In its 2021 report, the UNAIDS highlighted poor treatment outcomes among adolescents. Here, we report a virological suppression rate of 88.2% among adolescents. Our experience can guide future options to improve care and treatment in this key and fragile population.
Background
The human immunodeficiency virus (HIV) remains a major public health concern, which is amplified by the difficulties in accessing essential HIV prevention, testing, and treatment services due to the COVID-19 pandemic [
1]. An estimated 37.7 million people were living with HIV (PLHIV) globally, of which about 1.75 million were adolescents aged 10 to 19, and nearly 90% of them resided in sub-Saharan Africa (SSA) [
2]. Besides, HIV is more concerning among children and adolescents, who represent only 5% of PLHIV, but 15% of AIDS-related deaths [
3].
In 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) adopted ambitious fast-track targets that is by 2020, 90% of people living with HIV know their HIV status, 90% of people who know their status receive treatment, and 90% of people on treatment have suppressed viral load (VL). Recently, this target was increased to 95% by 2025 [
4]. The majority of Sub-Saharan African countries are far from achieving the 95-95-95 targets by 2025, only Botswana has achieved all three targets so far in SSA [
5]. In December 2021, the scorecard finds that countries in the African region reported 77% of PLHIV are on antiretroviral therapy and 68% have suppressed VL globally [
1]. Global data show huge disparities in achieving UNAIDS targets between countries and age groups, especially among adolescents who are still lagging behind in accessing ART [
6] and achieving viral suppression (VS) compared to adults [
7]. Indeed, only 55% of the estimated 1.75 million HIV-infected adolescents received ART in 2020, with the lowest treatment coverage in West and Central Africa (43%) [
6]. However, data about the extent to which adolescents are affected in sub-Saharan Africa are limited. Understanding the magnitude of the problem could help clinicians and policymakers tailor interventions aimed at optimizing adolescent HIV care. A multiregional and retrospective cohort study involving data from individuals initiating ART between January 1, 2010, and December 31, 2019 in 31 countries showed that, HIV-infected adults are approaching the global target of 95% VS, but progress among children and adolescents was much slower, with only 59% of them having achieved VS 3 years after ART initiation [
8].
In Cameroon, the HIV prevalence was estimated to be 3.4% in the general population [
9]. Based on the Cameroon Population-Based HIV Impact Assessment (CAMPHIA) and the 2019 AIDS impact module of the Spectrum software estimates, among 504,281 HIV-infected patients nationwide, 77% were tested for HIV infection, 62% were receiving ART and 53% achieved VS [
9,
10]. Moreover, VL monitoring remains a major challenge in Cameroon, as only 25% of the 504,281 HIV-infected patients nationwide accessed VL in 2019 [
10]. A study conducted between October 2016 and August 2017 among 1946 patients on treatment for at least 12 months and followed up mainly in the city capital of Cameroon showed that the VS rate was significantly lower in adolescents (53.3%), compared to adults (81.1%) and even children (75.8%) [
11]. A more recent study conducted in 2019, and involving 270 perinatally-infected adolescents followed up in two urban and two rural health facilities in the Center region of Cameroon reported up to 66% of VS [
12].
In this study, we prospectively assessed the rate of VS and the factors associated with virological failure (VF) in a cohort of adolescents living with HIV (ALHIV) on ART in Cameroon, followed up according to the WHO guidelines.
Discussion
In this study, we estimated the rate of VS and the factors associated with VF among HIV-1-infected adolescents followed up in the national ART Program in Cameroon according to the WHO guidelines.
Our results showed a VF rate of 11.8% in HIV-infected adolescents, i.e. virological suppression of 88.2%, close to the UNAIDS target of 95% [
4]. This low rate of VF is rarely observed compared to other studies conducted in sub-Saharan Africa, probably due to the promptness of the systematic intervention of therapeutic education to improve adherence to ART [
14‐
17]. A cross-sectional study conducted in Ethiopia in 2019, involving 9386 HIV-infected adolescents on ART for at least 6 months, reported a failure rate of 26% [
18]. Other previous studies conducted in Kenya (908 participants) and Uganda (567 participants), reported higher rates of VF, 20% and 31%, respectively [
19,
20]. The two previously mentioned studies on adolescents that found VS rates of 53.3% and 66% defined VF as a single VL ≥ 1000 copies/mL. However, in this study, the fact that VF was declared after a second VL ≥ 1000 copies/mL following therapeutic education and enhanced adherence counseling have significantly contributed to increase VS rate in our study. Indeed, the fact that up to 26 of the 57 (45.6%) ALHIV with an initial detectable VL ≥ 1000 copies/mL achieved viral suppression at re-testing is a proof that enhance adherence counseling is a critical part of the monitoring of ALHIV and must be widely implemented in our settings.
The high rate of VS observed in this study could be linked to the effort to implement differentiated health service delivery in our setting. Programs that make use of social workers, peer support and training on pediatric disclosure have reported better virological outcomes in HIV-infected children [
21] and adolescents [
22]. In our study settings, the fact that extended service hours on Wednesday (late afternoon) were offered to adolescents, along with the provision of games and television, have made clinics more adolescent-friendly and therefore improved retention in care and VS as suggested in a previous study in South Africa [
23]. Furthermore, the implementation of interventions such as keeping a list of those who had not achieved VS using a high VL register and linking each adolescent to a dedicated case manager offering social, psychological and sometimes financial support to the adolescent and his family have facilitated close monitoring of those failing ART. Although we didn’t directly assess the impact of these various interventions in our cohort of ALHIV, we assume they played a role in the achievement of VS in our study population as recently demonstrated in countries facing similar challenges [
24,
25]. Further evaluation studies are therefore needed in our context to better assess the impact of those interventions on treatment outcome, thus allowing to quickly extend their implementation to other programs with poorer VS levels.
Our study also revealed that the odd of VF was higher among ALHIV receiving a second- or third-line ART, with self-declared suboptimal adherence, and having received a previous detectable VL result ≥ 1000 copies/mL in the last 12 months. These findings are particularly concerning because it means that switching ALHIV to a second- or even third-line ART did not improve VS, probably because barriers to adherence were not sufficiently addressed before switching to other regimens. Indeed, adolescence is a period in life during which major changes occur, and HIV-infected adolescents may face issues with the diseases and ART leading to increased rates of VF when not correctly addressed [
18,
19]. A study including 12 cohorts of second-line antiretroviral treatment, representing 928 HIV-infected children and adolescents, showed that virological outcomes were 3-fold poorer among adolescents compared to children [
26]. Recent studies in South Africa [
18], Uganda [
19] and Kenya [
20] further showed that HIV-infected adolescents receiving a second-line regimen are more likely to experience VF than those on first-line ART. This could be due to the fact that second-line regimens are more complex than first-line regimens, are often twice daily regimens and have more adverse side effects than first-line regimens, hence negatively affecting adherence to ART [
18]. Considering the history of poor adherence behavior, it is also possible that in these patients, adherence problems persist even after switching to second-line ART. Therefore, it is crucial to identify and address adherence difficulties while changing ART regimen.
Our study was conducted in a particular context, since the study started almost one year after the onset of the first COVID-19 cases in Africa. Indeed, COVID-19–related stay-at-home orders have prevented patients from attending their routine visits and travel restrictions have affected essential HIV services worldwide [
27], including the provision of antiretroviral drugs and reagents for HIV testing and VL. This may partially explain why up to 27.2% (76/280) of ALHIV included in this study did not receive a VL test during the last 12 months. According to national and WHO guidelines, VL monitoring should be carried out six months after ART initiation, then at 12 months and every 12 months thereafter [
13]. Given the fact that this study was done in the health facility hosting the reference laboratory in charge of testing VL samples coming from other health facilities located in the Littoral Region of Cameroon, one can expect the situation to be worse in other regions with less access to laboratory infrastructures. In Uganda for instance, COVID-19 has led to a reduction of VL coverage from 96 to 85% between December 2019 and June 2020 [
28,
29]. Consequently, the impact of the COVID-19 pandemic on the provision of VL testing could not be excluded in our context knowing that laboratory staff members and equipment continue to be shared between the HIV and COVID-19 responses [
29].
This study has three major limitations which should be considered when interpreting the findings. Firstly, the lack of genotyping resistance testing has limited our understanding of the reasons of VF in this cohort of adolescents. Secondly, the study was conducted in one health facility located in an urban area and could not reflect the situation nationwide. Thirdly, in our context marked by a low ART coverage among adolescents [
6], this study has estimated VS rate only among ALHIV receiving treatment, and could not be extrapolated to all adolescents affected by HIV in the country.
Conclusion
We found a high rate (88.2%) of VL suppression among HIV-infected adolescents followed up according to national and WHO recommendations in Cameroon, almost meeting the 2020 UNAIDS/WHO goal of 95% VS. These results support the achievability of this goal in challenging contexts as in Sub-Sharan Africa, provided that necessary actions are in place to improve access to ART and its routine monitoring in this population. However, because continuous access to optimized ART, VL testing, retention in care services and psychosocial support in resource-limited setting remains challenging in Cameroon and in other RLCs, we should still be cautioned on the high risks that virological failure and drug resistance represent in these settings. Particular attention should be given to adolescents with past history of VF, sub-optimal adherence or receiving second- or third-line regimens.
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