Abstract
BackgroundHaiti initiated the scale-up of HIV viral load (VL) testing in 2015–2016, with plans to achieve 100% coverage for all patients on antiretroviral therapy (ART) for treatment of HIV/AIDS. In the absence of HIV drug susceptibility testing, VL testing is a key tool for monitoring response to ART and optimizing treatment results. This study describes trends in expanded use of VL testing, VL results, and use of second-line ART regimens, and explores the association between VL testing and second-line regimen switching in Haiti from 2010 to 2017.MethodsWe conducted a retrospective cohort study with 66,042 patients drawn from 88 of Haiti’s 160 national ART clinics. Longitudinal data from the iSanté electronic data system was used to analyze the trends of interest. We described patients’ VL testing status in five categories based on up to two most recent VL test results: no test; suppressed; unsuppressed followed by no test; re-suppressed; and confirmed failure. Among those with confirmed failure, we described ART adherence level. Finally, we used Cox proportional hazards regression to estimate the risk of second-line regimen switching by VL testing status, after adjusting for other individual characteristics.ResultsThe number of patients who had tests done increased annually from 11 in 2010 to 18,828 in the first 9 months of 2017, while the number of second-line regimen switches rose from 21 to 279 during this same period. Compared with patients with no VL test, the hazard ratio (HR) for switching to a second-line regimen was 22.2 for patients with confirmed VL failure (95% confidence interval [CI] for HR: 18.8–26.3; p < 0.005) after adjustment for individual characteristics. Among patients with confirmed VL failure, 44.7% had strong adherence, and fewer than 20% of patients switched to a second-line regimen within 365 days of VL failure.ConclusionsHaiti has significantly expanded access to VL testing since 2016. In order to promote optimal patient health outcomes, it is essential for Haiti to continue broadening access to confirmatory VL testing, to expand evidence-based initiatives to promote strong ART adherence, and to embrace timely switching for patients with confirmed ART failure despite strong ART adherence.
Highlights
Haiti initiated the scale-up of HIV viral load (VL) testing in 2015–2016, with plans to achieve 100% coverage for all patients on antiretroviral therapy (ART) for treatment of HIV/AIDS
VL Cascade by calendar year The total number of VL tests recorded in iSanté increased from 11 tests in 2010 to 20,221 in the first three quarters of 2017, while the number of patients with a VL test grew from 11 patients to 18,828 during during this time frame (Table 2)
Association between viral load testing and second-line regimen switching Our exploratory analysis of the association between VL testing and regimen switching showed that patients with confirmed VL failure had a 22.2 times higher hazard of switching to a second-line regimen compared with those with no VL test done, after adjusting for age, gender, World Health Organization (WHO) stage at ART initiation, and year of ART initiation (Table 5)
Summary
Haiti initiated the scale-up of HIV viral load (VL) testing in 2015–2016, with plans to achieve 100% coverage for all patients on antiretroviral therapy (ART) for treatment of HIV/AIDS. Antiretroviral therapy (ART) for treatment of HIV, when used consistently, suppresses HIV replication and prevents progression of HIV disease [1], leading to highly successful clinical, immunologic, and virologic outcomes for patients with HIV/AIDS. The initial treatment for most HIV patients is a firstline ART regimen, but either weak adherence or the presence of drug resistance can cause virologic failure. For patients with resistant forms of HIV, switching to second-line regimens is appropriate, and delays in switching can result in prolonged viremia, which leads to morbidity and mortality, as well as onward transmission of HIV
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