Access to HIV Viral Load Testing and Antiretroviral Therapy Switch Practices: A Multicountry Prospective Cohort Study in Sub-Saharan Africa

Abstract

Poor access to HIV viral load (VL) testing prevents the timely monitoring of HIV treatment adherence and efficacy. Factors enabling clinical benefits of VL testing when added to local standards of care, can inform the development of more cost-effective routine VL scale-up plans. We compared antiretroviral therapy (ART) switch practices in 13 clinics across 6 countries, with full (N = 8), phasing-in (N = 3) or no onsite access (N = 2) to VL. The analysis used data from the Pan-African Studies to Evaluate Resistance (PASER), observing virological and drug resistance outcomes among adults receiving first-or second-line ART between 2008 and 2015. Study plasma viral load (sVL) determined at baseline, every 12 months thereafter and at the time of switch served for retrospectively validating switch decisions, categorized into "necessary," "unnecessary," and "missed." Virological failure was defined as two consecutive sVL ≥1,000 HIV-RNA copies/mL. One thousand nine hundred ninety-five of the 2,420 (82.4%) study participants had continuous virological suppression during the median 30 months of follow-up. Among the 266 virological failures (11.0%), the proportion of necessary switches were similar in clinics with full (37%), phasing-in (25%), or no access (39%) to local VL testing. Documented utilization of local VL results for the switch decision was associated with higher percentage of necessary switch (87.6% vs. 67.9%). Shorter time to necessary switch was associated with higher rates of long-term virological suppression, regardless of access to local viral load. Availability of HIV VL testing capacity does not systematically result in adequate switch practices or better virological outcomes.

Men missing from the HIV care continuum in sub‐Saharan Africa: a meta‐analysis and meta‐synthesis

“…Of these, 81 studies were included in the meta‐analysis [33–113] and 29 studies were included in the meta‐synthesis [105,114–141]. Our updated searches identified 48 additional studies for the meta‐analysis [142–189] and 11 additional studies for the meta‐synthesis [190–200], most published in 2020.…”

“…South Africa was the most represented country (40 [31.0%]). Three studies included representation from eastern and southern Africa as well as western and central Africa [ 76 , 150 , 180 ]; of the remaining studies, eastern and southern Africa was more represented (113 [89.7%]) as compared to western and central Africa (13 [10.3%]). The median number of participants was 1688 (interquartile range [IQR], 552–5666; range, 63–248,002).…”

“…For the meta‐analysis, 47 studies reported data on knowledge of positive serostatus [39,41,44,52–55,58,59,63–65,69,73,77,79–81,83,84,86,91,94,95,97,99,101,102,108,110–113,144,146,149,151,154,157,167,171,178,185,186,188,189], 43 studies reported data on ART use [35,36,39,47,51,55,60,62,67,70,83–85,95,97–99,104,105,107,108,112,142,144–146,148–150,154,161,162,166–168,170,171,181,184–186,188,189] and 74 studies reported data on viral suppression (Table 1 and Table A2) [33,34,37,38,40–43,45,46,48–50,55–57,61,66,68,71,72,74–76,78,82,84,87–90,92,93,95–97,100,103,106–109,143,146,147,149,152–156,158–161,163–165,169,171–177,179,180,182,183,...…”

Changes in access to viral load testing, incidence rates of viral load suppression and rebound following the introduction of the ‘universal test and treat’ guidelines in Cameroon: A retrospective follow-up analysis

“…In addition, there was the removal of user fees, continuing mentorship of healthcare workers, the establishment of hub-and-spoke laboratories to reorganise the transport system, mobile coolers to strengthen the cold-chain, use of solar panel installations and refrigerators, as well as the use of psychosocial and community health workers to remind clients to visit the clinic for VLT [ 24 , 26 ]. Despite the scaling up of VLT, overall viral load testing coverage in this study and the country at large (47.6% vs.58.1%) remains low as significant challenges persist including prolonged and frequent commodity stock-outs, limited cold-chain capacity, long distances to health facilities and poor roads [ 21 , 23 , 27 ]. The persistently low VLT coverage is linked to the increasing number of patients who are also accessing ART because of UTT and who eventually require a VLT.…”

“…Viral load testing has been recommended by WHO as the preferred monitoring approach to diagnose and confirm treatment failure [ 4 , 19 , 20 ]. However, VLT has not been feasible during the first decade of ART scale-up in many resource-constraint settings because it is expensive and technically complex [ 21 , 22 ]. Only 24% of clients were accessing VLT in some clinics in Cameroon before the rollout of the UTT guidelines [ 23 ].…”