Virological Breakthrough : A Risk Factor for Loss to Followup in a Large Community-Based Cohort on Antiretroviral Therapy

Abstract EN

Background.

We have previously shown that 75% of individuals on antiretroviral therapy (ART) in a resource-limited setting who experienced virological breakthrough to >1000 copies/mL were resuppressed after an intensive adherence intervention.

This study examines the long-term outcomes of this group in order to understand the impact of the adherence intervention over time.

Methods.

ART-naïve adults commencing ART between September 2002 and December 2009 were reviewed.

Those who achieved suppression (<50 copies/mL) were categorised by subsequent viral load: any >1000 copies/mL (virological breakthrough) or not.

Those with breakthrough were sub-categorised by following viral load into failed (VL > 1000 copies/mL) or resuppressed (VL < 1000 copies/mL).

Their outcome (lost-to follow-up, death, in care on first-line therapy or in care on second-line therapy) was determined as of the 13th April 2010.

Findings.

4047 ART-naïve adults commenced ART.

3086 had >2 viral loads and were included in the analysis.

2959 achieved virological suppression (96%).

Thereafter 2109 (71%) remained suppressed and 850 (29%) experienced breakthrough (n=283 (33%) failed and n=567 (67%) resuppressed).

Individuals with breakthrough were younger (P<.001), had lower CD4 counts (P<.001), and higher viral loads (P<.001) than those who remained suppressed.

By 7 years the risk of breakthrough was 42% and of failure 15%.

Fewer adults with breakthrough remain in care over time (P<.001).

Loss to care is similar whether the individuals failed or resuppressed.

Interpretation.

While 67% of those who experience initial virological breakthrough resuppress after an adherence intervention, these individuals are significantly less likely be retained in care than those who remain virologically suppressed throughout.