# HIV Viral Re-Suppression on Second-Line ART in Southern Zimbabwe

## TL;DR

This study examines why second-line HIV treatment in Zimbabwe is not achieving high viral suppression rates, highlighting factors like poor adherence and delayed treatment switches.

## Contribution

The study identifies specific predictors of viral re-suppression on second-line ART in a resource-limited setting.

## Key findings

- Viral suppression rates on second-line ART were only 68.6%, far below the 95% target.
- Baseline CD4 count, adherence history, timely drug switches, and retention in care predicted viral re-suppression.
- Enhanced adherence counseling and timely treatment switches are recommended to improve outcomes.

## Abstract

The national prevalence of HIV among adults in Zimbabwe was 10.4% in 2023, while the HIV prevalence in Bulawayo Metropolitan Province was 11.7%. The country achieved the UNAIDS Fast Track goals of 95-95-95 ahead of the 2030 target, by reporting an ART coverage of 97.0% and a viral suppression rate of 95.0%. As the number of people on ART continues to grow, it is expected that the number of patients failing current first-line non-nucleoside treatment will increase. However, access to second-line treatment regimens remains very limited in resource-poor settings such as Zimbabwe. It is therefore imperative to review treatment success for persons on second-line treatment. A retrospective cohort analysis was conducted using routinely collected clinical and demographic data from 315 participants who had been on a second-line ART regimen in Bulawayo for at least six months between 2015 and 2020. Statistical analyses were conducted to identify risk factors for viral suppression using SPSS version 28. Viral suppression (68.6%) for adults was far below the target of 95%. After accounting for all other variables, baseline CD4 count (>200 c/µL) [AOR = 1.94 (1.05–3.61)], having no history of non-adherence on first-line ART [AOR = 3.88 (1.91–7.85)], drug switch within 12 months of failure [AOR = 4.13 (1.98–8.60)] and retention in care at 5 years [AOR = 6.35 (2.56–15.76)] predicted viral re-suppression. The second-line (rescue) regimen has not achieved the expected success in reversing initial viral non-suppression (due to late presentation and poor adherence), despite enhanced adherence counselling. Timely switching is effective when done within 12 months and coupled with persistent engagement in care. We recommend improved methods, such as enhanced adherence counselling for behaviour change to improve viral re-suppression rates, especially for those on with a history of poor adherence and virologic non-suppression.