Towards 95% Viral Suppression: Targeting HIV Drug Resistance, Adherence to Therapy, and Access to Care in Southern and East Africa

In 2015, the Joint United Nations Programme on HIV/AIDS (UNAIDS) set the ambitious ‘90-90-90’ targets with the aim that by 2020, 90% of people living with HIV should know their status, 90% of those who know that they have HIV should receive antiretroviral therapy (ART), and 90% of those receiving ART should achieve viral suppression. Success along this care cascade prevents HIV-related infections and progression to AIDS, leads to a life expectancy similar to that of people who do not have HIV, and prevents the onward transmission of HIV. Globally, these targets were narrowly missed at 84-87-90. To get back on track towards ending the epidemic by 2030, the target was raised to ‘95-95-95’ by 2025.
This thesis aims to address the ‘third 95’ – viral suppression – in southern and eastern Africa, with projects conducted in Lesotho and Tanzania. The projects presented here address outcomes along each step of the ‘viral load cascade’: among people receiving ART, the detection of an unsuppressed viral load triggers adherence counselling, repeat viral load testing, and possibly switching to a different ART regimen. Particular consideration is given to children and adolescents, who are at a heightened risk for poor treatment outcomes. In line with the major underlying causes of viraemia among people receiving ART, viral resistance, adherence to therapy, as well as access to healthcare – including appropriate diagnostic services and antiretrovirals – are crosscutting themes.
Some of the studies address ART provision: how does the timing of ART initiation affect long-term engagement in care and viral suppression; and how does the roll-out of new drug regimens impact viral suppression or adverse effects? Other studies question the algorithms that guide the management of viraemia: what threshold should be used to define viraemia; does the requirement for adherence counselling before switching ART facilitate the emergence (further) resistance; and, crucially, under what circumstances is resistance testing clinically beneficial, and how can it be implemented in resource-limited settings? Finally, we assess outcomes along the entire viral load cascade among children living with HIV.
All projects aim to inform clinical guidelines, country programmes, and healthcare implementers in order to contribute to improved care for people living with HIV in and beyond the project countries.