Only half of those on HIV treatment are virally suppressed in Ghana

The study, which took place in Kusami, Ghana, in February last year, provided same-day viral load testing for 330 outpatients on long-term antiretroviral treatment (ART). Immediate adherence support was provided to roughly half of participants (49%) who were found to have detectable viral loads, while one in five had treatment failure (defined as at least 1,000 viral copies/mL).

Trial participants, three-quarters of whom had been on ART for a median of nine years, also completed questionnaires on issues that can affect adherence to treatment, such as access to regular meals, alcohol consumption and the use of traditional medicine.

All participants with a detectable viral load were asked to return after eight weeks for further rapid viral-load testing, around 90% of whom did so. This retention rate is much higher than other similar trials, and may be due to the initial viral-load results being given to participants straightaway, coupled with the immediate commencement of adherence counselling.

At the eight-week follow-up visit, 21% of those who were previously found to have a detectable viral load had achieved viral re-suppression, but nearly all those experiencing treatment failure remained virally unsuppressed. Additional analysis conducted by the research team found this outcome to be strongly associated with drug resistance.

Around 90% of all trial participants were on a class of antiretrovirals known as non-nucleoside reverse transcriptase inhibitors (NNRTI). The remaining 10% were on a protease inhibitor (PI) combined with a nucleoside reverse transcriptase inhibitor (NRTI), including tenofovir.

Around 90 participants with detectable viral loads were assessed for drug resistance during the trial, 65 of whom were experiencing treatment failure. Those in the latter category were found to have more extensive drug resistance, and more complex resistance patterns, than those with lower detectable viral loads.

Around 85% of participants with treatment failure who underwent these additional tests had a strain of HIV containing at least one drug-resistant genetic mutation. Around three quarters (77%) had mutations that were NRTI-resistant, 85% had mutations that were NNRTI-resistant, and 40% had at least one mutation that was resistant to tenofovir.

The World Health Organization currently recommends that someone on ART with a viral load of over 1,000 copies/mL should be swapped to alternative treatment, but advises that three to six months of adherence counselling should take place before the switch is made.

However, the data on drug resistance gathered by this study, which found patients in treatment failure to have high-levels of drug resistance, suggests that prioritising adherence counselling above regimen switching could be counterproductive for people in this category. In these cases, a delay in switching treatment may enable HIV to progress, putting an individual’s health at risk, and potentially enable drug-resistant strains of HIV to be transmitted. Conversely, because people with lower-level detectable viral loads were found to have lower levels of drug resistance, the study’s findings suggest that offering immediate adherence counselling is likely to improve outcomes for a significant proportion of people whose treatment may be faltering, but is not yet failing.

The study provides further evidence of the value of same-day viral load testing for ensuring any issues with treatment are quickly identified and appropriate action taken. Where access to rapid viral load testing remains limited, strategies should be developed so that patients can be assessed according to their risk of treatment failure, enabling those with the greatest need to receive immediate testing, while providing laboratory diagnostics for others who are less at-risk.