Targeted adherence measures and viral load monitoring needed to improve retention in South African ART programme

Of the people living with HIV in South Africa who are eligible to start antiretroviral therapy (ART), only 57% are in care and only 37% of the 2012/2013 cohort of people receiving ART were given a viral load test, according to new results announced by the CEO of the South African National AIDS Council (SANAC) at the Southern African HIV Clinicians Society Conference held in Cape Town, South Africa, last month.

The session on viral load monitoring, adherence and retention in care was hosted by the South African activism organisations Treatment Action Campaign (TAC) and Section 27’s (formerly known as the AIDS Law Project) magazine called the NSP Review which tracks and monitors the implementation of South Africa’s National Strategic Plan on HIV, STIs and TB 2012-2015 (NSP).

South Africa’s ART programme is the largest in the world in terms of absolute numbers, with 2.3 million people being initiated on ART by the end of 2012 (and 200,000 people being enrolled on ART in the private sector). Between April 2011 and March 2012 (2011/2012) 558,085 people had been enrolled in care, which increased to 612,137 people in the following year (2012/2013).

According to the SANAC data, 72 to 75% of people initiated on ART remained in care after 12 months and 42 to 64% remained in care after five years. South Africa’s overall retention in care was 60%. The UNAIDS target for retention in care is 90% after 12 months and 70% after five years.

Data on viral load monitoring were not provided for any years other than 2012/2013, but of those who did receive viral load monitoring, 77% were virally suppressed after 12 months on treatment and 74% after five years.

Dr Francesca Conradie, president of the Southern African HIV Clinicians Society argued that there was a clinical need for viral load testing, as it is the best measure of adherence. According to the South African ART guidelines, the first viral load test after ART initiation should be done at six months, by which stage viral suppression should have been reached.

The latest World Health Organization HIV treatment guidelines call for people to receive a viral load test once a year to ensure their treatment is working, and to identify those people who are either on failing treatment, and must be switched to different drugs, or need extra adherence support to get back on track. Viral load testing confirms the level of HIV in a person’s blood, rather than CD4 cell monitoring which assesses the number of white blood cells that organise the immune system’s response to infections.

Viral load is more accurate in detecting a person’s response to ART than CD4 testing, which is commonly used today. Viral load testing can also prevent people from being unnecessarily switched to more expensive second-line medicines, by determining whether a CD4 cell decline is due to a rebound in viral load.

According to the South African ART guidelines, a follow-up viral load test should be conducted at 12 months and again every 12 months. “The problem is that clinicians and nurses are not ordering viral load tests. We need to retrain our healthcare staff to ignore CD4 cell count tests to determine when people should start ART or as a measure of how they are responding to treatment,” said Dr Conradie.

According to Dr Conradie, the most common reason why a person may not have reached viral suppression is due to non-adherence to treatment. “When a patient has not reached viral suppression at six months, this is the best opportunity to provide counselling to the patient and to address any side-effects they may be experiencing which may be deterring them from adhering to treatment. Detectable viral loads need to be addressed immediately with the patient as an indicator that there are problems with adherence.”

Dr Eric Goemaere, the HIV/TB Coordinator at the Southern African Medical Unit at Médicines Sans Frontières (MSF/Doctors Without Borders), echoed Dr Conradie’s sentiment, stating that MSF has been campaigning for CD4 monitoring to be replaced by viral load monitoring in all low-income settings.

A 2012 MSF survey of 23 resource-limited countries showed that while virtually all countries included viral load monitoring in their treatment guidelines, it was available in only four. Another MSF study examined the first-ever viral load test among adults on ART in Kenya, Malawi and Zimbabwe when they were starting to implement viral load monitoring. The study found that among people who were suspected of being on failing treatment based on clinical signs or CD4 testing alone, only 30% actually had an elevated viral load. This means that 70% of people could have been switched unnecessarily to second-line treatment if viral load had not subsequently been used to confirm treatment failure.

MSF also presented their adherence and retention strategies in a plenary session at the conference. These include fast-tracking ART initiation without compromising adherence preparation and strengthening the support given to the patient after ART initiation. An analysis of this approach showed that speeding up the process of ART initiation had no impact on short-term retention in care (HR: 1.11 for fast track initiation compared to standard procedure; 95%CI: 0.95-1.30).

MSF also implements ART adherence clubs for 27,800 patients who have remained in care at ART sites in Khayelitsha, a large township outside of Cape Town. At these clubs, patients receive two months of treatment, undergo a quick clinical assessment and a quick optimised peer support session, which is led by lay workers and supported by nurses who provide immediate referral support, blood investigations and annual check-ups and re-scripting of ART.

MSF also implements an 'at risk of treatment failure' intervention where patients who have not reached virological suppression are flagged and enrolled in a structured adherence-focused support group. Integrated clinical and adherence consultations are conducted by a nurse for all patients with two high viral load test results. An analysis of 722 patients who entered this programme (69% of whom entered on first-line ART) showed that 32% resuppressed viral load on first-line ART, 52% resuppressed on second-line ART and that 78% resuppressed following being switched from first- to second-line ART.

“We need to focus far more on our strategies for assisting people to adhere across the public sector if we are to address problems with adherence. These approaches need to be patient-friendly and the need to keep one's viral load undetectable is what we need to emphasise with patients,” said Dr Goemaere.