Academic journal article Bulletin of the World Health Organization

Viral Suppression after 12 Months of Antiretroviral Therapy in Low- and Middle-Income Countries: A Systematic review/Suppression Virale Apres 12 Mois De Traitement Antiretroviral Dans Les Pays a Revenu Faible et Intermediaire: Bilan systematique/Supresion Viral Tras 12 Mesas De Terapia Con Antiretrovirales En Paises De Renta Baja Y Media: Una Revision Sistematica

Academic journal article Bulletin of the World Health Organization

Viral Suppression after 12 Months of Antiretroviral Therapy in Low- and Middle-Income Countries: A Systematic review/Suppression Virale Apres 12 Mois De Traitement Antiretroviral Dans Les Pays a Revenu Faible et Intermediaire: Bilan systematique/Supresion Viral Tras 12 Mesas De Terapia Con Antiretrovirales En Paises De Renta Baja Y Media: Una Revision Sistematica

Article excerpt

Introduction

At the end of 2011, over 8 million people in low- and middle-income countries (LMICs) were receiving antiretroviral therapy (ART). (1) The guidelines of the World Health Organization (WHO) for the treatment of human immunodeficiency virus (HIV) infection recommend that, where possible, the viral loads of individuals receiving ART be measured every o months to detect viral replication and confirm treatment failure whenever it occurs. (2) Although viral load tests are currently too costly for routine use in many LMICs, the potential for increased access to such tests exists as costs decrease and countries prioritize this method of patient monitoring. (3)

WHO's guidelines for the treatment of HIV infection recommend that a viral load of > 5000 copies of viral ribonucleic acid (RNA) per ml be taken as indicative of virological failure. (2) According to WHO's strategy for the surveillance and monitoring of HIV drug resistance in LMICs, a viral load of < 1000 RNA copies per ml should be taken as evidence of viral suppression. (4) Guidelines for the treatment of HIV infection in high-income countries stipulate that a viral load of < 50 RNA copies per ml--or a load below the limit of detection of the most sensitive assay available--be taken as evidence of viral suppression, (5-7) and that a load of [greater than or equal to] 50 RNA copies per ml, (5,7) or one of [greater than or equal to] 200 viral RNA copies per ml confirmed by repeat testing, (6) be used as evidence of virological failure or rebound.

The proportion of a study cohort showing viral suppression is calculated as the number of patients with viral suppression divided either by the number of patients in the study cohort who began ART (i.e. the intention-to-treat population), or by the number of patients in the cohort who are alive and on treatment (i.e. the on-treatment population). On-treatment analyses reflect the effectiveness of ART for those receiving antiretroviral drugs. Intention-to-treat analyses, which use a denominator that includes individuals who die or are lost to follow-up during the study period, reflect factors at the individual or programme level that influence the risk of death and disengagement from care. Relatively high mortality in the first 6 to 12 months of ART and substantial loss to follow-up, both of which have been widely reported in LMICs, can therefore influence estimates of viral suppression based on intention to treat. (8,9)

Summary estimates of viral suppression (as measured, for example, 12 months after ART initiation) are needed to guide ART programme managers on the normative levels of population-level viral suppression and to define desirable levels of clinic and programme performance. Such estimates are also useful when creating and improving mathematical models of the different strategies that might be followed to provide ART in LMICs. Recent reviews of virological outcomes have focused on sub-Saharan Africa and levels of acquired resistance to antiretroviral drugs. (10,11) Across LMICs, summary estimates of viral suppression based on different HIV-RNA thresholds are lacking. The objective of this systematic review was to establish estimates, based on different viral RNA thresholds, of the percentages of the intention-to-treat and on-treatment populations in LMICs that show viral suppression 12 months after ART initiation.

Methods

Study selection

We included publications ("papers") or conference abstracts that reported the proportion of individuals in a study cohort from an LMIC for whom a virological outcome after 12 months of ART was reported, either as a primary or a secondary finding. If only the median duration of follow-up was reported for a study, that study was included in the review provided the median duration was between 9 and 15 months. Any definition of viral suppression (or failure) reporting a proportion of patients below (or above) a defined viral RNA threshold was accepted. …

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