VIRAL LOAD MONITORING OF ART PATIENTS LINKED TO LOWER DEATH RATE ON TREATMENT IN SOUTHERN AFRICA

VIRAL LOAD MONITORING OF ART PATIENTS HAS BEEN LINKED TO LOWER DEATH RATE ON TREATMENT IN SOUTHERN AFRICA.

AN ESTIMATED SIX MILLION PEOPLE ARE NOW RECEIVING ART IN RESOURCE-POOR SETTINGS AND AS ACCESS TO ART CONTINUES TO INCREASE, SO DOES THE RISK OF TREATMENT FAILURE AND SWITCHING TO SECOND-LINE REGIMENS.

COST AND LOGISTICS PRECLUDE THE USE OF VIRAL LOAD MONITORING TO DIAGNOSE TREATMENT FAILURE IN MOST OF THE PUBLIC SECTOR IN RESOURCE-POOR SETTINGS AND AS SUCH CD4 CELL COUNTS AND CLINICAL CRITERIA, WHILE SHOWN TO BE POOR PREDICTORS OF VIROLOGIC FAILURE, ARE ROUTINELY USED WHICH OFTEN RESULTS IN UNNECESSARY SWITCHING TO SECOND-LINE REGIMENS OR DELAYS IN SWITCHING WHEN FAILURE IS UNDETECTED.

THIS IS ACCORDING TO THE OLIVIA KEISER AND COLLEAGUES FROM THE INTERNATIONAL EPIDEMIOLOGICAL DATABASES TO EVALUATE AIDS IN SOUTHERN AFRICA COLLABORATION WHO REPORTED IN A COMPARATIVE STUDY PUBLISHED IN THE ADVANCE ONLINE EDITION OF AIDS.

A visualzation of viral load levels. Image from www.gileadhbv.com

STUDIES HAVE SHOWN PATIENTS WITH ACCESS TO VIRAL LOAD MONITORING ARE MORE LIKELY TO SWITCH TO SECOND-LINE REGIMENS AT A HIGHER CD4 CELL COUNT THAN THOSE WITHOUT AND LESS LIKELY TO ACQUIRE MUTATIONS CONFERRING RESISTANCE.

THE AUTHORS ANALYSED DATA TO COMPARE SWITCHING TO SECOND-LINE REGIMENS, LOSS TO FOLLOW-UP AND DEATH AT ART PROGRAMMES IN SOUTH AFRICA WHERE VIRAL LOAD MONITORING AND CD4 CELL COUNT IS ROUTINELY DONE EVERY THREE TO SIX MONTHS TO ART PROGRAMMES IN MALAWI AND ZAMBIA WHERE MONITORING IS BASED ON CD4 CELL COUNTS WITH VERY LIMITED ACCESS TO VIRAL LOAD MONITORING.

THE AUTHORS LOOKED AT CD4 RESPONSES IN SITES WITH AND WITHOUT VIRAL LOAD MONITORING AND A MULTI-STATE MODEL LOOKED AT THE PROBABILITY OF SWITCHING TO SECOND-LINE REGIMENS, DEATH AND LOSS TO FOLLOW-UP.

ALL MEASUREMENTS WERE EVALUATED FROM SIX MONTHS AFTER STARTING ART AND AT THREE YEARS DEATH RATES AND LOSS TO FOLLOW-UP WERE HIGHER IN ZAMBIA AND MALAWI THAN IN SOUTH AFRICA 6.3% AND 15.3% COMPARED TO 4.3% AND 9.2% RESPECTIVELY.

THE AUTHORS NOTE THAT WHILE THE TREATMENT PROGRAMMES MAY NOT BE REPRESENTATIVE OF ALL ART PROGRAMMES IN THE THREE COUNTRIES, THE CONSIDERABLE SAMPLE SIZE AND RANGE OF CLINICS MAKE THE RESULTS APPLICABLE TO MANY IN A HIGH HIV BURDEN REGION.

THIS STUDY, THEY ADD, SUPPORTS OTHER FINDINGS THAT HAVE SHOWN ROUTINE VIRAL LOAD MONITORING TO BE HELPFUL IN IDENTIFYING PATIENTS FOR ADHERENCE INTERVENTIONS AND PROMOTING RETENTION IN CARE.

THE AUTHORS CONCLUDED THAT OVER THREE YEARS OF ART MORTALITY WAS LOWER IN SOUTH AFRICA THAN IN MALAWI OR ZAMBIA AND THE MORE FAVOURABLE OUTCOME IN SOUTH AFRICA MIGHT BE EXPLAINED BY VIRAL LOAD MONITORING LEADING TO EARLIER DETECTION OF TREATMENT FAILURE, ADHERENCE COUNSELING AND TIMELIER SWITCHING TO SECOND-LINE ART.

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