Viral Load Testing Outcomes for Children on Nevirapine/Efavirenz Based First Line Antiretroviral Treatment at Selected Health Facilities in Western Kenya

Abstract

Access to Antiretroviral treatment (ART) has rapidly expanded in resource limited settings. Gaps however remains for children in maintaining long-term adherence to ART, and thus sustain virological suppression and prevent treatment failure. The general objective of this study was to determine viral load (VL) testing outcomes and reasons for missed opportunities for children on non-nucleoside reverse transcriptase inhibitor (NNRTI) – based first line ART regimen at selected health facilities in western Kenya.The specific objectives included to determine the proportion of HIV infected children initiated on Nevirapine or Efavirenz based first line treatment between 1st January 2010 and 31st December 2014 at selected health facilities in western Kenya who achieved viral suppression; to explore reasons for missing documentation of repeat VL tests for children with virological failure and to document proportion of children with confirmed treatment failure who had regimen switch to second line ART. The study was carried out in 46 health facilities in Western Kenya. Data was abstracted from central electronic medical records using a data abstraction guide, transferred to Microsoft excel and analyzed using Stata Version 13.1, 1985 – 2013 Stata Corp LP, USA. Individual chart reviews for those with missing repeat VL test results was done using a chart abstraction guide and data entered in excel 2013 and analyzed using descriptive statistics. Overall, out of 4,250 children, 3,118 (73.4%) had visited clinic within 90 days (active), 656 (15.4%) transferred out, 315 (7.4%) were deceased and 161 (3.8%) were lost to follow up. There was approximately 3-month and 4-month delay in ART initiation for those reported to have lost to follow up (LTFU) and deceased respectively. Of 3,432 children eligible for VL testing, based on time of implementation of routine VL testing (June 2014), 2,372 (69.1%) had VL results and 1,649 (69.5%) achieved viral suppression. This would however reduce to 63.1% if it is assumed that all those who died had not achieved viral suppression. Lower proportion of children who had exited from care had documented VL results compared with those who were active on care (29.3% versus 73.1%).The Odds of having documented VL results was higher for those who had been on ART for more than 24 months compared to those who had been on ART for less than 24 months (Adjusted odds ration [aOR] 1.7, 95% confidence interval [CI] 1.2 – 2.5) and for those initiated on ART before implementation of routine VL testing compare with those initiated after (aOR 1,6, 95% CI 1.2 – 2.1). Lower proportions of the very young (<2 yrs) and older children (>10 years) achieved viral suppression compared to age 2 – 5 and 5 – 10 years [64.6% and 63.7% versus 75.6% vs 71.9%). Likewise, lower higher proportion of children who had been on ART for less than 24 months achieved viral suppression (79.4%) compared to those on ART 24 – 60 months (67.5%) and more than 60 months (67.7%) although the difference was also not statically significant. The odds of achieving viral suppression was 1.4 times higher for children with baseline CD4 >500cells/mm3 compared to those with baseline CD <350 cells/mm3. (aOR 1.39, 95% CI 1.03 – 1.89). A higher proportion of children who started ART after implementation of routing VL testing achieved viral suppression compared to those who started ART before (82.8% versus 67.8). Of the 2,828 children who were active in care by December 2016, 2,712 (95.9%) had documented VL results out of whom 809 (29.8%) had VL >1000 copies/ml and of these, 673 (83.2%) had documented repeat VL results. In total 491 (73.0%) had repeat VL results of >1000 copies/ml out of whom 272 (55.4%) had been switched to second line ART. The median duration from date of first VL test result to switch to second line ART was 13.3 months (IQR 9.8 – 19.2). Of the 809 children with VL > 1000 copies/ml, 38.1% had been switched to second line ART without repeat VL test result and of these, 77.9% still had a follow up VL > 1000 copies/ml. Out of 112 records of children with missing repeat VL results, VL samples had been taken for 54 (48.2%) of the children and of these, 32 (59.3%) results were available at facility level but not documented in client records. In total, 49 (43.8%) had delayed sample collection and 9 (8.0%) had exited from care. Although most children achieved viral suppression, gaps in access to timely VL testing remain a challenge. Younger and older children, those on ART >24 months and those switched without repeat VL results may need additional support to achieve viral suppression.