Alternative methodological approaches to assess longterm HIV virological and clinical outcomes in resource limited settings

We have achieved a significant progress in increasing access to HIV care which resulted in declining HIV mortality. Of 38 million people living with HIV (PLHIV), 62% were receiving antiretroviral treatment (ART) by the end of 2018 (1). There is a global commitment to reach “95-95-95” targets and to end the AIDS epidemic by 2030 (2). However, the gaps to reach the last “95” of the UNAIDS fast track targets are still large. Scale up of access to routine HIV viral load (HIV VL) testing in resource limited settings has been suboptimal due to cost and complexity of HIV VL testing, but also due to lack of awareness among the health care providers and patients about the benefits of regular virological monitoring (3). The UNAIDS reports rates of virological suppression among PLHIV that vary from 58% (50-66%) in East and Southern African region to only 27% (15-44%) among PLHIV in the Middle East and North Africa in 2018 (1). Monitoring of patients on ART and management of treatment failures encounters multiple challenges (4). In 2017 only < 5% of the global ART cohort was receiving second line antiretroviral treatment (ART) (5). The needs for treatment beyond the first line ART are increasing and it has been estimated that by 2030, 4-6 million people could receive second line ART globally (6). Since 2001 Médecins Sans Frontières (MSF) provides a comprehensive package of HIV care in Myanmar and during this period of time MSF has implemented various innovative approaches to care delivery and adaptations of treatment guidelines. Studies of this PhD project will use the data from the MSF Myanmar HIV cohort consisting of more than 50,000 PLHIV receiving HIV treatment in the period from January 2001 until December 2019. The primary objective of the PhD project is to study the outcomes of patients on antiretroviral treatment in longer-term cohort. We will assess factors that predict unfavourable treatment outcomes among people living with HIV who are receiving antiretroviral treatment. We will demonstrate how different indicators are useful when analysing cohort data in the future, now that many cohorts in RLS have patients who are more than 10 years on treatment. The project aims to accomplish the main objective by: 1. describing burden of advanced HIV disease among PLHIV who reengage with HIV care and to investigate risk factors for attrition after reengagement, 2. assessing how history of disengagement and re-engagement from HIV care predicts virological failure among PLHIV on first line ART, 3. reporting virological treatment outcomes as total supressed time while being on second line ART and assessing predictors of unfavourable treatment outcomes in this cohort and by 4. assessing association of low viremia with unfavourable treatment outcomes (mortality, virological failure). By combining the results of specific objectives, we foresee that we can obtain knowledge on additional indicators and alternative methodologies that we should use when approaching long-term evaluation of HIV cohorts. Findings from the studies related to this PhD project will contribute in the development of future recommendations for the management of patients on HIV treatment in resource limited settings with the special focus on management of virological outcomes.

Trefwoorden:B780-tropische-geneeskunde