Introduction
Care for HIV-infected patients has changed dramatically over the last two decades, [
1] largely due to advances in antiretroviral therapy (ART), which has, in turn, allowed for improvements in CD4 cell counts, suppression of HIV RNA and increased life expectancy of human immunodeficiency virus (HIV)-infected patients [
2,
3]. However, in some patients, suppression of HIV-RNA concentration has been shown not to fall to undetectable levels, while, for other patients, viral rebound occurred after initially becoming undetectable [
4]. Such cases are termed virologic failure and have been conjectured to possibly be associated with poor adherence [
5], drug–drug interactions, treatment failure, drug-resistance, or unobserved factors [
6,
7]. To allow timely detection of virologic failure, the World Health Organization (WHO) recommended the use of HIV-RNA testing as the gold standard for monitoring of HIV-infected patients’ response to therapy [
8]. Assessment of the factors that affect viral load dynamics (i.e., viral suppression and rebound) is important in order to identify whether a patient is in need of more intensive adherence counseling and the timely detection of treatment failure in order to minimize the chances of development of drug resistance and unnecessary switching to an expensive regimen [
9].
In 2015, the UNAIDS set the 90-90-90 global targets in order to end the AIDS epidemic, whereby the third 90 represents the target to achieve a viral load suppression in at least 90% of HIV-infected patients under ART [
10]. Identifying the possible factors that may affect virologic failure is key to achieving these targets. Findings from previous studies highlight a number of factors that may affect the viral suppression status among HIV-infected patients initiating ART, including gender, clinician skill level, suboptimal adherence, age, treatment history, WHO stage, and baseline CD4 cell count [
5,
11‐
14]. Although clinical covariates are more capable of explaining and capturing realistic behavioral patterns of the VL responses, and are more sensitive to the source of variations in the viral load (VL), no previous study has directly examined the effects of several clinical attributes [i.e., white blood cell (WBC) parameters, red blood cell (RBC) parameters, blood chemistry parameters, and quality of life (QoL) domain scores] on VL dynamics. In addition, the relative role of various factors related to HIV VL responses may also further be dependent on the local context and the ART program setting. This study thus gives an insight into assessing the effect of several clinical, risk, and socio-demographic factors on long-term HIV VL dynamics. Therefore, we emphasize a comparison of viral rebound and viral suppression across different clinical attributes, and identify factors contributing to virologic failure which are key to informing adjustments in the program-level strategies most amenable to intervention in this context and key to achieving UNAIDS global target goals.
Mathematical models have been used extensively in research into HIV VL dynamics because they play an important role in improving our understanding of major factors contributing to the VL dynamics of the disease. These models range from logistic regression [
5,
15‐
17], Cox regression analysis [
18‐
20], accelerated failure time models [
21], generalized estimating equations [
22‐
24], to generalized linear mixed-effects models [
25]. It has also been argued that multistate Markov models are useful tools for studying the complex dynamics of chronic diseases such as HIV VL progression, and are further valuable for identifying factors associated with disease progression of HIV/AIDS [
26‐
28]. However, several multi-state Markov models assume that the intensities are homogeneous, conditional on the observed covariates. Unfortunately, it is hardly ever possible to include all the relevant factors, either due to it not being possible to measure all the relevant factors or because the researchers do not know all the relevant factors. Ignoring such frailty or unobserved heterogeneity may have a huge impact on the estimation of the parameters in multistate Markov models.
In this study, full-parametric and semi-parametric multistate Markov frailty models were used to model viral rebound, viral suppression, and state-specific duration in HIV-infected patients under treatment. Multistate frailty models are a powerful tool for modeling complex cycles of chronic diseases, encompassing the life history of a cohort [
29], considering all possible pathways [
30], and further allowing for dealing with heterogeneity between the sequence of transitions [
31,
32]. These models can also accommodate competing risks, censored data, recurrent outcomes ,and multiple outcomes [
33]. In this study, we classified the sequential adverse events by the degree of chronicity based on VL, with classifications defined by patients going through undetectable, low, moderate, and high VL. Most importantly, we have presented full and semi-parametric multistate Markov models, with patient-level frailties on all VL rebound, VL suppression and state-specific duration in HIV-infected patients, thus making the current study different from previous studies. Additionally, among the surrogate markers of HIV progression and ART responses, both the CD4 cell and VL counts are included in the same model. As discussed by Chikobvu and Shoko [
34], the effects of multi-collinearity on the VL count transitions can be corrected using the principal component approach. Therefore, in this study, we have presented a parametric multistate frailty model for predicting transition intensities between sequential events of HIV infection, which takes into account the CD4 cell count, in order to study several factors that may affect viral suppression, viral rebound and state-specific duration of HIV-infected patients.
Discussion
The current study was aimed to simultaneously model viral rebound, viral suppression, and state-specific duration of stay of AIDS patients, and to determine how these depend on level of educational status, age, marital status, quality of life scores, TB co-infection, RBC indices, hemoglobin and hematocrits, eosinophils, neutrophils, monocytes, electrolyte components, and liver enzyme abnormality. These factors may not adequately be modeled using constant hazards, although the bias in estimates of the hazard ratios was not large in this population. Thus, we have presented and compared full-parametric and semi-parametric multistate models. Results from the diagnostic plots, AIC and LRT, showed that the Weibull multistate model, fitted significantly better than the exponential and semi-parametric multistate models. We also improved the selected model, the Weibull multistate model, by including patient-level frailties and an orthogonal CD4 cell count component. This further improved the efficiency and predictive accuracy of the model.
Some of the results of this study supported the previous literature findings, while some results of this study provided new insights. The results of this study showed that young adolescents were significantly associated with decreased viral suppression and were associated with an increased probability of experiencing viral rebound, compared to those patients in older age groups (age > 40 years). This was supported by previous studies ([
5,
49,
50]), in which older age groups were more likely to achieve viral suppression compared to those in younger age groups. A plausible reason for this is that the treatment for adolescents may be affected by alcohol and recreational drug use [
51], lack of disclosure, stress, HIV-associated discrimination and stigma [
5,
52], and feelings of invulnerability to the consequences of HIV disease [
53]. These factors may mediate the observed association among younger aged individuals and viral rebound. We also found that patients with lower educational levels were associated with an increased probability of experiencing viral rebound, a finding that is in accordance with the literature [
54‐
56], where patients who have lower educational attainment were associated with viral rebound. It may reflect lower levels of health literacy or indicate a marker of overall poverty. Lower health literacy and greater poverty-related stress have been linked to medication non-adherence and poor virologic outcomes [
57,
58].
Having a high QoL domain score in our study was associated with increased suppression and reduced likelihood of viral rebound. As has been previously shown [
59,
60], patients with anxiety, depression, and low QoL are less likely to exhibit adherence to ART. Poor adherence may be associated with increased probability of experiencing viral rebound [
61‐
63], showing that at least part of the effect of low QoL scores on incomplete viral suppression is mediated through combination ART adherence. Patients diagnosed with TB after ART initiation are associated with increases in plasma HIV viremia [
64‐
66]. The risk of viral suppression may also be decreased by patients with TB co-infection, due to an increased risk of drug toxicity, drug–drug interactions, and the potential for lower adherence due to the high pill burden [
67]. Our data add to this literature by showing that patients with TB co-infection were associated with a decreased probability of experiencing viral suppression. Therefore, patients on ART with active TB should thus be prioritized for VL monitoring and adherence support. Furthermore, having many sex partners exposes them to an accelerated risk of viral rebound, from moderate to high VL.
Among the different hematological parameters for HIV-infected patients, as expected, an abnormally high number of eosinophils in the blood significantly decreased viral suppression and increased the probability of experiencing viral rebound, a finding that is in accordance with the literature [
68], where it has been found that patients with a higher eosinophils counts were more likely to have higher long-term viral rebound. We also found that patients having higher neutrophil counts were significantly associated with a decreased probability of experiencing viral rebound. This finding agrees with studies that have shown that worsening HIV disease, demonstrated by increasing VL rebound, has been associated with abnormality of neutrophils (neutropenia: absolute neutrophil counts < 500) [
69,
70]. We further observed that patients with high monocyte count were associated with a higher probability of experiencing viral rebound. Our finding is concurrent with those from prior reports, which noted that the monocyte CD69 expression rate was significantly positively correlated with the HIV-1 RNA [
71]. Consequently, caution is needed for risk assessment measures to monitor and screen patients’ pre- and post-ART initiation in African clinical settings to curtail potential risks associated with an increased probability of experiencing viral rebound. Moreover, liver enzyme abnormalities were significantly associated with a higher probability of experiencing viral rebound. Our findings are concurrent with those from prior reports [
72,
73], which noted that a positive correlation exists between VL and aminotransferase (ALT and AST). Thus, there is a need to monitor ALT and AST levels after initiation of ART, mainly in high-risk patients, to reduce side effect concerns.
We further found that patients having higher educational levels were more likely to spend a longer time in good states (particularly lower VL state), as compared to those with lower educational levels. This could be due to better knowledge about their treatment and disease, access to health services, or functional status. Similarly, higher QoL scores (particularly physical health scores) were significantly associated with longer time spent in lower VL states. Furthermore, those of younger age (< 20 years) with high liver abnormality scores and high social relationship scores were associated with an increased probability of staying in a higher VL state.
Readers should be cautious when interpreting the findings of this study since the study findings were limited to adult females, and hence the findings may not be generalized to all HIV-infected patients. In addition, this study has also some limitations, including missing data, which are expected for a study conducted on data collected from patients’ files and when dealing with a long-term follow-up period. Moreover, we did not assess some other clinical and risk factors, such as adherence level, hepatitis status, treatment change, drug–drug interactions, and drug abuse, that may affect VL dynamics. Despite these limitations, important information regarding clinical factors associated with viral rebound and viral suppression for women were identified. This information is of value in identifying women at risk for suboptimal therapeutic outcomes. Additionally, it will help to inform cART retention strategies for HIV-infected patients.
Conclusions
We have simultaneously modeled long-term viral suppression, viral rebound, and state-specific duration of stay of AIDS patients in seroconversion among South African women, using the Weibull multistate frailty model. This has resulted in precise estimates of covariate effects, time spent in each state, and expected survival times. Additionally, we have examined important information regarding factors that affect long-term viral dynamics. This information is of value in identifying women at risk for suboptimal therapeutic outcomes. Moreover, to achieve and maintain the UNAIDS 90% suppression targets, additional interventions are required to optimize ART outcomes, specifically targeting poor clinical characteristics, lower education, younger age individuals, and those with many sex partners.
From a methodological perspective, the parametric multistate with frailty approach is a flexible approach for modeling time-varying variable factors, allowing for dealing with heterogeneity between the sequence of transitions, allowing for a reasonable degree of flexibility with few additional parameters, and gaining a better insight into how the factors change over time. Furthermore, the parametric multistate frailty model further extends the knowledge as to the HIV disease burden transitions and can be used to learn more about the disease progression of other chronic diseases.
Acknowledgements
We would like to acknowledge Dr Nonhlanhla Yende-Zuma, Dr Nigel Garrett and the entire CAPRISA Acute Infection team including research leaders who formulated the research ideas that generated such rich data, thank you very much for allowing us to use this dataset. We also thank the participants for their involvement in this study. We would also like to thank the School of Mathematics, Statistics and Computer Science, University of KwaZulu-Natal, South Africa for providing their guidance and support.