Expansion of Viral Load Testing and the Potential Impact on Human Immunodeficiency Virus Drug Resistance

Chun, Helen M.; Obeng-Aduasare, Y; Broyles, Laura N.; Ellenberger, Dennis

doi:10.1093/infdis/jix404

Cited by 6 publications

(7 citation statements)

References 22 publications

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“…Therefore, ART programs need to combine roll-out of VL monitoring with strategies that ensure that patients with virological failure are followed-up and that confirmed virological failure results in action, in order to achieve virological re-suppression[3,7,19,20]. Sunpath and colleagues showed in three clinics in South Africa that introduction of a “viral load champion”, a nurse who was specifically assigned to ensure correct follow-up of VLs, resulted in a higher proportion monitored according to schedule[21].…”

Section: Discussionmentioning

confidence: 99%

“…While from a clinical perspective there is no doubt that VL is the method of choice to monitor the treatment success of ART, from a public health perspective its impact in resource-limited settings still remains to be proven[5]. To have an impact, VL testing must become part of a package of good care with reliably rapid turn-around times of VL results, correct interpretation by staff, feedback to the patient and appropriate subsequent action[6,7]. Several studies on VL monitoring in resource-limited settings indicate, however, large gaps along the VL cascade of care: in particular, delays in follow-up VL or in switching to second-line ART after confirmed virological failure hamper the effectiveness of VL monitoring [8,9].…”

Section: Introductionmentioning

confidence: 99%

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The viral load monitoring cascade in a resource-limited setting: A prospective multicentre cohort study after introduction of routine viral load monitoring in rural Lesotho

Glass

Motaboli²,

Nsakala³

et al. 2019

PLoS ONE

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Introduction For HIV-positive individuals on antiretroviral therapy (ART), the World Health Organization (WHO) recommends routine viral load (VL) monitoring. We report on the cascade of care in individuals with unsuppressed VL after introduction of routine VL monitoring in a district in Lesotho. Materials and methods In Butha-Buthe district 12 clinics (11 rural, 1 hospital) send samples for VL testing to the district laboratory. We included data from patients aged ≥15 years from Dec 1, 2015 to November 1, 2018. As per WHO guidelines VL <1000 copies/mL are considered suppressed, those ≥1000copies/mL unsuppressed. Patients with unsuppressed VL receive adherence counseling and follow-up VL within 8–12 weeks. Two consecutively unsuppressed VLs should trigger switch to second-line ART. For analysis of the VL monitoring cascade we defined care to be “according to guidelines” if patients with unsuppressed VL received a follow-up VL within <180 days and follow-up VL was either re-suppressed, or again unsuppressed and the individual was switched to second-line within 90 days. Results For 9,949 individuals 24,948 VL tests were available. The majority were female (73%), median age 41 years (interquartile range 33–52), and 58% seen at rural clinics. Overall, 25% (260/1028) of individuals were managed according to guidelines: 40% (410/1028) had a follow-up VL within 180 days of their initial unsuppressed VL and 25% (260/1028) of those either re-suppressed or switched to second-line within 90 days. Female patients were more likely to have a follow-up VL done, (p = 0.015). In rural clinics rates of two consecutively unsuppressed VLs were higher than in the hospital (64% vs. 44%, p<0.001), and rural clinics were less likely to switch these patients to second-line (35% vs. 66%, p<0001). Conclusions Our data show that in a real-life setting availability of routine VL monitoring may not be exploited to its potential. A lack of timely follow-up after a first unsuppressed VL and reluctance to switch patients with confirmed virological failure, reduce the benefit of VL monitoring, i.e. in the rural clinics. Future studies will have to assess models of care which ensure that VL results are met with an action and make use of scalable innovative approaches.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

The viral load monitoring cascade in a resource-limited setting: A prospective multicentre cohort study after introduction of routine viral load monitoring in rural Lesotho

Glass

Motaboli²,

Nsakala³

et al. 2019

PLoS ONE

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“…pVL testing is a gold standard for HIV treatment monitoring. The elevation of pVL among patients who achieved viral suppression after cART initiation is an indicator of adherence problems, which may need support interventions, or true treatment failure because of HIV drug resistance mutations, which may require cART regimen changes . However, in resource‐limited settings, pVL testing can be expensive, with the cost for reagents alone ranging from 10 to 85 US dollars/test .…”

Section: Discussionmentioning

confidence: 99%

Impact of the frequency of plasma viral load monitoring on treatment outcomes among children with perinatally acquired HIV

Sudjaritruk

Boettiger²,

Nguyen

et al. 2019

J Intern AIDS Soc

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Introduction Recommendations on the optimal frequency of plasma viral load ( pVL ) monitoring in children living with HIV ( CLWH ) who are stable on combination antiretroviral therapy ( cART ) are inconsistent. This study aimed to determine the impact of annual versus semi‐annual pVL monitoring on treatment outcomes in Asian CLWH. Methods Data on children with perinatally acquired HIV aged <18 years on first‐line, non‐nucleoside reverse transcriptase inhibitor‐based cART with viral suppression (two consecutive pVL <400 copies/ mL over a six‐month period) were included from a regional cohort study; those exposed to prior mono‐ or dual antiretroviral treatment were excluded. Frequency of pVL monitoring was determined at the site‐level based on the median rate of pVL measurement: annual 0.75 to 1.5, and semi‐annual >1.5 tests/patient/year. Treatment failure was defined as virologic failure (two consecutive pVL >1000 copies/ mL ), change of antiretroviral drug class, or death. Baseline was the date of the second consecutive pVL <400 copies/ mL . Competing risk regression models were used to identify predictors of treatment failure. Results During January 2008 to March 2015, there were 1220 eligible children from 10 sites that performed at least annual pVL monitoring, 1042 (85%) and 178 (15%) were from sites performing annual (n = 6) and semi‐annual pVL monitoring (n = 4) respectively. Pre‐ cART , 675 children (55%) had World Health Organization clinical stage 3 or 4, the median nadir CD 4 percentage was 9%, and the median pVL was 5.2 log 10 copies/ mL . At baseline, the median age was 9.2 years, 64% were on nevirapine‐based regimens, the median cART duration was 1.6 years, and the median CD 4 percentage was 26%. Over the follow‐up period, 258 (25%) CLWH with annual and 40 (23%) with semi‐annual pVL monitoring developed treatment failure, corresponding to incidence rates of 5.4 (95% CI : 4.8 to 6.1) and 4.3 (95% CI : 3.1 to 5.8) per 100 patient‐years of follow‐up respectively ( p = 0.27). In multivariable analyses, the frequency of pVL monitoring was not associated with treatment failure (adjusted hazard ratio: 1.12...

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“…Delays in viral suppression can lead to virologic failure, formally defined by the World Health Organization (WHO) in developing countries as the failure to achieve a plasma viral load level below 1,000 HIV-1 RNA copies/mL after three months on ART [ 1 ]. Virologic failure is associated with higher rates of mortality, immunosuppression and the accumulation of resistance mutations [ 2 , 3 ] and individuals who are not suppressed have a much higher probability of transmitting the virus to others [ 3 ].…”

Section: Introductionmentioning

confidence: 99%

Risk factors for delayed viral suppression on first-line antiretroviral therapy among persons living with HIV in Haiti, 2013–2017

et al. 2020

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Studies of viral suppression on first-line antiretroviral therapy (ART) in persons living with human immunodeficiency virus (PLHIV) in Haiti are limited, particularly among PLHIV outside of the Ouest department, where the capital Port-au-Prince is located. This study described the prevalence and risk factors for delayed viral suppression among PLHIV in all geographic departments of Haiti between 2013 and 2017. Individuals who received viral load testing 3 to 12 months after ART initiation were included. Data on demographics and clinical care were obtained from the Haitian Active Longitudinal Tracking of HIV database. Multivariable logistic regression was performed to predict delayed viral suppression, defined as a viral load ≥1000 HIV-1 RNA copies/mL after at least 3 months on ART. Viral load test results were available for 3,368 PLHIV newly-initiated on ART. Prevalence of delayed viral suppression was 40%, which is slightly higher than previous estimates in Haiti. In the multivariable analysis, delayed viral suppression was significantly associated with younger age, receiving of care in the Ouest department, treatment with lamivudine (3TC), zidovudine (AZT), and nevirapine (NVP) combined ART regimen, and CD4 counts below 200 cells/mm 3 . In conclusion, this study was the first to describe and compare differences in delayed viral suppression among PLHIV by geographic department in Haiti. We identified populations to whom public health interventions, such as more frequent viral load testing, drug resistance testing, and ART adherence counseling should be targeted.

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Expansion of Viral Load Testing and the Potential Impact on Human Immunodeficiency Virus Drug Resistance

Cited by 6 publications

References 22 publications

The viral load monitoring cascade in a resource-limited setting: A prospective multicentre cohort study after introduction of routine viral load monitoring in rural Lesotho

The viral load monitoring cascade in a resource-limited setting: A prospective multicentre cohort study after introduction of routine viral load monitoring in rural Lesotho

Impact of the frequency of plasma viral load monitoring on treatment outcomes among children with perinatally acquired HIV

Risk factors for delayed viral suppression on first-line antiretroviral therapy among persons living with HIV in Haiti, 2013–2017

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