Retention in care and virological failure among adult HIV+ patients on second-line ART in Rwanda: a national representative study

Abstract

Background Currently, there is limited evidence on the effectiveness of second-line antiretroviral therapy (ART) in sub-Saharan Africa. To address this challenge, outcomes of second-line protease inhibitor (PI) based ART in Rwanda were assessed. Methods A two-stage cluster sampling design was undertaken. 49 of 340 health facilities linked to the open-source electronic medical record (EMR) system of Rwanda were randomly sampled. Data sampling criteria included adult HIV positive patients with documented change from first to second-line ART regimen. Retention in care and treatment failure (viral load above 1000 copies/mL) were evaluated using multivariable Cox proportional hazards and logistic regression models. Results A total of 1688 patients (60% females) initiated second-line ART PI-based regimen by 31st December 2016 with a median follow-up time of 26 months (IQR 24–36). Overall, 92.5% of patients were retained in care; 83% achieved VL ≤ 1000 copies/ml, 2.8% were lost to care and 2.2% died. Defaulting from care was associated with more recent initiation of ART- PI based regimen, CD4 cell count ≤500 cells/mm 3 at initiation of second line ART and viral load > 1000 copies/ml at last measurement. Viral failure was associated with younger age, WHO stage III&IV at ART initiation, CD4 cell count ≤500 cells/mm 3 at switch, atazanavir based second-line ART and receiving care at a health center compared to hospital settings. Conclusions A high proportion of patients on second-line ART are doing relatively well in Rwanda and retained in care with low viral failure rates. However, enhanced understandings of adherence and adherence interventions for less healthy individuals are required. Routine viral load measurement and tracing of loss to follow-up is fundamental in resource limited settings, especially among less healthy patients.

Rate of Viral Re-Suppression and Retention To Care Among HIV Infected Patients on Second Line Antiretroviral Therapy at Dessie Comprehensive Specialized Hospital, Northeast Ethiopia.

“…The present study shows that one in every ve patients on second line therapy failed to achieve viral re-suppression. This nding was in agreement with studies conducted in resource limited settings (12)(13)(14)(15)(16)(17) and higher than a study conducted in south Africa (18). This variation is due to a difference in viral load measurement classi cation.…”

“…Having high viral load at the commencement of second line antiretroviral therapy is inversely related to viral resuppression. This nding is also supported by many studies (14,16,17,(25)(26)(27)(28). Hence, switching to second line therapy may not be a warranty for viral re-suppression for patients with high viral set point.…”

Prevalence and determinants of virological failure, genetic diversity and drug resistance among people living with HIV in a minority area in China: a population-based study

“…Timely replacement of new regimens for PLWH with drug resistance could prevent additional drug resistance mutation or multiple drug resistance. Last but not the least, continuum in care and retention in care are important factors in preventing virological failure [48], and enhanced understandings of adherence and adherence interventions for less healthy individuals are required to reduce the virological failure. Also, understanding the genotype distribution and drug resistance may contribute to designing target preventive interventions for improving treatment efficiency, aiming for the selection of more effective therapeutic regimens to promote viral suppression and prevent HIV-1 transmission.…”

Clinical Outcomes and Retention Among HIV-Infected Adolescents and Adults Initiated on Protease Inhibitors Antiretroviral Therapy Regimen in Dar ES Salaam; A Longitudinal Retrospective Descriptive Study

“…In India, 78% of patients on the second line achieved viral suppression at 12 months [19]. Other areas like Cambodia have reported viral suppression in 85.7% at 24 weeks among patients on the second line [20] and Rwanda 83% [2]. The difference found in our study could be explained by the delay to initiate the second line after the failure of the rst line, which was a prevalent practice in the years before scale-up of viral load monitoring in 2014, and this demonstrates the challenge of using a clinical and immunologic status for ART failure [21,22].…”

“…Sub-Saharan Africa carries the major portion of the global burden of HIV infection accounting for more than 80% of the global population of people living with HIV (PLHIV) [1,2]. In 2017 about 75% of deaths and 65% of new infections were reported to occur in sub-Saharan Africa (SSA) [1].…”