The human immunodeficiency virus (HIV) epidemic has affected populations around the world. In 2019, 38 million people globally were living with HIV, 1.7 million people became newly infected with HIV and 690,000 died from acquired immunodeficiency syndrome (AIDS)-related illnesses and Africa remains the continent with the highest number of cases, new infections and deaths [1].

Since the introduction of highly active antiretroviral therapy in 1996, there has been a significant reduction in HIV-related mortality rates [2] and effective treatment leads to better clinical and virological outcomes [3]. But, many patients on treatment experienced Virological and immunological failure in developing countries. For example, in Brazil, in a historical cohort study of 76,950 HIV patients aged 34 years on average, 85.2% achieved viral load suppression after 6 months of treatment [4] while in Uganda this proportion was 11% in a sample of 100,678 patients [5]. Factors associated with non-suppression of viral load vary from country to country and include co-morbidity, CD4 count , injection drug use, age, late diagnosis, type of treatment, drug pharmacokinetics, resistance to treatment and adherence [6] - [11].

Among people living with HIV, viral load suppression is one of the 10 global indicators for World Health Organization (WHO) guidelines on HIV infection information. This indicator is used to assess the United Nations Programme on HIV/AIDS (UNAIDS) latest “goal 90”: to ensure that 90% of people on antiretroviral treatment have permanently suppressed viral load by 2020 [12]. Viral load suppression is therefore becoming a key indicator in HIV surveillance, not only improving the quality of life of People Living with HIV but is also an effective means of preventing sexual [13].

In Congo, VIH seroprevalence was estimated at 3.2% in 2009 among people aged 15 and 49 years [14]. Based in this prevalence, in 2020 approximately 128 000 adults are living with HIV/AIDS in Congoand 16% are receiving antiretroviral treatment. For care, to date, there are 83 care centres. Antiretroviral treatment is offered to all people living with HIV after confirmation of diagnosis and clinical evaluation according national therapeutic guidelines. Antiretrovirals treatment (ART) initiation is offered on the same day to people who are ready to start. The efficacy of ART is defined as the maintenance of a viral load <50 copies/ml after 6 months of continuous treatment and failure determined by a viral load >1000 copies/ml confirmed for at least 6 months after correcting adherence problems in a patient.

However, studies on virological response to ART in Congo are sparse, available studies have found that the proportions of patients with incomplete virological suppression at 6 months and 12 months were 70% and 89.4% [15] [16], respectively after initiation of treatment. To our knowledge, no study has been carried out to date on the effectiveness and failure of long-term treatment of antiretroviral treatments used in the care units for HIV-infected patients in the Congo. In this context, this study aimed to determine antiretroviral treatments failure rates and associated risk factors among HIV-infected adult patients in Congo.

In this study carried out among patients initiating antiretroviral treatments and a follow-up in a long period of 14 years, patients experienced frequently episodes of treatment failure, despite an improvement in access to treatment over the last decade in the Congo, which is consistent with previous studies in AR-treated patients in sub-Saharan African countries [19] [20] [21]. The fact that most of HIV patients treated in Congo having difficulties to achieve undetectable viral load over follow-up can lead to high mortality and limits the effect of treatment as prevention (TasP), thus leading to the persistence of the epidemic. Our results highlight also factors associated with treatment failure. key factors contributing to the high proportion of treatment failure in this study included both individual situations and related to the quality of care provided. Our results also highlight factors associated with treatment failure. The main factors that explain the high proportion of treatment failure in this study are both individual situations and healthcare supply-related. These factors underline difficulties in the management of HIV-infected patients in monitoring units in the Congo. Our study is the first to provide data on long-term treatment failure based on usual treatment regimens in the Congo. This means that our results are of major interest for decision making to improve the quality of care offered to HIV patients within the framework of the national AIDS programme.

Firstly, our study reports that seven out of ten HIV patients are women. The feminisation of the HIV epidemic has already been reported by previous studies in Congo [15] and elsewhere in Africa [5]. In Congo, more HIV patients were recruited in Pointe Noire than compared to Brazzaville (P < 0.001), which consolidates the estimates of the Seroprevalence and AIDS Indicators Survey in Congo (ESISC-I) 2009 survey, which established HIV prevalence at 6.2% in Pointe Noire and 3.5% in Brazzaville [14].

Consistent with previous cohort study conducted at University Hospital in Brazzaville [15] or elsewhere in African region [22], low level of education was among most important predictors of treatment failure . It is well reported that low level of education which like poverty is an important systemic determinant of health in low-income countries and calls for major structural changes [23].

Results show also that compared to first-line treatment, patients receiving second-line treatment were less likely to have treatment failure viral load, something already shown by previous studies among HIV-patients [24]. In our cohort, only 8% of patients received second-line protocol drugs. Therefore, there is an urgent need to improve second-line treatment coverage for support the global treatment strategy as a means of prevention [25] [26].

Finally, as reported previously, non-adherence to ART was a major risk factor of treatment failure [5] [6] [7]. To ensure continuous and complete viral suppression, adherence of at least 95% (i.e. consumed at least 95% of the prescribed drugs) is required [27] [28] [29] [30]. Or, in this our study, approximately 57% of patients taking at least 95% of the tablets. The current result shows that patients with poor adherence is a problem that will in turn affect the UNAIDS global targets of 90% viral suppression by 2020 [31]. This may indicate the need for more investment and commitment to improving patient adherence in the study area. We reported above that the majority of patients in our study population have economic difficulties. However, adherence to treatment depends on several factors, including the regular acquisition of meals. Indeed, patients who do not have regular meals tend not to take their medication regularly [32] [33]. Thus, strategies to increase adherence to treatment must take into account the fact that it is urgent to provide regular meals to patients who are in financial need. Lack of adherence to treatment is of particular concern here, as poor adherence in HIV patients is associated with higher risk of engaging in unprotected sexual behaviours [34], and thus increasing the spread of HIV.

Despite these interesting results, some study limitations need to be recognized. Firstly, social behavioural factors such as stigmatization and discrimination are major factors associated with viral load as previously reported by several studies [35] - [40]. The major limitation of this study is that these socio-behavioural variables were did not assess because the design of study (i.e., a historical study), so researchers did not have any contact with patients. In addition, using a tablet count for assessing adherence may under or overestimate the proportion of patients with adherence to AR treatment [41]. Even so, we were able to adjust adherence according to VL and were able to show that the higher the VL the lower the adherence.

Antiretroviral treatments failure among HIV-treated patients is common in Congo. Developing treatment adherence-centred interventions with focus in patients who have low socio-economic status needed to reduced treatments failure. As treatment failure is not only determined by individual factors, psychosocial supports and availability of antiretroviral drugs needs to be taken into account. The high rate of treatment failure indicates the low quality of care. The development of a vast psychological support programme including advice on adherence to treatment, new technologies such as SMS reminders by phone to take the prescribed doses and the provision of meals to destitute patients is becoming an essential part of the national AIDS programme.

NG had the idea for and designed the study and had full access to all data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. AN, MFG, MNBU, AA DM and MED contributed to writing of the report. AA contributed to critical revision of the report. GN, MFG and MNBU contributed to the statistical analysis. All authors contributed to data acquisition, data interpretation, reviewed and approved the final version.

All authors declare no competing interests.

Ndziessi, G., Aloum- ba, A.J., Essie, D.E.M., Niama, A.C., Mbele, F.G., Diafouka, M. and Abena, A.A. (2020) Factors Associated with Antiretroviral Treatments Failure among HIV-Positive Patients in Congo: A Retrospective Cohort Study. World Journal of AIDS, 10, 201-214. https://doi.org/10.4236/wja.2020.104018