Page 243 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 6 of 7 Original Research

were likely to have unsuppressed VLs (defaulters, those that with viral suppression, and males, age group less than
demised or were LTFU) did not have VL data used for these 15 years and prior ART exposure were more likely to
measurements. The proportion of individuals virologically experience virologic failure. 13,14 When the factors that are
suppressed was therefore calculated based on the number of associated with viral suppression in the long term were
individuals who had data recorded at a particular time point. reviewed, gender and baseline laboratory results had no
significant association. It seemed as if males that were able
Our study found that 64% (n = 648), 70% (n = 577) and 72% to stay on treatment for longer had similar virologic response
(n = 366) of our cohort were virologically suppressed at 6, 12 to females. This may have been because of the retention bias,
and 60 months, respectively. When the definition of viral noted above, as more males died or were LTFU during the
suppression was changed to < 400 copies/mL, the minimum study. Bello et al. also found that absence of prior exposure
16
proportion of virologically suppressed individuals at to antiretrovirals before initiation on lifelong HAART was
every time point throughout the study was 80%. This was associated with viral suppression at 10 years post-initiation.
similar to a large meta-analysis conducted by Boender and They also found that age, race and baseline CD4+ cell count
colleagues in low- to medium-income countries. They found had no influence on viral suppression in the longer term.
that at every interval between 6 and 60 months, at least 80%
24
of patients were virally suppressed. This was an unexpected Limitations of the study
but important finding in the drive towards achieving one of
the ‘90-90-90 targets’ set by the UNAIDS. Present cART Although attempts were made to prevent bias, missing data
guidelines recommend initiation once diagnosed with HIV. on tier.net and the use of patient recall to record some
One of the major aims of this is to prevent HIV transmission variables, such as previous antiretroviral therapy exposure,
through achieving viral suppression, as revealed by the may have introduced some bias to the study. Furthermore,
Partner study. A review was, therefore, attempted to assess patients recorded as LTFU may have died. However, because
6
how consistently patients were able to maintain viral the data were not updated with the South African national
suppression after attainment. Fifty-nine per cent of the mortality database, the cumulative mortality may have been
sample were able to maintain one consecutive viral underestimated. Furthermore, being a retrospective study,
suppression. These patients maintained viral suppression data on some variables that may influence responses to cART,
over a period of at least 6 months. When reviewed for those such as adherence, were not available. This introduces the
able to maintain viral suppression consecutively for at least possibility of residual confounding into the study.
54 months, only 14% of the sample achieved this. This low
proportion of people with consistent viral suppression may Despite the limitations outlined above, this study has a
have a negative impact on the use of viral suppression as a number of strengths. The use of all patients on cART recorded
prevention strategy. on tier.net affords an opportunity to find a difference in
outcomes if there really is one. Finally, there is a paucity of
With the initiation of cART, immune recovery, in the form of studies reviewing immunologic and virologic responses
CD4+ cell count increase, is expected. In our review of in the long term in healthcare facilities in Limpopo,
immunological response to cART, the mean CD4+ cell count South Africa; therefore, this study will serve as a foundational
increased almost throughout the study, as was the case in a study for such research.
study in Tshwane District. However, their cohort did not
achieve a normal CD4+ cell count (> 500 cells/µL) at Conclusion
60 months, unlike in our study. Also, at 60 months, only 11% According to the South African NDoH definition for viral
25
of patients had a CD4+ cell count of less than 200 cells/µL. suppression, the proportion of individuals attaining viral
This meant that fewer patients may have needed prophylaxis suppression was well below the UNAIDS 90% target. Also,
against opportunistic infections. It must, however, be stated the sustainability of viral suppression seemed quite low
that the baseline CD4+ cell count of many patients initiated when individuals were reviewed over a 54-month period.
prior to 2010 was missing on tier.net.
Immunologic response was adequate for most individuals
in the period under review. Being male was associated
The only factors found to be significantly associated with with poorer virologic response to cART. Furthermore, the
early viral suppression were baseline CD4 count and gender, age group less than 15 years had poorer immunologic and
with individuals with higher CD4+ cell counts and females virologic outcomes. Therefore, a targeted approach focusing
more likely to achieve viral suppression at 6 months. The age on improving virologic and immunologic responses of males
group less than 15 years also had comparatively poorer and patients less than 15 years may aid in improving
immunological and virologic outcomes. Problems with outcomes at a community level because infected male
adherence and drug formulations may account for this. partners are likely to infect a female partner and vice versa. 26
Mlangeni and Senkubuge, in a study to ascertain patient
25
retention on ART after 5 years of treatment in Tshwane Acknowledgements
District, however, found that gender and age had no influence
on early VL response (6 months). Some other studies also The authors are grateful to officials of the Limpopo Provincial
found that higher baseline CD4+ cell count was associated Department of Health and Vhembe District Department of

http://www.sajhivmed.org.za 236 Open Access