Long-term HIV treatment outcomes and associated factors in sub-Saharan Africa: multicountry longitudinal cohort analysis

Objective: In a multicountry prospective cohort of persons with HIV from six countries between 2007 and 2015, we evaluated long-term outcomes of first-line non-nucleoside reverse-transcriptase inhibitor-based antiretroviral therapy (ART), and risk factors for loss-to-follow-up, mortality, virological failure, and incomplete CD4(+) T-cell recovery. Methods: We calculated cumulative incidence of lost-to-follow-up, death, virological failure (VL >= 1000 cps/ml) and incomplete CD4(+) T-cell recovery (<500 cells/mu l) at successive years, using Kaplan-Meier and Cox regression. Results: Of 2735 participants, 58.0% were female, median age was 37 (interquartile range [IQR] 32-43) years, and median pre-ART CD4(+) T-cell count was 135 (IQR 63-205)/mu l. Total follow-up time was 7208 person-years (median 24.3 months, IQR 18.7-58.3). Deaths by any cause and loss to follow-up occurred mostly during the first year of ART (84%, 201/240 and 56%, 199/353, respectively). During their first 6 years of ART, 71% (95% confidence interval [CI] 69.0-73.7) were retained on first-line, and among those 90-93% sustained viral suppression (<1000 cps/ml); CD4(+) T-cell recovery was incomplete in 60% (220/363) of participants. The risk factors associated with poor outcomes during long-term ART were: for loss-to-follow-up, recent VL >= 1000 cps/ml, recent CD4(+) T-cell count <= 50 cells/mu l, age <30 years, being underweight; for mortality, recent CD4(+) T-cell count <= 50 cells/mu l; and, for virological failure, age <40 years, recent CD4(+) T-cell count <= 200 cells/mu l, poor adherence, male sex, and low-level viremia. Conclusion: To achieve long-term ART success towards the UNAIDS targets, early ART initiation is crucial, coupled with careful monitoring and retention support, particularly in the first year of ART. Male and youth-centred care delivery models are needed to improve outcomes for those vulnerable groups.