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Global estimates of viral suppression in children and adolescents and adults on antiretroviral therapy adjusted for missing viral load measurements: a multiregional, retrospective cohort study in 31 countries

Han WM 1 , Law MG 2 , Egger M 3 , Wools-Kaloustian K 4 , Moore R 5 , McGowan C 6 Show all authors , Kumarasamy N 7 , Desmonde S 8 , Edmonds A 9 , Davies MA 10 , Yiannoutsos C 11 , Althoff KN 12 , Cortes CP 13 , Mohamed TJ 14 , Jaquet A 15 , Anastos K 16 , Euvrard J 10 , Castelnuovo B 17 , Salters K 18 , Coelho LE 19 , Ekouevi DK 20 , Eley B 21 , Diero L 22 , Zaniewski E 23 , Ford N 24 , Sohn AH 25 , Kariminia A 2 , IeDEA collaboration

Affiliations 

  • 1 The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia; HIV-NAT, Thai Red Cross AIDS Research Centre, Bangkok, Thailand. Electronic address: wmhan@kirby.unsw.edu.au
  • 2 The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
  • 3 Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland; Center for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
  • 4 Department of Medicine, Indiana University, Indianapolis, IN, USA
  • 5 School of Medicine, Johns Hopkins University, Baltimore, MD, USA
  • 6 Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA
  • 7 Chennai Antiviral Research and Treatment Clinical Research Site, The Voluntary Health Services, Chennai, India
  • 8 INSERM U1027, Toulouse III University, Toulouse, France
  • 9 Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
  • 10 Center for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
  • 11 RM Fairbanks School of Public Health, Indiana University, Indianapolis, IN, USA
  • 12 Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
  • 13 Fundación Arriaran-Facultad de Medicina Universidad de Chile, Santiago, Chile
  • 14 Pediatric Institute, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
  • 15 University of Bordeaux, Inserm, French National Research Institute for Sustainable Development, UMR 1219, Bordeaux, France
  • 16 Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
  • 17 Infectious Diseases Institute, Makerere University, Kampala, Uganda
  • 18 British Columbia Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada
  • 19 Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
  • 20 Program PAC-CI, Abidjan, Côte d'Ivoire; Bordeaux Population Health (UMR1219), Bordeaux, France
  • 21 Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
  • 22 Department of Medicine, Moi University School of Medicine and Moi Teaching and Referral Hospital, Eldoret, Kenya
  • 23 Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
  • 24 Center for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa; HIV/AIDS Department and Global Hepatitis Program, WHO, Geneva, Switzerland
  • 25 TREAT Asia/amfAR, The Foundation for AIDS Research, Bangkok, Thailand
Lancet HIV, 2021 Dec;8(12):e766-e775.
PMID: 34856180 DOI: 10.1016/S2352-3018(21)00265-4

Abstract

BACKGROUND: As countries move towards the UNAIDS's 95-95-95 targets and with strong evidence that undetectable equals untransmittable, it is increasingly important to assess whether those with HIV who are receiving antiretroviral therapy (ART) achieve viral suppression. We estimated the proportions of children and adolescents and adults with viral suppression at 1, 2, and 3 years after initiating ART.

METHODS: In this retrospective cohort study, seven regional cohorts from the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium contributed data from individuals initiating ART between Jan 1, 2010, and Dec 31, 2019, at 148 sites in 31 countries with annual viral load monitoring. Only people with HIV who started ART after the time a site started routine viral load monitoring were included. Data up to March 31, 2020, were analysed. We estimated the proportions of children and adolescents (aged <18 years at ART initiation) and adults (aged ≥18 years at ART initiation) with viral suppression (viral load <1000 copies per mL) at 1, 2, and 3 years after ART initiation using an intention-to-treat approach and an adjusted approach that accounted for missing viral load measurements.

FINDINGS: 21 594 children and adolescents (11 812 [55%] female, 9782 [45%] male) from 106 sites in 22 countries and 255 662 adults (163 831 [64%] female, 91 831 [36%] male) from 143 sites in 30 countries were included. Using the intention-to-treat approach, the proportion of children and adolescents with viral suppression was 7303 (36%) of 20 478 at 1 year, 5709 (30%) of 19 135 at 2 years, and 4287 (24%) of 17 589 at 3 years after ART initiation; the proportion of adults with viral suppression was 106 541 (44%) of 240 600 at 1 year, 79 141 (36%) of 220 925 at 2 years, and 57 970 (29%) of 201 124 at 3 years after ART initiation. After adjusting for missing viral load measurements among those who transferred, were lost to follow-up, or who were in follow-up without viral load testing, the proportion of children and adolescents with viral suppression was 12 048 (64% [plausible range 43-81]) of 18 835 at 1 year, 10 796 (62% [41-77]) of 17 553 at 2 years, and 9177 (59% [38-91]) of 15 667 at 3 years after ART initiation; the proportion of adults with viral suppression was 176 964 (79% [53-80]) of 225 418 at 1 year, 145 552 (72% [48-79]) of 201 238 at 2 years, and 115 260 (65% [43-69]) of 178 458 at 3 years after ART initiation.

INTERPRETATION: Although adults with HIV are approaching the global target of 95% viral suppression, progress among children and adolescents is much slower. Substantial efforts are still needed to reach the viral suppression target for children and adolescents.

FUNDING: US National Institutes of Health.

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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