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

Abstract

ObjectivesAs countries have scaled up access to antiretroviral therapy (ART) for HIV, attrition rates of up to 30% annually have created a large pool of individuals who initiate treatment with prior ART experience. Little is known about the proportion of non-naïve reinitiators within the population presenting for treatment initiation.DesignSystematic review of published articles and abstracts reporting proportions of non-naïve adult patients initiating ART in sub-Saharan Africa.Data sourcesPubMed, Embase Elsevier, Web of Science Core Collection, International AIDS Society conferences, Conference on Retroviruses and Opportunistic Infections conferences.Eligibility criteriaClinical trials and observational studies; reporting on adults in sub-Saharan Africa who initiated lifelong ART; published in English between 1 January 2018 and 11 July 2023 and with data collected after January 2016. Initiator self-report, laboratory discernment of antiretroviral metabolites, and viral suppression at initiation or in the medical record were accepted as evidence of prior exposure.Data extraction and synthesisWe captured study and sample characteristics, proportions with previous ART exposure and the indicator of previous exposure reported. We report results of each eligible study, estimate the risk of bias and identify gaps in the literature.ResultsOf 2740 articles, 11 articles describing 12 cohorts contained sufficient information for the review. Proportions of initiators with evidence of prior ART use ranged from 5% (self-report only) to 53% (presence of ART metabolites in hair or blood sample). The vast majority of screened studies did not report naïve/non-naïve status. Metrics used to determine and report non-naïve proportions were inconsistent and difficult to interpret.ConclusionsThe proportion of patients initiating HIV treatment who are truly ART naïve is not well documented. It is likely that 20%–50% of ART patients who present for ART are reinitiators. Standard reporting metrics and diligence in reporting are needed, as is research to understand the reluctance of patients to report prior ART exposure.PROSPERO registration numberCRD42022324136.

Prevalence 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 NRTI-associated DRMs [ 125 , 126 , 127 ].…”

Experiences and preferences in Zambia and South Africa for delivery of HIV treatment during a client’s first six months: a cross-sectional survey

“…One implication of this result is that the development of accurate risk stratification approaches to identify individuals at risk of negative outcomes who might require different services, which we believe is a promising direction for further research [21,22], may be even more challenging than expected [24,25]. If self-reported HIV/ART history and basic demographic characteristics do not provide sufficient information to determine optimal service delivery models, the role of selfidentification of risk and individual choice of service delivery characteristics may become more important, allowing clients to self-select what is best for them [19,22,23].…”

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].…”