Faculty of Health Sciences (ETDs)
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Item Virological response in children and adolescents switching to dolutegravir based regimens in Johannesburg, South Africa – A Longitudinal Cohort Study(University of the Witwatersrand, Johannesburg, 2023) Mafora, Tshiamo; Technau, KarlIntroduction: Dolutegravir (DTG) was introduced into South African HIV management guidelines in November 2019, and has since been the mainstay of both adult and paediatric first line antiretroviral treatment (ART) regimens. Following its rapid and widespread introduction we assessed the rate of virological suppression over two years in paediatric patients switching to DTG as part of first line treatment. Methods: We performed a retrospective cohort study at Rahima Moosa Mother and Child Hospital in Johannesburg, South Africa. Children and adolescents already on first line ART who switched to DTG (between November 2019 and November 2021) were included. Baseline characteristics (at DTG switch) included age, weight, gender, viral load (VL), CD4, and pre-switch regimen. Past ART exposure and past viraemic periods (years VL >1000 copies/ml) were assessed and VL suppression rates (< 50 copies/ml) were calculated at 6, 12 and 24 months post-switch. Associations with non-suppression were assessed using uni- and multivariate analysis. Results: Of the 747 participants that were switched to DTG, 724 (97%) qualified for a VL and 697 (96%) of those had at least one VL done after switch. Overall, 83% (450/543) were suppressed at 6 months, 86% (434/504) at 12, 91% (487/534) at 24 months. Overall, at a median of 637 days after switch, 90% (624/697) were suppressed at their last VL. Factors associated with not being suppressed at the last VL included: missing a follow-up visit by more than 90 days post-switch to DTG (OR: 3.2 [CI:1.5-6.8], p=0.003), switching to DTG with a VL of 50-1000 rather than <50 copies/ml (OR 2.0 [CI:1.1-3.9], p=0.042), having the blood test done during July December (OR 2.0 [CI:1.2-3.4], p=0.011), and having had exposure to viraemia ≥1000 copies/ml for more than two years between first ART start and DTG switch (OR: 1.9 [CI: 0.9-3.7], p=0.071). Conclusion: In our population, similar to other studies, VL suppression was effectively maintained in the majority of patients after switching to DTG. The switch did however result in a loss of suppression in some patients and caution is needed in children and adolescents with missed visits and extensive prior viraemiaItem Routine laboratory and clinical monitoring of HIV-positive pregnant women on antiretroviral therapy(2024) Khulu, Kwano Mahlako KgweranoBackground Developments in South Africa’s prevention of mother-to-child transmission of HIV (PMTCT) programme show a decline in AIDS-related paediatric deaths. In 2015, PMTCT guidelines were updated, with revised protocols for clinical and laboratory monitoring for patients on antiretroviral therapy (ART). The aim of this study was to assess adherence to monitoring guidelines for HIV-positive pregnant women on ART. Methods This was a clinical audit of 185 HIV-positive pregnant women, on pre-pregnancy ART, or initiated during the index pregnancy and delivered at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) in the period January to June 2017. Data were collected on timing of HIV diagnosis and ART initiation, clinical and laboratory monitoring, and initiation of prophylaxis for opportunistic infections. Results Of the 185 patients, 64.9% (120/185) were known with HIV infection prior to the index pregnancy, and 85.8% (103/120) were initiated on ART pre-pregnancy, with 64/103 (62.1%) virally suppressed (<50 copies/ml)d t baseline. Overall, 179/185 women accessed antenatal care. A total of 82 patients were initiated on ART in the index pregnancy, and of these 60/82 (73.2%) had a 3-month viral load done, and 22/82 (26.8%) were suppressed. A total of 153/185 (82.7%) patients had CD4 counts done, and of these, 63/153 (41.2%) were ≤350 cells/dl, with 7/63 (11.1%) patients receiving cotrimoxazole prophylaxis. Tuberculosis (TB) screening was documented for 35/179 (19.6%) patients, with 6/35 (17.1%) receiving TB preventative therapy. Birth HIV PCR tests were available for 175/185 (94.6%) neonates, and all were negative. Conclusion There were gaps identified in laboratory and clinical monitoring. ART initiation was however high, with no cases of MTCT reported.Item Revalence and factors associated with virological nonsuppression amongst HIV positive pregnant and lactating adult women in the Kingdom of Eswatini in 2016-2017(2024) Ndlangamandla, MpumeleloAntiretroviral treatment (ART) is the primary intervention for preventing mother to child transmission of HIV service package. The likelihood of vertical transmission of HIV can be drastically reduced by using ART. The World Health Organization (WHO) recommends ART initiation in pregnant and lactating women living with HIV regardless of WHO clinical staging and thereafter to continue combination Antiretroviral Therapy (cART) for life. There are some challenges in implementing the WHO recommendations in settings where many women cannot attend antenatal care services due to social or economic barriers or structural barriers and even fewer women attend postnatal care services. The objectives of this study are to determine the prevalence of virological non-suppression among pregnant and lactating women living with HIV, to quantify the association between self-reported ART use and virological non-suppression and determine socio-demographic, clinical and behavioural characteristics associated with virological non-suppression among pregnant and lactating women living with HIV. This is a cross-sectional study using secondary data from the Swaziland HIV Incidence Survey. The primary study was a population-based survey which was nationally representative, using a cross-sectional study design conducted in 2016-2017 in the Kingdom of Eswatini employing a two-stage stratified cluster sample design. This study sample included adult women living with HIV who were either pregnant or lactating at the time of the survey. Data analysis was conducted using Stata 17. The data analysis made use of sampling weights and clustering of individuals within each enumeration area using weighted clustered logistic regression survey analysis commands in Stata. A total of 195 adult women living with HIV were included in the survey with a median age of 28 years old. Among the women, 104 (54.4%) were either married or cohabiting with someone, and 151 (71.9%) were living in a rural setting. Only 77 (38.8%) had attained primary education as their highest level of education while 122 (63.8%) were lactating. A total of 120 (62%) reported being on ARVs and 158 (81.8%) being virally suppressed. The overall virological non-suppression prevalence of 36.8% was higher than the UNAIDS target of 10% by 2020 to speed up HIV elimination. In a multivariable analysis, two risk factors remained statistically significant. Women who were aged 17 to 24 years old were almost five times more likely to be virologically non-suppressed (aOR=4.7, 95% CI 1.8 - 11.8, p=0.001) while women who did not report ARV use during pregnancy were eight times more likely to have virological non- RESEARCH REPORT (COMH7060) 320775 IV suppression (aOR=8.1, 95% CI 3.0 - 21.8, p<0.001). Maternal age was dichotomised with the younger group compared to the older group (17-24 years, vs 25+ years). An additional analysis excluding self-reported ARV use at pregnancy found that virological non-suppression was associated with maternal age (OR=5.5, 95% CI 2.3 – 13.7, p<0.001) and number of sexual partners in the previous 12 months (OR=7.9, 95% CI 1.6 – 40.5, p=0.013). Maternal age was dichotomised with the younger group compared to the older group (17-24 years, vs 25+ years) The study found that virological non-suppression was associated with maternal age and ARV use at pregnancy. The additional analysis also found a strong association with maternal age and number of sexual partners the women reported having in the previoustwelve months. However, the primary study was not powered to detect differences in virological non-suppression among our population of interest. The sample size was also small, which limited the ability to investigate other possible risk factors. To help the country address the identified gaps, I would recommend the scale up of the DREAMS program and strict following of HIV guidelines to actively monitor viral load and ART uptake during pregnancy and lactation. In addition, messaging around avoidance of multiple sexual partners should be strengthened