Viral load care of HIV-1 infected children and adolescents: A longitudinal study in rural Zimbabwe

Abstract

Introduction: Maintaining virologic suppression of children and adolescents on ART in rural communities in sub-Saharan Africa is challenging. We explored switching drug regimens to protease inhibitor (PI) based treatment and reducing nevirapine and zidovudine use in a differentiated community service delivery model in rural Zimbabwe.

Methods: From 2016 through 2018, we followed 306 children and adolescents on ART in Hurungwe, Zimbabwe at Chidamoyo Christian Hospital, which provides compact ART regimens at 8 dispersed rural community outreach sites. Viral load testing was performed (2016) by Roche and at follow-up (2018) by a point of care viral load assay. Virologic failure was defined as viral load ≥1,000 copies/ml. A logistic regression model which included demographics, treatment regimens and caregiver's characteristics was used to assess risks for virologic failure and loss to follow-up (LTFU).

Results: At baseline in 2016, 296 of 306 children and adolescents (97%) were on first-line ART, and only 10 were receiving a PI-based regimen. The median age was 12 years (IQR 8-15) and 55% were female. Two hundred and nine (68%) had viral load suppression (<1,000 copies/ml) and 97(32%) were unsuppressed (viral load ≥1000). At follow-up in 2018, 42/306 (14%) were either transferred 23 (7%) or LTFU 17 (6%) and 2 had died. In 2018, of the 264 retained in care, 107/264 (41%), had been switched to second-line, ritonavir-boosted PI with abacavir as a new nucleotide analog reverse transcriptase inhibitor (NRTI). Overall viral load suppression increased from 68% in 2016 to 81% in 2018 (P<0.001).

Conclusion: Viral load testing, and switching to second-line, ritonavir-boosted PI with abacavir significantly increased virologic suppression among HIV-infected children and adolescents in rural Zimbabwe.

Fig 1. Hurungwe district in Northwestern Zimbabwe.

A-map of the Southern part of Africa showing Zimbabwe and surrounding countries; B-map of Zimbabwe showing the Hurungwe District in the Northwestern part of Zimbabwe. The approximate location of Chidamoyo Christian Hospitalis indicated by the white star and the relative locations of five outpatient sites (Batanayi, Magororo, Chedope, Nyamutora, and Zvarai) are indicated by white circles; C-the arrow is pointing to Chidamoyo Christian Hospital. This figure was downloaded online from the Humanitarian Response info website (https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/ZWE).

Fig 2. Longitudinal assessment of viral load measures at baseline and after 18 months of follow-up among 264 children and adolescents.

The regimen changes (from non-nucleoside reverse transcriptase inhibitor to protease inhibitor-based combinations) were based on the Zimbabwe guidelines on formulations, dosing, toxicities, and availability of combination ART in 2017. Virologic failure (≥1,000 copies/ml) at enrollment and follow-up are indicated in red.