People with HIV on failing treatment still being spotted too late

People on failing HIV treatment are still being identified too late – once they have developed late-stage HIV – and it is taking around 17 months to swap treatment, an evidence review from sub-Saharan Africa has found.

What is the research about?

The stage at which people who are on ineffective HIV treatment are identified as having viral failure and swapped to an alternative treatment regimen.

Viral failure occurs when antiretroviral treatment (ART) fails to suppress HIV in the body to a point where someone’s CD4 count reaches less than 200 copies/mL – the level used to diagnose AIDS.

This research reviewed and analysed 36 studies conducted between 2009 to 2020 among 14,000 people with HIV experiencing viral failure. Studies were done in 15 African countries, mostly South Africa, Uganda and Nigeria.

Why is this research important?

The longer it takes to diagnose someone who has HIV with viral failure, the more their health is at risk. They are also at risk of passing HIV on to others.

What did they find out?

People’s CD4 counts had already fallen below 200 cells/mm³ when they were identified as being on failing treatment. The average CD4 count when this happened was 187 cells/mm³. This level remained the same or very similar in later studies compared to earlier ones.

The average CD4 count of people when they were switched to a second line treatment was 108 cells/mm³. This slightly increased over time, but only by around 10 CD4 cells a year.

It took around 530 days (17 months) to be switched to second-line ART after being diagnosed with viral failure. There has been no significant improvement on this since 2009.

What does this mean for HIV services?

Although viral load monitoring is part of many public sector HIV treatment programmes, it is not always available. And when it is available, it is not working as it should for people on failing treatment.

One key issue is that it is not always clear which healthcare worker in a clinic is responsible for taking action if someone has an increased viral load or is in viral failure. Ensuring a specific healthcare worker is responsible for booking a return visit, providing adherence support, and repeat viral load testing over the course of weeks, rather than months, would help to close this gap. For example, a big improvement in viral load testing rates was seen in clinics in South Africa after they introduced a nurse-led ‘viral load champion’ programme.

Another issue is that people in treatment failure are highly likely to miss clinic visits due to ill health or other issues, such as not having money for transport because they are not able to work. Finding ways to reach these people through outreach to offer adherence support is essential. It can also be effective to support with practical issues, such as transport, to enable people to get to clinics to have their viral load monitored.