Long-term virologic responses to antiretroviral therapy among HIV-positive patients entering adherence clubs in Khayelitsha, Cape Town, South Africa: a longitudinal analysis.

Kathleen Kehoe,Morna Cornell,Mary Ann Davies,Andrew Boulle,Priscilla R Tsondai,Jonathan Euvrard

doi:10.1002/jia2.25476

Kathleen Kehoe, Morna Cornell + Show 4 more

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https://doi.org/10.1002/jia2.25476

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Abstract

IntroductionIn South Africa, an estimated 4.6 million people were accessing antiretroviral therapy (ART) in 2018. As universal Test and Treat is implemented, these numbers will continue to increase. Given the need for lifelong care for millions of individuals, differentiated service delivery models for ART services such as adherence clubs (ACs) for stable patients are required. In this study, we describe long‐term virologic outcomes of patients who have ever entered ACs in Khayelitsha, Cape Town.MethodsWe included adult patients enrolled in ACs in Khayelitsha between January 2011 and December 2016 with a recorded viral load (VL) before enrolment. Risk factors for an elevated VL (VL >1000 copies/mL) and confirmed virologic failure (two consecutive VLs >1000 copies/mL one year apart) were estimated using Cox proportional hazards models. VL completeness over time was assessed.ResultsOverall, 8058 patients were included in the analysis, contributing 16,047 person‐years of follow‐up from AC entry (median follow‐up time 1.7 years, interquartile range [IQR]:0.9 to 2.9). At AC entry, 74% were female, 46% were aged between 35 and 44 years, and the median duration on ART was 4.8 years (IQR: 3.0 to 7.2). Among patients virologically suppressed at AC entry (n = 8058), 7136 (89%) had a subsequent VL test, of which 441 (6%) experienced an elevated VL (median time from AC entry 363 days, IQR: 170 to 728). Older age (adjusted hazard ratio [aHR] 0.64, 95% confidence interval [CI] 0.46 to 0.88), more recent year of AC entry (aHR 0.76, 95% CI 0.68 to 0.84) and higher CD4 count (aHR 0.67, 95% CI 0.54 to 0.84) were protective against experiencing an elevated VL. Among patients with an elevated VL, 52% (150/291) with a repeat VL test subsequently experienced confirmed virologic failure in a median time of 112 days (IQR: 56 to 168). Frequency of VL testing was constant over time (82 to 85%), with over 90% of patients remaining virologically suppressed.ConclusionsThis study demonstrates low prevalence of elevated VLs and confirmed virologic failure among patients who entered ACs. Although ACs were expanded rapidly, most patients were well monitored and remained stable, supporting the continued rollout of this model.

Highlights

In South Africa, an estimated 4.6 million people were accessing antiretroviral therapy (ART) in 2018
Of the 8413 eligible patients, 63 (0.7%) patients were excluded for the following reasons: missing gender (5), unable to link on patient identifier (58) and a viral load (VL) ≥400 copies/mL at adherence clubs (ACs) entry (292)
For year of AC entry when assessing an elevated VL

Summary

Introduction

In South Africa, an estimated 4.6 million people were accessing antiretroviral therapy (ART) in 2018. Among patients with an elevated VL, 52% (150/291) with a repeat VL test subsequently experienced confirmed virologic failure in a median time of 112 days (IQR: 56 to 168). In September 2016, South Africa adopted the World Health Organization universal Test and Treat strategy, substantially increasing the number of individuals eligible for lifelong ART services [3,4]. This expansion of ART has major implications in terms of service delivery and costs. Differentiated service delivery (DSD) models for ART services are being explored to ensure PLHIV are retained and remain virologically suppressed in long-term care One such model, adherence clubs (ACs), reduces the burden on patients and on the healthcare system

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