Immuno-virological response and associated factors amongst HIV-1 vertically infected adolescents in Yaoundé-Cameroon

Determinants of Immunovirological Response among Children and Adolescents Living with HIV-1 in the Central Region of Cameroon

About 90% of new HIV-1 infections in children occur in sub-Saharan Africa, where treatment monitoring remains suboptimal. We sought to ascertain factors associated with immunovirological responses among an ART-experienced paediatric population in Cameroon. A laboratory-based and analytical study was conducted from January 2017 throughout December 2020 wherein plasma viral load (PVL) analyses and CD4 cell counts were performed. Viral suppression (VS) was defined as PVL < 1000 copies/mL and immunological failure (IF) as CD4 < 500 cells/µL for participants ≤5 years and CD4 < 250 cells/µL for those >5 years; p < 0.05 was considered statistically significant. Overall, 272 participants were enrolled (median age: 13 [9-15.5] years; 54% males); median ART duration 7 [3-10] years. Globally, VS was achieved in 54.41%. VS was 56.96% in urban versus 40.48% in rural areas (p = 0.04). IF was 22.43%, with 15.79% among participants ≤5 years and 22.92% among those >5 years (p = 0.66). IF was 20.43% in urban versus 33.33% in rural areas (p = 0.10). Following ART, IF was 25.82% on first-line (non-nucleoside reverse transcriptase inhibitors; NNRTI-based) versus 10.17% on second-line (protease inhibitor-based) regimens (p = 0.01). Interestingly, IF was 7.43% among virally suppressed versus 40.32% among virally unsuppressed participants (p < 0.0001). A low VS indicates major challenges in achieving AIDS' elimination in this paediatric population, especially in rural settings and poor immune statuses. Scaling up NNRTI-sparing regimens alongside close monitoring would ensure optimal therapeutic outcomes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Virological failure and adherence to antiretroviral therapy in adolescents and young adults living with human immunodeficiency virus

OBJECTIVE

HIV (human immunodeficiency virus) infection remains a major public health challenge. Infected young people at any age are less likely to adhere to care in a timely manner and to maintain a suppressed VL. This review aims to identify factors associated with virologic failure and adherence to drug therapy in adolescents and young adults (10-24 years) living with HIV.

METHODS

Systematic review using the PubMed and Virtual Health Library databases and including articles published between 2009 and 2021. Data were analysed in six categories: individual factors, pharmacological/therapy-related aspects, factors related to HIV/acquired immunodeficiency syndrome (AIDS) infection, HIV/AIDS stigma, social support and health system/services. The study's protocol was registered on the PROSPERO platform (CRD42020167581).

RESULTS

A total of 19,819 articles were found in the initial search and 31 studies were included in this systematic review. Most studies were carried out on the African continent. Male sex, alcohol use, low education, adverse effects of medication, lack of social support, stigma related to HIV/AIDS, need for transportation to access the health service and forgetfulness were linked to poor adherence to therapy. Good adherence was achieved with sufficient nutrition, good social support, greater confidence in the use of therapy and fewer ART side effects. Low levels of CD4, alcohol use, substance abuse, low education, non-adherence to medication and forgetfulness were linked to virological failure.

CONCLUSION

Individual, social and structural factors constitute barriers to adherence to ART among adolescent and young adults. It is necessary to know the difficulties related to the use of therapy to work out specific strategies that create conditions to improve medication adherence and viral suppression, reducing the levels of virological failure in this population.

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

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

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

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

Magnitude and associated factors of anti-retroviral therapy adherence among children attending HIV care and treatment clinics in Dar es Salaam, Tanzania

Introduction

The HIV pandemic continues to contribute significantly towards childhood mortality and morbidity. The up-scaling of the Anti-retroviral therapy (ART) access has seen more children surviving and sanctions great effort be made on ensuring adherence. Adherence is a dynamic process that changes over time and is determined by variable factors. This necessitates the urgency to conduct studies to determine the potential factors affecting adherence in our setting and therefore achieve the 90-90-90 goal of sustainable viral suppression.

Objectives

To assess the magnitude and associated factors of ART adherence among children (1–14 years) attending HIV care and treatment clinics during the months of July to November 2018 in Dar es Salaam.

Methods

A cross-sectional clinic-based study, conducted in three selected HIV care and treatment clinics in urban Dar es Salaam; Muhimbili National Hospital (MNH), Temeke Regional Referral Hospital (TRRH), Infectious Disease Centre- DarDar Paediatric Program (IDC-DPP) HIV clinics during the months of July to November 2018. HIV-infected children aged 1–14 years who had been on treatment for at least six months were consecutively enrolled until the sample size was achieved. A structured questionnaire was used for data collection. Four-day self-report, one-month self-recall report and missed clinic appointments were used to assess adherence. Frequencies and percentages were used to describe categorical data. The odds ratio was used to analyse the possible factors affecting ART adherence Logistic regression models were used to determine the factors associated with ART adherence. Analysis was conducted using SPSS version 20.0 and p-value <0.05 were considered statistically significant.

Results

333 participants were recruited. The overall good adherence (≥95%) was approximated to be 60% (CI-54.3–65.1) when subjected to all three measures. On multivariable logistic regression, factors associated with higher odds of poor adherence were found to be caregivers aged 17–25 years [AOR = 3.5, 95%CI-(1.5–8.4)], children having an inter-current illness [AOR = 10.8, 95%CI-(2.3–50.4)], disbelief in ART effectiveness [AOR = 5.495; 95%CI-(1.669–18.182)] and advanced clinical stage [AOR = 1.972; 95% CI-(1.119–3.484)]. The major reasons reported by caregivers for missing medications included forgetfulness (41%), high pill burden (21%), busy schedule (11%) and long waiting hours at the clinic (9%).

Conclusion and recommendations

In the urban setting of Dar es Salaam, ART adherence among children was found to be relatively low when combined adherence measures were used. Factors associated with poor ART adherence found were younger aged caregivers, and child intercurrent illness, while factors conferring good adherence were belief in ART effectiveness and lower HIV clinical stage. More attention and support should be given to younger aged caregivers, children with concomitant illness and advanced HIV clinical stages. Educating caregivers on ART effectiveness may also aid in improving adherence.

Depression management and antiretroviral treatment outcome among people living with HIV in Northwest and East regions of Cameroon

Background

Several interventions have shown benefits in improving mental health problems such as depression which is common in people living with HIV. However, there is a paucity of evidence on the effect of these interventions in improving HIV treatment outcomes. This study aimed at bridging this evidence gap and guiding the integration of depression and HIV management, particularly in rural health settings of Cameroon.

Materials and methods

We carried out a cluster-randomized intervention study targeting persons aged 13 years and above who had been on antiretroviral treatment for 6–9 months. Participants were followed up for 12 months during which those in the intervention group underwent routine screening and management of depression. Comparisons were done using the two-way ANOVA and Chi-squared test with significance set at 5%.

Results

Overall, 370 participants with a median age of 39 years (IQR: 30–49) were enrolled in this study. Of these, 42 (11.3%) were screened with moderate to severe depressive symptoms and 41 (11.1%) had poor treatment adherence. There was a significant drop in depression scores in the intervention group from 3.88 (± 3.76) to 2.29 (± 2.39) versus 4.35 (± 4.64) to 3.39 (± 3.0) in controls (p < 0.001) which was accompanied by a drop in the prevalence of moderate to severe depressive symptoms in the intervention group from 9% to 0.8% (p = 0.046). Decreased depression scores were correlated with better adherence scores with correlation coefficients of − 0.191, − 0.555, and − 0.513 at baseline, 6 months, and 12 months of follow-up respectively (p < 0.001) but there was no significant difference in adherence levels (p = 0.255) and viral suppression rates (p = 0.811) between groups.

Conclusion

The results of this study suggest that considering routine screening and management of depression as an integral component of HIV care could positively impact HIV treatment outcomes. However, there is a need for more research to identify the best combinations of context-specific and cost-effective strategies that can impactfully be integrated with HIV management.

Trial registration Trial registration Number: DRKS00027440. Name of Registry: German Clinical Trials Register. Date registration: December 10, 2021 (‘retrospectively registered’). Date of enrolment of the first participant: 05/08/2019

Factors associated with HIV viral suppression among adolescents in Kabale district, South Western Uganda

Background

The goal of antiretroviral therapy is to achieve sustained human immune deficiency virus (HIV) viral suppression. However, research on factors associated with viral load suppression among adolescents in low and middle-income countries is limited. The objectives of this study were to determine HIV viral suppression levels among adolescents in Kabale district and the associated clinical, adherence and psychosocial factors.

Methods

Cross-sectional and retrospective cohort study designs were used. Two hundred and forty-nine adolescents living with HIV that attended clinics between September and October 2019 at nine health facilities were interviewed and their medical records reviewed. A data abstraction tool was used to collect clinical data from adolescent’s clinical charts, face to face interviews were conducted using semi-structured questionnaire adopted from the HEADS tool and in-depth interviews conducted with ten key informants. Qualitative data was analyzed using thematic content analysis. Logistic regression was used to determine the magnitude by which clinical and psychosocial factors influence viral load suppression. Odds Ratios (ORs) were used for statistical associations at 95% confidence interval considering statistical significance for p-values less than 0.05. Qualitative data collected from Key informants to support our quantitative findings was analyzed using thematic content analysis.

Results

HIV viral suppression among (n = 249) adolescents was at 81%. Having no severe opportunistic infections was associated with viral load suppression among adolescent living with HIV (OR = 1.09; 95%CI [1.753–4.589]; p<0.001) as well as having no treatment interruptions (OR = 0.86; 95% CI [2.414–6.790]; p = 0.004). Belonging to a support group (OR = 1.01; 95% CI [1.53–4.88]; P = 0.020), having parents alive (OR = 2.04; 95% CI[1.02–4.12]; P = 0.047) and having meals in a day (OR = 5.68; C.I = 2.38–6.12, P = 0.010), were significantly associated to viral load suppression. The findings also indicated that long distances from health facilities, transport challenges and unprofessional conduct of health workers that make adolescent unwelcome at health facilities negatively affected viral suppression among adolescents.

Conclusion

The findings indicate that HIV viral suppression among adolescents on ART was at 81%. Kabale district was likely not to achieve the third 90 of the UNAIDS 90-90-90 global target for this population category. The findings further indicate that having no severe opportunistic infection and no treatment interruptions, good nutrition status, peer support and support from significant others, were highly associated with viral load suppression.

Accuracy of measures for antiretroviral adherence in people living with HIV

BACKGROUND

Good patient adherence to antiretroviral (ART) medication determines effective HIV viral suppression, and thus reduces the risk of progression and transmission of HIV. With accurate methods to monitor treatment adherence, we could use simple triage to target adherence support interventions that could help in the community or at health centres in resource-limited settings.

OBJECTIVES

To determine the accuracy of simple measures of ART adherence (including patient self-report, tablet counts, pharmacy records, electronic monitoring, or composite methods) for detecting non-suppressed viral load in people living with HIV and receiving ART treatment.

SEARCH METHODS

The Cochrane Infectious Diseases Group Information Specialists searched CENTRAL, MEDLINE, Embase, LILACS, CINAHL, African-Wide information, and Web of Science up to 22 April 2021. They also searched the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov for ongoing studies. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included studies of all designs that evaluated a simple measure of adherence (index test) such as self-report, tablet counts, pharmacy records or secondary database analysis, or both, electronic monitoring or composite measures of any of those tests, in people living with HIV and receiving ART treatment. We used a viral load assay with a limit of detection ranging from 10 copies/mL to 400 copies/mL as the reference standard. We created 2 × 2 tables to calculate sensitivity and specificity.

DATA COLLECTION AND ANALYSIS

We screened studies, extracted data, and assessed risk of bias using QUADAS-2 independently and in duplicate. We assessed the certainty of evidence using the GRADE method. The results of estimated sensitivity and specificity were presented using paired forest plots and tabulated summaries. We encountered a high level of variation among studies which precluded a meaningful meta-analysis or comparison of adherence measures. We explored heterogeneity using pre-defined subgroup analysis.

MAIN RESULTS

We included 51 studies involving children and adults with HIV, mostly living in low- and middle-income settings, conducted between 2003 and 2021. Several studies assessed more than one index test, and the most common measure of adherence to ART was self-report. - Self-report questionnaires (25 studies, 9211 participants; very low-certainty): sensitivity ranged from 10% to 85% and specificity ranged from 10% to 99%. - Self-report using a visual analogue scale (VAS) (11 studies, 4235 participants; very low-certainty): sensitivity ranged from 0% to 58% and specificity ranged from 55% to 100%. - Tablet counts (12 studies, 3466 participants; very low-certainty): sensitivity ranged from 0% to 100% and specificity ranged from 5% to 99%. - Electronic monitoring devices (3 studies, 186 participants; very low-certainty): sensitivity ranged from 60% to 88% and the specificity ranged from 27% to 67%. - Pharmacy records or secondary databases (6 studies, 2254 participants; very low-certainty): sensitivity ranged from 17% to 88% and the specificity ranged from 9% to 95%. - Composite measures (9 studies, 1513 participants; very low-certainty): sensitivity ranged from 10% to 100% and specificity ranged from 49% to 100%. Across all included studies, the ability of adherence measures to detect viral non-suppression showed a large variation in both sensitivity and specificity that could not be explained by subgroup analysis. We assessed the overall certainty of the evidence as very low due to risk of bias, indirectness, inconsistency, and imprecision. The risk of bias and the applicability concerns for patient selection, index test, and reference standard domains were generally low or unclear due to unclear reporting. The main methodological issues identified were related to flow and timing due to high numbers of missing data. For all index tests, we assessed the certainty of the evidence as very low due to limitations in the design and conduct of the studies, applicability concerns and inconsistency of results.

AUTHORS' CONCLUSIONS

We encountered high variability for all index tests, and the overall certainty of evidence in all areas was very low. No measure consistently offered either a sufficiently high sensitivity or specificity to detect viral non-suppression. These concerns limit their value in triaging patients for viral load monitoring or enhanced adherence support interventions.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Factors associated with non-adherence to antiretroviral therapy among HIV-infected adolescents aged 15-19 years: a snapshot from the Mother and Child Center in Yaounde, Cameroon

Introduction

non-adherence to antiretroviral therapy (ART) constitutes the main cause of therapeutic failure among HIV-infected adolescents, especially in the aged group 15 to 19 years. We aimed to determine factors associated with this non-adherence in this specific population.

Methods

we conducted a cross-sectional study at the Mother and Child Center in Yaounde from August to October 2018. Delayed clinic appointment was referred to as defaulters. Non-adherence was measured during the 3 days preceding inclusion by self-reported method following quantitative (missing dosage of ART), qualitative (ART taken with a delay of more than 2 hours) and combined measure. A threshold of non-adherence > 20% was considered high, with p<0.05 statistically significant.

Results

overall, 195 out of 251 (77.7%) eligible adolescents were included, of which 56.9% were girls (sex-ratio = 4/3). The mean age was 16.8 ± 1.5 years. The rate of defaulters was 21.0%. Following quantitative approach, 33.8% were non-adherent. Using combined approach, we had 41.0%. This non-adherence was associated with duration on ART > 5 years (adjusted Odds Ratio [aOR]: 2.33;95% Confidence Interval [CI]: 1.08-5.00; p:0.030), defaulters (aOR: 2.56;95% CI: 1.12-5.82; p:0.025) and HIV Viral Load (VL) ≥ 40 copies/ml (aOR: 0.42; 95% CI: 0.21-0.83; p:0.013).

Conclusion

at this reference pediatric center, 4 out of 10 adolescents aged 15-19 years on ART are non-adherent, driven by missing dosage of drug intake. Strategies for enhanced adherence for late age adolescents are therefore warranted, by prioritizing interventions on defaulters and duration on ART > 5 years.

Predictors of Current CD4+ T-Cell Count Among Women of Reproductive Age on Antiretroviral Therapy in Public Hospitals, Southwest Ethiopia

Background

HIV/AIDS is one of the major global public health problems. CD4 is a glycoprotein found on the surface of different immune cells. CD4 cell counts determine the need for screening and prophylactic interventions against common opportunistic infections in those with advanced HIV disease. Thus, this study aimed to assess the predictors of current CD4⁺ T-cell count among women of reproductive age on antiretroviral therapy in public hospitals, southwest Ethiopia.

Methods

A cross-sectional study was conducted from February to April 2018. A total of 422 participants in the three public hospitals were selected using a systematic random sampling method. Linear regression analyses were used to determine the important predictors of current CD4⁺ T-cell count at p-values of <0.05.

Results

A total of 422 women with a median age of 37.00 years participated in this study. More than one in ten (12.8%) respondents experienced immunological failure. An increased current CD4⁺ T-cell count was observed among patients with a tertiary level of education [β = 56.45, 95% CI (3.5, 109.4)], baseline WHO clinical stage II [β = 44.06, 95% CI (5.3, 82.9)], initial regimen of AZT+3TC+EFV [β = 167.23, 95% CI (100.4, 234.1)], with increased baseline CD4⁺ T-cell count [β = 0.35, 95% CI (0.2, 0.5)], and with increased time duration on ART [β = 14.36, 95% CI (6.304, 22.4)]. On the other hand, the current CD4⁺ T-cell count was lowered among patients with poor baseline adherence, opportunistic infection, and viral load of ≥1000 by 181.06 cells/mm³, 101.62 cells/mm³, and 137.53 cells/mm³ compared to good baseline adherence, no opportunistic infection and undetectable viral load, respectively.

Conclusion

The immunological failure was relatively low. Maintaining adherence, early identification and treatment of opportunistic infections, and minimizing viral load to undetectable levels may further decrease immunological failure.

Determinants of switch to paediatric second-line antiretroviral therapy after first-line failure in Cameroon

OBJECTIVE

With scale-up of antiretroviral therapy (ART) children, treatment failure and switch to subsequent ART regimens are common. Our objectives were to evaluate switching practices and identify factors associated among children and adolescents failing their first-line ART.

METHODS

A facility-based survey study was conducted in a cohort of children living with HIV experiencing virological failure (VF) at the Essos Hospital Centre of Yaounde, Cameroon. Data were collected using a standard questionnaire, and key variables were as follows: (a) VF defined as viral load (VL) > 1000 copies/ml, (b) rate of switch to second-line and (c) reason(s) for switching ART. Odds ratio (OR) with 95% confidence interval (CI) was used to assess the association between study variables, and P < 0.05 was considered statistically significant.

RESULTS

A total of 106 children experiencing VF were enrolled: median age was 8 [interquartile range (IQR): 3-15] years; 60.38% were boys and 39.62% were orphans of one/both parents. A proportion of 69% were at the WHO clinical stage III/IV, and 13.21% were experiencing immunological failure (CD4 < 200 cells/mm³ ). The median duration on first-line ART was 36 [IQR: 7-157] months prior to detecting VF, and the rate of switch to second-line ART was 70.75% (75/106). Delay in switching ART after a confirmed VF was 11 [IQR: 7-16] months. After switch to second-line ART, the median time to achieve undetectable VL (<40 copies/ml) was 14 [IQR: 9-21] months. Multivariate analysis revealed that only children with viral rebound (aOR = 0.09; 95% CI = 0.03-0.24) were less likely to be switched. Of note, being orphaned (aOR = 0.35, CI = 0.11-1.11), biological sex (aOR = 1.77, CI = 0.60-5.29) and immune status (aOR = 0.19, CI = 0.03-1.31, 0.09) had no significant effect on switching to second-line ART.

CONCLUSION

In this paediatric population experiencing VF after about 3-4 years from ART initiation, the majority are switched to second-line ART after a delay of almost one year. Delayed switch to second-line was driven essentially by viral rebound, underscoring the need for close viral monitoring.

Correlation between the immuno-virological response and the nutritional profile of treatment-experienced HIV-infected patients in the East region of Cameroon

BACKGROUND

HIV management remains concerning and even more challenging in the frame of comorbidities like malnutrition that favors disease progression and mortality in resource-limited settings (RLS).

OBJECTIVE

To describe the nutritional parameters of antiretroviral therapy (ART) recipients (without nutritional support) with respect to CD4 count and virological failure.

METHODS

A cross-sectional study was conducted from October to December 2018 among 146 consenting participants enrolled in two health facilities of the East-Region of Cameroon. Socio-demographic data, basic clinical information and treatment history were collected; blood samples were collected by venipuncture for laboratory analysis (HIV-1 viral load, CD4 Tcells measurement and biochemical analysis) performed at the "Chantal Biya" International Reference Center", Yaounde, Cameroon. The nutritional profile was assessed by using anthropometric and biochemical parameters. Data were analyzed using Excel 2016, Graph pad prism version 6; Spearman correlation and Kruskal-Wallis test were used; with p<0.05 considered statistically significant.

RESULTS

Median [IQR] age was 42 [33-51] years, 76.0% (111/146) were female and median [IQR] duration on ART was 54 [28-86] months. Of these participants, 11.6% (17/146) were underweight based on the body mass index and 4.7% (7/146) were at the stage of advanced weight loss. According to immunovirological responses, 44.5% (65/146) were immunocompromised (CD4<500 cell/μl) and 75.3% (110/146) had an undetectable viremia (<40 copies/mL). CD4 count inversely correlated with total protein concentration (r = -0.18, p = 0.005**). Viremia was inversely correlated with albumin (r = -0.21; p = 0.047*), nutritional risk index (r = -0.28; p = 0.013*), total cholesterol (r = -0.27; p = 0.007**), and positively correlated with total protein (r = 0.27; p<0.001**) concentrations.

CONCLUSION

In this RLS, with patients having about five years of ART-experience, malnutrition appears to be driven mainly by a poor BMI, indicating that about one of ten patients falls within this severe condition. However, the largely normal nutritional profiles should be interpreted with caution, considering local realities and food support programs in place. The present outcomes highlight the need for monitoring nutritional status of people receiving ART in RLS, toward the design of optimal food interventions.

Virologic response of adolescents living with perinatally acquired HIV receiving antiretroviral therapy in the period of early adolescence (10-14 years) in South Africa

BACKGROUND AND OBJECTIVES

Adolescents living with perinatally acquired HIV (ALPHIV) on antiretroviral therapy (ART) have been noted to have poorer adherence, retention and virologic control compared to adolescents with non-perinatally acquired HIV, children or adults. We aimed to describe and examine factors associated with longitudinal virologic response during early adolescence.

DESIGN

A retrospective cohort study.

METHODS

We included ALPHIV who initiated ART before age 9.5 years in South African cohorts of the International epidemiology Database to Evaluate AIDS-Southern Africa (IeDEA-SA) collaboration (2004-2016); with viral load (VL) values <400 copies/ml at age 10 years and at least one VL measurement after age 10 years. We used a log-linear quantile mixed model to assess factors associated with elevated (75th quantile) VLs.

RESULTS

We included 4396 ALPHIV, 50.7% were male, with median (interquartile range) age at ART start of 6.5 (4.5, 8.1) years. Of these, 74.9% were on a non-nucleoside reverse transcriptase inhibitor (NNRTI) at age 10 years. After adjusting for other patient characteristics, the 75th quantile VLs increased with increasing age being 3.13-fold (95% CI 2.66, 3.68) higher at age 14 versus age 10, were 3.25-fold (95% CI 2.81, 3.75) higher for patients on second-line protease-inhibitor and 1.81-fold for second-line NNRTI-based regimens (versus first-line NNRTI-based regimens). There was no difference by sex.

CONCLUSIONS

As adolescents age between 10 and 14 years, they are increasingly likely to experience higher VL values, particularly if receiving second-line protease inhibitor or NNRTI-based regimens, which warrant adherence support interventions.

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

OBJECTIVES

Adolescents living with perinatal HIV infection (ALPHI) experience persistently high mortality rates, particularly in resource-limited settings. It is therefore clinically important for us to understand the therapeutic response, acquired HIV drug resistance (HIVDR) and associated factors among ALPHI, according to geographical location.

METHODS

A study was conducted among consenting ALPHI in two urban and two rural health facilities in the Centre Region of Cameroon. World Health Organization (WHO) clinical staging, self-reported adherence, HIVDR early warning indicators (EWIs), immunological status (CD4 count) and plasma viral load (VL) were assessed. For those experiencing virological failure (VF, VL ≥ 1000 copies/mL), HIVDR testing was performed and interpreted using the Stanford HIV Drug Resistance Database v.8.9-1.

RESULTS

Of the 270 participants, most were on nonnucleoside reverse transcriptase inhibitor (NNRTI)-based regimens (61.7% urban vs. 82.2% rural), and about one-third were poorly adherent (30.1% vs. 35.1%). Clinical failure rates (WHO-stage III/IV) in both settings were < 15%. In urban settings, the immunological failure (IF) rate (CD₄  < 250 cells/μL) was 15.8%, statistically associated with late adolescence, female gender and poor adherence. The VF rate was 34.2%, statistically associated with poor adherence and NNRTI-based antiretroviral therapy. In the rural context, the IF rate was 26.9% and the VF rate was 52.7%, both statistically associated with advanced clinical stages. HIVDR rate was over 90% in both settings. EWIs were delayed drug pick-up, drug stock-outs and suboptimal viral suppression.

CONCLUSIONS

Poor adherence, late adolescent age, female gender and advanced clinical staging worsen IF. The VF rate is high and consistent with the presence of HIVDR in both settings, driven by poor adherence, NNRTI-based regimen and advanced clinical staging.

Level of adherence and associated factors among HIV-positive adolescents on antiretroviral therapy in Cameroon

Aim: Globally, there were over 250 000 new HIV infections among adolescents in 2017, with a higher proportion of these in sub-Saharan Africa. In Cameroon, UNICEF estimated over 4 200 new HIV infections in adolescents in 2015; by 2016, there were over 40 000 adolescents who had HIV. Given that the number of adolescents living with HIV in Cameroon is on the increase, there is a need to better understand the factors influencing adherence to treatment. The objective of this study was to assess the factors associated with adherence among adolescents in Cameroon. Methods: A cross-sectional study was conducted. A total of 460 HIV+ adolescents who were receiving antiretroviral therapy were sampled randomly from nine health facilities. Questionnaires and data extraction forms were used to collect data. Descriptive (frequencies and proportions) and inferential (chi-square and multivariate logistic regression) statistical analyses methods were used to analyse the data. Statistical significance was set at p = 0.05 and 95% confidence level. Results: The level of adherence to antiretroviral therapy among the adolescents was 83%. Twelve out of 30 independent variables examined showed significant statistical association with adherence at the bivariate level. In the multivariable logistic regression analyses, however, only two variables significantly predicted adherence - experiencing side effects (AOR = 2.63; 95% CI = 1.14, 6.09; p = 0.02), and internalized stigma (AOR = 2.51; 95% CI = 1.04, 6.04; p = 0.04). Conclusion: Adherence to treatment among adolescents in Cameroon was found to be suboptimal. There is a need for more individualized, targeted medication counselling for adolescents and their guardians as well as strategies to reduce internalized stigma and improve adherence to antiretroviral treatment.

Immunological Response During HAART and Determinants of Current CD4+ T-Cell Count Among HIV/AIDS Patients Attending University of Gondar Referral Hospital, Northwest Ethiopia

PURPOSE

After the initiation of highly active antiretroviral therapy (HAART), successful HAART is characterized by an increase in the CD4+ count. Several factors affect the CD4+ T-cell count. This study aimed to assess the immunological response during HAART and determinants of the current CD4+ T-cell count among HIV/AIDS patients on HAART.

PATIENTS AND METHODS

A hospital-based cross-sectional study was conducted from February 1 to April 1, 2017. A total of 423 HIV/AIDS patients on HAART were enrolled using simple random sampling. Descriptive statistics, and bivariate and multiple regression analyses were conducted. Variables with p-value <0.2 in the bivariate analysis were entered in the multiple regression models. p-Values <0.05 and 95% confidence intervals were used to identify determinants of the current CD4+ T-cell count.

RESULTS

The mean CD4+ T-cell count gradually increased until 8 years on HAART but declined thereafter. An increased current CD4+ T-cell count was observed among patients with an initial regimen of pediatric d4T-3TC-NVP [β=185.5, 95% CI (8.8, 362.2)] (p=0.040), with increased baseline CD4+ T-cell count [β=0.468, 95% CI (0.342, 0.594)] (p<0.0001), and with long duration on HAART [β=18.0, 95% CI (9.9, 26.1)] (p<0.0001), whereas a decreased level of current CD4+ T-cell count was observed among males [β=-72.7, 95% CI (-114.5, -30.9)]) (p<0.0001) and those with poor baseline adherence [β=-108.9, 95% CI (-210.9, -7.0)] (p=0.036) and viral load >1000 copies [β=-189.2, 95% CI (-243.5, -134.9)] (p<0.0001).

CONCLUSION

The trend in immunological response was not increased linearly throughout the HAART duration. Sex, type of initial regimen, baseline adherence, baseline CD4+ count, viral load, and duration on HAART were independent determinants of current CD4+ count. These determinants could be addressed by regular monitoring of HIV patients on HAART, and special attention should be paid to male patients.

Long-term outcomes in perinatally HIV-infected adolescents and young adults on antiretroviral therapy: a review of South African and global literature

Paediatric antiretroviral programmes have been implemented globally for more than a decade, yet information on long-term treatment outcomes in perinatally HIV-infected adolescents is limited. Published literature on long-term treatment outcomes was reviewed, including virologic, immunologic and growth outcomes, as well as drug resistance and factors associated with drug resistance. Outcomes were compared between high-income countries and low- and middle-income countries (LMIC), with additional focus on South Africa, the country with the biggest HIV epidemic in the world and the largest treatment programme. Treatment outcomes varied but viral suppression results globally were generally concerning. No studies from LMIC have reported on outcomes after >10 years follow-up, demonstrating that further studies are needed.

A Longitudinal Study of Behavioral Risk, Adherence, and Virologic Control in Adolescents Living With HIV in Asia

BACKGROUND

Adolescents living with HIV (ALHIV) have poorer adherence and clinical outcomes than adults. We conducted a study to assess behavioral risks and antiretroviral therapy outcomes among ALHIV in Asia.

METHODS

A prospective cohort study among ALHIV and matched HIV-uninfected controls aged 12-18 years was conducted at 9 sites in Malaysia, Thailand, and Vietnam from July 2013 to March 2017. Participants completed an audio computer-assisted self-interview at weeks 0, 48, 96, and 144. Virologic failure (VF) was defined as ≥1 viral load (VL) measurement >1000 copies/mL. Generalized estimating equations were used to identify predictors for VF.

RESULTS

Of 250 ALHIV and 59 HIV-uninfected controls, 58% were Thai and 51% females. The median age was 14 years at enrollment; 93% of ALHIV were perinatally infected. At week 144, 66% of ALHIV were orphans vs. 28% of controls (P < 0.01); similar proportions of ALHIV and controls drank alcohol (58% vs. 65%), used inhalants (1% vs. 2%), had been sexually active (31% vs. 21%), and consistently used condoms (42% vs. 44%). Of the 73% of ALHIV with week 144 VL testing, median log VL was 1.60 (interquartile range 1.30-1.70) and 19% had VF. Over 70% of ALHIV had not disclosed their HIV status. Self-reported adherence ≥95% was 60% at week 144. Smoking cigarettes, >1 sexual partner, and living with nonparent relatives, a partner or alone, were associated with VF at any time.

CONCLUSIONS

The subset of ALHIV with poorer adherence and VF require comprehensive interventions that address sexual risk, substance use, and HIV-status disclosure.

Evaluation of treatment response, drug resistance and HIV-1 variability among adolescents on first- and second-line antiretroviral therapy: a study protocol for a prospective observational study in the centre region of Cameroon (EDCTP READY-study)

Background

Sub-Saharan Africa (SSA) alone has nine out of every 10 children living with HIV globally and monitoring in this setting remains suboptimal, even as these children grow older. With scalability of antiretroviral therapy (ART), several HIV-infected children are growing towards adolescence (over 2.1 million), with the potentials to reach adulthood. However, despite an overall reduction in HIV-related mortality, there are increasing deaths among adolescents living with HIV (ADLHIV), with limited evidence for improved policy-making. Of note, strategies for adolescent transition from pediatrics to adult-healthcare are critical to ensure successful treatment response and longer life expectancy. Interestingly, with uptakes in prevention of mother-to-child transmission, challenges in ART programs, and high viremia among children in SSA, the success rate of paediatric ART might be quickly jeopardised, with possible HIV-1 drug-resistance (HIVDR) emergence, especially after years of paediatric ART exposure. Therefore, monitoring ART response in adolescents and evaluating HIVDR patterns might limit disease progression and guide on subsequent ART options for SSA ADLHIV.

Objectives

Among Cameroonian ADLHIV receiving ART, we shall evaluate the rate of immunovirologic failure, acquired HIVDR-associated mutations, HIV-1 subtype distribution, genetic variability in circulating (plasma) versus archived (cellular) viral strains, and HIVDR early warning indicators (EWIs) at different time-points.

Methods

A prospective and observational study will be conducted among 250 ADLHIV (10–19 years old) receiving ART in the centre region of Cameroon, and followed-up at 6 and 12 months after enrollment. Following consecutive sampling at enrolment, plasma viral load and CD4/CD8 count will be measured, and genotypic resistance testing (GRT) will be performed both in plasma and in buffy coat for participants experiencing virological failure (two consecutive viremia > = 1000 copies/ml). Plasma viral load and CD4/CD8 will be monitored for all participants at 6 and 12 months after enrolment. HIVDR-EWIs will be monitored and survival analysis performed during the 12 months follow-up. Primary outcomes are rates of virological failure, acquired-HIVDR, and mortality.

Discussion

Our findings will provide evidence-based recommendations to ensure successful transition from paediatrics to adult ART regimens and highlight further needs of active ART combinations, for reduced morbidity and mortality in populations of ADLHIV within SSA.

Electronic supplementary material

The online version of this article (10.1186/s12887-019-1599-z) contains supplementary material, which is available to authorized users.

Outcomes of protease inhibitor-based antiretroviral therapy amongst children and associated-factors in Yaoundé, Cameroon

Background

There are limited data on protease inhibitor (PI)-based antiretroviral therapy (ART) amongst children in resource-limited settings, for informing on optimal paediatric regimens.

Objective

To evaluate therapeutic response to PI-based ART amongst HIV-infected Cameroonian children.

Methods

A retrospective study was conducted amongst children aged 2–18 years receiving a PI-based ART at the Essos Hospital Centre (EHC), Yaounde, Cameroon. Primary end points were therapeutic success on PI-based ART, defined as clinical success (WHO I/II clinical stage), immunological success (CD4 ≥ 500/mm³) and viral suppression (viral load [VL]<1000 copies/ml). Factors associated with therapeutic success were assessed in uni- and multivariate analysis using SPSS software v.2.0; with p<0.05 considered statistically significant.

Results

A total of 71 eligible children on PI-based ART were enrolled (42 on initial and 29 on substituted regimens), with a median age of 8 [IQR: 5–12] years and mean duration on ART of 7 years. Following therapeutic responses, all (100%) experienced clinical success, 95.2% experienced immunological success (91.7% on initial and 97.2% on substituted PI/r-based regimens) and 74.7% viral suppression. In univariate analysis, viral suppression was associated with: younger age (p<0.0001), living with parents as opposed to guardians (p = 0.049), and the educational level (p<0.0001). In multivariate analysis, only the age ranges of 10–14 years (OR: 0.22 [0.07–0.73]) and 15–18 years (OR: 0.08 [0.02–0.57]), were determinants of poor viral suppression.

Conclusion

Among these Cameroonian children, PI-based ART confers favourable clinical and immunological outcomes. The poor rate of viral suppression was mainly attributed to adolescence (10–18 years).

HIV virologic failure and its predictors among HIV-infected adults on antiretroviral therapy in the African Cohort Study

INTRODUCTION

The 2016 WHO consolidated guidelines on the use of antiretroviral drugs defines HIV virologic failure for low and middle income countries (LMIC) as plasma HIV-RNA ≥ 1000 copies/mL. We evaluated virologic failure and predictors in four African countries.

MATERIALS AND METHODS

We included HIV-infected participants on a WHO recommended antiretroviral therapy (ART) regimen and enrolled in the African Cohort Study between January 2013 and October 2017. Studied outcomes were virologic failure (plasma HIV-RNA ≥ 1000 copies/mL at the most recent visit), viraemia (plasma HIV-RNA ≥ 50 copies/mL at the most recent visit); and persistent viraemia (plasma HIV-RNA ≥ 50 copies/mL at two consecutive visits). Generalized linear models were used to estimate relative risks with their 95% confidence intervals.

RESULTS

2054 participants were included in this analysis. Viraemia, persistent viraemia and virologic failure were observed in 396 (19.3%), 160 (7.8%) and 184 (9%) participants respectively. Of the participants with persistent viraemia, only 57.5% (92/160) had confirmed virologic failure. In the multivariate analysis, attending clinical care site other than the Uganda sitebeing on 2nd line ART (aRR 1.8, 95% CI 1·28-2·66); other ART combinations not first line and not second line (aRR 3.8, 95% CI 1.18-11.9), a history of fever in the past week (aRR 3.7, 95% CI 1.69-8.05), low CD4 count (aRR 6.9, 95% CI 4.7-10.2) and missing any day of ART (aRR 1·8, 95% CI 1·27-2.57) increased the risk of virologic failure. Being on 2nd line therapy, the site where one receives care and CD4 count < 500 predicted viraemia, persistent viraemia and virologic failure.

CONCLUSION

In conclusion, these findings demonstrate that HIV-infected patients established on ART for more than six months in the African setting frequently experienced viraemia while continuing to be on ART. The findings also show that being on second line, low CD4 count, missing any day of ART and history of fever in the past week remain important predictors of virologic failure that should trigger intensified adherence counselling especially in the absence of reliable or readily available viral load monitoring. Finally, clinical care sites are different calling for further analyses to elucidate on the unique features of these sites.

Patterns of detectable viraemia among children and adults with HIV infection taking antiretroviral therapy in Zimbabwe

OBJECTIVE

To investigate the incidence and predictors of viraemia among individuals on antiretroviral therapy (ART) in Harare, Zimbabwe.

METHODS

Children (0-19 years) and adults (>19 years) starting ART between 2013 and 2015 were followed for a median of 2.8 and 2.7 years, respectively. The incidence rates of virological failure (VF), low-level viraemia (LLV), and viral blips were assessed and the predictors of viraemia were determined using logistic and parametric survival regression analyses.

RESULTS

A total of 630 individuals initiated ART, and 19.7% of children and 5.6% of adults did not achieve viral suppression by 12 months. Younger age and CD4 count ≤200 cells/mm3 at baseline were associated with not being virally suppressed at 12 months in adults. Among those who achieved viral suppression during the follow-up period, the incidence of VF was higher in children (4.0/100 person-years vs. 0.4/100 person-years in adults; p<0.001), as was the incidence of LLV (1.9/100 person-years vs. 0.3/100 person-years in adults; p=0.03). The incidence rate of blips was 10.9 per 100 person-years in children and 4.0 per 100 person-years in adults.

CONCLUSIONS

Children are less likely to reach viral suppression and are at higher risk of viraemia while on ART than adults. The significance of LLV and blips needs further study.

Factors associated with viral non-suppression among adolescents living with HIV in Cambodia: a cross-sectional study

BACKGROUND

Adolescents living with HIV on antiretroviral therapy (ART) have worse treatment adherence, viral suppression, and mortality rates compared to adults. This study investigated factors associated with viral non-suppression among adolescents living with HIV in Cambodia.

METHODS

A cross-sectional study was conducted in August 2016 among 328 adolescents living with HIV aged 15-17 years who were randomly selected from 11 ART clinics in the capital city of Phnom Penh and 10 other provinces. Clinical and immunological data, including CD4 count and viral load, were obtained from medical records at ART clinics. Adolescents were categorized as having achieved viral suppression if their latest viral load count was < 1000 ribonucleic acid (RNA) copies/mL. Multivariate logistic regression analysis was performed to identify factors independently associated with viral non-suppression.

RESULTS

The mean age of the participants was 15.9 years (SD = 0.8), and 48.5% were female. Median duration on ART was 8.6 (interquartile range = 6.0-10.6) years. Of total, 76.8% of the participants had achieved viral suppression. After adjustment for other covariates, the likelihood of having viral non-suppression remained significantly lower among adolescents who were: older/aged 17 (AOR = 0.46, 95% CI 0.21-0.98), had been on ART for more than 9 years (AOR = 0.35, 95% CI 0.19-0.64), had most recent CD4 count of > 672 (AOR = 0.47, 95% CI 0.26-0.86), had a relative as the main daily caregiver (AOR = 0.37, 95% CI 0.17-0.80), and did not believe that there is a cure for AIDS (AOR = 0.40, 95% CI 0.21-0.75) compared to their reference group. The likelihood of having viral non-suppression also remained significantly higher among adolescents who had first viral load > 628 RNA copies/mL (AOR = 1.81, 95% CI 1.05-4.08) and among those who were receiving HIV care and treatment from an adult clinic (AOR = 2.95, 95% CI 1.56-5.59).

CONCLUSIONS

The proportion of adolescents living with HIV with viral suppression in this study was relatively high at 76.8%, but falls short of the global target of 90%. Programs targeting younger adolescents and adolescents in transition from pediatric to adult care with a range of interventions including psychosocial support and treatment literacy could further improve viral suppression outcomes.