Virological Therapeutic Failure and Associated Factors in People Living with HIV Followed up at the Regional Hospital and University of Borgou (RHU-B) in 2019 ()
1. Introduction
Antiretroviral treatment aims to make the viral load undetectable and restore immunity, which increases life expectancy, improves quality of life and reduces the risk of HIV transmission [1]. It is a lifelong treatment due to the chronicity of the HIV infection. New concerns related to this chronicity are emerging, in particular the emergence of cardiovascular and metabolic diseases but also therapeutic failure (TF) which compromises treatment efficacy, especially in the context of countries with limited resources [2]. There are many causes of TF. Among these, we can distinguish patient-related causes such as difficulties in compliance, inappropriate use of treatment, non-compliance with mealtimes, insufficient intake, absorption disorders [3] [4]; those related to the virus such as infection with a resistant strain, the occurrence of resistant virus and those related to the treatment such as drug interactions, insufficient dosages and inter-individual variability [5]. Early detection of cases and their management reduce the probability of progression of the infection and a better quality of life for HIV-infected subjects [6]. The care of people living with HIV (PLHIV) began several years ago in Benin with the existence of decentralized centers within the country. Despite the efforts made, health workers are increasingly confronted with the frequency of opportunistic infections within the population of PLHIV while they are on antiretrovirals testifying to a TF. This is a question widely studied in Africa but few studies were done on it in Benin with a quasi non-existent study in the northern part. In the Democratic Republic [7] of Congo and in Ethiopia [8] respectively 27.2% and 13.52% of PLHIV had treatment failure. The present study was initiated to identify the extent of TF as well as the associated factors for better management of patients living with HIV patient.
2. Study Site and Methods
Study sit: the study took place in the Internal Medicine department of the Regional Hospital and University of Parakou.
Type and period of study: this was a cross-sectional, descriptive and analytical study covering the period from July 21, 2019 to September 21, 2019.
Study population: all people living with HIV followed in the Internal Medicine department in 2019. All patients of both sexes, aged at least 18 years old, on antiretrovirals for at least 6 months who have given their consent were included in the study. Patients with a previous TF, transferred, lost to follow-up and unable to answer the questions were not included in the study.
Variables: the dependent variable studied was the virological TF which appeared during follow-up. Virological failure was defined as a viral load ≥ 1000 copies/mL after 6 months of treatment with or without clinical manifestations. The independent variables concerned sociodemographic data, lifestyle, clinic, biology, treatment and evolution.
Technique and data collection tool: data collection was done by using the consultation register, face-to-face interview, clinical and anthropometric examination. A data collection sheet and other appropriate tools were used.
Data processing and analysis: The data had been entered using the EPIDATA version 3.1 software after verification of each sheet, they had been analyzed using the EPIINFO version 7 and STATA 11 software. A p value less than 0.05 was considered significant.
Ethical aspects: data confidentiality was respected during the survey. After explaining to the patients the purpose of the work, they were free to participate or not to participate in the survey and that once accepted, they were entitled to withdraw afterwards. Anonymity was required on the survey sheets.
3. Results
A total of 498 PLHIV were included in the study, among them, 379 were female, i.e. a sex ratio of 0.3. The average age of PLHIV was 40 ± 9.90 years with extremes of 20 years and 72 years. The age group of 30 to 40 years represented 38.7% of the population. Regarding lifestyle, 23 (4.6%) smoked tobacco; 179 (33.9%) patients took alcoholic beverages; 1 (0.2%) used injection drugs; 158 (31.7%) practiced phytotherapy and 10 (2%) were sedentary. The serological status of the partner was unknown in 240 (48.2%) patients and 392 (78.7%) patients had shared their HIV serological status. During follow-up, 90 (18.1%) patients had at least one opportunistic infection; 373 (74.9%) had gained weight and 50 (10%) were malnourished. Compliance with ARV treatment was good in 378 (75.9%) patients. That CTM prophylaxis was good in 374 (75.1%) patients. TF was effective in 76 patients, i.e. a frequency of 15.3% (Table 1).
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Table 1. General characteristics of the study population of PLHIV followed in the Internal Medicine department of RHU-B in 2019 (n = 498).
The factors associated with TF in bivariate analysis were: phytotherapy (21.5% vs 12.3%), more than 2 tablets per day (29.4% vs 9.4%), poor compliance with ARVs (41.7% vs 6.9%) and cotrimoxazole (40.3% vs 6.9%), the presence of opportunistic infections (36.7% vs 10.5%), the absence of weight gain (26.4% vs 11.5%), undernutrition (28% vs 13.8%) and anemia (19.5% vs 11.6%) (Table 2).
In multivariate analysis, poor compliance with ARVs (OR: 7.25), the presence of opportunistic infections (OR: 2.17), phytotherapy (OR: 1.9), lack of weight gain (OR: 1.6) and anemia (OR: 2.3) are associated with TF (Table 3).
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Table 2. Factors associated with TF in bivariate analysis in PLHIV followed in the internal medicine department of RHU-B in 2019.
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Table 3. Factors associated with TF in multivariate analysis in PLHIV followed in the internal medicine department of RHU-B in 2019.
4. Discussion
The present study was interested in TF in PLHIV followed up in the Internal Medicine department in Parakou. TF had been assessed by virological failure in accordance with current recommendations.
The study population consisted mainly of women. This female predominance could be explained by the fact that HIV screening is systematic in pregnant women. In the study by Buju et al. [7] in the Democratic Republic of Congo and that of Kebede et al. [8] in Ethiopia, respectively 70% and 53.38% of the subjects were female. The average age of the patients was 40 ± 9.90 years. It was a relatively young population. Our results were the same as those reported by Ba et al. [9] in Senegal where the average age was 44 ± 11 years.
The frequency of TF in this study was 15.3%. Our result was similar to Shad et al. [10] in the Democratic Republic of Congo with a TF frequency of 19%. In the study by Azamar-Alonso et al. [6] in Mexico a higher frequency of TF had been reported (41%) while Ly et al. [11] in Mauritania reported a lower frequency (9%). This frequency of TF was not negligible given the limited effective therapeutic possibilities for HIV; hence the need to take an interest in the associated factors.
In multivariate analysis, poor adherence to ARVs, presence of opportunistic infections, phytotherapy, lack of weight gain and anemia were associated with TF. Several studies have got similar results. This was the case for the studies by Amagnu et al. [12] in Ethiopia, Jones et al. [13] in Zambia, Sithole et al. [14] in Zimbabwe and Ortiz et al. [15] in Guatemala where poor adherence to ARVs was associated with treatment failure. Decreased immunity promotes infections in PLHIV. This explains the frequency of opportunistic infections in HIV-infected subjects on ARVs in TF. In the studies by Buju et al. [7] and Ba et al. [9], subjects classified at WHO stage 3 or 4 were more at risk of developing TF. The practice of herbal medicine could lead to drug interactions with ARVs. Also, patients could abandon antiretroviral treatment in order to get traditional medicine. Lack of weight gain during follow-up was significantly associated with TF in our study. Melsew et al. [16] in Ethiopia had made the same observation. In the study by Amagnu et al. [12], the presence of anemia in PLHIV was associated with TF.
We could not document the mutations of resistance associated with therapeutic failures. This is a limitation in our study and can be explained by the limited accessibility to these tests in RHU-B. Thus, it would be relevant to conduct epidemiological surveillance of resistance by performing genotyping tests to justify the choice of effective molecules for the treatment of HIV infection.
5. Conclusion
TF to antiretrovirals was a reality despite the advantages of antiretroviral treatment. It was frequent in patients in the active file of the Internal Medicine department of RHU-B despite regular follow-up. The systematic investigation for failure must be made in all people living with HIV on antiretrovirals, especially those who present during their follow-up with anemia, opportunistic infections or lack of weight gain. Good compliance with antiretroviral treatment and avoidance of phytotherapy will prevent treatment failure.
Appendix: Questionnaire
1) Age (years)
2) Sex
3) Nutritional status
Weight (kgs)
Weight gain Yes No
Size (m)
Mass index (kg/m2)
4) Way of life
Alcohol consumption Yes No
Tobacco consumption Yes No
Phytotherapy Yes No
Sedentary lifestyle Yes No
5) HIV and Antiretroviral therapy
Sharing HIV status Yes No
Serological status of the partner Positive Negative
Good Adherence to antiretrovirals Yes No
Good Adherence to cotrimoxazole Yes No
Number of tablets per day
Presence of opportunistic infections
6) Psychological status
Anxiety Yes No
Depression Yes No
7) Biological date
Anemia Yes No
Elevated serum creatinine Yes No
Viral load