Factors associated with virological non-suppression among HIV-positive children receiving antiretroviral therapy at the Joint Clinical Research Centre in Lubowa, Kampala Uganda

HIV viral load suppression rates among adults and children living with HIV in the North West Region of Cameroon: A call for action!

INTRODUCTION

HIV continues to be a major public health problem in Cameroon where 2.7% of the population aged 15 to 49 are living with HIV. The prevalence remains higher in females, 3.4% versus 1.9% in males. The North West region of Cameroon has a higher prevalence than the national average; 4% in the general population, 5.8% in females and 1.6% in males. Despite the availability of pediatric HIV treatment, gaps in outcomes of children living with HIV (CLHIV) persists. This study aimed to compare the HIV viral suppression rates among adults and children living with HIV receiving antiretroviral therapy (ART) in the North West Region of Cameroon. In this study we hypothesized that the virologic outcome of children living with HIV is unfavorable compared to adults.

METHODOLOGY

This study was a comparative cross-sectional analytical study with secondary analysis of Viral load laboratory database. Data was collected in June 2023. We systematically collected deidentified data on viral load test of all PLHIV with HIV viral load results in the Bamenda TB reference laboratory database for the period January 1, 2022 to December 31, 2022. Data was analyzed using Stata SE 14.2. Categorical variables were described using absolute and relative frequencies. These were compared using Pearson's chi-squared test. Quantitative variables were described using mean as a characteristic of central tendency and standard deviation (SD) as a characteristic of dispersion.

RESULTS

Analysis revealed that of the 23,814 PLHIV whose viral load test was done at the Bamenda TB reference laboratory during the year 2022, 17,364(73%) were female and 1436 (6%) were children. The level of HIV viral suppression (viral load<1000 copies/ml) in children was lower compared to that of adults (80% vs. 95%; p<0.001). Females had lower viral suppression than males (94% vs. 91%; p<0.001).

CONCLUSION

The results revealed a significant lower HIV viral suppression rate in children than in adults. Women also had a significantly higher HIV viral suppression than males. Findings indicated that HIV viral suppression rate is significantly higher for routine viral load testing than for targeted testing after enhanced adherence counselling, thus the need to systematically offer enhanced adherence counselling and other evidence-based support interventions in routine care to all PLHIV to avoid persistent high viral non-suppression. Action is needed to tackle all known factors contributing to high viral non-suppression in children living with HIV and to help achieve 95% viral suppression rate in CLHIV in the North West region of Cameron.

Assessment of the impact of HIV infection on the hypothalamic-pituitary-ovarian axis and pubertal development among adolescent girls at a tertiary centre in Zimbabwe: a cross-sectional study

BACKGROUND

Proper planning of reproductive health needs for HIV-infected adolescents requires a clear understanding of the effects of HIV infection on adolescents' pubertal development.

OBJECTIVE

To assess the effects of HIV infection on the hypothalamic-pituitary-ovarian (HPO) axis, ovarian reserve and pubertal development in adolescent girls at a tertiary hospital in Zimbabwe.

METHODS

This was a cross-sectional survey of HIV-infected adolescent girls aged 10-19 years, with available CD4 + count results at a tertiary hospital in Zimbabwe. Consecutive sampling was used to select study participants. Pubertal milestones were assessed using the age of menarche and Tanner stage for breast and pubic hair development. Growth was assessed using World Health Organisation growth charts. The HPO axis was evaluated by measuring serum follicular stimulating hormone (FSH), luteinising hormone (LH) and estradiol. The ovarian reserve was assessed in adolescents above 18 years of age by measuring the serum anti-mullein hormone (AMH) levels. Data were analysed in STATA version 13.0, and the results are presented as mean (SD) or median (quartiles) and proportions, as appropriate.

RESULTS

One hundred and one (101) HIV-infected adolescents were recruited for the study. Menarche, thelarche and pubarche were delayed in 15.9%, 28.6% and 46.8% of the adolescents, respectively. A total of 59.4% had moderate to severe stunting, and 53.5% were either overweight or obese. Most participants had normal serum FSH, LH, and estradiol levels, and there was no association between these hormone levels and growth indicators. The serum AMH levels were reduced in 24.1% of the adolescents. There were no significant differences in the hormonal levels and pubertal development between the WHO CD4 classes.

CONCLUSION

HIV infection is associated with stunted growth and delayed sexual maturation with an intact HPO axis in the majority of adolescents. There was no association between growth indicators and FSH and LH levels. The degree of HIV immunosuppression had no significant impact on the HPO axis and pubertal development. A larger study is needed to assess the impact of HIV infection on ovarian reserve.

TRIAL REGISTRATION

This protocol was approved by the Medical Research Council of Zimbabwe (MRCZ) (reference number MRCZ/A/1730).

Virological failure and associated factors among patients receiving anti-retroviral therapy in Ethiopia: A systematic review and meta-analysis

OBJECTIVE

This study aimed to pool the prevalence of virological failure and associated factors.

DESIGN

Systematic review and meta-analysis.

PRIMARY OUTCOME MEASURE

Prevalence of virological failure.

SECONDARY OUTCOME MEASURE

Factors affecting virological failure.

ANALYSIS

The extracted data were exported to STATA V.17 for statistical analysis. A random-effects DerSimonian-Laird model was used to compute the pooled prevalence of virological failure.

SETTING

Ethiopia.

PARTICIPANTS

Patients receiving anti-retroviral therapy.

RESULTS

A total of 51 primary studies with a sample size of 38, 789 participants were included in the final meta-analysis. The pooled prevalence of virological failure among patients receiving anti-retroviral therapy (ART) in Ethiopia was 15.95% (95% CI: 12.63, 19.27; I2=97.99%; p<0.001). Substance use (adjusted OR (AOR)=2.37, 95% CI: 1.28, 4.39), non-disclosure of HIV status (AOR=4.63, 95% CI: 3.51, 6.11), interruption of ART (AOR=2.61, 95% CI: 1.55, 4.40), poor adherence to ART (AOR=4.31, 95% CI: 2.73, 6.79), baseline CD4 cell count <200 cells/mm3 (AOR=2.65, 95% CI: 1.62, 4.33), baseline advanced WHO clinical stage (WHO clinical stages III and IV) (AOR=3.02, 95% CI: 1.67, 5.45), baseline viral load >1000 copies/mL (AOR=4.63, 95% CI: 2.60, 8.26), opportunistic infections (AOR=3.58, 95% CI: 2.58, 4.96) and TB-HIV coinfection (AOR=3.97, 95% CI: 2.41, 6.54) were significantly associated with virological failure among patients receiving anti-retroviral therapy in Ethiopia.

CONCLUSIONS

The pooled prevalence of virological failure among patients receiving anti-retroviral therapy was high in Ethiopia. Therefore, due attention should be given to patients with these identified factors. Moreover, we recommend researchers to conduct a triangulated study that can address additional factors associated with virological failure.

PROSPERO REGISTRATION NUMBER

The protocol was registered with the Prospero database (PROSPERO, 2024: CRD42024512411).

Experiences of support by unsuppressed adolescents living with HIV and their caregivers in Windhoek, Namibia: a qualitative study

Background

Adolescents living with HIV (ALHIV) lag behind younger children and adults in the achievement of HIV care and treatment targets for HIV epidemic control. Treatment outcomes for adolescents may be influenced by their experiences with the support provided in HIV programs. We report on the experiences of virally unsuppressed adolescents and their caregivers with the current support in primary healthcare settings in Namibia.

Methods

A qualitative descriptive and exploratory study was conducted in 13 public primary healthcare facilities in Windhoek, Namibia. A total of 25 in-depth interviews were conducted with unsuppressed adolescents (n = 14) and their caregivers (n = 11) between August and September 2023. The audio-recorded interviews were transcribed verbatim, and uploaded into ATLAS.ti software, and subjected to thematic content analysis.

Findings

Three main support domains for the unsuppressed adolescents emerged from our analysis, namely: psychosocial, clinical and care, and socioeconomic support. The psychosocial support was delivered through peer support (teen clubs and treatment supporters) and enhanced adherence counselling mostly. The clinical and care support included implementing adolescent-friendly HIV services, differentiated service delivery approaches, and caregivers and healthcare worker care support for improved ART adherence, clinic attendance and continuous engagement in care. Socioeconomic support was provided for nutritional support, transport to access clinics, and school supplies, as well as income-generating projects.

Conclusion

Psychosocial, clinical and care, and socioeconomic support are key elements in addressing the needs of adolescents challenged with achieving viral suppression. Health systems may benefit from whole-of-society and whole-of-government approaches to meet the needs of ALHIV that are beyond the scope of health service delivery such as nutritional, education and socioeconomic influences on both the health and well-being of ALHIV.

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

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

Virological Non-Suppression, Non-Adherence and the Associated Factors Among People Living with HIV on Dolutegravir-Based Regimens: A Retrospective Cohort Study

Background

HIV is one of the leading causes of morbidity and mortality, with 39.0 million people living with HIV worldwide, 25.6 million of whom reside in the African region. Highly active anti-retroviral therapy (HAART) has improved survival and quality of life, yet some patients develop viral non-suppression. Dolutegravir (DTG) has been recommended since 2018 as a first-line treatment option in low- and middle-income countries owing to its effectiveness, low cost, and tolerability, but some studies have reported virological non-suppression with its use. This study aims to explore the prevalence and factors associated with virological non-suppression in adults taking DTG-based regimens in Mbarara Regional Referral Hospital.

Methods

A retrospective cohort study was carried out among people living with HIV (PLWHIV) taking DTG-based HAART regimens by way of record review. SPSS was used for analysis, and both binary and multivariate logistic regression analyses were performed to test associated factors.

Results

Among the 422 participants' records reviewed, 62.8% were female (median age 40 years, IQR=13). The prevalence of virological non-suppression was 4.2%. Poor adherence to HAART was significantly associated with virological non-suppression, with 100.3 increased adjusted odds (95% CI: 28.90-348.12, p<0.001) compared to those with a record of good adherence. The reasons for poor adherence included alcohol use, stigma, forgetting to take medication, transport problems, and irregular timing of swallowing.

Conclusion

This study found poor adherence to be associated with a 4.2% prevalence of virological non-suppression among PLWHIV in a large public HIV care clinic. Despite the high suppression rates on DTG-based regimens, adherence counseling and viral load monitoring need to be emphasized at all HIV care centers to mark the trends of virological non-suppression.

"Swallowing these drugs every day, you get tired": a mixed-methods study to identify Barriers and facilitators to retention and HIV Viral Load suppression among the Adolescents living with HIV in TASO Mbale and TASO Soroti centers of excellence

Background

Adolescents aged 10-19, living with HIV (ALHIV) lag behind in attaining optimal viral load suppression (VLS) rates and retention in care, an important impediment to reaching epidemic control. This study aimed to identify barriers and facilitators to both VLS and retention among in the sub-population who seek care from TASO Mbale and TASO Soroti centers of excellence, to facilitate adaptation of the operation triple zero in the setting.

Methods

We used a mixed methods approach, extracting secondary data on ALHIV who were active in care during April-June 2022 quarter to determine one year retention in care. Analysis was done in STATA Corp, 15.0. We used logistic regression to determine associated factors and adjusted odds ratio (aOR) to report level of predictability, using 95% confidence interval (CI) and P<0.05 for statistical significance. For qualitative component, purposive sampling of 59 respondents was done. Focused group discussions, key informant interviews, and in-depth interviews were used to collect data. Thematic content analysis was done using Atlas ti.

Results

There were 533 ALHIV, with 12-month retention rate of 95.9% and VLS rate of 74.9%. Predictors for good VLS included good adherence [aOR:95%CI 0.066(0.0115, 0.38) P=0.02], being on first line treatment [aOR:95%CI 0.242 (0.0873,0.6724) P=0.006]. For retention, they include being a school going [aOR:95%CI 0.148(0.024,0.9218) P=0.041], multi month dispensing aOR:95%CI 32.6287(5.1446,206.9404) P<0.001, OVC enrolment aOR:95%CI 0.2625(0.083, 0.83) P=0.023]. Meanwhile key barriers included: individual ones such as internal stigma, lack of transport and treatment/drug fatigue; facility-level such as prolonged waiting time and lack of social activities; community level include stigma and discrimination, inadequate social support and food shortage. In terms of facilitators, individual level ones include good adherence and knowledge of one's HIV status; facility-level such as provision of adolescent friendly services and community-level such as social support and decent nutrition.

Conclusions

VLS rate was sub-optimal mainly due to poor adherence. HIV programs could utilize the barriers and facilitators identified to improve VLS. Conversely, retention rate at one year was good, likely due to provision of adolescent friendly health services. ALHIV and their caregivers need to be empowered to sustain retention and improve VLS.

Contributions to science

By accentuating the barriers and facilitators to retention and VLS among the ALHIV, we ensure HIV programs continue to prioritize effective interventions and discard others as the epidemic evolves. To this, our findings strategically validate the effectiveness of provision of adolescent friendly services and client-centered care in attaining good retention rate.Secondly, being a mixed-methods study, complementarily adds value to the existing body of knowledge on barriers and facilitators while reminding programmers that VLS remains sub-optimal and more efforts are necessary.Finally, different stakeholders could use our findings to advocate for more resources to address some of the barriers such as food shortage, empowerment of ALHIV and caregivers and strengthening skilling programs for ALHIV, especially the out-of-school.

Trend and factors associated with non-suppression of viral load among adolescents on ART in Tanzania: 2018-2021

Background

Tanzania is one of the countries with a high burden of HIV. It has an estimated 1.4 million people living with HIV in 2021. Adolescents living with HIV on antiretroviral therapy (ART) have worse treatment adherence, viral suppression, and mortality rates compared to adults. This study aim was to determine the trend of non-suppression among adolescents on ART in Tanzania from 2018 to 2021 and latest associated predictors.

Methodology

The study utilized data of adolescents (10-19 years) receiving ART in Tanzania mainland for the period of 2018-2021 from the National Care and Treatment Centers database. The primary outcome of interest was non-suppression of viral load, defined as a VL above 1,000 copies/ml. The study employed multivariable logistic regression models to identify factors associated with non-suppression of VL. STATA 15 statistical software was used to analyze the data.

Results

Records of 65,942 adolescents present in the CTC database Tanzania were analyzed. Approximately more than half were female 38,544 (58.5%). The proportion of non-suppression was 34.5%, 23.3%, 12.1%, and 9.7% for the years 2018-2021, respectively. After adjusting for other factors, adolescents with a history of poor adherence to ART in the last six months had higher odds of non-suppression (OR = 1.95, 95% CI = 1.64, 2.31). Adolescents on second or third line ART regimens were almost two times more likely to be non-suppressed compared to those on first-line regimens (OR = 2.85, 95% CI = 2.52, 3.23). Girls had lower odds of non-suppression compared to boys (OR = 0.91, 95% CI = 0.84, 0.98), and similarly, patients attending hospitals had lower odds compared to those attending dispensaries (OR = 0.79, 95% CI = 0.72, 0.87).

Conclusion

Being female, having good history of adherence over the last six months, and attending hospital level was significantly associated with lower levels of non-suppression, while being on second line ART or attending lower health facilities increased the odds of non-suppression. Efforts to enhance the quality and capacity of health services at lower-level facilities (dispensaries and health centers) should be prioritized, as well as promoting gender-sensitive approaches that take into account the unique needs and experiences of adolescent girls and boys are needed to improve VL suppression among this population.

Micronutrients and nutritional status among children living with HIV with and without severe acute malnutrition: IMPAACT P1092

BACKGROUND

Micronutrient deficiencies from malabsorption, gut infections, and altered gut barrier function are common in children living with the human immunodeficiency virus (CLHIV) and may worsen with severe acute malnutrition (SAM). Exploratory data of baseline zinc and selenium levels and changes over 48 weeks in children living with HIV by nutritional status are presented.

METHODS

Zinc, selenium, serum protein and albumin levels measured at study entry and over 48 weeks were compared between children aged 6 to < 36 months who were living with HIV and had SAM or mild malnutrition-normal nutrition. Children with SAM were enrolled after 10-18 days of nutritional rehabilitation. Two-sided t-tests were used to compare levels and changes in levels of micronutrients and proteins by nutritional status.

RESULTS

Fifty-two participants, 25 with and 27 without SAM, of median (Q1,Q3) age 19 (13,25) and 18 (12,25) months respectively, were enrolled. Zinc deficiency was present at entry in 2/25 (8%) of those who had SAM. Mean (SD) baseline zinc levels were [52.2(15.3) and 54.7(12.0) µg/dL] for the SAM and non-SAM cohorts respectively while selenium levels were similar [92.9(25.0), 84.3(29.2) µg/L]. Mean changes of zinc and selenium from study entry to week 48 were similar between the children with and without SAM. There was no significant difference between baseline protein levels [75.2(13.2), 77.3(9.4) g/L] and the mean change from study entry to 48 weeks was also similar between the two groups; with a mean difference of 4.6 g/L [95% CI, (-2.4,11.6)]. Children with SAM compared to those without had significantly lower serum albumin levels at study entry with similar levels at 48 weeks.

CONCLUSIONS

Children with severe malnutrition who were initiated/switched to zidovudine/lamivudine/boosted lopinavir following 10 to 18 days of nutritional rehabilitation showed normal baseline levels of selenium and zinc, and had comparable selenium levels after 48 weeks. There was a strong positive correlation in entry and week 48 selenium levels within each cohort and for zinc in the non-SAM cohort. These data support the current WHO recommended approach to management of severe malnutrition in CLHIV who are initiated on combination antiretroviral treatment.

TRIAL REGISTRATION

Registered with ClinicalTrials.gov Identifier NCT01818258 26/03/2013.

Diabetes mellitus care cascade among a cohort of persons living with HIV and hypertension in Uganda: A retrospective cohort study

BACKGROUND

In Uganda, it is recommended that persons with HIV receive integrated care to address both hypertension and diabetes. However, the extent to which appropriate diabetes care is delivered remains unknown and was the aim of this study.

METHODS

We conducted a retrospective study among participants receiving integrated care for HIV and hypertension for at least 1 year at a large urban HIV clinic in Mulago, Uganda to determine the diabetes care cascade.

RESULTS

Of the 1115 participants, the majority were female (n = 697, 62.5%) with a median age of 50 years (Inter Quartile Range: 43, 56). Six hundred twenty-seven participants (56%) were screened for diabetes mellitus, 100 (16%) were diagnosed and almost all that were diagnosed (n = 94, 94%) were initiated on treatment. Eighty-five patients (90%) were retained and all were monitored (100%) in care. Thirty-two patients (32/85, 38%) had glycaemic control. Patients on a Dolutegravir-based regimen (OR = 0.31, 95% CI = 0.22-0.46, p < 0.001) and those with a non-suppressed viral load (OR = 0.24, 95% CI = 0.07-0.83, p = 0.02) were less likely to be screened for diabetes mellitus.

CONCLUSIONS

In very successful HIV care programs, large gaps still linger for the management of non-communicable diseases necessitating uniquely designed intervention by local authorities and implementing partners addressing the dual HIV and non-communicable diseases burden.

Virological Non-Suppression among Newly Diagnosed HIV-Positive Individuals on Dolutegravir-Based Antiretroviral Treatment in Eastern Ethiopia: Follow-Up Study

There have been limited studies linking baseline factors, including the viral load (VL) test, with virological non-suppression since the introduction of dolutegravir (DTG)-based regimens as first-line antiretroviral treatment (ART) in Ethiopia. This study aimed to identify baseline factors associated with virological non-suppression between October 2020 and July 2022. A follow-up study was conducted in eastern Ethiopia among newly diagnosed people living with HIV (PLHIV). A questionnaire and a checklist were used to collect the data. Five milliliters of venous blood were obtained at baseline and six months to determine the VL. A VL test was performed using the Abbott RealTime HIV-1 assay. To determine predictors of virological non-suppression, bivariate and multivariate logistic regression analyses were used. There were 235 PLHIV enrolled, 70.6% of whom were female, with a mean age of 33.9 years. Of the 161 retained on ART, virological non-suppression was 8.7% at six months. Baseline predictors of virological non-suppression were age ≤ 30 years, a history of substance use, and a VL greater than 4-log10 copies/mL. In this cohort, virological non-suppression was found to be optimal but still lagged slightly behind the third 95%-target. Thus, targeted interventions, the introduction of baseline VL testing to improve treatment outcomes, and fostering the attainment of UNAIDS 95-95-95 targets are recommended. Furthermore, broader research is recommended to explore the reasons for virological non-suppression in the study area.

The association between low-level viraemia and subsequent viral non-suppression among people living with HIV/AIDS on antiretroviral therapy in Uganda

BACKGROUND

Uganda's efforts to end the HIV epidemic by 2030 are threatened by the increasing number of PLHIV with low-level viraemia (LLV). We conducted a study to determine the prevalence of LLV and the association between LLV and subsequent viral non-suppression from 2016 to 2020 among PLHIV on ART in Uganda.

METHOD

This was a retrospective cohort study, using the national viral load (VL) program data from 2016 to 2020. LLV was defined as a VL result of at least 50 copies/ml, but less than 1,000 copies/ml. Multivariable logistic regression was used to determine the factors associated with LLV, and cox proportional hazards regression model was used to determine the association between LLV and viral non-suppression.

RESULTS

A cohort of 17,783 PLHIV, of which 1,466 PLHIV (8.2%) had LLV and 16,317 (91.8%) had a non-detectable VL was retrospectively followed from 2016 to 2020. There were increasing numbers of PLHIV with LLV from 2.0% in 2016 to 8.6% in 2020; and LLV was associated with male sex, second line ART regimen and being of lower age. 32.5% of the PLHIV with LLV (476 out of 1,466 PLHIV) became non-suppressed, as compared to 7.7% of the PLHIV (1,254 out of 16,317 PLHIV) with a non-detectable viral load who became non-suppressed during the follow-up period. PLHIV with LLV had 4.1 times the hazard rate of developing viral non-suppression, as compared to PLHIV with a non-detectable VL (adjusted hazard ratio was 4.1, 95% CI: 3.7 to 4.7, p < 0.001).

CONCLUSION

Our study indicated that PLHIV with LLV increased from 2.0% in 2016 to 8.6% in 2020, and PLHIV with LLV had 4.1 times the hazard rate of developing viral non-suppression, as compared to PLHIV with a non-detectable VL. Hence the need to review the VL testing algorithm and also manage LLV in Uganda.

Low-level viraemia: An emerging concern among people living with HIV in Uganda and across sub-Saharan Africa

Attaining viral load (VL) suppression for over 95% of the people living with HIV on antiretroviral therapy is a fundamental step in enabling Uganda and other sub-Saharan African countries to achieve global Sustainable Development Goal targets to end the HIV/AIDS epidemic by 2030. In line with the 2013 World Health Organization recommendations, several sub-Saharan African countries, including Uganda, use a threshold of 1000 HIV viral RNA copies/mL to determine HIV viral non-suppression. The United States Centers for Disease Control and Prevention and the International Association of Providers of AIDS Care deem this threshold very high, and hence recommend using 200 copies/mL to determine viral non-suppression. Using 1000 copies/mL as a threshold ignores people living with HIV who have low-level viraemia (LLV; HIV VL of at least 50 copies/mL but less than 1000 copies/mL). Despite the 2021 World Health Organization recommendations of using intensive adherence counselling for people living with HIV with LLV, several sub-Saharan African countries have no interventions to address LLV. However, recent studies have associated LLV with increased risks of HIV drug resistance, virologic failure and transmission. The purpose of this narrative review is to provide insights on the emerging concern of LLV among people living with HIV receiving antiretroviral therapy in sub-Saharan Africa. The review also provides guidance for Uganda and other sub-Saharan African countries to implement immediate appropriate interventions like intensive adherence counselling, reducing VL thresholds for non-suppression and conducting more research to manage LLV which threatens progress towards ending HIV by 2030.

Spatiotemporal Variation and Predictors of Unsuppressed Viral Load among HIV-Positive Men and Women in Rural and Peri-Urban KwaZulu-Natal, South Africa

Unsuppressed HIV viral load is an important marker of sustained HIV transmission. We investigated the prevalence, predictors, and high-risk areas of unsuppressed HIV viral load among HIV-positive men and women. Unsuppressed HIV viral load was defined as viral load of ≥400 copies/mL. Data from the HIV Incidence District Surveillance System (HIPSS), a longitudinal study undertaken between June 2014 to June 2016 among men and women aged 15−49 years in rural and peri-urban KwaZulu-Natal, South Africa, were analysed. A Bayesian geoadditive regression model which includes a spatial effect for a small enumeration area was applied using an integrated nested Laplace approximation (INLA) function while accounting for unobserved factors, non-linear effects of selected continuous variables, and spatial autocorrelation. The prevalence of unsuppressed HIV viral load was 46.1% [95% CI: 44.3−47.8]. Predictors of unsuppressed HIV viral load were incomplete high school education, being away from home for more than a month, alcohol consumption, no prior knowledge of HIV status, not ever tested for HIV, not on antiretroviral therapy (ART), on tuberculosis (TB) medication, having two or more sexual partners in the last 12 months, and having a CD4 cell count of <350 cells/μL. A positive non-linear effect of age, household size, and the number of lifetime HIV tests was identified. The higher-risk pattern of unsuppressed HIV viral load occurred in the northwest and northeast of the study area. Identifying predictors of unsuppressed viral load in a localized geographic area and information from spatial risk maps are important for targeted prevention and treatment programs to reduce the transmission of HIV.

Predictors of Viral Non-Suppression among Patients Living with HIV under Dolutegravir in Bunia, Democratic Republic of Congo: A Prospective Cohort Study

The Democratic Republic of the Congo adopted the integrase inhibitor dolutegravir (DTG) as part of its preferred first-line HIV treatment regimen in 2019. This study aimed to identify predictors of viral non-suppression among HIV-infected patients under a DTG-based regimen in the context of ongoing armed conflict since 2017 in the city of Bunia in the DRC. We conducted a cohort study of 468 patients living with HIV under DTG in all health facilities in Bunia. We calculated the proportion of participants with an HIV RNA of below 50 copies per milliliter. About three in four patients (72.8%) in this cohort had a viral load (VL) of <50 copies/mL after 6–12 months. After controlling for the effect of other covariates, the likelihood of having non-suppression remained significantly lower among the 25–34 age group and self-reported naïve patients with a baseline VL of ≥50 copies/mL. The likelihood of having non-suppression remained significantly higher among those who were at advanced stages of the disease, those with abnormal serum creatinine, those with high baseline HIV viremia over 1000 copies/mL, and the Sudanese ethnic group compared to the reference groups. This study suggests that we should better evaluate adherence, especially among adolescents and economically vulnerable populations, such as the Sudanese ethnic group in the city of Bunia. This suggests that an awareness of the potential effects of DTG and tenofovir is important for providers who take care of HIV-positive patients using antiretroviral therapy (ART), especially those with abnormal serum creatinine levels before starting treatment.

Clinical outcomes among adolescents living with HIV in Kenya following initiation on antiretroviral treatment

In Kenya, HIV/AIDS remains a leading cause of morbidity and mortality among adolescents living with HIV (ALHIV). Our study evaluated associations between demographic and healthcare factors and HIV treatment outcomes among ALHIV in care in Kenya. This retrospective cohort study evaluated the clinical outcomes of newly diagnosed ALHIV enrolled in HIV care during January 2017-June 2018 at 32 healthcare facilities in Homabay and Kakamega Counties. Demographic and clinical data were abstracted from patient clinical records and registers during the follow up study period January 2017-through May 2019. ALHIV were stratified by age (10-14 versus 15-19 years). Categorical variables were summarized using descriptive statistics; continuous variables were analyzed using mean values. The latest available treatment and virological outcomes for ALHIV were assessed. 330 ALHIV were included in the study (mean age 15.9 years; 81.8% female, 63.0% receiving HIV care at lower-level healthcare facilities). Most (93.2%) were initiated on ART within 14 days of diagnosis; 91.4% initiated EFV-based regimens. Of those on ART, only 44.6% were active on care at the end of the study period. Of those eligible for viral load testing, 83.9% were tested with 84.4% viral suppression rate. Retention in care was higher at higher-level facilities (67.5%) compared to lower-level facilities (28.6%). Factors associated with higher retention in care were school attendance (aRR = 1.453), receipt of disclosure support (aRR = 13.315), and receiving care at a high-level health facility (aRR = 0.751). Factors associated with viral suppression included older age (15-19 years) (aRR = 1.249) and pre-ART clinical WHO stage I/II (RR = .668). Viral suppression was higher among older ALHIV. Studies are needed to evaluate effective interventions to improve outcomes among ALHIV in Kenya.

A randomized controlled trial evaluating the effects of a family-centered HIV care model on viral suppression and retention in care of HIV-positive children in Eswatini

Introduction

A family-centered care model (FCCM) providing family-based HIV services, rather than separate adult/pediatric services, has been proposed to increase pediatric retention and treatment adherence.

Materials and methods

Eight health-care facilities in the Hhohho region of Eswatini were randomized to implement FCCM (n = 4) or continue standard-of-care (SOC) separate adult/pediatric clinics (n = 4). HIV-positive children and caregivers were enrolled; caregiver interview and child/caregiver chart abstraction were done at enrollment and every three months; pediatric viral load was evaluated at enrollment and every six months through 12 months. Because of study group differences in 12-month viral load data availability (89.4% FCCM and 72.0% SOC children had 12-month viral load), we used three separate analyses to evaluate the effects of FCCM on children’s viral suppression (<1,000 copies/mL) and undetectable virus (<400 copies/mL) at 12 months. In the first analysis, all children with missing viral outcome data were excluded from the analysis (modified intent to treat, mITT). The second analysis used inverse probability of missingness weighted logistic regression to estimate the effect of FCCM on 12-month viral outcomes compared to SOC (weighted mITT). For the third approach, missing virologic outcome data were imputed as virologic failure (imputed ITT). We also examined factors associated with viral suppression at 12 months using multivariable logistic regression.

Results

We enrolled 379 HIV-positive children and 363 caregivers. Among all children at enrollment, viral suppression and undetectability was 78.4% and 73.9%, respectively, improving to 90.2% and 87.3% at 12 months. In mITT and weighted mITT analyses, there was no significant difference in children’s 12-month viral suppression between FCCM and SOC groups (89.2% and 91.6%, respectively). Using imputed ITT, there was a modest increase in 12-month viral suppression in FCCM versus SOC children (79.7% and 69.8%, respectively, p = 0.051) and 12-month undetectability (78.7% and 65.7%, respectively, p = 0.015). Among the 255 children suppressed at enrollment, more FCCM versus SOC children (98.0% versus 95.3%) were suppressed at 12-months, but this was not statistically significant in mITT or weighted mITT analyses, with a marginally significant difference using imputed mITT analysis (p = 0.042). A higher proportion of children suppressed at enrollment had undetectable viral load at 12 months in FCCM versus SOC children (98.0% versus 92.5%), a statistically significant difference across analytical methods. Among the 61 children unsuppressed at enrollment, achieving suppression was higher among SOC versus FCCM children, but this difference was not statistically significant and included only 38 children; and there were no significant differences in detectable viral load at 12 months.

There were no significant differences between study groups in retention or ART adherence at 12 months for children or caregivers. Factors associated with lack of viral suppression/detectability at 12 months included lack of viral suppression at enrollment and having a younger caregiver (age <25 years).

Conclusions

FCCM in Eswatini was associated with a modest increase in viral suppression/undetectability at 12-months; 12-month retention and adherence did not differ by study group for children or caregivers. High levels of suppression and retention in both groups may have limited our ability to detect a difference.

Trial registration

NCT03397420; ClinicalTrials.gov.