Adherence Level to Antiretroviral Therapy Predicts the Time to Viral Load Suppression of Adult People Living with HIV on Antiretroviral Therapy in Arba Minch General Hospital
Access to antiretroviral drugs for all human immunodeficiency virus (HIV) infected persons in need is a global health priority. The primary goal of initiating antiretroviral therapy (ART) among HIV patients is to suppress HIV viral replication and to restore immune function. Regular monitoring of viral load and CD4 counts is essential, and the plasma viral load should be reduced as much and as quickly as possible. Poor adherence to ART leads to antiretroviral agents not persisting at adequate concentrations to suppress HIV replication in infected cells, thereby failing to lower the plasma viral load. Identifying factors like adherence to HIV treatment that predict the time to viral load suppression of patients on antiretroviral therapy regimens is thus vital to optimizing therapeutic success.
An observational clinic-based follow-up study was conducted using prospective data abstracted from medical records, patient interviews, and laboratory work-up during a six-month follow-up of HIV patients in Arba Minch Hospital from March 1, 2017, to February 28, 2018. Ethical clearance was obtained from the institutional review board (IRB) of the College of Medicine and Health Sciences of Arba Minch University. Written consent was obtained from all study participants for blood draws and interviews. The confidentiality and privacy of participants were actively protected. Data were collected from 152 naive HIV-infected patients. Specimens for the laboratory tests of CD4 count and viral load were collected by trained laboratory staff at the facility. For both tests, 4–5 mL of whole blood was drawn from each participant using vacutainer tubes separately with anticoagulant following standard venipuncture protocols for viral load testing. Furthermore, plasma samples were assayed for the presence of HIV RNA using the Amplicor Monitor standard assay, version 1.5 (Roche Molecular Systems, Switzerland).
According to the World Health Organization (WHO) strategy for the surveillance and monitoring of HIV drug resistance in low and middle-income countries (LMICs), a viral load of <1000 RNA copies/mL was taken as evidence of viral load suppression. Based on this WHO recommendation, it was found that the median time taken to reach viral load suppression was three months with a 95% confidence interval (CI) of 2.68 to 3.32 during the six-month follow-up. The median viral load was 1452 copies/mL (interquartile range (IQR) 1120–3407.25 copies/mL). The minimum viral load was 456 copies/mL, and the maximum was 455,896 copies/mL. The average viral load of the patients strictly decreased from baseline to the second month and then slightly decreased from month 2 to month 6. This time to viral load suppression was significantly affected by the level of patient adherence to ART. The hazard rate for those who had good adherence to ART drugs was three times higher to experience early viral load suppression compared to those who had poor adherence to ART drugs (adjusted hazard ratio (AHR) = 2.648, 95% CI = 1.202, 5.834, P = 0.016). This finding is supported by previous findings that adherence is the key, potentially modifiable, variable associated with time to viral load suppression.
Supportive HIV treatments like cotrimoxazole preventive therapy (CPT) and isoniazid preventive therapy (IPT) also had a significant effect on the duration of viral load suppression. The effect of CPT on time to viral load suppression might be due to early initiation of cotrimoxazole prophylaxis associated with a significant reduction in serious bacterial infections and mortality. Providing preventive therapy reduces the co-infection of tuberculosis (TB), which further reduces the duration of viral load suppression since TB is highly associated with the depletion of CD4+ T-cell count and high viral load.
The findings of this study showed that the time needed for viral load suppression of those who had ≥200 cells/mm³ CD4 count was shorter than those who had <200 cells/mm³ CD4 count. This might be due to those who have higher CD4 counts during ART treatment having rare HIV-related clinical complications, which in turn provide the patient an opportunity for early suppression of the viral load. At the same time, patients with low baseline viral load (<10,000 copies/mL) experienced viral load suppression earlier than those with high baseline viral load (≥10,000 copies/mL), which is supported by findings from other studies.
Therefore, different stakeholders working on HIV programs can maintain and potentially improve the time to viral load suppression by improving access to targeted viral load testing and CD4 count, including routine viral load and CD4 count for all patients on ART starting from the first day of treatment, streamlining and strengthening adherence monitoring and counseling. Furthermore, healthcare professionals and adherence supporters should consciously and closely follow up patients and intensify targeted adherence support for those patients with poor adherence, low levels of initial CD4 count, and high baseline viral load.
Readers should be cautious when interpreting these findings since the data were obtained from patients in one hospital, and thus the findings cannot be generalized to all people living with HIV in Ethiopia. In addition, the follow-up time of six months in our study was relatively shorter compared to other studies that followed their participants for a longer period. Thus, our findings are conservative.
doi.org/10.1097/CM9.0000000000000519
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