Study Finds Slower Viral Suppression Progress in Children, Adolescents Than Adults With HIV

Adults with HIV are approaching the global target of 95% viral suppression, but there is much slower progress among children and adolescents, a study published in Lancet HIV reported.

According to the retrospective cohort study, significant efforts are needed to reach the viral suppression target for children and adolescents.

In 2013, the World Health Organization (WHO) recommended routine viral load testing to improve monitoring and earlier identification of HIV treatment failure. UNAIDS established the 95-95-95 targets, which included reaching viral suppression in 95% of all people taking antiretroviral therapy (ART) by 2030.

“To support the undetectable equals untransmittable and treatment-as-prevention strategies, accurate estimation of the third 95 of UNAIDS’s 95-95-95 targets is crucial,” the authors wrote. “Although routine viral load testing is the standard of care in high-income countries, viral load testing has been slow to expand in low-income and middle-income countries.”

Researchers analyzed data from 7 regional cohorts from the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium regarding patients with HIV initiating ART between January 1, 2010, and December 31, 2019.

Children and adolescents were grouped together and defined as aged less than 18 years at ART initiation, and adults were defined as aged 18 years and older at ART initiation. Researchers estimated the proportions of children and adolescents and adults with viral suppression (defined as viral load <1000 copies per mL) at 1, 2, and 3 years after initiating ART.

A total of 21,594 children and adolescents and 255,662 adults were included at the beginning of the study.

Using the intention-to-treat approach, the proportions of children and adolescents with viral suppression at years 1, 2, and 3 after ART initiation were 36%, 30%, and 24%, respectively. The proportion for adults at years 1, 2, and 3 were 44%, 36%, and 29%, respectively.

When limiting the analysis to only those in follow-up with an available viral load measurement, the proportions increased for both groups. For children and adolescents, proportions increased to 74%, 75% and 76% at years 1, 2, and 3, respectively. Adults continued to have higher proportions in general, with 89%, 89%, and 90% being virally suppressed at years 1, 2, and 3, respectively.

“Overall, among 17,589 children and adolescents by the end of year 3, 735 (4%) had died, 3076 (17%) had transferred out, and 5819 (33%) had been classified as lost to follow-up, with proportions varying between regions,” the authors added. “Overall, among 201,124 adults by the end of year 3, 30,130 (5%) had died, 30,130 (15%) had transferred out, and 72,337 (36%) were classified as lost to follow-up, with proportions varying between regions.”

At the end of the study, after adjusting for missing data, the proportion of children and adolescents with viral suppression was as follows after each year of ART initiation:

• 1 year: 12,048 of 18,835 (64%)
• 2 years: 10,796 of 17,553 (62%)
• 3 years: 9177 of 15,667 (59%)

The proportion of adults with viral suppression was as follows after each year of ART initiation:

1. 1 year: 176,964 of 225,418 (79%)
2. 2 years: 145,552 of 201,238 (72%)
3. 3 years: 115,260 of 178,458 (65%)

After adjustments were made, the estimated overall proportions of people with HIV with viral suppression increased substantially, regardless of whether they remained in care.

“Estimates of viral suppression that do not account for the sizeable proportion of people with HIV who are lost to follow-up who are connected to care elsewhere and still receiving ART, or estimates that do not account for people with HIV in care who are not tested, are unlikely to reflect the actual proportion who are virally suppressed among those who are accessing care,” the authors concluded. “Although adults with HIV are approaching the 95% target, progress among children and adolescents is slower and estimates are still behind the UNAIDS targets.”

Reference

Han WM, Law MG, Egger M, et al. Global estimates of viral suppression in children and adolescents and adults on antiretroviral therapy adjusted for missing viral load measurements: a multiregional, retrospective cohort study in 31 countries. Lancet HIV. 2021;8(12):e766-e775. doi:10.1016/S2352-3018(21)00265-4