Abstract
IntroductionGuidelines for antiretroviral therapy recommend enhanced adherence counselling be provided to individuals with an initial elevated viral load before making a decision whether to switch antiretroviral regimen. We undertook this systematic review to estimate the proportion of patients with an initial elevated viral load who resuppress following enhanced adherence counselling.MethodsTwo databases and two conference abstract sites were searched from January 2012 to October 2019 for studies reporting the number of patients with an elevated viral load whose viral load was undetectable when subsequently assessed. Data were pooled using random effects meta‐analysis.ResultsFifty‐eight studies reported outcomes of 45,720 viraemic patients, mostly from Africa (48 studies), and among patients on first‐line antiretroviral therapy (43 studies). Almost half (46.1%, 95% CI 42.6% to 49.5%) of patients with an initial elevated viral load resuppressed following an enhanced adherence intervention. Of those on first‐line ART with confirmed virological failure (6280 patients, 21 studies), only 53.4% (40.1% to 66.8%) were appropriately switched to a different regimen. Resuppression was higher among studies that provided details of adherence support. The proportion resuppressing was lower among children (31.2%, 21.1% to 41.3%) and adolescents (40.4%, 15.7% to 65.2%) compared to adults (50.4%, 42.6% to 58.3%). No important differences were observed by date of study publication, gender, viral failure threshold, publication status, time between viral loads or treatment regimen. Information on resistance testing among people with an elevated viral load was inconsistently reported.ConclusionsThe findings of this review suggest that in settings with limited resources, current guideline recommendations to provide enhanced adherence counselling can result in resuppression of a substantial number of these patients, avoiding unnecessary drug regimen changes. Appropriate action on viral load results is limited across a range of settings, highlighting the importance of viral load cascade analyses to identify gaps and focus quality improvement to ensure that action is taken on the results of viral load testing.
Highlights
Guidelines for antiretroviral therapy recommend enhanced adherence counselling be provided to individuals with an initial elevated viral load before making a decision whether to switch antiretroviral regimen
Key challenges include ensuring that patients with an elevated viral load receive enhanced adherence counselling and a follow-up viral load, and those whose viral load remains elevated are switched to a new antiretroviral regimen [2,3]
Enhanced adherence counselling was documented for 37 studies, but details of adherence support were provided by only 14 studies
Summary
Guidelines for antiretroviral therapy recommend enhanced adherence counselling be provided to individuals with an initial elevated viral load before making a decision whether to switch antiretroviral regimen. Guidelines for antiretroviral therapy in resource-limited settings recommend enhanced adherence counselling following a first elevated viral load [1] This approach helps programme managers and clinicians to discriminate between suboptimal adherence and viral resistance as two possible reasons for elevated viral loads and guide an appropriate response in the absence of other information such as the results of drug resistance testing. This has led to proposals to include HIV drug resistance testing as part of the algorithm [4], or to switch all patients following an initial elevated viral load [5] It is important from a patient and programme management perspective to avoid the additional cost and complexity of switching treatment regimens in individuals with an elevated viral load if the underlying reason is suboptimal adherence
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