factors affecting virological non-suppression among

Public Health Fellowship Program – Field Epidemiology Track

Factors Affecting Virological

Non-suppression among Patients on ART:

Uganda, Aug 2014-Jul 2015

Lilian Bulage, BSTB, MHSR

Fellow, Cohort 2015

2

Factors affecting virological

non-suppression

Scanty info about centralized viral load

monitoring in resource-limited settings

Measure amount of HIV present in blood

Viral load testing improves monitoring of patients’

response to HIV therapy

Little info on non-suppression rates among ART

patients

Factors contributing to virological non-suppression

not well documented

3


non-suppression

Viral load guidelines in Uganda

Done 6 months after ART

initiation

Suppressed Detectable viraemia

Targeted adherence

support:6 months Repeat test annually

Confirm test Not Suppressed

Treatment failure

Switch 2nd line

4


non-suppression

Objectives

To estimate proportion of patients with virological

non-suppression

To identify factors associated with virological non-

suppression

5


non-suppression

Central viral load data analyzed

Data on ART patients extracted from viral load central

database

Extracted data on social demographic, clinical

characteristics and viral load testing results

Used logistic regression to identify factors associated

with virological non-suppression

6


non-suppression

Definition of virological non-suppression

For plasma: ≥1000 copies of viral RNA/ml blood

For dry blood spots: ≥5000 copies of viral RNA/ml

7


non-suppression

Socio-demographic and clinical characteristics,

N=100678

56

26

18

68

32

76

10

8

4

2

0 20 40 60 80 100

Age category

35+

25-34

0-24

Gender

Female

Male

Ident. for treat initiation

CD4<500

Child under 15

PMTCT/Option B+

TB infection

Other

8


non-suppression

Socio-demographic and clinical characteristics,

N=100678

88.3

10.4

1.3

95

6

0.1

7

3

1

0 20 40 60 80 100

ARV adherence

Good >95%

Fair 85-95%

<85%

Treatment line

First line

Second line

Third line

Breast feeding

Pregnant

Active TB

9


non-suppression

Males had slightly higher non-suppression rate

0

2

4

6

8

10

12

14

16

18

20

Female Male

Overall

non-suppression

rate

10


non-suppression

Children 0-4 and 15-19 years had the highest

non-suppression rate

0

5

10

15

20

25

30

35

0 10 20 30 40 50 60No

n s

up

pre

ss

ion

ra

te (

%)

Age

Overall non-suppression rate

11


non-suppression

Breast feeding and pregnant mothers had the

lowest non-suppression rates

0

2

4

6

8

10

12

14

Breast feeding Pregnant

No

n-s

up

pre

ssio

n r

ate

(%

)

Over all non-suppression rate

12


non-suppression

Gradual increase in virological non-suppression

observed with advancement in treatment line

0

5

10

15

20

25

First Second Third

No

n-s

up

pre

ssio

n r

ate

(%

)

Treatment line


13


non-suppression

Non-suppression rate highest among patients

with reported adherence <85%

0

5

10

15

20

25

30

35

40

<85% 85-94% >95%

No

n-s

up

pre

ssio

n r

ate

(%

)

Reported adherence level

Over all non suppression rate

14


non-suppression

Re-testers (2nd time testers) had the highest


0

10

20

30

40

50

60

No Yes

No

n-s

up

pre

ssio

n r

ate

(%

)

Re-testers(2nd time testers)


15


non-suppression

Suspected treatment failure contributed a

bigger % of non-suppressors

0

5

10

15

20

25

30

35

No Yes

No

n-s

up

pre

ssio

n r

ate

(%

)

Suspected treatment failure


16


non-suppression

Referral hospitals had the highest


0 5 10 15 20

NRH

RRH

Mulago NRH

Specialized HIV Services

HCIII & HCII

HCIV

General hospital

Non-suppression rate (%)

Healt

h facil

ity level

Over all

non-suppression

rate

17


non-suppression

West Nile and Eastern regions had the highest


0 10 20 30 40 50 60

West Nile

Eastern

Western

Karamoja

North

Eastcentral

Central 2

Kampala

Southwestern

Central 1

Non-suppression rate (%)

Hea

lth

reg

ion


18


non-suppression

Non-suppression rate for patients with active

TB was almost twice that of general population

0

5

10

15

20

25

Yes No

No

n-s

up

pre

ssio

n r

ate

(%

)

Having active TB


19


non-suppression

Second timer testers & 0-19 were most at risk of

being virologically non-suppressed

Variable Not suppressed (%) AOR 95%CI

2nd time testers

No 10 - -

Yes 50 7.0 (6.2-7.9)

Age category

35+ 7 - -

34-30 10 1.5 (1.4-1.6)

29-25 11 1.7 (1.5-1.8)

24-20 16 2.3 (2.1-2.6)

19-15 27 4.1 (3.7-4.5)

14-10 23 3.5 (3.2-3.8)

9-5 23 3.6 (3.3-4.0)

4-0 29 5.3 (4.8-6.0)

20


non-suppression

Suspected treatment failures, <85% adherence

were also more likely to be non-suppressed


ARV adherence

>95% 10

85-94% 16 1.5 (1.4-1.6)

<85% 35 3.4 (3.0-3.9)

Suspected treat. fail

No 10

Yes 29 4.0 (3.7-4.4)

Treatment line

First line 11

Second line 13 0.85 (0.78-0.93)

Third line 22 1.5 (0.63-3.4)

Gender

Female 10

Male 13 1.2 (1.2-1.3)

21


non-suppression

Patients with active TB were also more likely to

be non-suppressed


Active TB

No 11

Yes 20 1.8 (1.5-2.3)

Health Region

Central 2 12

Central 1 8 0.72 (0.64-0.81)

Kampala 11 1.1 (1.0-1.2)

Western 17 1.4 (1.2-1.7)

Southwestern 10 0.77 (0.66-0.90)

Eastern 23 1.8 (1.5-2.2)

Eastcentral 13 1.5 (1.2-1.8)

Karamoja 15 1.7 (1.2-2.3)

North 14 1.3 (1.1-1.6)

West Nile 49 2.8 (1.2-7.0)

22


non-suppression

Breast feeding and pregnant mothers were

less likely to be virologically non-suppressed


Breast feeding

No 11 1.0

Yes 6 0.61 (0.54-0.69)

Pregnant

No 11 1.0

Yes 8 0.77 (0.65-0.91)

23


non-suppression

Summary: population groups with high

non-suppression rates

2nd time testers

Young age

Suspected treatment failure

Advancement in treatment regimen

Active TB

Poor adherence

24


non-suppression

Limitations and strengths

Limitations:

Incomplete and missing data

Programmatic data collected from health facilities

Strengths:

Relatively large sample size used

Cut-off used is different and higher compared to

other studies in resource-limited settings

25


non-suppression

Conclusions

Second time testers: biggest proportion of non-

suppressors and most at risk for non-suppression.

Children and adolescents (0-19) significantly

associated virological non-suppression

TB co-infection significantly associated with

non-suppression

26


non-suppression

Recommendations

Close follow up and targeted adherence for 2nd time

testers, children and adolescents

ART clinics should adhere to the standard

guidelines for managing TB/HIV co-infections

Public Health Fellowship Program – Field Epidemiology Track

Acknowledgements

•

Host institution: CPHL

PHFP-FET secretariat

Christine Kihembo, Fred

Nsubuga & Pande Gerald

Dr. Ario Alex Riolexus,

Joseph Matovu, Daniel Kadobera

& Dr. Bao-Ping Zhu

Mentors

Isaac Ssewanyana, Charles

Kiyaga, Atek Kagirita,

Dr. Henry Kajumbula &

Aisu Stephen

Dr. Victoria Nankabirwa

factors affecting virological non-suppression among

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