Abstract
IntroductionIn South Africa, HIV patients with an elevated viral load (VL) should receive repeat VL testing after adherence counselling. We set out to use a national HIV Cohort to describe time to repeat viral load testing across South Africa and identify predictors of time to repeat testing.MethodsWe conducted a cohort study of prospectively collected laboratory data. HIV treatment guidelines have changed over time in South Africa, but call for repeat VL testing within six months if 400 to 1000 copies/mL and two to three months if >1000 copies/mL. We included patients with suppressed viral loads (indicating they are on ART) and a first elevated VL (>400 copies/mL) between April 2004 and December 2014. Follow‐up began at first elevated VL and continued until repeat testing, loss to follow‐up or December 2016. We calculated adjusted hazard ratios (aHR) using Cox proportional hazard models.ResultsOf 371,648 patients with a VL > 400, 83.9% (311,790) had a repeat VL, in a median (IQR) of 7.0 (4.1 to 12.2) months. Of those with a first viral load 400 to 1000 copies/mL, 56.4% had a repeat VL within guideline recommended six months (defined as up to nine months), whereas among those >1000 copies/mL only 47.7% had a repeat viral load within guideline recommended two to three months (defined as up to six months). We found a small increase in repeat testing associated with higher VL value (aHR 1.11; 95% CI: 1.10 to 1.12 comparing >1000 vs 400 to 1000 copies/mL) and very low CD4 counts at first elevated VL (aHR 1.16; 95% CI: 1.13 to 1.19 comparing CD4 < 50 vs <500 cells/mm3). We also found strong variation in time to repeat VL testing by province.ConclusionsMedian time to repeat viral load testing for those with an elevated viral load was longer than guidelines recommend. Future work should identify whether delays are due to patient or provider factors.
Highlights
In South Africa, HIV patients with an elevated viral load (VL) should receive repeat VL testing after adherence counselling
Patient characteristics at the data of first unsuppressed viral load after first suppressed viral load are summarized in Table 1, stratified by whether or not the patient had a repeat viral load after the enrolment elevated viral load
We found a small increase in likelihood of repeat testing associated with both higher viral load value (adjusted Hazard Ratio 1.11; 95% CI: 1.10 to 1.12 comparing viral load >1000 vs 400 to 1000 copies/mL) and very low CD4 counts at first elevated viral load
Summary
In South Africa, HIV patients with an elevated viral load (VL) should receive repeat VL testing after adherence counselling. Programme success is often assessed based on the UNAIDS recommended 90-90-90 targets [1], of which the third 90 seeks to get 90% of those on ART to achieve viral suppression Achieving this goal is important as trials [2] and cohort studies [3,4] have shown that those who are virally suppressed are extremely unlikely to transmit the virus to uninfected partners. Not all countries are able to provide viral load testing as part of national programmes but for those that do, patients with an elevated viral load are recommended to undergo adherence counselling and have a repeat measure within three to six months to determine if treatment failure has occurred and the treatment regimen should be switched. In the absence of widespread resistance testing in low- and middle-income countries, patients who do not resuppress after
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