Detection of HIV Virologic Failure and Switch to Second-Line Therapy: A Systematic Review and Meta-analysis of Data From Sub-Saharan Africa

Abstract

Introduction The late recognition of virologic failure (VF) places persons with HIV in sub-Saharan Africa at risk for HIV transmission, disease progression and death. We conducted a systematic review and meta-analysis to determine if the recognition and response to VF in the region has improved. Methods We searched for studies reporting CD4 count at confirmed VF or at switch to second-line ART. Using a random-effects meta-regression model, we analyzed temporal trends in CD4 count at VF – or at second-line ART switch – over time. We also explored temporal trends in delay between VF and switch to second-line ART. Results We identified 26 studies enrolling patients with VF and 10 enrolling patients at second-line ART switch. For studies that enrolled patients at VF, pooled mean CD4 cell count at failure was 187 cells/ mm 3 (95% confidence interval [CI]: 111 - 263). There was no significant change in CD4 count at confirmed failure over time (+4 cells/year, 95% CI: -7 to 15 cells/year). Among studies that enrolled patients at second-line switch, pooled mean CD4 count was 108 cells/ mm 3 (95% CI: 63 - 154). CD4 count at switch increased slightly over time (+10 CD4 cells/year, 95% CI: 2 to 19 cells/year). During the same period, mean delay between confirmation of VF and switch was 530 days with no significant decline over time (-14 days/year, 95% CI: -58 to 52 days). Conclusions VF in Africa remains an event recognized late in HIV infection, a problem compounded by ongoing delays between VF and second-line switch.

Determinants of health-related quality of life in people with Human Immunodeficiency Virus, failing first-line treatment in Africa

“…Even PWH with advanced disease may feel a return to health as soon as 6 to 12 months after starting ART. VL is an important clinical indicator of ART adherence ART response, our study findings enforce that the early detection of virological failure and achievement of virological suppression are critical to improving HRQoL in this population [ 31 ]. Furthermore, significant positive associations between CD4 and utility support the importance of CD4 count monitoring in clinical settings in Uganda.…”

Advanced HIV disease in Homa Bay County, Kenya: Characteristics of newly-diagnosed and antiretroviral therapy-experienced clients

“…A systematic review and meta-analysis from sub-Saharan Africa reported a mean delay between confirmation of treatment failure and switch of therapy of 530 days. [ 25 ] In Kenya, a review of program data reported the average time taken to ART regimen switch in clients with treatment failure is 411 days.…”

Virological failure and treatment switch after ART initiation among people living with HIV with and without routine viral load monitoring in Asia

“…Moreover, adherence challenges, the high cost or unavailability of second‐line regimens may be the reasons for delayed switching in low/upper middle‐income countries [ 8 , 26 , 27 ]. The lack of routine VL testing has also contributed to delayed VF detection and first‐line ART switches [ 28 ]. Switching to DTG as per WHO recommendation has been implemented across several countries.…”