Brief Report: Appraising Viral Load Thresholds and Adherence Support Recommendations in the World Health Organization Guidelines for Detection and Management of Virologic Failure

• Type of Material: Article
• Authors: Suzanne M. McCluskey, Massachusetts General Hospital; Yap Boum, Epicentre; Nicholas Musinguzi, Mbarara University of Science and Technology; Jessica E. Haberer, Massachusetts General Hospital; Jeffrey N. Martin, University of California San Francisco; Peter W. Hunt, University of California San Francisco; Vincent Marconi, Emory University; David R. Bangsberg, Massachusetts General Hospital; Mark J. Siedner, Massachusetts General Hospital
• Language: English
• Date: 2017-10-01
• Publisher: Lippincott, Williams & Wilkins
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © Copyright 2017 The Author(s). Published by Wolters Kluwer Health, Inc.
• Final Published Version (URL): http://dx.doi.org/10.1097/QAI.0000000000001479
• Title of Journal or Parent Work: Journal of Acquired Immune Deficiency Syndromes
• ISSN: 1525-4135
• Volume: 76
• Issue: 2
• Start Page: 183
• End Page: 187
• Grant/Funding Information: This work was supported by the National Institutes of Health [T32 AI007433-25 to S.M.M, P30 AI027763 and UM1 CA181255 to J.N.M, K23 MH099916 to M.J.S., and R01 MH054907] and the Harvard Center for AIDS Research [P30AI060354 to M.J.S].; The contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.
• Keywords: Longitudinal Studies; Reverse Transcriptase Inhibitors; Viremia; World Health Organization; Viral Load; Antiretroviral Therapy, Highly Active; Anti-HIV Agents; HIV-1; Uganda; Adult; Treatment Outcome; Prospective Studies; Humans; Rural Population; Male; HIV Infections; RNA, Viral; Female
• Research Categories: Health Sciences, Immunology; Biology, Virology

Abstract

Background: The World Health Organization defines HIV virologic failure as 2 consecutive viral loads >1000 copies/mL, measured 3-6 months apart, with interval adherence support. We sought to empirically evaluate these guidelines using data from an observational cohort. Setting: The Uganda AIDS Rural Treatment Outcomes study observed adults with HIV in southwestern Uganda from the time of antiretroviral therapy (ART) initiation and monitored adherence with electronic pill bottles. Methods: We included participants on ART with a detectable HIV RNA viral load and who remained on the same regimen until the subsequent measurement. We fit logistic regression models with viral resuppression as the outcome of interest and both initial viral load level and average adherence as predictors of interest. Results: We analyzed 139 events. Median ART duration was 0.92 years, and 100% were on a nonnucleoside reverse-transcriptase inhibitor-based regimen. Viral resuppression occurred in 88% of those with initial HIV RNA <1000 copies/mL and 42% if HIV RNA was >1000 copies/mL (P <0.001). Adherence after detectable viremia predicted viral resuppression for those with HIV RNA <1000 copies/mL (P = 0.011) but was not associated with resuppression for those with HIV RNA >1000 copies/mL (P = 0.894; interaction term P = 0.077). Conclusions: Among patients on ART with detectable HIV RNA >1000 copies/mL who remain on the same regimen, only 42% resuppressed at next measurement, and there was no association between interval adherence and viral resuppression. These data support consideration of resistance testing to help guide management of virologic failure in resource-limited settings.