Routine versus Targeted Viral Load Strategy among Patients Starting Antiretroviral in Hanoi, Vietnam

Area of Science:

• Infectious Diseases
• Public Health
• Clinical Medicine

Background:

• The World Health Organization recommends HIV viral load (VL) testing for monitoring antiretroviral therapy (ART).
• Evidence supporting improved clinical outcomes with routine VL (RVL) monitoring is limited.
• Early mortality and loss to follow-up are significant challenges in ART management.

Purpose of the Study:

• To compare the effectiveness of routine VL (RVL) monitoring versus targeted VL (TVL) monitoring in patients initiating ART.
• To assess the impact of different VL monitoring strategies on clinical outcomes and virological suppression.
• To evaluate patient outcomes over a three-year period.

Main Methods:

• A prospective, randomized controlled trial was conducted involving 647 patients starting ART.
• Patients were randomized to either RVL monitoring (every six months) or TVL monitoring (based on clinical or immunological status).
• Primary endpoints included death or WHO Stage 4 events between 6 and 36 months, and virological suppression at 3 years.

Main Results:

• No significant difference in death or Stage 4 events was observed between RVL and TVL groups (3.6% vs. 3.9%, p=0.823).
• Viral suppression rates at 36 months were high and similar in both groups (97.2% RVL vs. 98.9% TVL at 400 copies/mL; 98.0% RVL vs. 98.9% TVL at 1000 copies/mL).
• A substantial proportion of study events, including deaths, occurred within the first six months of ART initiation.

Conclusions:

• Routine VL monitoring did not demonstrate a significant benefit over targeted VL monitoring in terms of clinical outcomes or virological failure after three years.
• High overall viral suppression rates and limited events after six months suggest the study had reduced power to detect differences.
• Focusing on reducing early mortality and improving ART retention may be more impactful than the choice of VL monitoring strategy.