Prior exposure to antiretroviral therapy among adult patients presenting for HIV treatment initiation or re-initiation in sub- Saharan Africa: a systematic review

Abstract

BackgroundAs countries in sub-Saharan Africa have scaled up access to antiretroviral therapy (ART) for HIV, patient attrition rates of up to 30% per year have created a large pool of individuals who initiate treatment with prior ART experience (non-naïve re-initiators). Little is known about the proportion of non-naïve re-initiators within the population presenting for treatment initiation.MethodsWe conducted a comprehensive, rapid review of recent peer-reviewed reports that presented data on proportions of adult patients initiating ART who were treatment naïve and non-naive in sub-Saharan Africa. Searching PubMed, EMBASE, Web of Science, and international conference abstracts, we sought studies published after 1 January 2018 with data collected after January 2016, when universal HIV treatment access became the norm. We included clinical trials and observational studies and accepted self-report, laboratory discernment of antiretroviral metabolites, or viral suppression at initiation or previously reported in the medical record as evidence of prior exposure. We report results of each eligible study and identify gaps in the literature.ResultsOf 1,782 articles returned in our initial search, we found nine, describing ten cohorts, that contained sufficient information for the review, of which half were from South Africa. The proportion of the study samples with evidence of prior ART use ranged from 5% (self-report only) to 53% (presence of ART metabolites in hair or blood sample among self-reported naïve patients). The vast majority of studies that were screened did not report proportions of initiators who were non-naïve, and among the few that did, the metrics used to determine and report non-naïve proportions were inconsistent and difficult to interpret.ConclusionThe proportion of patients initiating HIV treatment who are truly ART-naïve is not well documented in the literature. From the studies identified, it seems likely that 20% to 50%—and likely at least 30%—of ART patients who present for ART are re-initiators. Standard reporting metrics and diligence in reporting this characteristic of ART initiation cohorts are needed, as is research to understand the reluctance of patients to report prior ART exposure.

Reasons for disengagement from antiretroviral care in the era of “Treat All” in low‐ or middle‐income countries: a systematic review

“…Disengagement from HIV care—having started taking ART, but then stopped treatment for a defined period of time—is relatively common: in a large multi‐country study which updated data through tracing, only 67% of people who started ART between 2009 and 2014 were engaged in care at 5 years [5], with similar findings in more recent studies in Zambia, South Africa, Tanzania and eSwatini [6–9]. People initiating ART at clinics are often re‐initiating treatment after a period of disengagement, although clients do not always report previous ART experience: a recent review found that 20−50% of ART patients who present for ART were re‐initiators [10]. Disengagement from ART care jeopardizes individuals and communities from realizing the benefits of “Treat All” [3, 11].…”

Risk of Emergent Dolutegravir Resistance Mutations In People Living With HIV: A Rapid Scoping Review

“…Moreover, participants in a clinical trial of first-line ART are usually required to be ART-naïve. In contrast, in real-world settings, a significant proportion of individuals presenting for first-line ART are re-initiating therapy and may harbor acquired NRTIassociated DRMs [127][128][129].…”

Preferences for services in a patient’s first six months on antiretroviral therapy for HIV in South Africa and Zambia (PREFER): research protocol for a prospective observational cohort study

“…It will be a structured questionnaire designed for primarily quantitative analysis but with some open-ended questions (Extended data -Supplementary file 3). Questions will build on previous work of the AMBIT Project and on the authors' experience in studying retention in HIV care 1,3,[17][18][19] . The questionnaire has eight substantive sections, addressing the respondent's demographics and socio-economic status, HIV testing history, HIV treatment history, current HIV care and treatment experience, other healthcare, preferences for features of treatment delivery, expectations, and costs of seeking care.…”