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A targeted approach for routine viral load monitoring in Malawian adults on antiretroviral therapy
Author(s) -
Mungwira Randy G.,
Divala Titus H.,
Nyirenda Osward M.,
Kanjala Maxwell,
Muwalo Francis,
Mkandawire Felix A.,
Choko Augustine,
Taylor Terrie E.,
Mallewa Jane,
Oosterhout Joep J.,
Laufer Miriam K.,
Laurens Matthew B.
Publication year - 2018
Publication title -
tropical medicine and international health
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.056
H-Index - 114
eISSN - 1365-3156
pISSN - 1360-2276
DOI - 10.1111/tmi.13047
Subject(s) - medicine , viral load , antiretroviral therapy , receiver operating characteristic , pediatrics , human immunodeficiency virus (hiv) , immunology
Abstract Objectives WHO recommends HIV viral load ( VL ) testing 6 months after antiretroviral therapy ( ART ) initiation and every 12 months thereafter, but cost prohibits routine, universal VL testing in many developing countries. We sought to devise a targeted approach to routine VL monitoring that could reduce cost and identify those at low risk for virologic failure ( VF ). Methods We analysed screening data from a clinical trial enrolling adults on ART in Malawi. We identified risk factors associated with VF and employed the Knill–Jones method to assign summary score identifying persons at lower risk for VF . Results Among 957 adults, prevalence of VF was 9.4%. Factors independently associated with VF included age <38 years ( OR 3.44, 95% CI 2.01–5.89), ART duration >2.5 years ( OR 2.98, 95% CI 1.79–4.96), ART adherence <95% ( OR 1.76, 95% CI 1.06–2.94), CD 4 count <200 cells/μl ( OR 5.94, 95% CI 3.27–10.78), haemoglobin <13 g/dl ( OR 2.76, 95% CI 1.70–4.50) and CD 8 count >885 cells/μl ( OR 2.10, 95% CI 1.28–3.44). Our VF prediction summary score included all factors above except CD 8 count and was fairly accurate with validated area under receiver operating characteristic curve of 0.76. Implementation could reduce VL testing by 65%. Conclusion A simple score incorporating age, ART duration and adherence, and CD 4 count can accurately identify adults at low risk for VF in a sub‐Saharan African setting. In areas with high ART utilisation and limited VL testing capacity, a targeted approach could optimise routine VL monitoring while identifying adults in need of alternate ART regimens.