospital Roosevelt "Dr. Carlos Rodolfo Mejía Villatoro", Calzada Roosevelt, 5ta. Calle, zona 11, Guatemala City, Guatemala
| | - Ana J Samayoa
- Unidad de Atención Integral del VIH e Infecciones Crónicas del Hospital Roosevelt "Dr. Carlos Rodolfo Mejía Villatoro", Calzada Roosevelt, 5ta. Calle, zona 11, Guatemala City, Guatemala
| | - Carlos Mejia-Chew
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, USA
| | - Jane A O Halloran
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, USA
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20
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Scheibe K, Urbańska A, Jakubowski P, Hlebowicz M, Bociąga-Jasik M, Raczyńska A, Szymczak A, Szetela B, Łojewski W, Parczewski M. Low prevalence of doravirine-associated resistance mutations among polish human immunodeficiency-1 (HIV-1)–infected patients. Antivir Ther 2021; 26:69-78. [DOI: 10.1177/13596535211043044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction Doravirine (DOR) is a novel non-nucleoside reverse transcriptase inhibitor (NNRTI) that retains activity against common NNRTI resistance mutations. In this study, we aimed to investigate the prevalence of DOR resistance mutations compared with that of resistance mutations for other NNRTIs among HIV-1-infected treatment‐experienced and -naïve patients from Poland. Methods Resistance to DOR and other NNRTIs was assessed in two datasets: 1760 antiretroviral treatment-naïve HIV-1 patients and 200 treatment‐experienced patients. All 1960 sequences were derived from the patients using bulk sequencing. For resistance analyses, Stanford HIV drug resistance database scores were used. Results Overall, DOR resistance was present in 32 patients (1.62%), of whom 13 (0.74%) were naïve and 19 (9.50%) were treatment-experienced. The most common DOR resistance mutations observed among the naïve patients were A98G and K101E (0.2% each), and those among cART-experienced patients were L100I (2.0%), K101E, V108I, H221Y, and P225H (1.5% each). Furthermore, among the naïve patients, less common resistance to DOR (0.7%) compared with that to nevirapine (NVP) (2.1%; p = 0.0013) and rilpivirine (5.40%; p < 0.0001) was observed. For sequences obtained from treatment-experienced patients, the frequency of resistance to DOR (9.5%) was lower than that for efavirenz (25.5%; p < 0.0001) and NVP (26.0%; p < 0.0001). Conclusions The frequency of transmitted drug resistance to DOR is low, allowing for effective treatment of antiretroviral treatment-naïve patients and rapid treatment initiation. In cART-experienced patients, this agent remains an attractive NNRTI option with a higher genetic barrier to resistance.
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Affiliation(s)
- Kaja Scheibe
- Department of Infectious, Tropical Diseases and Immune Deficiency, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Anna Urbańska
- Department of Infectious, Tropical Diseases and Immune Deficiency, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | | | - Maria Hlebowicz
- Department of Infectious Diseases, Medical University of Gdansk, Gdańsk, Poland
| | - Monika Bociąga-Jasik
- Department of Infectious and Tropical Diseases, Jagiellonian University Medical College, Kraków, Poland
| | - Aleksandra Raczyńska
- Department of Infectious and Tropical Diseases, Jagiellonian University Medical College, Kraków, Poland
| | - Aleksandra Szymczak
- Department of Infectious Diseases, Liver Diseases and Acquired Immune Deficiencies, Wroclaw Medical University, Wrocław, Poland
| | - Bartosz Szetela
- Department of Infectious Diseases, Liver Diseases and Acquired Immune Deficiencies, Wroclaw Medical University, Wrocław, Poland
| | - Władysław Łojewski
- Department of Infectious Diseases, Regional Hospital in Zielona Gora, Zielona Góra, Poland
| | - Miłosz Parczewski
- Department of Infectious, Tropical Diseases and Immune Deficiency, Pomeranian Medical University in Szczecin, Szczecin, Poland
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21
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Low A, Sachathep K, Rutherford G, Nitschke AM, Wolkon A, Banda K, Miller LA, Solmo C, Jackson K, Patel H, McCracken S, Findley S, Mutenda N. Migration in Namibia and its association with HIV acquisition and treatment outcomes. PLoS One 2021; 16:e0256865. [PMID: 34473757 PMCID: PMC8412347 DOI: 10.1371/journal.pone.0256865] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 08/17/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In the 21st century, understanding how population migration impacts human health is critical. Namibia has high migration rates and HIV prevalence, but little is known about how these intersect. We examined the association between migration and HIV-related outcomes using data from the 2017 Namibia Population-based HIV Impact Assessment (NAMPHIA). METHODS AND FINDINGS The NAMPHIA survey selected a nationally representative sample of adults in 2017. All adults aged 15-64 years were invited to complete an interview and home-based HIV test. Recent infection (<130 days) was measured using HIV-1 LAg avidity combined with viral load (>1000 copies/mL) and antiretroviral analyte data. Awareness of HIV status and antiretroviral use were based on self-report and/or detectable antiretrovirals in blood. Viremia was defined as having a viral load ≥1000 copies/mL, including all participants in the denominator regardless of serostatus. We generated community viremia values as a weighted proportion at the EA level, excluding those classified as recently infected. Significant migrants were those who had lived outside their current region or away from home >one month in the past three years. Recent cross-community in-migrants were those who had moved to the community <two years ago. Separate analyses were done to compare significant migrants to non-migrants and recent cross-community in-migrants to those who in-migrated >two years ago to determine the association of migration and timing with recent infection or viral load suppression (VLS). All proportions are weighted. Of eligible adults, we had HIV results and migration data on 9,625 (83.9%) of 11,474 women and 7,291 (73.0%) of 9,990 men. Most respondents (62.5%) reported significant migration. Of cross-community in-migrants, 15.3% were recent. HIV prevalence was 12.6% and did not differ by migration status. Population VLS was 77.4%. Recent cross-community in-migration was associated with recent HIV infection (aOR: 4.01, 95% CI 0.99-16.22) after adjusting for community viremia. Significant migration (aOR 0.73, 95% CI: 0.55-0.97) and recent cross-community in-migration (aOR 0.57, 95% CI: 0.35-0.92) were associated with lower VLS, primarily due to lack of awareness of HIV infection. The study was limited by lack of precise data on trajectory of migration. CONCLUSIONS Despite a high population-level VLS, Namibia still has migrant populations that are not accessing effective treatment for HIV. Targeting migrants with effective prevention and testing programs in communities with viremia could enable further epidemic control.
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Affiliation(s)
- Andrea Low
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, United States of America
- * E-mail:
| | - Karam Sachathep
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, United States of America
| | - George Rutherford
- Institute for Global Health Sciences, University of California, San Francisco, CA, United States of America
| | | | - Adam Wolkon
- Centers for Disease Control and Prevention, Windhoek, Namibia
| | - Karen Banda
- Institute for Global Health Sciences, University of California, San Francisco, CA, United States of America
| | | | - Chelsea Solmo
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, United States of America
| | - Keisha Jackson
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Center for Global Health, Atlanta, GA, United States of America
| | - Hetal Patel
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Center for Global Health, Atlanta, GA, United States of America
| | - Stephen McCracken
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Center for Global Health, Atlanta, GA, United States of America
| | - Sally Findley
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, United States of America
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22
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Does antiretroviral therapy alter the course of Parkinson's disease in people living with HIV? J Neurovirol 2021; 27:595-600. [PMID: 34351573 DOI: 10.1007/s13365-021-00999-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 06/21/2021] [Accepted: 07/01/2021] [Indexed: 10/20/2022]
Abstract
South Africa has the world's largest antiretroviral programme which has resulted in an increase in life expectancy in persons living with HIV. Parkinson's disease (PD) is an age-related neurodegenerative disorder. No data has been published in this setting with regards to the interaction between PD and people infected with HIV. This was a retrospective study which matched two HIV non-infected PD patients to one HIV-infected patient with PD. Patients with secondary causes of Parkinsonism were excluded. Demographic, clinical and laboratory data were extracted from the charts. Hoehn and Yahr scale was used to assess PD severity. Twenty PD patients were recruited from 1 January 2008 to 31 October 2020 and were diagnosed with HIV for a median of 72 months. The median age at onset of PD was 52 years. All patients were on antiretroviral therapy. There were no statistically significant differences in the levodopa equivalent daily dose, clinical phenotype, impulse control disorders (ICDs) and frequency of a positive family history between the two groups. HIV-infected patients had a higher frequency of dopamine dysregulation syndrome. At the end of follow-up, 3 (15%) PLH-PD had moderate to severe PD compared to 16 (40%) of PD controls. The OR of having moderate to severe PD in HIV non-infected PD patients was 4. Persons living with HIV and Parkinson's disease present with PD symptoms at a younger age, progress slower to a severe stage and respond well to dopaminergic replacement therapy.
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23
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Hermans LE, Nijhuis M, Tempelman HA, Houts T, Schuurman R, Burger DM, Wensing AMJ, ter Heine R. Point-of-Care Detection of Nonadherence to Antiretroviral Treatment for HIV-1 in Resource-Limited Settings Using Drug Level Testing for Efavirenz, Lopinavir, and Dolutegravir: A Validation and Pharmacokinetic Simulation Study. J Acquir Immune Defic Syndr 2021; 87:1072-1078. [PMID: 34153013 DOI: 10.1097/qai.0000000000002681] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 12/30/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Virological failure during antiretroviral treatment (ART) may indicate the presence of drug resistance, but may also originate from nonadherence. Qualitative detection of ART components using drug level testing may be used to differentiate between these scenarios. We aimed to validate and implement qualitative point-of-care drug level tests for efavirenz (EFV), lopinavir (LPV), and dolutegravir (DTG) in rural South Africa. METHODS Qualitative performance of immunoassays for EFV, LPV, and DTG was assessed by calculating limit of detection (LoD), region of uncertainty, and qualitative agreement with a reference test. Minimum duration of nonadherence resulting in a negative drug level test was assessed by simulation of treatment cessation using validated population pharmacokinetic models. RESULTS LoD was 0.05 mg/L for EFV, 0.06 mg/L for LPV, and 0.02 mg/L for DTG. Region of uncertainty was 0.01-0.06 mg/L for EFV, 0.01-0.07 mg/L for LPV, and 0.01-0.02 mg/L for DTG. Qualitative agreement with reference testing at the LoD in patient samples was 95.2% (79/83) for EFV, 99.3% (140/141) for LPV, and 100% (118/118) for DTG. After simulated treatment cessation, median time to undetectability below LoD was 7 days [interquartile range (IQR) 4-13] for EFV, 30 hours (IQR 24-36) for LPV, and 6 days (IQR 4-7) for DTG. CONCLUSIONS We demonstrate that qualitative ART drug level testing using immunoassays is feasible in a rural resource-limited setting. Implementation of this technology enables reliable detection of recent nonadherence and may allow for rapid and cost-effective differentiation between patients in need for adherence counseling and patients who require drug resistance testing or alternative treatment.
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Affiliation(s)
- Lucas E Hermans
- Virology, Department of Medical Microbiology, University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
- Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
- Ndlovu Research Consortium, Elandsdoorn, South Africa
| | - Monique Nijhuis
- Virology, Department of Medical Microbiology, University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
- Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
- Ndlovu Research Consortium, Elandsdoorn, South Africa
| | | | - Tom Houts
- ARK Diagnostics, Inc., Fremont, CA; and
| | - Rob Schuurman
- Virology, Department of Medical Microbiology, University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
| | - David M Burger
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Annemarie M J Wensing
- Virology, Department of Medical Microbiology, University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
- Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
- Ndlovu Research Consortium, Elandsdoorn, South Africa
| | - Rob ter Heine
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
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24
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Abstract
Supplemental Digital Content is Available in the Text. Background: HIV differentiated service delivery (DSD) models are scaling up in resource-limited settings for stable patients; less is known about DSD outcomes for patients with viremia. We evaluated the effect on viral suppression (VS) of a streamlined care DSD model implemented in the SEARCH randomized universal test and treat trial in rural Uganda and Kenya (NCT:01864603). Methods: We included HIV-infected adults at baseline (2013) who were country guideline antiretroviral therapy (ART) eligible (prior ART experience or CD4 ≤ 350) with ≥1 HIV clinic visit between 2013 and 2017 in SEARCH communities randomized to intervention (N = 16) or control (N = 16). We assessed the effect of streamlined care in intervention community clinics (patient-centered care, increased appointment spacing, improved clinic access, reminders, and tracking) on VS at 3 years. Analysis was stratified by the baseline care status: ART-experienced with viremia, ART-naïve with CD4 ≤ 350, or ART-experienced with VS. Results: Among 6190 ART-eligible persons in care, year 3 VS was 90% in intervention and 87% in control arms (RR 1.03, 95% CI: 1.01 to 1.06). Among ART-experienced persons with baseline viremia, streamlined care was associated with higher VS (67% vs 47%, RR 1.41, 95% CI: 1.05 to 1.91). Among ART-naïve persons, VS was not significantly higher with streamlined care (83% vs 79%, RR 1.05, 95% CI: 0.95 to 1.16). Among ART-experienced persons with baseline VS, nearly all remained virally suppressed in both arms (97% vs 95%, RR 1.01, 95% CI: 1.00 to 1.03). Conclusions: Streamlined care was associated with higher viral suppression among ART-experienced patients with viremia in this randomized evaluation of ART-eligible patients who were in care after universal HIV testing.
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Dorward J, Sookrajh Y, Ngobese H, Lessells R, Sayed F, Bulo E, Moodley P, Samsunder N, Lewis L, Tonkin-Crine S, Drain PK, Hayward G, Butler CC, Garrett N. Protocol for a randomised feasibility study of Point-Of-care HIV viral load testing to Enhance Re-suppression in South Africa: the POwER study. BMJ Open 2021; 11:e045373. [PMID: 33593788 PMCID: PMC7888322 DOI: 10.1136/bmjopen-2020-045373] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 01/21/2021] [Accepted: 02/02/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Access to HIV viral load testing remains difficult for many people on antiretroviral therapy (ART) in low-income and middle-income countries. Weak laboratory and clinic systems often delay the detection and management of viraemia, which can lead to morbidity, drug resistance and HIV transmission. Point-of-care testing could overcome these challenges. We aim to assess whether it is feasible to conduct a randomised trial of point-of-care viral load testing to manage viraemia. METHODS AND ANALYSIS We will conduct an open-label, single-site, individually randomised, feasibility study of Point-Of-care HIV viral load testing to Enhance Re-suppression, in Durban, South Africa. We will enrol approximately 100 people living with HIV who are aged ≥18 years, receiving first-line ART but with recent viraemia ≥1000 copies/mL, and randomise them 1:1 to receive point-of-care viral load or standard laboratory viral load monitoring, after 12 weeks. All participants will continue to receive care from public sector healthcare workers following South African HIV management guidelines. Participants with persistent viraemia ≥1000 copies/mL will be considered for switching to second-line ART. We will compare the proportion in each study arm who achieve the primary outcome of viral suppression <50 copies/mL at 24 weeks after enrolment. Additional outcomes include proportions retained in the study, proportions with HIV drug resistance, time to viral load results and time to switching to second-line ART. We will assess implementation of point-of-care viral load testing using process evaluation data, and through interviews and focus groups with healthcare workers. ETHICS AND DISSEMINATION University of Oxford Tropical Research Ethics Committee and the Biomedical Research Ethics Committee of the University of KwaZulu-Natal have approved the study. We will present results to stakeholders, and through conferences and open-access, peer-reviewed journals. TRIAL REGISTRATION NUMBER PACTR202001785886049.
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Affiliation(s)
- Jienchi Dorward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Centre for the Aids Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
| | | | - Hope Ngobese
- eThekwini Municipality Health Unit, Durban, South Africa
| | - Richard Lessells
- Centre for the Aids Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
- KwaZulu-Natal Research and Innovation Sequencing Platform (KRISP), University of KwaZulu-Natal, Durban, South Africa
| | - Fathima Sayed
- Centre for the Aids Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
| | - Elliot Bulo
- eThekwini Municipality Health Unit, Durban, South Africa
| | - P Moodley
- Department of Virology, University of KwaZulu-Natal, Durban, South Africa
- National Health Laboratory Service, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Natasha Samsunder
- Centre for the Aids Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
| | - Lara Lewis
- Centre for the Aids Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| | - Paul K Drain
- Department of Global Health, Schools of Medicine and Public Health, University of Washington, Seattle, Washington, USA
- Department of Medicine, School of Medicine, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington, USA
| | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nigel Garrett
- Centre for the Aids Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
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Zhao Y, Han MJ, Gan XM, Ma Y, Zhao DC. Characteristics and viral suppression among people living with HIV from the National Free Antiretroviral Therapy Programme, 2019. HIV Med 2020; 21:701-707. [PMID: 33369034 DOI: 10.1111/hiv.13020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES This study aimed to present the clinical characteristics of and viral suppression in the national antiretroviral therapy (ART) cohort in China. METHODS A cross-sectional study was conducted among the participants enrolled in China's National Free Antiretroviral Therapy Programme (NFATP) who were on ART at the end of 2019. The data used were from China's NFATP information system. The primary outcome was viral load (VL) suppression. Full virological suppression and low-level viraemia (LLV) were defined as VL < 50 copies/mL and between 51 and 999 copies/mL, respectively. RESULTS At the end of 2019, 853 429 people living with HIV (PLWH) were on ART. The median age was 44 years [interquartile range (IQR): 33-54]. The majority of PLWH were 25-44 years old (47.2%) and male (73.5%) and reported HIV infection via heterosexual contact (64.5%). The median (IQR) baseline CD4 count was 257 (140-376) cells/μL. Among the 704 375 PLWH who were on ART for at least 12 months, 82.9% had full virological suppression, 6.5% had VL between 50 and 1000 copies/mL (LLV) and 4.3% had VL > 1000 copies/mL. Optimal full virological suppression occurred in participants who acquired HIV through homosexual contact (88.4%). CONCLUSIONS Although China can be credited for substantial progress in scaling up ART and viral suppression, challenges remain in some key populations, such as injecting drug users, participants with a history of treatment failure and hepatitis C virus co-infected people. To improve the programme output, additional monitoring and intervention for LLV are necessary.
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Affiliation(s)
- Y Zhao
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - M J Han
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - X M Gan
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Y Ma
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - D C Zhao
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
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Girdwood SJ, Crompton T, Sharma M, Dorward J, Garrett N, Drain PK, Stevens W, Nichols BE. Cost-effectiveness of adoption strategies for point of care HIV viral load monitoring in South Africa. EClinicalMedicine 2020; 28:100607. [PMID: 33294817 PMCID: PMC7700965 DOI: 10.1016/j.eclinm.2020.100607] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/08/2020] [Accepted: 10/08/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Viral load (VL) testing is recommended for monitoring people on ART. The National Health Laboratory Service (NHLS) in South Africa conducts >5million laboratory-based VL tests but faces challenges with specimen integrity and results delivery. Point-of-care (POC) VL monitoring may improve VL suppression (VLS). We assessed the cost-effectiveness of different strategies for POC testing in South Africa. METHODS We developed a cost-outcome model utilizing NHLS data, including facility-level annual VL volumes, proportion with VLS, specimen rejection rates, turn-around-time, and the cost/test. We assessed the impact of adopting POC VL technology under 4 strategies: (1) status-quo; (2) targeted POC testing at facilities with high levels of viral failure; (3) targeted POC testing at low-performing facilities; (4) complete POC adoption. For each strategy, we determined the total cost, effectiveness (expected number of virally suppressed people) and incremental cost-effectiveness ratio (ICER) based on expected (>10%) VLS improvement. FINDINGS Existing laboratory-based VL testing costs $126 m annually and achieves 85.2% VLS. Strategy 2 was the most cost-effective approach, with 88.5% VLS and $40/additional person suppressed, compared to the status-quo. Should resources allow, complete POC adoption may be cost-effective (ICER: $136/additional person suppressed), requiring an additional $49 m annually and achieving 94.5% VLS. All other strategies were dominated in the incremental analysis. INTERPRETATION Assuming POC VL monitoring confers clinical benefits, the most cost-effective strategy for POC adoption in South Africa is a targeted approach with POC VL technologies placed at facilities with high level of viral failure. FUNDING Funding support from the Bill & Melinda Gates Foundation.
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Affiliation(s)
- Sarah J. Girdwood
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Viroscience, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Thomas Crompton
- Strategic Information Analytics, Right to Care, Johannesburg, South Africa
| | - Monisha Sharma
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, WA, USA
| | - Jienchi Dorward
- Centre for the AIDS Programme of Research in Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Nigel Garrett
- Centre for the AIDS Programme of Research in Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Paul K. Drain
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, WA, USA
| | - Wendy Stevens
- National Health Laboratory Service, Johannesburg, South Africa
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Brooke E. Nichols
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Ave, Crosstown Center, 3rd floor, Boston, MA 02118, USA
- Corresponding author at: Department of Global Health, Boston University School of Public Health, 801 Massachusetts Ave, Crosstown Center, 3rd floor, Boston, MA 02118, USA.
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Amstutz A, Nsakala BL, Vanobberghen F, Muhairwe J, Glass TR, Namane T, Mpholo T, Battegay M, Klimkait T, Labhardt ND. Switch to second-line versus continued first-line antiretroviral therapy for patients with low-level HIV-1 viremia: An open-label randomized controlled trial in Lesotho. PLoS Med 2020; 17:e1003325. [PMID: 32936795 PMCID: PMC7494118 DOI: 10.1371/journal.pmed.1003325] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/11/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Current World Health Organization (WHO) antiretroviral therapy (ART) guidelines define virologic failure as two consecutive viral load (VL) measurements ≥1,000 copies/mL, triggering empiric switch to next-line ART. This trial assessed if patients with sustained low-level HIV-1 viremia on first-line ART benefit from a switch to second-line treatment. METHODS AND FINDINGS This multicenter, parallel-group, open-label, superiority, randomized controlled trial enrolled patients on first-line ART containing non-nucleoside reverse transcriptase inhibitors (NNRTI) with two consecutive VLs ≥100 copies/mL, with the second VL between 100-999 copies/mL, from eight clinics in Lesotho. Consenting participants were randomly assigned (1:1), stratified by facility, demographic group, and baseline VL, to either switch to second-line ART (switch group) or continued first-line ART (control group; WHO guidelines). The primary endpoint was viral suppression (<50 copies/mL) at 36 weeks. Analyses were by intention to treat, using logistic regression models, adjusted for demographic group and baseline VL. Between August 1, 2017, and August 7, 2019, 137 individuals were screened, of whom 80 were eligible and randomly assigned to switch (n = 40) or control group (n = 40). The majority of participants were female (54 [68%]) with a median age of 42 y (interquartile range [IQR] 35-51), taking tenofovir disoproxil fumarate/lamivudine/efavirenz (49 [61%]) and on ART for a median of 5.9 y (IQR 3.3-8.6). At 36 weeks, 22/40 (55%) participants in the switch versus 10/40 (25%) in the control group achieved viral suppression (adjusted difference 29%, 95% CI 8%-50%, p = 0.009). The switch group had significantly higher probability of viral suppression across different VL thresholds (<20, <100, <200, <400, and <600 copies/mL) but not for <1,000 copies/mL. Thirty-four (85%) participants in switch group and 21 (53%) in control group experienced at least one adverse event (AE) (p = 0.002). No hospitalization or death or other serious adverse events were observed. Study limitations include a follow-up period too short to observe differences in clinical outcomes, missing values in CD4 cell counts due to national stockout of reagents during the study, and limited generalizability of findings to other than NNRTI-based first-line ART regimens. CONCLUSIONS In this study, switching to second-line ART among patients with sustained low-level HIV-1 viremia resulted in a higher proportion of participants with viral suppression. These results endorse lowering the threshold for virologic failure in future WHO guidelines. TRIAL REGISTRATION The trial is registered at ClinicalTrials.gov, NCT03088241.
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Affiliation(s)
- Alain Amstutz
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | | | - Fiona Vanobberghen
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | | | - Tracy Renée Glass
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Tilo Namane
- Motebang Government Hospital, Leribe, Lesotho
| | | | - Manuel Battegay
- University of Basel, Basel, Switzerland
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Thomas Klimkait
- Molecular Virology, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Niklaus Daniel Labhardt
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
- * E-mail:
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Ross J, Ribakare M, Remera E, Murenzi G, Munyaneza A, Hoover DR, Shi Q, Nsanzimana S, Yotebieng M, Nash D, Anastos K. High levels of viral load monitoring and viral suppression under Treat All in Rwanda - a cross-sectional study. J Int AIDS Soc 2020; 23:e25543. [PMID: 32536033 PMCID: PMC7293767 DOI: 10.1002/jia2.25543] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/14/2020] [Accepted: 05/13/2020] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Aiming to reach UNAIDS 90-90-90 targets, nearly all sub-Saharan African countries have expanded antiretroviral therapy (ART) to all people living with HIV (PLWH) (Treat All). Few published data exist on viral load testing and viral suppression under Treat All in this region. We assessed proportions of patients with available viral load test results and who were virally suppressed, as well as factors associated with viral suppression, among PLWH in 10 Rwandan health centres after Treat All implementation. METHODS Cross-sectional study during 2018 of adults (≥15 years) engaged in HIV care at 10 Rwandan health centres. Outcomes were being on ART (available ART initiation date in the study database, with no ART discontinuation prior to 1 January 2018), retained on ART (≥2 post-ART health centre visits ≥90 days apart during 2018), available viral load test results (viral load measured in 2018 and available in study database) and virally suppressed (most recent 2018 viral load <200 copies/mL). We used modified Poisson regression models accounting for clustering by health centre to determine factors associated with being virally suppressed. RESULTS Of 12,238 patients, 7050 (58%) were female and 1028 (8%) were aged 15 to 24 years. Nearly all patients (11,933; 97%) were on ART, of whom 11,198 (94%) were retained on ART. Among patients retained on ART, 10,200 (91%) had available viral load results; of these 9331 (91%) were virally suppressed. Viral suppression was less likely among patients aged 15 to 24 compared to >49 years (adjusted prevalence ratio (aPR): 0.83, 95% CI 0.76 to 0.90 and those with pre-ART CD4 counts of <200 compared to ≥500 cells/mm3 (aPR: 0.92, 95% CI 0.90 to 0.93). There was no statistically significant difference in viral suppression among patients who entered after Treat All implementation compared to those who enrolled before 2010 (aPR 0.98, 95% CI 0.94 to 1.03). CONCLUSIONS In this large cohort of Rwandan PLWH receiving HIV care after Treat All implementation, patients in study health centres have surpassed the third UNAIDS 90-90-90 target. To ensure all PLWH fully benefit from ART, additional efforts should focus on improving ART adherence among younger persons.
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Affiliation(s)
- Jonathan Ross
- Division of General Internal MedicineMontefiore Medical Center/Albert Einstein College of MedicineBronxNYUSA
| | - Muhayimpundu Ribakare
- Institute of HIV/AIDS Disease Prevention and ControlRwanda Biomedical CenterKigaliRwanda
| | - Eric Remera
- Institute of HIV/AIDS Disease Prevention and ControlRwanda Biomedical CenterKigaliRwanda
| | - Gad Murenzi
- Research DivisionRwanda Military HospitalKigaliRwanda
| | | | - Donald R Hoover
- Department of Statistics and Biostatistics and Institute for HealthHealth Care Policy and Aging ResearchRutgers the State University of New JerseyNJUSA
| | - Qiuhu Shi
- Department of Epidemiology and Community HealthNew York Medical CollegeValhallaNYUSA
| | - Sabin Nsanzimana
- Institute of HIV/AIDS Disease Prevention and ControlRwanda Biomedical CenterKigaliRwanda
| | - Marcel Yotebieng
- Division of General Internal MedicineMontefiore Medical Center/Albert Einstein College of MedicineBronxNYUSA
| | - Denis Nash
- Institute for Implementation Science in Population HealthCity University of New YorkNew YorkNYUSA
| | - Kathryn Anastos
- Division of General Internal MedicineMontefiore Medical Center/Albert Einstein College of MedicineBronxNYUSA
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Hermans LE, Steegen K, ter Heine R, Schuurman R, Tempelman HA, Moraba R, van Maarseveen E, Nijhuis M, Pillay T, Legg‐E’Silva D, Snyman T, Schapiro JM, Burger DM, Carmona S, Wensing AMJ. Drug level testing as a strategy to determine eligibility for drug resistance testing after failure of ART: a retrospective analysis of South African adult patients on second-line ART. J Int AIDS Soc 2020; 23:e25501. [PMID: 32515898 PMCID: PMC7282495 DOI: 10.1002/jia2.25501] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 03/23/2020] [Accepted: 03/27/2020] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION When protease inhibitor (PI)-based second-line ART fails, guidelines recommend drug resistance testing and individualized third-line treatment. However, PI-resistant viral strains are rare and drug resistance testing is costly. We investigated whether less costly PI-exposure testing can be used to select those patients who would benefit most from drug resistance testing. METHODS We performed a retrospective analysis of South African adults living with HIV experiencing failure of ritonavir-boosted-lopinavir (LPV/r)-based second-line ART for whom drug resistance testing results were available. We included patients who received plasma-based drug resistance testing at a central South African reference laboratory in 2017 and patients who received dried blood spots (DBS)-based drug resistance testing at a rural South African clinic between 2009 and 2017. PI-exposure testing was performed on remnant plasma or DBS using liquid chromatography mass spectrometry (LCMS). Additionally, a low-cost immunoassay was used on plasma. Population genotypic drug resistance testing of the pol region was performed on plasma and DBS using standard clinical protocols. RESULTS Samples from 544 patients (494 plasma samples and 50 DBS) were included. Median age was 41.0 years (IQR: 33.3 to 48.5) and 58.6% were women. Median HIV-RNA load was 4.9 log10 copies/mL (4.3 to 5.4). Prevalence of resistance to the NRTI-backbone was 70.6% (349/494) in plasma samples and 56.0% (28/50) in DBS. Major PI-resistance mutations conferring high-level resistance to LPV/r were observed in 26.7% (132/494) of plasma samples and 12% (6/50) of DBS. PI-exposure testing revealed undetectable LPV levels in 47.0% (232/494) of plasma samples and in 60.0% (30/50) of DBS. In pooled analysis of plasma and DBS samples, detectable LPV levels had a sensitivity of 90% (84% to 94%) and a negative predictive failure of 95% (91% to 97%) for the presence of major LPV/r resistance. CONCLUSIONS PI-exposure testing revealed non-adherence in half of patients experiencing failure on second-line ART and accurately predicted the presence or absence of clinically relevant PI resistance. PI-exposure testing constitutes a novel screening strategy in patients with virological failure of ART that can differentiate between different underlying causes of therapy failure and may allow for more effective use of limited resources available for drug resistance testing.
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Affiliation(s)
- Lucas E Hermans
- VirologyDepartment of Medical MicrobiologyUniversity Medical Center Utrecht (UMCU)UtrechtThe Netherlands
- Wits Reproductive Health and HIV Institute (Wits RHI)University of the WitwatersrandJohannesburgSouth Africa
- Ndlovu Research ConsortiumElandsdoornSouth Africa
| | - Kim Steegen
- Department of Molecular Medicine and HaematologyFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Molecular Medicine and HaematologyNational Health Laboratory Service (NHLS)JohannesburgSouth Africa
| | - Rob ter Heine
- Department of PharmacyRadboud Institute for Health SciencesRadboud University Medical CenterNijmegenThe Netherlands
| | - Rob Schuurman
- VirologyDepartment of Medical MicrobiologyUniversity Medical Center Utrecht (UMCU)UtrechtThe Netherlands
| | - Hugo A Tempelman
- Wits Reproductive Health and HIV Institute (Wits RHI)University of the WitwatersrandJohannesburgSouth Africa
- Ndlovu Research ConsortiumElandsdoornSouth Africa
| | | | | | - Monique Nijhuis
- VirologyDepartment of Medical MicrobiologyUniversity Medical Center Utrecht (UMCU)UtrechtThe Netherlands
- Wits Reproductive Health and HIV Institute (Wits RHI)University of the WitwatersrandJohannesburgSouth Africa
- Ndlovu Research ConsortiumElandsdoornSouth Africa
| | - Taryn Pillay
- Department of ChemistryUniversity of the WitwatersrandJohannesburgSouth Africa
- National Health Laboratory Service (NHLS)JohannesburgSouth Africa
| | - Derryn Legg‐E’Silva
- Department of ChemistryUniversity of the WitwatersrandJohannesburgSouth Africa
- National Health Laboratory Service (NHLS)JohannesburgSouth Africa
| | - Tracy Snyman
- Department of ChemistryUniversity of the WitwatersrandJohannesburgSouth Africa
- National Health Laboratory Service (NHLS)JohannesburgSouth Africa
| | | | - David M Burger
- Department of PharmacyRadboud Institute for Health SciencesRadboud University Medical CenterNijmegenThe Netherlands
| | - Sergio Carmona
- Department of Molecular Medicine and HaematologyFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Molecular Medicine and HaematologyNational Health Laboratory Service (NHLS)JohannesburgSouth Africa
| | - Annemarie MJ Wensing
- VirologyDepartment of Medical MicrobiologyUniversity Medical Center Utrecht (UMCU)UtrechtThe Netherlands
- Wits Reproductive Health and HIV Institute (Wits RHI)University of the WitwatersrandJohannesburgSouth Africa
- Ndlovu Research ConsortiumElandsdoornSouth Africa
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