Prevalence and predictors of persistent low-level HIV viraemia: a retrospective cohort study among people receiving dolutegravir-based antiretroviral therapy in Southern Nigeria

Background

Persistent low-level viraemia (PLLV) is a risk factor for virologic failure among people receiving antiretroviral therapy (ART).

Objectives

We assessed the prevalence and predictors of PLLV among individuals receiving Dolutegravir-based ART in southern Nigeria.

Design

This retrospective cohort study used routine program data from electronic medical records of persons receiving Dolutegravir-based first-line ART in 154 PEPFAR/USAID-supported health facilities in Akwa Ibom and Cross Rivers states, Nigeria.

Methods

Clients on first-line Dolutegravir-based ART ⩾6 months, who had a viral load result in the 12 months preceding October 2021 (baseline), and a second viral load result by September 2022 were included. Persons with low-level viraemia (LLV) (viral load 51-999 copies/ml) received additional adherence support. The outcome analysed was PLLV (two consecutive LLV results). Indices were summarized using descriptive statistics, and predictors of PLLV were determined using multivariate logistic regression.

Results

In total, 141,208 persons on ART were included, of which 63.3% (n = 89,944) were females. The median age was 36 [29-44] years, median ART duration was 19 [11-42] months. At the end of the study, 10.5% (14,759/141,208) had initial LLV, 90.1% (13,304/14,759) of which attained undetectable viral load (⩽50 copies/ml), and 1.1% (163/14,759) transitioned to virologic failure (⩾1000 copies/ml) by the end of the study. PLLV prevalence was 0.9% (1292/141,208). Increasing ART duration [adjusted odds ratio (aOR) = 1.0; 95% confidence interval (CI): 1.005-1.008; p < 0.001] and viral suppression (<1000 copies/ml) before initial LLV (aOR = 1.7; 95% CI: 1.50-2.00; p < 0.001) were positively associated with PLLV, while receipt of tuberculosis preventive therapy reduced the likelihood of PLLV (aOR = 0.3; 95% CI: 0.10-0.94; p = 0.039).

Conclusion

PLLV was uncommon among individuals receiving dolutegravir-based ART and was associated with longer ART duration, prior viral suppression, and non-receipt of tuberculosis preventive therapy. This strengthens recommendations for continuous adherence support and comprehensive health services with ART, to prevent treatment failure.

How Hypertension Rates and HIV Treatment Outcomes Compare between Older Females and Males Enrolled in an HIV Treatment Program in Southern Nigeria: A Retrospective Analysis

Studies show that treatment outcomes may vary among persons living with HIV. To fast-track the attainment of epidemic control across gender and age groups, the Accelerating Control of the HIV Epidemic (ACE-5) Project implemented in Akwa Ibom and Cross Rivers States, Nigeria, examined the hypertension rates and treatment outcomes of older adults living with HIV. The demographic and treatment characteristics of males and females ≥ 50 years living with HIV, who initiated antiretroviral therapy (ART) as of September 2021, were abstracted from medical records across 154 health facilities and community sites in Akwa Ibom and Cross River states, Nigeria. We compared these characteristics by sex using the chi-square test. The log-rank test was used to compare differences in their retention (i.e., being on treatment) and viral suppression (VS) rates [<1000 copies/Ml] in September 2022. Of the 16,420 older adults living with HIV (10.8% of the treatment cohort) at the time of the study, 53.8%, and 99.5% were on a first-line ART regimen. Among the 3585 with baseline CD4 documented (21.8% of the cohort), the median [IQR] CD4 count was 496 [286-699] cells/mm3, with more males having lower baseline CD4 than females [13.4% of males vs. 10.2% of females, p-value = 0.004]. In total, 59.9% received treatment at out-of-facility locations, with more males receiving treatment in this setting than females [65.7% vs. 54.8% p-value < 0.001]. Of those in whom blood pressure was assessed (65.9% of the treatment cohort), 9.6% were hypertensive, with males being less likely to be hypertensive [8.0% vs. 11.1% p-value < 0.001] than females. Overall, retention as of September 2022 was 96.4%, while VS was 99.0% and did not differ significantly by sex [retention: p = 0.901; VS: p = 0.056]. VS was slightly but not significantly higher among females than males (98.8% versus 99.2%; Aor = 0.79, 95%CI = 0.58-1.10, p = 0.17). Although older males and females living with HIV had similar treatment outcomes, hypertension screening was suboptimal and could impact long-term morbidity and mortality. Our study emphasizes the need to integrate noncommunicable disease screening and the management of hypertension in the care of older persons living with HIV.

Improved access to HIV diagnosis and linkage to antiretroviral therapy among children in Southern Nigeria: a before-after study

BACKGROUND

Globally, two out of five children living with HIV (CLHIV) are unaware of their HIV status, and a little more than 50% are receiving antiretroviral therapy (ART). This paper describes case-finding strategies and their contribution to identifying CLHIV and linking them to ART in Nigeria.

METHODS

This before-after study used program data abstracted during the implementation of different paediatric-focused strategies (provider-initiated testing and counselling, orphans and vulnerable children testing, family-based index testing, early infant diagnosis (EID), community-driven EID, and community-based testing) delivered in health facilities and in communities to improve HIV case identification. Data were abstracted for children (0 to 14 years) who received HIV testing services and were initiated on ART in Akwa Ibom State, Nigeria during the pre-implementation period (April-June 2021) and during the implementation period (July-September 2021). Descriptive statistics were used to describe the testing coverage, positivity rate (proportion of tests that were positive for HIV), linkage to ART, and ART coverage, by age, sex, and testing modality. Interrupted time series analysis (ITSA) on STATA 14 was used to estimate the effect of the implementation of these strategies on HIV testing uptake and positivity rate at a 0.05 significance level.

RESULTS

A total of 70,210 children were tested for HIV within the six-month period, and 1,012 CLHIV were identified. A total of 78% (n = 54,821) of the tests and 83.4% (n = 844) CLHIV were diagnosed during the implementation period. During implementation, the HIV positivity rate increased from 1.09% (168/15,389) to 1.54% (844/54,821), while linkage to ART increased from 99.4% (167/168) to 99.8% (842/844). The contribution from community-based modalities to CLHIV identified increased from 63% (106/168) to 84% (709/844) during the implementation, with the majority, 60.8% (431/709), from community-based index testing. Overall, ART coverage increased from 39.7 to 55.6% at the end of the intervention period.

CONCLUSION

The findings show that expanding differentiated HIV testing approaches provided mostly in the community significantly increased pediatric case identification. However, ART coverage remains low, especially for younger age groups, and requires further efforts.

Predictors of treatment interruption among patients on antiretroviral therapy in Akwa Ibom, Nigeria: outcomes after 12 months

Understanding the characteristics of people living with HIV who interrupt antiretroviral therapy (ART) is critical for designing client-centered services to ensure optimal outcomes. We assessed predictors of treatment interruption in 22 HIV clinics in Nigeria. We reviewed records of HIV-positive patients aged ≥15 years who started ART 1 January and 31 March 2019. We determined treatment status over 12 months as either active, or interrupted treatment (defined as interruption in treatment up to 28 days or longer). Potential predictors were assessed using Cox hazard regression models. Overall, 1185 patients were enrolled on ART, 829 (70%) were female, and median age was 32 years. Retention at 1, 3, 6, 9, and 12 months was 85%, 80%, 76%, 72%, and 68%, respectively. Predictors of treatment interruption were post-secondary education (p = 0.04), diagnosis through voluntary counseling and testing (p < 0.001), receiving care at low-volume facilities (p < 0.001), lack of access to a peer counselor (p < 0.001), and residing outside the clinic catchment area (p = 0.03). Treatment interruption was common but can be improved by focusing on lower volume health facilities, providing peer support especially to those with higher education, and client-centered HIV services for those who live further from clinics..

Improving access to HIV testing for pregnant women in community birth centres in Nigeria: an evaluation of the Prevention of Mother-to-Child Transmission program

Background

The elimination of mother-to-child HIV transmission requires access to HIV testing services (HTS) for pregnant women. In Akwa Ibom, Nigeria, 76% of pregnant women receive antenatal care from traditional birth attendants and may not have access to HIV testing.

Objectives

This study examines the contribution of traditional birth attendants and other healthcare workers in community birth centres in improving access to HTS among pregnant women and their HIV-exposed infants.

Design

A retrospective cross-sectional study of previously collected programme data at two points in time to evaluate the prevention of mother-to-child transmission (PMTCT) programme.

Methods

We assessed programme records before and after introducing an intervention that engaged traditional birth attendants and other healthcare workers in community birth centres to expand access to HTS among pregnant women and their HIV-exposed infants in Akwa Ibom State, Nigeria. Data were abstracted from the programme database for the preintervention period (April 2019 to September 2020) and the intervention period (October 2020 to March 2022). Data abstracted include the number of pregnant women tested for HIV, those diagnosed with HIV, the number of HIV-exposed infants who had samples collected for early infant diagnosis and those diagnosed with HIV. The data were analysed descriptively and inferentially.

Results

Before the intervention, 39,305 pregnant women and 2248 HIV-exposed infants were tested for HIV. After the intervention, the number of pregnant women tested increased to 127,005 and the number of HIV-exposed infants tested increased to 2490. Among pregnant women, the postintervention testing increased by 3.2-fold, with community birth centres reporting 63% of all tests. The intervention also resulted in an 11% increase in HIV-exposed infants benefitting from early infant diagnosis with community birth centres reporting 5% of all tests. Of those diagnosed with HIV, 24% of pregnant women and 12% of infants were diagnosed at community birth centres.

Conclusion

Community-based HIV testing for pregnant women can reduce mother-to-child transmission and improve early diagnosis and treatment of exposed infants. Collaboration with birth attendants is crucial to ensure testing opportunities are not missed. Prospective research is needed to understand the clinical outcomes of intervention programmes in the community.

Achieving HIV epidemic control through integrated community and facility-based strategies: Lessons learnt from ART-surge implementation in Akwa Ibom, Nigeria

This study examines the lessons learnt from the implementation of a surge program in Akwa Ibom State, Nigeria as part of the Strengthening Integrated Delivery of HIV/AIDS Services (SIDHAS) Project. In this analysis, we included all clients who received HIV counseling and testing services, tested HIV positive, and initiated ART in SIDHAS-supported local government areas (LGAs) from April 2017 to March 2021. We employed descriptive and inferential statistics to analyze our results. A total of 2,018,082 persons were tested for HIV. Out of those tested, 102,165 (5.1%) tested HIV-positive. Comparing the pre-surge and post-surge periods, we observed an increase in HIV testing from 490,450 to 2,018,082 (p≤0.031) and in HIV-positive individuals identified from 21,234 to 102,165 (p≤0.001) respectively. Of those newly identified positives during the surge, 98.26% (100,393/102,165) were linked to antiretroviral therapy compared to 99.24% (21,073/21,234) pre-surge. Retention improved from 83.3% to 92.3% (p<0.001), and viral suppression improved from 73.5% to 96.2% (p<0.001). A combination of community and facility-based interventions implemented during the surge was associated with the rapid increase in case finding, retention, and viral suppression; propelling the State towards HIV epidemic control. HIV programs should consider a combination of community and facility-based interventions in their programming.

Reaching Viral Suppression Among People With HIV With Suspected Treatment Failure who Received Enhanced Adherence Counseling in Southern Nigeria: A Retrospective Analysis

Background

This study assessed viral load (VL) testing and viral suppression following enhanced adherence counseling (EAC) among people with HIV (PWH) with suspected treatment failure and identified factors associated with persistent viremia.

Methods

We conducted a retrospective review of electronic medical records of PWH aged 15 years or older who had received antiretroviral therapy (ART) for at least 6 months as of December 2020 and had a high viral load (HVL; ≥1000 copies/mL) across 22 comprehensive HIV treatment facilities in Akwa Ibom State, Nigeria. Patients with HVL were expected to receive 3 EAC sessions delivered in person or virtually and repeat VL testing upon completion of EAC and after documented good adherence. At 6 months post-EAC enrollment, we reviewed the data to determine client uptake of 1 or more EAC sessions, completion of 3 EAC sessions, a repeat viral load (VL) test conducted post-EAC, and persistent viremia with a VL of ≥1000 copies/mL. Selected sociodemographic and clinical variables were analyzed to identify factors associated with persistent viremia using SPSS, version 26.

Results

Of the 3257 unsuppressed PWH, EAC uptake was 94.8% (n = 3088), EAC completion was 81.5% (2517/3088), post-EAC VL testing uptake was 75.9% (2344/3088), and viral resuppression was 73.8% (2280/3088). In multivariable analysis, those on ART for <12 months (P ≤ .001) and those who completed EAC within 3 months (P = .045) were less likely to have persistent viremia.

Conclusions

An HVL resuppression rate of 74% was achieved, but EAC completion was low. Identification of the challenges faced by PWH with a higher risk of persistent viremia is recommended to optimize the potential benefit of EAC.

How Home Delivery of Antiretroviral Drugs Ensured Uninterrupted HIV Treatment During COVID-19: Experiences From Indonesia, Laos, Nepal, and Nigeria

INTRODUCTION

Faced with the coronavirus disease (COVID-19) pandemic, governments worldwide instituted lockdowns to curtail virus spread. Health facility closures and travel restrictions disrupted access to antiretroviral (ARV) therapy for people living with HIV. This report describes how HIV programs in Indonesia, Laos, Nepal, and Nigeria supported treatment continuation by introducing home delivery of ARVs.

METHODS

Staff supporting the programs provided accounts of when and how decisions were taken to support ARV home delivery. They captured programmatic information about home delivery implementation using an intervention documentation tool. The 4 country experiences revealed lessons learned about factors favoring successful expansion of ARV home delivery.

RESULTS

Three of the countries relied on existing networks of community health workers for ARV delivery; the fourth country, Indonesia, relied on a private sector courier service. Across the 4 countries, between 19% and 51% of eligible clients were served by home delivery. The experiences showed that ARV home delivery is feasible and acceptable to health service providers, clients, and other stakeholders. Essential to success was rapid mobilization of stakeholders who led the design of the home delivery mechanisms and provided leadership support of the service innovations. Timely service adaptation was made possible by pre-existing differentiated models of care supportive of community-based ARV provision by outreach workers. Home delivery models prioritized protection of client confidentiality and prevention measures for COVID-19. Sustainability of the innovation depends on reinforcement of the commodity management infrastructure and investment in financing mechanisms.

CONCLUSION

Home delivery of ARVs is a feasible client-centered approach to be included among the options for decentralized drug distribution. It serves as a measure for expanding access to care both when access to health services is disrupted and under routine circumstances.

Differentiated service delivery models among PLHIV in Akwa Ibom and Cross River States, Nigeria during the COVID-19 pandemic: descriptive analysis of programmatic data

Introduction

The rapid increase in the number of people living with HIV (PLHIV) on antiretroviral therapy (ART) in Akwa Ibom and Cross River states in Nigeria led to overcrowding at clinics. Patients were devolved to receive ART refills through five differentiated service delivery (DSD) models: fast‐track (FT), adolescent refill clubs (ARCs), community pharmacy ART refill programs (CPARPs), community ART refill clubs (CARCs) and community ART refill groups (CARGs) designed to meet the needs of different groups of PLHIV. In the context of COVID‐19‐related travel restrictions, out‐of‐facility models offered critical mechanisms for continuity of treatment. We compared retention and viral suppression among those devolved to DSD with those who continued standard care at facilities.

Methods

A retrospective cohort study was conducted among patients devolved to DSD from January 2018 to December 2020. Bivariate analyses were conducted to assess differences in retention and viral suppression by socio‐demographic characteristics. Kaplan–Meier assessed retention at 3, 6, 9 and 12 months. Differences in proportions were compared using the chi‐square test; a p‐value of <0.05 was considered significant.

Results

A total of 40,800 PLHIV from 84 facilities received ART through the five models: CARC (53%), FT (19.1%), ARC (12.1%), CPARP (10.4%) and CARG (5.4%). Retention rates at 6 months exceeded 96% for all models compared to 94% among those continuing standard care. Among those using DSD, retention rate at 12 months was higher among adults than children (97.8% vs. 96.7%, p = 0.04). No significant sex differences in retention rates were found among those enrolled in DSD. Viral suppression rates among PLHIV served through DSD were significantly higher among adults than children (95.4% vs. 89.2%; p <0.01). Among adults, 95.4% enrolled in DSD were virally suppressed compared to 91.8% of those in standard care (p <0.01). For children, 89.2% enrolled in DSD were virally suppressed compared to 83.2% in standard care (p <0.01).

Conclusions

PLHIV receiving ART through DSD models had retention but higher viral suppression rates compared to those receiving standard care. Expanding DSD during COVID‐19 has helped ensure uninterrupted access to ART in Nigeria. Further scale‐up is warranted to decongest facilities and improve clinical outcomes.