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

Virological and care outcomes of community ART distribution: Experience with the PODI+ model in Kinshasa, Democratic Republic of the Congo

INTRODUCTION

Differentiated service delivery models for HIV treatment can minimize unnecessary burdens on health systems and promote efficient delivery of antiretroviral therapy (ART). Under the PODI+ (poste de distribution communautaire) model, ART multi-month dispensation (MMD) was provided by lay workers (peers) in communities. We compared outcomes among clinically stable adults living with HIV receiving MMD via PODI+ or health facility (HF).

METHODS

Clients receiving MMD at nine HFs and two PODI+ sites in Kinshasa were followed prospectively for one year (2018-2020). Medication possession ratio (MPR) was measured as proportion of total days with medication during the study through record abstraction at 3-month intervals. Viral load was assessed at enrollment and 12 months. We compared MPR and viral load suppression by arm and examined associations and potential confounders using unadjusted and adjusted odds ratios (AOR). Likert-style client satisfaction was collected during 12-month interviews and described by arm.

RESULTS

Odds of maintaining viral load suppression at 12 months for PODI+ participants were two times that for HF participants. In adjusted models, PODI+ participants had 1.89 times the odds of being suppressed at 12 months compared to HF participants (95% CI: 1.10, 3.27). No significant differences in MPR were found between groups (OR: 0.86, 0.38-1.99). Older participants had significantly higher odds of MPR (AOR: 1.02, 95% CI: 1.01, 1.03) and viral suppression (AOR: 1.03, 95% CI: 1.00, 1.07). Satisfaction with services was ≥87% overall, but PODI+ participants rated time spent at site, provider attributes and other care aspects more favorably.

CONCLUSIONS

Participants receiving MMD via peer-run community distribution points had similar MPR, but better virological outcomes and greater satisfaction with care than clinically similar participants receiving MMD through facilities. PODI+ could be a useful model for expansion to serve larger clinic populations from overburdened health facilities, particularly as policy shifts towards more inclusive MMD eligibility requirements.

Virological failure and its predictors among human immunodeficiency virus infected individuals on second line antiretroviral treatment in North-East Ethiopia, 2021

INTRODUCTION

Acquired immune deficiency syndrome (AIDS) becomes a manageable chronic disease due to the presence of effective prevention, diagnosis, treatment, and care accesses. Viral load cascade analyses are important to identify gaps in human immunodeficiency virus (HIV)/AIDS treatment and care for quality improvements.

OBJECTIVE

Time to Virological Failure and its Predictors among HIV Infected Individuals on Second Line Antiretroviral Treatment (SLART) in North-East Ethiopia, 2021.

METHODS

Institution-based retrospective follow-up study was conducted on 474 HIV-infected individuals who were on SLART between September 2016 and April 2020. A universal sampling technique was used to recruit study participants. Data were entered by EpiData-3.3.1 and analyzed by STATA-14. Cox proportional hazard assumptions were checked to determine the effect of predictor variables on virological failure (VF). The study was conducted from February 1 to April 30, 2021.

RESULTS

The rate of VF in this study was 15.4% with an incidence rate of 4.93 per 100 person-years. As participants' age and duration of ART use increased by 1 year the hazards of VF was reduced by 2.9% (AHR: 0.971, 95% CI: 0.945, 0.995) and 10.6% (AHR: 0.894, 95% CI: 0.828, 0.963), respectively. The hazards of VF were twice higher among those who were on a non-protease inhibitor-based regimen. Individuals who had a history of making enhanced adherence counseling (EAC) sessions during SLART had three times more risk to develop VF (AHR: 3.374, 95% CI: 1.790, 6.361).

CONCLUSION AND RECOMMENDATIONS

The rate of VF among SLART users was high. Keeping SLART users on PI-based regimens may improve virological outcomes in HIV care and treatment. Making EAC sessions effective in promoting better ART adherence might reduce VF.

Factors Associated with Retention of HIV Patients on Antiretroviral Therapy in Care: Evidence from Outpatient Clinics in Two Provinces of the Democratic Republic of the Congo (DRC)

Interruptions in the continuum of care for HIV can inadvertently increase a patient’s risk of poor health outcomes such as uncontrolled viral load and a greater likelihood of developing drug resistance. Retention of people living with HIV (PLHIV) in care and determinants of attrition, such as adherence to treatment, are among the most critical links strengthening the continuum of care, reducing the risk of treatment failure, and assuring viral load suppression. Objective: To analyze the variation in, and factors associated with, retention of patients enrolled in HIV services at outpatient clinics in the provinces of Kinshasa and Haut-Katanga, Democratic Republic of the Congo (DRC). Methods: Data for the last visit of 51,286 patients enrolled in Centers for Disease Control (CDC)-supported outpatient HIV clinics in 18 health zones in Haut-Katanga and Kinshasa, DRC were extracted in June 2020. Chi-square tests and multivariable logistic regressions were performed. Results: The results showed a retention rate of 78.2%. Most patients were classified to be at WHO clinical stage 1 (42.1%), the asymptomatic stage, and only 3.2% were at stage 4, the severest stage of AIDS. Odds of retention were significantly higher for patients at WHO clinical stage 1 compared to stage 4 (adjusted odds ratio (AOR), 1.325; confidence interval (CI), 1.13−1.55), women as opposed to men (AOR, 2.00; CI, 1.63−2.44), and women who were not pregnant (vs. pregnant women) at the start of antiretroviral therapy (ART) (AOR, 2.80; CI, 2.04−3.85). Odds of retention were significantly lower for patients who received a one-month supply rather than multiple months (AOR, 0.22; CI, 0.20−0.23), and for patients in urban health zones (AOR, 0.75; CI, 0.59−0.94) rather than rural. Compared to patients 55 years of age or older, the odds of retention were significantly lower for patients younger than 15 (AOR, 0.35; CI, 0.30−0.42), and those aged 15 and <55 (AOR, 0.75; CI, 0.68−0.82). Conclusions: Significant variations exist in the retention of patients in HIV care by patient characteristics. There is evidence of strong associations of many patient characteristics with retention in care, including clinical, demographic, and other contextual variables that may be beneficial for improvements in HIV services in DRC.

Incidence and Predictors of Virological Failure Among Adult HIV/AIDS Patients on Second-Line Anti-Retroviral Therapy, in Selected Public Hospital of Addis Ababa, Ethiopia: Retrospective Follow-Up Study

Introduction

Objective

Methods

Results

Conclusion

Predictors of Virological Failure Among People Living with HIV Switching from an Effective First-Line Antiretroviral Regimen

Aim of this study was to assess the predictors of virological failure (VF) among patients living with HIV (PLWHIV) switching from an effective first-line antiretroviral therapy (ART) regimen, and to evaluate the emergence of resistance-associated mutations. All adult patients enrolled in the Antiviral Response Cohort Analysis cohort who started ART after 2010, with at least 6 months of virological suppression (VS) before ART switch and with an available genotypic resistance test (GRT) at baseline were included. Thirty-two patients out of the 607 PLWHIV included (5.3%) experienced VF after a median of 11 months from ART switch. Younger age (adjusted Hazard Ratio [aHR] 0.96, 95% confidence interval [CI] 0.92-0.99, p = .023), being male who have sex with male (aHR 0.15, 95% CI 0.03-0.69, p = .014), and longer time from VS to ART switch (aHR 0.97, 95% CI 0.95-1.00, p = .021) resulted protective toward VF, while receiving a first-line regimen containing a backbone other than ABC/3TC or TXF/FTC (aHR 3.61, 95% CI 1.00-13.1, p = .050) and a boosted protease inhibitor as anchor drug (aHR 3.34, 95% CI 1.20-9.28, p = .021) were associated with higher risk of VF. GRT at the moment of VF was available only for 13 patients (40.6%). ART switch in patients with stable control of HIV infection is a safe practice, even if particular attention should be paid in certain cases of patients switching from regimens containing low-performance backbones or protease inhibitors.

Men missing from the HIV care continuum in sub-Saharan Africa: a meta-analysis and meta-synthesis

Introduction

Men are missing along the HIV care continuum. However, the estimated proportions of men in sub‐Saharan Africa meeting the UNAIDS 95‐95‐95 goals vary substantially between studies. We sought to estimate proportions of men meeting each of the 95‐95‐95 goals across studies in sub‐Saharan Africa, describe heterogeneity, and summarize qualitative evidence on factors influencing care engagement.

Methods

We systematically searched PubMed and Embase for peer‐reviewed articles published between 1 January 2014 and 16 October 2020. We included studies involving men ≥15 years old, with data from 2009 onward, reporting on at least one 95‐95‐95 goal in sub‐Saharan Africa. We estimated pooled proportions of men meeting these goals using DerSimonion‐Laird random effects models, stratifying by study population (e.g. studies focusing exclusively on men who have sex with men vs. studies that did not), facility setting (healthcare vs. community site), region (eastern/southern Africa vs. western/central Africa), outcome measurement (e.g. threshold for viral load suppression), median year of data collection (before vs. during or after 2017) and quality criteria. Data from qualitative studies exploring barriers to men's HIV care engagement were summarized using meta‐synthesis.

Results and discussion

We screened 14,896 studies and included 129 studies in the meta‐analysis, compiling data over the data collection period. Forty‐seven studies reported data on knowledge of serostatus, 43 studies reported on antiretroviral therapy use and 74 studies reported on viral suppression. Approximately half of men with HIV reported not knowing their status (0.49 [95% CI, 0.41–0.58; range, 0.09–0.97]) or not being on treatment (0.58 [95% CI, 0.51–0.65; range, 0.07–0.97]), while over three‐quarters of men achieved viral suppression on treatment (0.79 [95% CI, 0.77–0.81; range, 0.39–0.97]. Heterogeneity was high, with variation in estimates across study populations, settings and outcomes. The meta‐synthesis of 40 studies identified three primary domains in which men described risks associated with engagement in HIV care: perceived social norms, health system challenges and poverty.

Conclusions

Psychosocial and systems‐level interventions that change men's perceptions of social norms, improve trust in and accessibility of the health system, and address costs of accessing care are needed to better engage men, especially in HIV testing and treatment.

Rate of Viral Re-Suppression and Retention to Care Among PLHIV on Second-Line Antiretroviral Therapy at Dessie Comprehensive Specialized Hospital, Northeast Ethiopia: A Retrospective Cohort Study

Background

In Ethiopia, first-line antiretroviral therapy failure is growing rapidly. However, unlike first-line therapy, to date, very little is known about the outcomes of second-line therapy. Thus, this study assessed the rate of viral re-suppression and attrition to care and their predictors among people living with HIV on second-line therapy.

Methods

A retrospective cohort study was conducted on 642 people living with HIV at Dessie Comprehensive Specialized Hospital from October 2016 to November 2019. A proportional Cox regression model was computed to explore predictors of viral re-suppression (viral load less than 1000 copies/mL) and attrition to care.

Results

Out of 642 subjects, 19 (3%), 44 (6.9%), 70 (10.9%), and 509 (79.3%) patients were lost to follow up, died, transferred out, and alive on care, respectively. Similarly, 82.39% (95% CI: 79.24–85.16%) of patients had achieved viral re-suppression, with 96 per 100 person-year rate of re-suppression. Patients who switched timely to second-line therapy were at a higher rate of viral re-suppression than delayed patients [adjusted hazard rate, AHR = 1.43 (95% CI: 1.17–1.74)]. Not having drug substitution history [AHR = 1.25 (95% CI: 1.02–1.52)] was positively associated with viral re-suppression. In contrast, being on anti-TB treatment [AHR = 0.67 (95% CI: 0.49–0.91)] had lower likelihood with viral re-suppression. In the current study, attrition to care was 11% (95% CI: 8.7–13.9%). Ambulatory or bedridden patients were more at risk of attrition to care as compared with workable patients [AHR = 2.61 (95% CI: 1.40–4.87)]. Similarly, being not virally re-suppressed [AHR = 6.87 (95% CI: 3.86–12.23)] and CD4 count ≤450 cells/mm³ [AHR = 2.61 (95% CI: 1.40–4.87)] were also positively associated with attrition to care.

Conclusion

A significant number of patients failed to achieve viral re-suppression and attrition from care. Most identified factors related to patient monitoring. Hence, patient-centered intervention should be strengthened, besides treatment switch.

Attrition and Its Predictors Among Adults Receiving First-Line Antiretroviral Therapy in Woldia Town Public Health Facilities, Northeast Ethiopia: A Retrospective Cohort Study

Introduction

There is an expansion and advancement of antiretroviral therapy. However, attrition of patients from HIV care is one of the major drivers of poor performance of HIV/AIDS programs, which leads to drug resistance, morbidity and mortality. The study aimed to assess the incidence of attrition and its predictors among adults receiving first-line antiretroviral therapy.

Methods

An institution-based retrospective cohort study was conducted among 634 adults receiving antiretroviral therapy, and study participants were selected using a simple random sampling technique. Data were cleaned and entered into Epi Data version 3.1 and exported to STATA 14.1 for further analysis. The predictors of attrition were identified using bivariable and multivariable Cox Proportional hazard models; then, variables at a p-value of less than 0.25 and 0.05 were included in the multivariable analysis and statistically significant, respectively.

Results

The total time observed was found to be 1807.08 person-years of observation with a median follow-up time of 2.67 years (IQR 1.25−4.67). The incidence rate of attrition was 8.36 (95% CI: 7.12−9.80) per 100 person-years. Significant predictors of attrition were being young age [adjusted hazard ratio (AHR) =2.0, 95% CI, (1.11−3.58)], nearest calendar year of ART initiation [AHR =2.32, 95% CI, (1.08–5.01)], bedridden functional status [AHR=3.25, 95% CI, (1.33−7.96)], WHO stage III [AHR=3.57, 95% CI, (1.58−8.06)] and stage IV [AHR=5.46, 95% CI, (1.97−15.13)], viral load result of ≤1000 [AHR=0.11, 95% CI, (0.06−0.23)], disclosure status [AHR=2.03, 95% CI, (1.22−3.37)] and adherence level of poor [AHR=3.19, 95 CI, (1.67−6.09)].

Conclusion

The result of this study showed that the incidence of attrition among adults receiving antiretroviral therapy was high. However, as a standard, every client who started antiretroviral therapy should be retained. Positive predictors of attrition were young age (15–24), recent year of ART initiation, baseline functional status, advanced WHO stage III and IV, no disclosure status, fair/poor adherence whereas, viral load result of ≤1000 copies/mL had a preventive effect on attrition.

Determinants of Virologic Failure Among Adults on Second Line Antiretroviral Therapy in Wollo, Amhara Regional State, Northeast Ethiopia

Background

Treatment failure among the population on second line antiretroviral therapy is a major public health threat. In Ethiopia there has been limited research done on second line treatment failure.

Objective

To identify determinants of virologic failure among adults on second line antiretroviral therapy in six public hospitals of Wollo, Amhara regional state, northeast Ethiopia.

Methods

An institution-based unmatched case–control study was conducted from February 1, 2020 to April 30, 2020 on a total of 377 clients in six public hospitals of Wollo, Amhara regional state, northeast Ethiopia. Clients whose viral load result >1,000 copies/mL in two consecutive results at least 3 month apart were cases, while ≤1,000 copies/mL were controls. The sample size was calculated by using Epi-Info version 7. Cases (94) and controls (283) were selected using a simple random sampling method in a ratio of cases-to-controls of 1:3. The model fitted and binary logistic assumptions were fulfilled with 95% confidence level and P-values<0.05 were taken as statistically significant.

Results

Virologic failure was predicted by poor adherence (AOR=6.060, 95% CI=2.837–12.944), not disclosing their HIV status (AOR=4.178, 95% CI=1.431–12.198), OI (AOR=4.11, 95% CI=1.827–9.246), CD4 count <100 cells/mm³ (AOR=3.497, 95% CI=1.233–9.923) and 100–350 cells/mm³ (AOR=5.442, 95% CI=2.191–13.513), low BMI <16 kg/m² (AOR=7.223, 95% CI=2.218–23.520), and young age 15–29 years (AOR=2.898, 95% CI=1.171–7.170).

Conclusion and Recommendations

Determinants of second line ART virologic failure were patients who had poor adherence to ART, not disclosed, opportunistic infection, low CD4 counts <350 cell/mm³, low BMI (<16 kg/m²), and young age 15–29 year patients. Social support, disclosing their HIV status, and getting early treatment for any opportunistic infection is crucial to patients.

Lessons for test and treat in an antiretroviral programme after decentralisation in Uganda: a retrospective analysis of outcomes in public healthcare facilities within the Lablite project

BACKGROUND

We describe the decentralisation of antiretroviral therapy (ART) alongside Option B+ roll-out in public healthcare facilities in the Lablite project in Uganda. Lessons learned will inform programmes now implementing universal test and treat (UTT).

METHODS

Routine data were retrospectively extracted from ART registers between October 2012 and March 2015 for all adults and children initiating ART at two primary care facilities (spokes) and their corresponding district hospitals (hubs) in northern and central Uganda. We describe ART initiation over time and retention and use of Cox models to explore risk factors for attrition due to mortality and loss to follow-up. Results from tracing of patients lost to follow-up were used to correct retention estimates.

RESULTS

Of 2100 ART initiations, 1125 were in the north, including 944 (84%) at the hub and 181 (16%) at the spokes; children comprised 95 (10%) initiations at the hubs and 14 (8%) at the spokes. Corresponding numbers were 642 (66%) at the hub and 333 (34%) at the spokes in the central region (77 [12%] and 22 [7%], respectively, in children). Children <3 y of age comprised the minority of initiations in children at all sites. Twenty-three percent of adult ART initiations at the north hub were Option B+ compared with 45% at the spokes (25% and 65%, respectively, in the central region). Proportions retained in care in the north hub at 6 and 12 mo were 92% (95% CI 90 to 93) and 89% (895% CI 7 to 91), respectively. Corresponding corrected estimates in the north spokes were 87% (95% CI 78 to 93) and 82% (95% CI 72 to 89), respectively. In the central hub, corrected estimates were 84% (95% CI 80 to 87) and 78% (95% CI 74 to 82), and were 89% (95% CI 77.9 to 95.1) and 83% (95% CI 64.1 to 92.9) at the spokes, respectively. Among adults newly initiating ART, being older was independently associated with a lower risk of attrition (adjusted hazard ratio [aHR] 0.93 per 5 y [95% CI 0.88 to 0.97]). Other independent risk factors included initiating with a tenofovir-based regimen vs zidovudine (aHR 0.60 [95% CI 0.46 to 0.77]), year of ART initiation (2013 aHR 1.55 [95% CI 1.21 to 1.97], ≥2014 aHR 1.41 [95% CI 1.06 to 1.87]) vs 2012, hub vs spoke (aHR 0.35 [95% CI 0.29 to 0.43]) and central vs north (aHR 2.28 [95% CI 1.86 to 2.81]). Independently, patient type was associated with retention.

CONCLUSIONS

After ART decentralisation, people living with human immunodeficiency virus (HIV) were willing to initiate ART in rural primary care facilities. Retention on ART was variable across facilities and attrition was higher among some groups, including younger adults and women initiating ART during pregnancy/breastfeeding. Interventions to support these groups are required to optimise benefits of expanded access to HIV services under UTT.

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

BACKGROUND

Liangshan Yi Autonomous Prefecture is one of the areas that most severely affected by human immunodeficiency virus (HIV) in China, and virological failure on antiretroviral therapy (ART) is serious in this area. Analyses of prevalence and determinants of ART failure, the genetic diversity and drug resistance among people living with HIV (PLWH) helps improve HIV treatment efficiency and prevent HIV transmission.

METHODS

A total of 5157 PLWH were recruited from 2016 to 2017. The venous blood samples were subjected to RT-PCR, followed by sequencing of the HIV-1 pol gene, targeting the protease and reverse transcriptase fragments. HIV-1 diversity was analyzed using the DNAStar software and drug resistance mutations were analyzed using the Stanford University HIV Drug Resistance Database.

RESULTS

A total of 2156 (41.81%) PLWH showed virological failure on ART. Males (ORm = 1.25), heterosexual behaviors and drug injection (ORm = 1.44) and mother to child transmission routes (ORm = 1.58), the clinical stage of AIDS (ORm = 1.35), having used illicit drugs and shared the needles (1-4 times: ORm = 1.34; more than 5 times: ORm = 1.52), having ever replaced ART regimen (ORm = 1.48) increased the risk of virological failure among PLWH, while higher education lever (ORm = 0.77) and ≥ 12 months on ART (12 ~ 36 months: ORm = 0.72; ≥36 months: ORm = 0.66) was associated with lower likelihood of virological failure. The data revealed that CRF07_BC (1508, 95.62%) were the most common strains, and the drug-resistant rate was 32.10% among PLWH with virological failure in this area. The high frequencies of drug resistance were found in EFV and NVP of NNRTIs, ABC, FTC and 3TC of NRTIs, and TPV/r in PIs. The most common mutations in NNRTIs, NRTIs and PIs were K103N/KN (64.69%), M184V/MV/I (36.29%) and Q58E/QE (4.93%), respectively.

CONCLUSION

We concluded that surveillance of virological failure, HIV-1 subtypes, and drug resistance to understand HIV-1 epidemiology and guide modification of ART guidelines, and target prevention and control strategies should be formatted to reduce the virological failure and drug resistance to promote viral suppression and prevent HIV-1 transmission.