Targets for intervention to improve virological outcomes for patients receiving free antiretroviral therapy in Tamil Nadu, India

Abstract

Operational research to identify factors predicting poor clinical outcomes is critical to maximize patient care and prolong first-line regimens for those receiving free antiretroviral therapy (ART) in India. We sought to identify social or clinical factors amenable to intervention that predict virological outcomes after 12 months of ART. We examined a retrospective cohort of consecutive adults initiating free nonnucleoside reverse transcriptase inhibitor-based regimens. Individuals remaining in care 12 months post-ART initiation were tested for HIV viral load and surveyed to identify barriers and facilitators to adherence, and to determine clinic travel times and associated costs. Uni- and multivariate logistic regression identified factors predicting HIV viral load >200 copies/mL after 12 months of ART. Of 230 adults initiating ART, 10% of patients died, 8% transferred out, 5% were lost to follow-up, and 174/230 (76%) completed 12 months of ART, the questionnaire, and viral load testing. HIV viral load was <200 copies/mL in 140/174 (80%) patients. In multivariate models, being busy with work or caring for others (OR 2.9, p < 0.01), having clinic transport times ≥ 3 hours (OR 3.0, p = 0.02), and alcohol use (OR 4.8, p = 0.03) predicted viral load >200 copies/mL after 12 months of ART. Clinical outcomes following ART are related to programmatic factors such as prolonged travel time and individual factors such as being busy with family or using alcohol. Simple interventions that alter these factors should be evaluated to improve clinical outcomes for populations receiving free ART in similar settings.

Alcohol, smoking, recreational drug use and association with virological outcomes among people living with HIV: cross‐sectional and longitudinal analyses

“…However, cohort sample sizes were smaller than ours with only two studies recruiting > 500 PLWH [ 2 , 12 ]. Furthermore, heterosexual men and women were under‐represented in previous studies despite marked differences in alcohol use between gender groups, and several did not exclude participants with < 6 months’ ART use [ 2 , 5 , 10 , 11 ]. Previous studies also employed different strategies for classifying high alcohol use, some of which were unvalidated [ 10 , 11 , 12 ], hampering meta‐analysis of existing literature [ 19 ].…”

“…Furthermore, heterosexual men and women were under‐represented in previous studies despite marked differences in alcohol use between gender groups, and several did not exclude participants with < 6 months’ ART use [ 2 , 5 , 10 , 11 ]. Previous studies also employed different strategies for classifying high alcohol use, some of which were unvalidated [ 10 , 11 , 12 ], hampering meta‐analysis of existing literature [ 19 ]. Cultural, financial and social determinants for alcohol consumption vary between nations and influence definitions of alcohol misuse.…”

“…While there is evidence that higher alcohol consumption is associated with ART non‐adherence among PLWH [ 1 ], the impact of alcohol on virological outcomes of ART per se is less clear. Although several studies reported a positive association between high alcohol intake and viral load rebound [ 2 , 5 , 10 , 11 , 12 , 13 ], others have not found significant associations [ 1 , 14 , 15 ]. Lack of consistent definitions of what constitutes hazardous or harmful alcohol use, the potential for non‐linear associations with amount of alcohol and, in some cases, small sample sizes have hampered interpretation of this literature.…”