{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,23]],"date-time":"2026-09-23T04:40:35Z","timestamp":1790138435827,"version":"4.0.1"},"reference-count":51,"publisher":"Wiley","issue":"10","license":[{"start":{"date-parts":[[2018,10,22]],"date-time":"2018-10-22T00:00:00Z","timestamp":1540166400000},"content-version":"vor","delay-in-days":21,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"UNITAID"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["J Intern AIDS Soc"],"published-print":{"date-parts":[[2018,10]]},"abstract":"Abstract<\/jats:title>Introduction<\/jats:title>As antiretroviral therapy (ART<\/jats:styled-content>) is scaled up, more patients become eligible for routine viral load (VL<\/jats:styled-content>) monitoring, the most important tool for monitoring ART<\/jats:styled-content> efficacy. For HIV<\/jats:styled-content> programmes to become effective, leakages along the VL<\/jats:styled-content> cascade need to be minimized and treatment switching needs to be optimized. However, many HIV<\/jats:styled-content> programmes in resource\u2010constrained settings report significant shortfalls.<\/jats:p><\/jats:sec>Methods<\/jats:title>From a public sector HIV<\/jats:styled-content> programme in rural Swaziland, we evaluated the VL<\/jats:styled-content> cascade of adults (\u226518\u00a0years) on ART<\/jats:styled-content> from the time of the first elevated VL<\/jats:styled-content> (>1000 copies\/mL) between January 2013 and June 2014 to treatment switching by December 2015. We additionally described HIV<\/jats:styled-content> drug resistance for patients with virological failure. We used descriptive statistics and Kaplan\u2013Meier estimates to describe the different steps along the cascade and regression models to determine factors associated with outcomes.<\/jats:p><\/jats:sec>Results and Discussion<\/jats:title>Of 828 patients with a first elevated VL<\/jats:styled-content>, 252 (30.4%) did not receive any enhanced adherence counselling (EAC<\/jats:styled-content>). Six hundred and ninety\u2010six (84.1%) patients had a follow\u2010up VL<\/jats:styled-content> measurement, and the predictors of receiving a follow\u2010up VL<\/jats:styled-content> were being a second\u2010line patient (adjusted hazard ratio (aHR<\/jats:styled-content>): 0.72; p\u00a0<\/jats:italic>=\u00a0<\/jats:italic>0.051), Hlathikhulu health zone (aHR<\/jats:styled-content>: 0.79; p<\/jats:italic>\u00a0=\u00a00.013) and having received two EAC<\/jats:styled-content> sessions (aHR<\/jats:styled-content>: 1.31; p\u00a0<\/jats:italic>=\u00a0<\/jats:italic>0.023). Four hundred and ten patients (58.9%) achieved VL<\/jats:styled-content> re\u2010suppression. Predictors of re\u2010suppression were age 50 to 64 (adjusted odds ratio (aOR<\/jats:styled-content>): 2.02; p\u00a0<\/jats:italic>=\u00a0<\/jats:italic>0.015) compared with age 18 to 34\u00a0years, being on second\u2010line treatment (aOR<\/jats:styled-content>: 3.29; p\u00a0<\/jats:italic>=\u00a0<\/jats:italic>0.003) and two (aOR<\/jats:styled-content>: 1.66; p\u00a0<\/jats:italic>=\u00a0<\/jats:italic>0.045) or three (aOR<\/jats:styled-content>: 1.86; p\u00a0<\/jats:italic>=\u00a0<\/jats:italic>0.003) EAC<\/jats:styled-content> sessions. Of 278 patients eligible to switch to second\u2010line therapy, 120 (43.2%) had switched by the end of the study. Finally, of 155 successfully sequenced dried blood spots, 144 (92.9%) were from first\u2010line patients. Of these, 133 (positive predictive value: 92.4%) had resistance patterns that necessitated treatment switching.<\/jats:p><\/jats:sec>Conclusions<\/jats:title>Patients on ART<\/jats:styled-content> with high VL<\/jats:styled-content>s were more likely to re\u2010suppress if they received EAC<\/jats:styled-content>. Failure to re\u2010suppress after counselling was predictive of genotypically confirmed resistance patterns requiring treatment switching. Delays in switching were significant despite the ability of the WHO<\/jats:styled-content> algorithm to predict treatment failure. Despite significant progress in recent years, enhanced focus on quality care along the VL<\/jats:styled-content> cascade in resource\u2010limited settings is crucial.<\/jats:p><\/jats:sec>","DOI":"10.1002\/jia2.25194","type":"journal-article","created":{"date-parts":[[2018,10,23]],"date-time":"2018-10-23T06:46:40Z","timestamp":1540277200000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":49,"title":["Successes and challenges in optimizing the viral load cascade to improve antiretroviral therapy adherence and rationalize second\u2010line switches in Swaziland"],"prefix":"10.1002","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2807-6272","authenticated-orcid":false,"given":"David","family":"Etoori","sequence":"first","affiliation":[{"name":"Research Department M\u00e9decins Sans Fronti\u00e8res Mbabane Swaziland"},{"name":"Department of Population Health London School of Hygiene and Tropical Medicine London United Kingdom"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Iza","family":"Ciglenecki","sequence":"additional","affiliation":[{"name":"Research Department M\u00e9decins Sans Fronti\u00e8res Geneva Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mpumelelo","family":"Ndlangamandla","sequence":"additional","affiliation":[{"name":"Research Department M\u00e9decins Sans Fronti\u00e8res Mbabane Swaziland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Celeste G","family":"Edwards","sequence":"additional","affiliation":[{"name":"Research Department M\u00e9decins Sans Fronti\u00e8res Mbabane Swaziland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kiran","family":"Jobanputra","sequence":"additional","affiliation":[{"name":"The Manson Unit M\u00e9decins Sans Fronti\u00e8res London United Kingdom"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Munyaradzi","family":"Pasipamire","sequence":"additional","affiliation":[{"name":"Swaziland National AIDS Programme (SNAP) Ministry of Health Mbabane Swaziland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gugu","family":"Maphalala","sequence":"additional","affiliation":[{"name":"Swaziland National Reference Laboratory (NRL) Ministry of Health Mbabane Swaziland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chunfu","family":"Yang","sequence":"additional","affiliation":[{"name":"Division of Global HIV\/AIDS The Centre for Disease Control Atlanta GA USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Inoussa","family":"Zabsonre","sequence":"additional","affiliation":[{"name":"Research Department M\u00e9decins Sans Fronti\u00e8res Mbabane Swaziland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Serge M","family":"Kabore","sequence":"additional","affiliation":[{"name":"Research Department M\u00e9decins Sans Fronti\u00e8res Mbabane Swaziland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Javier","family":"Goiri","sequence":"additional","affiliation":[{"name":"Research Department M\u00e9decins Sans Fronti\u00e8res Geneva Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Roger","family":"Teck","sequence":"additional","affiliation":[{"name":"Research Department M\u00e9decins Sans Fronti\u00e8res Geneva Switzerland"},{"name":"South African Medical Unit M\u00e9decins Sans Fronti\u00e8res Cape Town South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bernhard","family":"Kerschberger","sequence":"additional","affiliation":[{"name":"Research Department M\u00e9decins Sans Fronti\u00e8res Mbabane Swaziland"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2018,10,22]]},"reference":[{"key":"e_1_2_8_2_1","unstructured":"WHO.Consolidated Guidelines on the Use of Antiretroviral Drugs for Treating and Preventing HIV Infection: Recommendations for a Public Health Approach[Internet].Geneva:World Health Organization;2013[cited 2016 Aug 8]. 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