Durable Suppression of HIV-1 after Virologic Monitoring-Based Antiretroviral Adherence Counseling in Rakai, Uganda

Billioux, Alexander; Nakigozi, Gertrude; Newell, Kevin; Chang, Larry W.; Quinn, Thomas C.; Gray, Ron; Ndyanabo, Anthony; Galiwango, Ronald M.; Kiggundu, Valerian; Serwadda, David; Reynolds, Steven J.

doi:10.1371/journal.pone.0127235

Cited by 25 publications

(28 citation statements)

References 28 publications

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“…This finding supports the strong recommendation of the Haiti National HIV Treatment guidelines to actively screen PLHIV for TB [ 3 ]. Our findings also highlight the importance of enhanced adherence counseling to sustain virologic suppression [ 33 ]. Indeed, 86% of patients with two consecutive VL maintained virologic suppression and of those with an initial HIV-1 RNA ≥ 1000 copies/mL, 25% achieved virologic suppression after intensive adherence counseling.…”

Section: Discussionmentioning

confidence: 58%

Virologic outcome among patients receiving antiretroviral therapy at five hospitals in Haiti

Louis¹,

Buteau²,

François

et al. 2018

PLoS ONE

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IntroductionViral load (VL) assessment is the preferred method for diagnosing and confirming virologic failure for patients on antiretroviral therapy (ART). We conducted a retrospective cross-sectional study to evaluate the virologic suppression rate among patients on ART for ≥6 months in five hospitals around Port-au-Prince, Haiti.MethodsPlasma VL was measured and patients with VL <1,000 copies/mL were defined as virologically suppressed. A second VL test was performed within at least six months of the first test. Factors associated with virologic suppression were analyzed using logistic regression models accounting for site-level clustering using complex survey procedures.ResultsData were analyzed for 2,313 patients on ART for six months or longer between July 2013 and February 2015. Among them, 1,563 (67.6%) achieved virologic suppression at the first VL test. A second VL test was performed within at least six months for 718 (31.0%) of the patients. Of the 459 patients with an initial HIV-1 RNA <1,000 copies/mL who had a second VL performed, 394 (85.8%) maintained virologic suppression. Virologic suppression was negatively associated with male gender (adjusted odds ratio [aOR]: 0.80, 95% CI: 0.74–0.0.86), 23 to 35 months on ART (aOR:0.72[0.54–0.96]), baseline CD4 counts of 201–500 cells/mm3 and 200 cells/mm3 or lower (aORs: 0.77 [0.62–0.95] and 0.80 [0.66–0.98], respectively), poor adherence (aOR: 0.69 [0.59–0.81]), and TB co-infection (aOR: 0.73 [0.55–0.97]).ConclusionsThis study showed that over two-thirds of the patients in this evaluation achieved virologic suppression after ≥ six months on ART and the majority of them remained suppressed. These results reinforce the importance of expanding access to HIV-1 viral load testing in Haiti for monitoring ART outcomes.

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Section: Discussionmentioning

confidence: 58%

Virologic outcome among patients receiving antiretroviral therapy at five hospitals in Haiti

Louis¹,

Buteau²,

François

et al. 2018

PLoS ONE

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“…In 2005, RHSP initiated bi-annual routine VL monitoring to identify patients experiencing virologic failure. Interventions to address virologic failure included intensified adherence counseling, peer support, and switching to second-line ART [ 13 ]. Decisions about and timing of the switch to second-line ART were made on a case-by-case basis at the clinician’s discretion, and were based on the suspected cause of virologic failure (poor adherence or suspected drug resistance).…”

Section: Methodsmentioning

confidence: 99%

Rates of switching to second-line antiretroviral therapy and impact of delayed switching on immunologic, virologic, and mortality outcomes among HIV-infected adults with virologic failure in Rakai, Uganda

et al. 2017

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BackgroundSwitch from first to second-line ART is recommended by WHO for patients with virologic failure. Delays in switching may contribute to accumulated drug resistance, advanced immunosuppression, increased morbidity and mortality. The 3rd 90′ of UNAIDS 90:90:90 targets 90% viral suppression for persons on ART. We evaluated the rate of switching to second-line antiretroviral therapy (ART), and the impact of delayed switching on immunologic, virologic, and mortality outcomes in the Rakai Health Sciences Program (RHSP) Clinical Cohort Study which started providing ART in 2004 and implemented 6 monthly routine virologic monitoring beginning in 2005.MethodsRetrospective cohort study of HIV-infected adults on first-line ART who had two consecutive viral loads (VLs) >1000 copies/ml after 6 months on ART between June 2004 and June 2011 was studied for switching to second-line ART. Immunologic decline after virologic failure was defined as decrease in CD4 count of ≥50 cells/ul and virologic increase was defined as increase of 0.5 log 10 copies/ml. Competing risk models were used to summarize rates of switching to second-line ART while cox proportional hazard marginal structural models were used to assess the risk of virologic increase or immunologic decline associated with delay to switch first line ART failing patients.ResultsThe cumulative incidence of switching at 6, 12, and 24 months following virologic failure were 30.2%, 44.6%, and 65.0%, respectively. The switching rate was increased with higher VL at the time of virologic failure; compared to those with VLs ≤ 5000 copies/ml, patients with VLs = 5001–10,000 copies/ml had an aHR = 1.81 (95% CI = 0.9–3.6), and patients with VLs > 10,000 copies/ml had an aHR = 3.38 (95%CI = 1.9–6.2). The switching rate was also increased with CD4 < 100 cells/ul at ART initiation, compared to those with CD4 ≥ 100 cells/ul (aHR = 2.30, 95% CI = 1.5–3.6). Mortality in patients not switched to second-line ART was 11.9%, compared to 1.2% for those who switched (p = 0.009). Patients switched after 12 months of of virologic failure were more likely to experience CD4 decline and/or further VL increases.ConclusionsIntervention strategies that aid clinicians to promptly switch patients to second-line ART as soon as virologic failure on 1st line ART is confirmed should be prioritized.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-017-2680-6) contains supplementary material, which is available to authorized users.

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“…As a result, studies in the region are now reporting long-term viral suppression 10 that is comparable to that in developed countries, 11 and can be improved further with new approaches to adherence counselling. 12 As O'Connor and colleagues note, the high rates of viral rebound after initial suppression in black Africans who have migrated to the UK are difficult to explain with certainty, but they might be related to socioeconomic and psychosocial factors such as homelessness, substance abuse, and mental health issues that were not measured in their study.…”

mentioning

confidence: 93%

Long-term durability of HIV viral load suppression

Dharan

Cooper

2017

The Lancet HIV

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Durable Suppression of HIV-1 after Virologic Monitoring-Based Antiretroviral Adherence Counseling in Rakai, Uganda

Cited by 25 publications

References 28 publications

Virologic outcome among patients receiving antiretroviral therapy at five hospitals in Haiti

Virologic outcome among patients receiving antiretroviral therapy at five hospitals in Haiti

Rates of switching to second-line antiretroviral therapy and impact of delayed switching on immunologic, virologic, and mortality outcomes among HIV-infected adults with virologic failure in Rakai, Uganda

Long-term durability of HIV viral load suppression

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