Viral suppression among pregnant adolescents and women living with HIV in rural KwaZulu-Natal, South Africa: a cross sectional study to assess progress towards UNAIDS indicators and Implications for HIV Epidemic Control

Characterizing the HIV care continuum among children and adolescents with HIV in eastern and southern Africa in the era of "Universal Test and Treat": A systematic review and meta-analysis

INTRODUCTION

The "Universal Test and Treat" (UTT) era for antiretroviral therapy (ART) increased HIV service delivery to children and adolescents aged 0-19 with HIV. The goal is to reach ≥95% of people with HIV diagnosed, receiving ART and virally suppressed. We conducted a systematic review and meta-analysis to describe the care continuum among children and adolescents with HIV during the UTT era in the UNAIDS eastern and southern African region.

METHODS

We searched PubMed, EMBASE and African Index Medicus databases for peer-reviewed articles published from 1 January 2010 to 1 June 2023. We included studies reporting ≥1 care continuum proportion in ≥1 country in the study region during the country's UTT implementation. We extracted summary proportions and pooled them using random-effects logistic regression.

RESULTS

Of 10,281 studies screened, 190 met the inclusion criteria. Studies came from 16 countries; many from South Africa (n = 37) and Ethiopia (n = 32). The meta-analysis pooled proportions (95% confidence intervals) for children aged 0-14 were: 72% (60%, 81%) aware of HIV diagnosis; 95% (89%, 97%) on ART among diagnosed; 88% (76%, 95%) retained in HIV care after 12 months on ART; 77% (68%, 84%) self-/caregiver-reported ART adherence; 90% (79%, 95%) had a viral load test after ART initiation; and 76% (72%, 79%) viral suppression (<1000 copies/ml) while on ART with a viral load test. Similar proportions were estimated among adolescents aged 15-19: 73% (66%, 79%) diagnosed; 93% (92%, 94%) on ART; 80% (54%, 93%) retained; 74% (63%, 83%) adherent; 90% (79%, 95%) viral load test; and 78% (74%, 81%) viral suppression.

DISCUSSION

Estimates from this study on diagnosis, ART initiation and viral suppression were consistent with UNAIDS official estimates. Estimates on retention, adherence and viral suppression were similar to previous meta-analyses conducted before UTT.

CONCLUSIONS

Consistent with UTT expectations, most children and adolescents with HIV in eastern and southern Africa have initiated ART, but challenges remain on other care continuum indicators. Future planning for HIV programmes should consider locally informed, community-supported approaches to consistently support children and adolescents with HIV throughout the HIV care continuum.

Tracking viral control in adolescents on antiretroviral therapy in Lusaka, Zambia: A retrospective cohort analysis

Background

In 2023, an estimated 39.9 million people globally were living with HIV, of which 1.55 million were adolescents aged 10-19 years. The 2021 Zambia HIV Impact Assessment revealed lower viral suppression rates in adolescents (15-24 years old) compared to adults on antiretroviral therapy (ART). Lusaka District, Zambia, has the highest number of adolescents on ART, with a 15.1% HIV prevalence in 2018.

Objectives

To determine the prevalence and factors associated with viral suppression among adolescents living with HIV (10-19 years) on ART in Lusaka District, Zambia.

Method

A retrospective cohort analysis was done of 3409 adolescents on ART at public health facilities in Lusaka from January 2023 to December 2023, and who had viral loads recorded. Socio-demographic, clinical, treatment and behavioural data were extracted from electronic health records and analysed using SPSS version 29.

Results

The adolescent cohort in Lusaka achieved 91.8% viral suppression rate (< 1000 copies/mL), with 79% fully suppressed (< 50 copies/mL). In multivariate analysis, older adolescents (15-19 years) had lower odds of suppression compared to younger adolescents (10-14 years) (adjusted odds ratio [AOR] = 1.79; confidence interval [CI] : 1.32-2.43). Higher odds of viral suppression were linked to first-line dolutegravir regimen (AOR = 5.12; CI: 3.23-8.11) and optimal adherence (AOR = 1.89; CI: 1.03-3.47), while regimen switches reduced the odds of viral suppression (AOR = 0.60; CI: 0.45-0.80).

Conclusion

Zambia reached the previous UNAIDS 90-90-90 targets with a viral suppression rate of 91.8%. However, to reach the revised 95% target by 2030, tailored interventions should be implemented to improve adherence and retention in care, particularly for older adolescents.

Opportunities to Optimize Outcomes of Diagnosis and Treatment of HIV and Syphilis in Pregnancy: the Quest to Eliminate Maternal and Vertical Transmission

BACKGROUND

There is an urgent need to improve interventions for HIV and syphilis in pregnancy to achieve elimination.

RESULTS

The tenets of vertical transmission strategies for HIV and syphilis overlap but have varying success due to differences in their transmission dynamics, diagnoses, and treatment. Key principles include prevention of maternal infection, screening and diagnosis early and throughout antenatal care, curative treatment (syphilis), viral load suppression (HIV), early infant diagnosis and treatment (HIV and congenital syphilis). We recommend improved guidelines, provider training and focused research and surveillance, including implementation studies to align HIV and syphilis screening and treatment during pregnancy. Opportunities to integrate syphilis screening and treatment into antenatal and HIV care enable providers to offer comprehensive maternal care.

CONCLUSION

Integrated HIV/syphilis services ensure a cohesive and person-centered approach, improving health outcomes through streamlined, efficient, and family-centered care pathways. We recommend key interventions to reduce HIV and syphilis in pregnancy and prevent vertical transmission.

Human Immunodeficiency Virus (HIV) viral load suppression status and associated factors among pregnant women receiving Highly Active Antiretroviral Therapy (HAART) in Ethiopia

BACKGROUND

Mothers with an undetectable viral load pose no risk of transmitting the Human Immunodeficiency Virus (HIV) to their fetuses. However, there is limited information on the HIV viral suppression status (≤ 1000 RNA copies/mL) among pregnant mothers at the national level. This study aimed to assess the HIV viral load suppression status among pregnant women and identify factors associated with unsuppressed maternal viral levels (> 1000 RNA copies/mL).

METHODS

We conducted a cross-sectional study using secondary data from the national HIV viral load data repository. The study included all pregnant women who initiated antiretroviral therapy (ART) and underwent routine HIV viral load testing. Data were collected from July 2022 to June 2023 (2015 Ethiopian Fiscal Year (EFY)). Analysis was performed using STATA v.17, with descriptive statistics (frequency, percentage, mean, and standard deviation) calculated. A mixed-effects logistic regression model was used to quantify the strength of associations between variables and HIV viral load status (suppressed vs. unsuppressed), expressed through odds ratios.Variables showing a significant association with the outcome (p < 0.02) were selected for further analysis using multiple logistic regression models.

RESULTS

The analysis included a total of 13,000 mothers with complete data from viral load tests conducted on pregnant women. The HIV viral suppression rate among these women before delivery was 96.8%. Among those with suppressed results, 96.5% had an undetectable HIV viral load. Multiple binary logistic regression analysis indicated that individuals aged 19-29 had 3.17 times higher odds (AOR 3.17, 95% CI 1.17-5.17, p = 0.002) of having an unsuppressed viral load compared to those under 19. Additionally, individuals with poor adherence to treatment had 12.6 times higher odds of experiencing unsuppressed viral loads (AOR 12.64, 95% CI 10.74-14.54, p = 0.001). However, no significant association was found between the timing of viral load testing and unsuppressed maternal HIV viral load.

CONCLUSION

The findings indicate that while the overall rates of HIV viral suppression among pregnant women are high, specific demographic factors such as age and treatment adherence play crucial roles in achieving undetectable viral loads. The data suggests a need for targeted interventions focusing on mothers age from 19 to 30 years and strategies to improve adherence to treatment regimens to enhance outcomes further.The results have significant implications for policy and clinical practices aimed at improving health outcomes for mothers and newborns affected by HIV/AIDS.

Socio-Behavioural Barriers to Viral Suppression in the Older Adult Population in Rural South Africa

South Africa has the largest share of people living with HIV in the world and this population is ageing. The social context in which people seek HIV care is often ignored. Apart from clinical interventions, socio-behavioural factors impact successful HIV care outcomes for older adults living with HIV. We use cross-sectional data linked with demographic household surveillance data, consisting of HIV positive adults aged above 40, to identify socio-behavioural predictors of a detectable viral load. Older adults were more likely to have a detectable viral load if they did not disclose their HIV positive status to close family members (aOR 2.56, 95% CI 1.89-3.46), resided in the poorest households (aOR 1.98, 95% CI 1.23-3.18), or were not taking medications other than ART (aOR 1.83, 95% CI 1.02-1.99) likely to have a detectable. Clinical interventions in HIV care must be supported by understanding the socio-behavioural barriers that occur outside the health facility. The importance of community health care workers in bridging this gap may offer more optimum outcomes for older adults ageing with HIV.

Factors associated with vertical transmission of HIV in the Western Cape, South Africa: a retrospective cohort analysis

INTRODUCTION

Monitoring mother-infant pairs with HIV exposure is needed to assess the effectiveness of vertical transmission (VT) prevention programmes and progress towards VT elimination.

METHODS

We used routinely collected data on infants with HIV exposure, born May 2018-April 2021 in the Western Cape, South Africa, with follow-up through mid-2022. We assessed the proportion of infants diagnosed with HIV at birth (≤7 days), 10 weeks (>1 to 14 weeks) and >14 weeks as proxies for intrauterine, intrapartum/early breastfeeding and late breastfeeding transmission, respectively. We used mixed-effects Poisson regression to assess factors associated with VT in mothers known with HIV by delivery.

RESULTS

We included 50,461 infants born to mothers known with HIV by delivery. HIV was diagnosed in 894 (1.8%) infants. Among mothers, 51% started antiretroviral treatment (ART) before and 27% during pregnancy; 17% restarted during pregnancy after ≥6 months interruption; and 6% had no recorded ART during pregnancy. Most pregnancy ART regimens included non-nucleoside reverse transcriptase inhibitors (83%). Of mothers with available results (90% with viral load [VL]; 70% with CD4), VL nearest delivery was <100 copies/ml in 78% and CD4 count ≥350 cells/μl in 62%. HIV-PCR results were available for 86%, 67% and 48% of eligible infants at birth, 10 weeks and >14 weeks. Among these infants, 0.9%, 0.4% and 1.5% were diagnosed positive at birth, 10 weeks and >14 weeks, respectively. Among infants diagnosed with HIV, 43%, 16% and 41% were diagnosed at these respective time periods. Among mothers with VL<100, 100-999, 1000-99,000 and ≥100,000 copies/ml nearest delivery, infant HIV diagnosis incidence was 0.4%, 2.3%, 6.6% and 18.4%, respectively. Increased VT was strongly associated with recent elevated maternal VL with a seven-fold increased rate with even modestly elevated VL (100-999 vs. <100 copies/ml). VT was also associated with unknown/low maternal CD4, maternal age <20 years, no antenatal ART, later maternal ART start/restart in pregnancy and ART gaps.

CONCLUSIONS

Despite high maternal ART coverage and routine postnatal prophylaxis, ongoing VT remains a concern. Timing of infant HIV diagnoses suggests intrapartum and/or breastfeeding transmission in nearly 60%. Interventions to ensure retention on ART and sustained maternal viral suppression are needed to reduce VT.

Children and young women in eastern and southern Africa are key to meeting 2030 HIV targets: time to accelerate action

New HIV infections and AIDS-related deaths among children and adolescent girls and young women (aged 15-24 years) in eastern and southern Africa continue to occur at unacceptably high rates. The COVID-19 pandemic has also severely undermined ongoing initiatives for HIV prevention and treatment, threatening to set the region back further in its efforts to end AIDS by 2030. Major impediments exist to attaining the UNAIDS 2025 targets among children, adolescent girls, young women, young mothers living with HIV, and young female sex workers residing in eastern and southern Africa. Each population has specific but overlapping needs with regard to diagnosis and linkage to and retention in care. Urgent action is needed to intensify and improve programmes for HIV prevention and treatment, including sexual and reproductive health services for adolescent girls and young women, HIV-positive young mothers, and young female sex workers.

Adverse Perinatal Outcomes among Adolescent Pregnant Women Living with HIV: A Propensity-Score-Matched Study

HIV infection and adolescent pregnancy are known to increase the risk of adverse perinatal outcomes. However, data are limited concerning the outcomes of pregnancies among adolescent girls living with HIV. This retrospective propensity-score matched study aimed to compare adverse perinatal outcomes in adolescent pregnant women living with HIV (APW-HIV-positive) with HIV-negative adolescent pregnant women (APW-HIV-negative) and adult pregnant women with HIV (PW-HIV). APW-HIV-positive were propensity-score matched with APW-HIV-negative and PW-HIV. The primary endpoint was a composite endpoint of adverse perinatal outcomes, comprising preterm birth and low birth weight. There were 15 APW-HIV-positive and 45 women in each control group. The APW-HIV-positive were aged 16 (13-17) years and had had HIV for 15.5 (4-17) years, with 86.7% having perinatally acquired HIV. The APW-HIV-positive had higher rates of perinatally acquired HIV infection (86.7 vs. 24.4%, p < 0.001), a longer HIV infection time (p = 0.021), and longer exposure to antiretroviral therapy (p = 0.034) compared with the PW-HIV controls. The APW-HIV-positive had an almost five-fold increased risk of adverse perinatal outcomes compared with healthy controls (42.9% vs. 13.3%, p = 0.026; OR 4.9, 95% CI 1.2-19.1). The APW-HIV-positive and APW-HIV-negative groups had similar perinatal outcomes.

Spatiotemporal Variation and Predictors of Unsuppressed Viral Load among HIV-Positive Men and Women in Rural and Peri-Urban KwaZulu-Natal, South Africa

Unsuppressed HIV viral load is an important marker of sustained HIV transmission. We investigated the prevalence, predictors, and high-risk areas of unsuppressed HIV viral load among HIV-positive men and women. Unsuppressed HIV viral load was defined as viral load of ≥400 copies/mL. Data from the HIV Incidence District Surveillance System (HIPSS), a longitudinal study undertaken between June 2014 to June 2016 among men and women aged 15−49 years in rural and peri-urban KwaZulu-Natal, South Africa, were analysed. A Bayesian geoadditive regression model which includes a spatial effect for a small enumeration area was applied using an integrated nested Laplace approximation (INLA) function while accounting for unobserved factors, non-linear effects of selected continuous variables, and spatial autocorrelation. The prevalence of unsuppressed HIV viral load was 46.1% [95% CI: 44.3−47.8]. Predictors of unsuppressed HIV viral load were incomplete high school education, being away from home for more than a month, alcohol consumption, no prior knowledge of HIV status, not ever tested for HIV, not on antiretroviral therapy (ART), on tuberculosis (TB) medication, having two or more sexual partners in the last 12 months, and having a CD4 cell count of <350 cells/μL. A positive non-linear effect of age, household size, and the number of lifetime HIV tests was identified. The higher-risk pattern of unsuppressed HIV viral load occurred in the northwest and northeast of the study area. Identifying predictors of unsuppressed viral load in a localized geographic area and information from spatial risk maps are important for targeted prevention and treatment programs to reduce the transmission of HIV.