Viral non-suppression, perceptions and effectiveness of intensive adherence counselling among people living with HIV/AIDS on antiretroviral therapy with low-level Viraemia in Uganda

Abstract

Background and significance: One of the major aspects of controlling HIV transmission is the Undetectable equals Untransmissible (U=U). This indicates that PLHIV who take ART well attain an effective and sustainable undetectable viral load, and have a low probability of transmitting HIV. Previously, Uganda was using a threshold of 1,000 copies/ml to determine HIV viral load non-suppression, as per the 2013 WHO recommendations. This resulted into an emerging public health concern of increasing PLHIV with low-level viraemia (≥50 to <1,000 copies/ml). Low-level viraemia (LLV) had previously been associated with an increased risk of HIV transmission and treatment failure. This threatened Uganda’s progress to end the HIV epidemic by 2030. In this PhD study, we set out to; a) determine the association between LLV and HIV viral non-suppression among PLHIV on ART of the period from 2016 to 2020 in Uganda; b) explore the perceptions of PLHIV on ART and healthcare providers in Uganda, about LLV and viral load testing; and c) determine the effectiveness of intensive adherence counselling (IAC) on achieving a non-detectable HIV viral load among PLHIV on ART with LLV, in Uganda. Methodology: Data from a cohort of 17,783 PLHIV followed from 2016 to 2020 in the Uganda national viral load program were analysed to determine the association between LLV and viral non-suppression using survival analysis methods namely Kaplan Meier and Cox Proportional-Hazards models. Associations were determined using median survival times and hazard ratios. To explore the perceptions about viral load testing and LLV, 32 in-depth interviews and 15 key informant interviews were conducted and analysed using thematic analysis. A cluster randomized clinical trial was conducted to determine the effectiveness of IAC on LLV management; effectiveness was assessed using risk ratios estimated with modified Poisson regression. The outcome was proportions of PLHIV with a non-detectable VL (VL < 50 copies/ml) in both groups. Results: The proportion of PLHIV with LLV in Uganda increased from 2.0% in 2016 to 8.6% in 2020 (p-value = 0.072). LLV was associated with being male, second line regimen and being < 18 years of age. Relative to clients with a non-detectable viral load, PLHIV with LLV had 4.1 times higher risk of developing viral non-suppression (adjusted hazard ratio was 4.1, 95% CI: 3.7 to 4.7, p < 0.001). Qualitative interviews showed that majority of the PLHIV were unaware about LLV, and hence did not understand its associated risks. Furthermore, majority of healthcare workers providing HIV care also lacked sufficient knowledge about LLV and therefore did not offer formal adherence counselling to manage LLV. In the interventional study, the effect of IAC on attaining a viral load non-detectable status among LLV clients was nearly twice as high in the intervention arm (57.4%), as compared to the non-intervention arm (29.9%), adj. RR=1.9 (1.0, 3.5), p=0.037. Conclusion: There were increasing proprotions of PLHIV with LLV in Uganda, and LLV was associated with a higher risk of viral non-suppression. However IAC doubled the likelihood to achieve a non-detectable VL among PLHIV with LLV. Hence there was an urgent need to review the VL algorithm, and institute interventions including IAC and sensitization of PLHIV and health workers to manage LLV in Uganda.