Page 392 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 5 of 8 Original Research

TABLE 4: Socio-economic indicators in 82 participants and their association with the 44% and 56% at the 50 copies/mL and 400 copies/mL
viraemia (transient or persistent) and full or partial adherence, as indicated by
the self-assessed visual analogue scale. thresholds shown in other South African studies in pregnant
Indicator N % Association Association with patients. 25,29 Retesting was preceded by adherence counselling
with viraemia adherence (VAS) without a change in treatment regimen, suggesting that
Highest educational level p = 0.88 p = 0.86 initial viraemia may be at least in part a result of non-
Primary 18 21.9
Secondary 35 42.7 adherence.
Tertiary 29 35.4
Employment status p = 0.74 p = 0.72 Eight of our participants (9.8%) remained persistently
Currently employed or studying 36 43.9 viraemic, of whom five (63%) showed LLV below 400 copies/
Current unemployed 46 56.1 mL, and three (38% of the persistent group, 6% of the total
Marital status p = 0.33 p = 0.81 cohort) had a VL exceeding 1000 copies/mL, suggesting
Single 51 62.2 virological failure. Cragg et al. reported a persistent viraemia
Married, stable relationship or 31 37.8 rate of 3% at a threshold of 400 copies/mL, whereas Myer
29
widowed
Consistent condom use 12 15 et al. reported that 22% of pregnant patients receiving ART
Adverse socio-economic factors p = 0.79 p = 0.11 remained persistently viraemic at a threshold of
0 factors 13 15.9 50copies/mL. It is concerning that the rate of viral
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1 factor 21 25.6 suppression reported for patients on ART in South Africa
2 factors 26 31.7 does not appear to have improved in the past decade. Three
3 factors 16 9.5 studies concluded in or before 2008 reported viraemia rates
4 factors 6 7.3 of 12% – 16% in patients on ART, 31,41,42 not significantly
VAS, visual analogue scale.
The adverse socio-economic factors are overcrowding, food insecurity, failure to complete different to our findings or to the other recent studies we
secondary schooling and unemployment. quote. This is contrary to expectation. Current first-line ART
regimens have better side-effect and toxicity profiles than
planned. Viraemia at presentation was associated with non- previous regimens, which included stavudine and
adherence, as evidenced by low VAS scores for viraemic zidovudine, and the current pill burden of one pill per day in
patients compared to those who were virally suppressed. first-line ART is much lower than the burden of five or more
Knowledge, socio-economic status and previous PMTCT pills of earlier regimens. Both these factors might be expected
exposure were not associated with viraemia. to improve adherence. Secondly, wider use of ART at
community level could be expected to result in lower rates of
The proportion of clinic attendees on ART is higher than reinfection in patients on ART as a result of lower levels of
those reported in earlier studies at 35% – 38%, 5,29 in keeping viraemia in HIV-positive sexual partners. Indeed, 69% of
43
with increasing ART coverage in the South African our participants’ partners who were reported to be HIV-
population. Most of our participants were unmarried, had seropositive partners were themselves on ART.
had an unplanned pregnancy and booked later than
recommended. The mean age was 30 years, which is Recent reports have suggested a high prevalence of drug
consistent with data from South African ANC populations on resistance in Southern African patients with ART failure on
ART. A significant number had not disclosed their HIV status first-line regimens that contain tenofovir. This is frequently
to their partners. The unemployment rate at 56.1% is associated with the presence of thymidine analogue
consistent with findings in other South African studies of mutations and is frequently associated with resistance to
both antenatal populations and general HIV-positive other ARV drug classes as well. 44,45 Numerous associations
populations, 31,36,37 and it may reflect relative disadvantage with viraemia in pregnant patients receiving ART have been
among the HIV-positive population. 38 reported in studies from Africa. These include ART duration,
younger age, previous exposure to PMTCT, single status,
We found the prevalence of baseline viraemia to be 11.0% non-disclosure of HIV status to their partner, illiteracy, a
(CI 5.9% – 19.6%) at a threshold of 400 copies/mL and 18.3% lower CD4+ count, concurrent TB treatment, ART commenced
(CI 11.4% – 28.0%) at 50 copies/mL. This is broadly consistent in third trimester of pregnancy and previous treatment
with experience in the general South African population of default. 26,29,46 Studies in higher-income countries, where the
patients on ART and with the rates reported in South African incidence of viraemia is lower, have found that vulnerable
studies of pregnant women on PCART, where prevalences of and disadvantaged populations are more likely to present
22% – 23% have been reported at a threshold of 50 copies/mL 34,39 with viraemia. Burch et al. found an association between
47
and of 13% – 14% at a threshold of 400 copies/mL. 24,29 viraemia and poor socio-economic circumstances, including
Interestingly, Hoffmann et al. have shown that resuppression unemployment, lack of university education, financial
40
may be noted even where patients harbour drug-resistant virus. constraints and lack of stable housing in a British patient
population. None of these associations were demonstrated
48
Most of those who were initially viraemic showed a lower VL in our study. The data from South Africa are conflicting. Azia
at the follow-up visit four weeks later (Table 1). Eighty per et al. found economic constraints to be a barrier to adherence,
49
cent had a VL below 400 copies/mL and 47% a VL below while others 31,41 failed to identify socio-economic challenges
50 copies/mL. Our rate of viral resuppression is similar to as barriers to good ART outcomes. That socio-economic

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