Factors associated with recent unsuppressed viral load in HIV-1-infected patients in care on first-line antiretroviral therapy in South Africa

Abstract

Unsuppressed viral load (VL) in patients on antiretroviral therapy (ART) occurs when treatment fails to suppress a person's VL and is associated with decreased survival and increased HIV transmission. The objective of this study was to evaluate factors associated with unsuppressed VL (VL > 400 copies/ml) in patients currently in care on first-line ART for ≥ 6 months attending South African public healthcare facilities. We analysed electronic medical records of ART patients with a VL result on record who started ART between January 2004 and April 2016 from 271 public health facilities. We present descriptive and multivariable logistic regression for unsuppressed VL at last visit using a priori variables. We included 244,370 patients (69% female) on first-line ART in April 2016 for ≥ 6 months. Median age at ART start was 33 years (7% were < 15 years old). Median duration on ART was 3.7 years. Adjusting for other variables, factors associated with having an unsuppressed VL at the most recent visit among patients in care included: (1) < 15 years old at ART start (adjusted odds ratio [aOR]=2.58; 95% CI = 2.37, 2.81) versus 15-49 years at ART start, (2) male gender (aOR = 1.29; 95% CI = 1.25, 1.35), (3) 6-12 months on ART versus longer (aOR = 1.34; 95% CI = 1.29, 1.40), (4) on tuberculosis (TB) treatment (aOR = 1.78; 95% CI = 1.48, 2.13), and (5) prior ART exposure versus none (aOR = 1.20; 95% CI = 1.08, 1.32). Approximately 85% of the ART cohort who were in care had achieved viral suppression, though men, youth/adolescents, patients with prior ART exposure, those with short duration of ART, and patients on TB treatment had increased odds of not achieving viral suppression. There is a need to develop and evaluate targeted interventions for ART patients in care who are at high risk of unsuppressed VL.

Factors associated with viral non-suppression among adolescents living with HIV in Cambodia: a cross-sectional study

“…Because adolescence is characterized by increasing cognition [ 35 – 37 ], the relationship between viral suppression and age among long-term survivors of HIV could be mediated by the impact of self-efficacy and self-competency and risk-taking on ART adherence [ 3 , 33 ]. Similar findings regarding age were also found in a study among people living with HIV in South Africa, whereby adolescents aged < 15 were more likely to have unsuppressed viral load (viral load > 400 RNA copies/mL) compared with older patients [ 38 ]. Indeed, studies have consistently reported that increasing age reduced odds of non-viral suppression in Uganda (≥ 1000 RNA copies/mL) [ 39 ] and in several countries across Europe (> 50 RNA copies/mL) [ 40 ].…”

“…Shorter duration on ART was associated with viral non-suppression, which is to be expected given the destruction of CD4 cells resulting from high viral replication. Although the relationship between viral non-suppression, immunological responses, and duration on ART is not always consistent [ 41 ], similar findings were reported in a South African study, which reported that adolescents who had been on ART between six and 12 months were more likely to have viral non-suppression (viral load > 400 RNA copies/mL) compared with those who had been on treatment longer [ 38 ]. In our study, a lower viral load at the time of initial clinic enrollment also predicted viral suppression, which is in line with mechanisms of ART action [ 3 ].…”

Non-uptake of viral load testing among people receiving HIV treatment in Gomba district, rural Uganda

“…Shorter duration on ART is also associated with higher odds of viral non-suppression [ 12 ]. To identify patients with unsuppressed VL in need of adherence interventions and at risk of virologic failure, providers should prioritize VL testing after 6 months of ART [ 36 ] in accordance with WHO guidelines. Timely targeted adherence counseling decreases the risk of treatment failure and drug resistance, negating the need for more expensive second-line or third-line therapy [ 37 ].…”

Descriptive analysis of World Health Organization-recommended second-line antiretroviral treatment: A retrospective cohort data analysis

“…historical first-line treatment (85% suppression rate) in Johannesburg subdistrict F. [20] The low CD4+ cell counts despite viral suppression could be indicative of slow CD4+ cell count recovery. [21] Just under three-quarters (72.4%) of our patients remained in care in the study sites over the reported period.…”