Journal Article

Factors associated with unsuppressed viremia in women living with HIV on lifelong ART in the multi-country US-PEPFAR PROMOTE study: A cross-sectional analysis

Cassim, Haseena, Aizire, Jim, Hanley, Sherika, Atuhaire, Patience, Stranix-Chibanda, Lynda, Makanani, Bonus, Yende-Zuma, Nonhlanhla, Taha, Taha, Milala, Beteniko, Fowler, Mary Glenn

2019

Overview

Despite recent efforts to scale-up lifelong combination antiretroviral therapy (cART) in sub-Saharan Africa, high rates of unsuppressed viremia persist among cART users, and many countries in the region fall short of the UNAIDS 2020 target to have 90% virally suppressed. We sought to determine the factors associated with unsuppressed viremia (defined for the purpose of this study as >200 copies/ml) among sub-Saharan African women on lifelong cART. This cross-sectional analysis was based on baseline data of the PROMOTE longitudinal cohort study at 8 sites in Uganda, Malawi, Zimbabwe and South Africa. The study enrolled 1987 women living with HIV who initiated lifelong cART at least 1-5 years ago. Socio-demographic, clinical, and cART adherence data were collected. We used multivariable Poisson regression with robust variance to identify factors associated with unsuppressed viremia. At enrolment, 1947/1987 (98%) women reported taking cART. Of these, HIV-1 remained detectable in 293/1934 (15%), while 216/1934 (11.2%) were considered unsuppressed (>200 copies/ml). The following factors were associated with an increased risk of unsuppressed viremia: not having household electricity (adjusted prevalence risk ratio (aPRR) 1.74, 95% confidence interval (CI) 1.28-2.36, p<0.001); not being married (aPRR 1.32, 95% CI 0.99-1.78, p = 0.061), self-reported missed cART doses (aPRR 1.63, 95% CI 1.24-2.13, p<0.001); recent hospitalization (aPRR 2.48, 95% CI 1.28-4.80, p = 0.007) and experiencing abnormal vaginal discharge in the last three months (aPRR 1.88; 95% CI 1.16-3.04, p = 0.010). Longer time on cART (aPRR 0.75, 95% CI 0.64-0.88, p<0.001) and being older (aPRR 0.77, 95% CI 0.76-0.88, p<0.001) were associated with reduced risk of unsuppressed viremia. Socioeconomic barriers such as poverty, and individual barriers like not being married, young age, and self-reported missed doses are key predictors of unsuppressed viremia. Targeted interventions are needed to improve cART adherence among women living with HIV with this risk factor profile.

• Publisher: Public Library of Science,Public Library of Science (PLoS)
• Subject: Acquired immune deficiency syndrome / Adult / Africa South of the Sahara - epidemiology / AIDS / Anti-Retroviral Agents - therapeutic use / Antiretroviral agents / Antiretroviral drugs / Antiretroviral therapy / Biology and Life Sciences / CD4 Lymphocyte Count / Confidence intervals / Cross-Sectional Studies / Demographic aspects / Demographics / Disease transmission / Drug therapy / Female / Health risks / Highly active antiretroviral therapy / HIV / HIV Infections - drug therapy / HIV Infections - epidemiology / HIV Infections - virology / HIV patients / HIV-1 - drug effects / HIV-1 - physiology / Human immunodeficiency virus / Humans / Longitudinal Studies / Medicine and Health Sciences / Middle Aged / Patient outcomes / People and Places / Poisson density functions / Poverty / Prevalence / Regression analysis / Risk analysis / Risk Factors / Risk management / Risk reduction / Robustness (mathematics) / Self Report / Socioeconomic Factors / Statistical analysis / Vagina / Vaginal discharge / Viral Load - drug effects / Viremia / Viremia - drug therapy / Viremia - epidemiology / Virus diseases / Womens health / Young Adult