Abstract
IntroductionThere is limited literature on the appropriateness of viral load (VL) monitoring and management of detectable VL in public health settings in rural South Africa.MethodsWe analysed data captured in the electronic patient register from HIV‐positive patients ≥ 15 years old initiating antiretroviral therapy (ART) in 17 public sector clinics in rural KwaZulu‐Natal, during 2010–2016. We estimated the completion rate for VL monitoring at 6, 12, and 24 months. We described the cascade of care for those with any VL measurement ≥ 1000 HIV‐1 RNA copies/mL after ≥ 20 weeks on ART, including the following proportions: (1) repeat VL within 6 months; (2) re‐suppressed; (3) switched to second‐line regimen.ResultsThere were 29 384 individuals who initiated ART during the period [69% female, median age 31 years (interquartile range 25–39)]. Of those in care at 6, 12, and 24 months, 40.7% (9861/24 199), 34% (7765/22 807), and 25.5% (4334/16 965) had a VL test at each recommended time‐point, respectively. The VL results were documented at all recommended time‐points for 12% (2730/22 807) and 6.2% (1054/16 965) of ART‐treated patients for 12 and 24 months, respectively. Only 391 (18.3%) of 2135 individuals with VL ≥ 1000 copies/mL on first‐line ART had a repeat VL documenting re‐suppression or were appropriately changed to second‐line with persistent failure. Completion of the treatment failure cascade occurred a median of 338 days after failure was detected.ConclusionWe found suboptimal VL monitoring and poor responses to virologic failure in public‐sector ART clinics in rural South Arica. Implications include increased likelihood of morbidity and transmission of drug‐resistant HIV.
Highlights
There is limited literature on the appropriateness of viral load (VL) monitoring and management of detectable VL in public health settings in rural South Africa
We described the cascade of care for all individuals with a VL measurement ≥ 1000 copies/mL after at least 5 months on antiretroviral therapy (ART), including the proportion with a repeat VL within 6 months, the proportion who re-suppressed, and the proportion who changed to a second-line regimen if a repeat VL remained ≥ 1000 copies/mL
The median age was 31 years [interquartile range (IQR): 26–39] and 69.9% were female. Of those on ART for 6, 12 and 24 months, we found that 40.7% (9861/24 199), 34% (7765/22 807), and 25.5% (4334/16 965) had a VL test documented at each recommended time-point, respectively
Summary
There is limited literature on the appropriateness of viral load (VL) monitoring and management of detectable VL in public health settings in rural South Africa. UNAIDS estimates that to end HIV/AIDS as a public health threat by 2030, 95% of people living with HIV. Must be diagnosed, 95% of those diagnosed need to be taking antiretroviral therapy (ART), and 95% of those must achieve long-term virologic suppression [1] To ascertain this third target, HIV treatment programmes in sub-Saharan Africa (SSA) will need to scale up viral load (VL) monitoring, and to institute prompt and appropriate management strategies for those failing therapy. With increases in drug resistance in the region [3,4,5], there is concern over an epidemic of ART failure compromising already challenging efforts to combat HIV/AIDS as a public health threat
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