Factors associated with antiretroviral treatment failure among people living with HIV on antiretroviral therapy in resource-poor settings: a systematic review and metaanalysis

Background Despite the increase in the number of people accessing antiretroviral therapy (ART), there is limited data regarding treatment failure and its related factors among HIV-positive individuals enrolled in HIV care in resource-poor settings. This review aimed to identify factors associated with antiretroviral treatment failure among individuals living with HIV on ART in resource-poor settings. Methods We conducted a comprehensive search on MEDLINE (PubMed), Excerpta Medica Database (EMBASE), Cochrane Central Register of Controlled Trials (CENTRAL), World Health Organization’s (WHO’s) library database, and Latin American and Caribbean Health Sciences Literature (LILACS). We included observational studies (cohort, case-control, and cross-sectional studies) where adolescents and adults living with HIV were on antiretroviral treatment regardless of the ART regimen. The primary outcomes of interest were immunological, virological, and clinical failure. Some of the secondary outcomes were mm3 opportunistic infections, WHO clinical stage, and socio-demographic factors. We screened titles, abstracts, and the full texts of relevant articles in duplicate. Disagreements were resolved by consensus. We analyzed the data by doing a meta-analysis to pool the results for each outcome of interest. Results Antiretroviral failure was nearly 6 times higher among patients who had poor adherence to treatment as compared to patients with a good treatment adherence (OR = 5.90, 95% CI 3.50, 9.94, moderate strength of evidence). The likelihood of the treatment failure was almost 5 times higher among patients with CD4 < 200 cells/mm3 compared to those with CD4 ≥ 200 CD4 cells/mm3 (OR = 4.82, 95% CI 2.44, 9.52, low strength of evidence). This result shows that poor adherence and CD4 count below < 200 cells/mm3 are significantly associated with treatment failure among HIV-positive patients on ART in a resource-limited setting. Conclusion This review highlights that low CD4 counts and poor adherence to ART were associated to ART treatment failure. There is a need for healthcare workers and HIV program implementers to focus on patients who have these characteristics in order to prevent ART treatment failure. Systematic review registration The systematic review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO), registration number: 2019 CRD42019136538.


Background
Human immunodeficiency virus (HIV) infections are a major global public health concern. In 2019, an estimated 38 million people were living with HIV infection (PLWH) [1]. With new infections, an estimated 1.7 million people became newly infected with HIV in 2019. Sub-Saharan Africa (SSA) remains the most affected region in the world, with about 20.7 million prevalent cases and 730,000 new infections were recorded in 2019, seconded by Asia and the Pacific region with 5.8 million prevalent cases [1]. Although Southern Africa is home to less than 1% of the global population, the region has more than a fourth of all HIV infection in the world, with 300,000 acquired immune deficiency syndrome (AIDS)-related deaths registered in the same year in SSA [1].
Although anti-retroviral therapy (ART) coverage in this region has rapidly increased over the past decade [2]. The greatest gains in access to ART occurred in SSA [3]. In 2019, only 15 million (73%) PLHIV in the region were accessing ART, while 3.5 million (60%) in Asia and the Pacific region [1]. Increasing the use of ART has contributed to a prominent decline in HIV-associated morbidity and death/mortality in SSA [2]. United Nations program on HIV/AIDS (UNAIDS) has suggested universal targets for the year 2020 (90-90-90), which means diagnosing 90% of all PLHIV who should know their status (PLHIV), initiating antiretroviral treatment (ART) for 90% of those diagnosed with HIV infection, and attaining an undetectable viral load in 90% of those on ART [4]. Significant progress has been made in achieving that goal. Globally, PLWH accessing ART has increased from 21.7 million in 2015 to 25.4 million in 2019, an increase from 45 to 67% of all PLHIV [3,5].

Antiretroviral treatment failure
Patients with ART failure are increasingly encountered in resource-limited settings, while recent estimates suggest only 2% of those currently on ART are on second-line [6], a far greater number is likely to be failing virologically but have not switched to an alternative regimen. Furthermore, an increase in the coverage of ART use among PLHIV, which has resulted in an increase in the number of individuals failing first-line ART, and therefore, the magnitude increases with prolonged use of ART. The WHO predicted earlier on that 500,000 and 800,000 PLWH on the first-line combination of ART will require a switch to the second-line therapy by 2010 [2]. However, the burden of treatment failure is not well-documented, while there is a large scale of ARV in resource-limited countries. Metaanalysis data showed that the rate of the treatment failure for the first-line was 6.08% globally; however, the study noted a substantial heterogeneity across regions with 7.10% in Africa and 2.55% in Asia [3].
A retrospective cohort study done in South Africa found that among patients on non-nucleotide reverse transcriptase inhibitor (NNRTI)-based ART, after a median of 15 months on ART treatment, 19% had failed virologically and immunologically [6]. Studies in East Africa have shown a high prevalence of immunologic failure ranging from 8 to 57% among clients on the firstline ART [7][8][9].
Treatment failure is typically measured in three ways in poor-resource settings: (i) clinically, as evidenced by disease progression; (ii) immunologically, as evidenced by trends in CD4 counts over time; and (iii) virologically, as evidenced by measurement of HIV RNA levels. In 2013, WHO recommended viral load testing as the preferred monitoring approach to diagnose and to confirm ARV treatment failure [10].

Factors associated with treatment failure
Earlier studies have emphasized a number of factors that may be associated with virological suppression in ART; these are reasons for testing: routine testing, suspected treatment failure, and repeat testers after suspected failure [9][10][11]. While a significant number of studies have found that treatment failure is significantly associated with young age, unsatisfactory adherence, low hemoglobin, history of lost to follow-up, being male and educational status, and treatment regimen [12][13][14], some studies have recognized low baseline CD4 cell count, rate of CD4 decline, prior exposure to ART and treatment interruptions, and nonadherence as determinants of treatment failure [15,16].
In 2016, WHO most recent guideline defined a clinical failure as a new or recurrent clinical event indicating severe immunodeficiency (WHO clinical stage 4 condition) after 6 months of effective treatment. Immunological failure is defined as CD4 count at or below 250 cells/mm 3 following a clinical failure or persistent CD4 levels below 100 cells/mm 3 , and virological failure is defined as viral load above 1000 copies/mL based on two consecutive viral load measurements in 3 months, with adherence support following the first viral load test [17]. The results from a previous study have confirmed that low baseline CD4 cell count, particularly < 100 cells/mm 3 , and history of loss to follow-up are risk factors for immunological discordance [18]. Independent risk factors associated with virological failure were being followed-up at the semirural center, having experienced unstructured treatment interruptions, and having low CD4 counts at enrolment [19].
Gender, time on ART, baseline CD4 T cell count, WHO stage, ART regimen, adherence, and TB co-infection were associated with viral suppression [20]. The history of the antiretroviral use before starting ART, change of antiretroviral therapy due to toxicity, opportunistic infections while on ART treatment, level of CD4 + lymphocytes below 100 cells/ml at start of ART, adherence, and clinical stage were independently associated with virological failure [21]. Age younger than 40 years was also associated with virologic failure [22]. The relative contribution of the main predictors to virological failure may differ across settings and population groups and context. Thus, specific data are critical to the carrying out of corrective measures.

Importance of the review
Viral load testing provides early and accurate indications of the treatment failure and the need to switch from the first-line to second-line drugs, thereby reducing the accumulation of the drug-resistant mutations and improving clinical outcomes [23].
However, regular access to routine viral load testing remains a challenge due to the high cost. In such a situation, clinical and immunological monitoring is used for detecting treatment failure [24][25][26][27]. The number of people accessing ART has significantly increased in many poor resource settings [28]. Hence, it is significant to sustain treatment success and limit the development of treatment failure. For the timely detection of treatment failure, WHO reconfirmed the use of viral load testing as the gold standard test to monitor patients' response to ART [29]. Where the viral load is not routinely available, CD4 count and clinical monitoring should be used to diagnose treatment failure. In spite of a large number of patients receiving ARTs in lowand middle-income countries (LMICs) and poor settings, there are few reports on ART outcomes in these settings. Identifying baseline predictors of the first-line ART outcome among PLWH on ART in LMICs where access to viral load testing is limited is of paramount importance.
The technique and accuracy of identifying treatment failure in poor settings are important but challenging. Delayed detection of ART failure may increase drug toxicity may lead to the increase of drug resistance related with mutations (further controlling treatment choices) and may result in increased morbidity and mortality. Early detection of treatment failure is crucial to ensure the effectiveness of the first-line therapy [6].
The main objective of this review was to identify factors associated with antiretroviral treatment failure among PLWH on ART in resource-poor settings.

Primary objective
The primary objective of the study was to determine the clinical, immunological, and virological factors associated with antiretroviral treatment failure among PLWH in resource-poor settings.

Secondary objective
The secondary objective of the study is to identify the socio-demographic and economic factors associated with antiretroviral treatment failure among PLWH among PLWH in resource-poor settings.

Methods
The methods of this systematic review and meta-analysis were reported as per the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRIS MA-P) checklist [30]. We registered the protocol for this systematic review on the International Prospective Register of Systematic Reviews (PROSPERO) with a registration number: CRD42019136538.

Criteria for considering studies for review Types of studies
We included all types of observational studies including prospective/retrospective or ambi-directional cohort studies, case-control studies, population-based/nested or hospitalbased case-control studies, and cross-sectional studies. Interventional studies were excluded from this review.

Types of participants
Adolescents and adults living with HIV who were on ART for ≥ 6 months, regardless of the regimen. Only participants with documented baseline CD4 and VL were considered for this systematic review.

Type of outcome Primary outcome
Treatment failure was defined as follows:

Virological failure
Virological failure is defined as a plasma viral load above 1000 copies/ml based on two consecutive viral load measurements after 3 months, with adherence support. A viral load test is a measurement of the amount of HIV in a sample of the blood. This is usually reported as the number of copies per milliliter (copies/mm 3 ) [17].

Immunological failure
Immunological failure is defined as a fall in CD4 count to the baseline (or below) or persistent CD4 levels below 100 cells/mm 3 . The CD4 lymphocyte count is an excellent indicator of how healthy the immune system is. These are a type of white blood cells, called T cells, which move throughout the human body to find and destroy bacteria, viruses, and other invading germs. The CD4 cell count is indicated in cells per mm 3 , and it is measured by taking a blood sample [17].

Clinical failure
Clinical failure is defined as the occurrence of new opportunistic infections (excluding immune reconstitution inflammatory syndrome [IRIS]) and/or other clinical evidence of HIV disease progression during therapy. AIDSdefining illnesses (opportunistic infections) are those which the Centers for Disease Control and Prevention (CDC) have classified as being directly associated with advanced HIV infection. We considered the common diseases, which are pneumonia, TB, lymphoma, and cryptococcosis [17].

Secondary outcome
Secondary outcomes for this study are all the predictors' variables that contribute to treatment failure. The following information was collected if measured at baseline: CD4 cells (cells/mm 3 ), viral load (copies/ml), WHO clinical, tuberculosis, opportunistic infection, treatment regimen (NRTI or NNRTI), BMI, weight, study site (rural versus urban), gender, age, educational status, employment status, marital status, and spouse HIV serostatus.

Inclusion and exclusion criteria Included studies
Participants in the study were (1) those who had been on ART for ≥ 6 months and (2) those who had documented CD4 cell count and viral load measurement at baseline and 6 months.

Excluded studies
All studies with participants who had pregnancy history the past 6 months while on treatment and at 6 months' visit or had missing values of CD4 cell count and viral load at baseline and 6 months' visit were excluded.

Search methods for identification of the studies
We conducted a comprehensive search on 5 databases from December 1, 2000, to November 2019. With assistance from an information specialist, we searched in the following databases: MEDLINE (Pubmed), EMBASE (OVID), LILACS (BIREME), Science Citation Index Expanded (SCI-EXPANDED, Web of Science), Social Sciences citation index (SSCI, Web of Science), Conference Proceedings Citation Index-Social Science & Humanities (CPCI-SSH, Web of Science), and Cinahl (EBSCOHost). A detailed search strategy is provided in Appendix 1. A hand search of citations from selected studies was conducted to identify additional studies missing from the original electronic searches.

Screening and assessments of study eligibility
All potential studies were imported into Covidence (Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia), and two review authors (YL and SJ) independently screened the titles and abstracts. Both authors also assessed full-text eligibility.
All published full-text articles, abstracts, and brief reports were included, and provided/available complete data were elicited from them. The disagreements between the two authors who assessed study eligibility were resolved by discussion and consensus.

Data extraction, management, and analysis
Data from the full-text articles were extracted by two independent review authors (YL, SJ) using a standardized pre-piloted data extraction form. A third reviewer (MK, PN) checked whether the extracted data were correct. Extracted data were categorized into four main headings: general information, socio-demographic and economic characteristics of participants, and clinical and immunological information of the participant. In case of missing information, we clarified the conducted study or the studies that had relevant data, which were not reported in the published manuscript, and we contacted the authors for additional information.

Risk of bias and quality of evidence
Two authors independently assessed the risk of bias in each study by examining the study population, study attrition, prognostic factor measurement, outcomes measurement, study confounding, and statistical reporting (YL and OA). They coded studies as at high, medium, low, or unclear risk of bias for each of these features using the Quality in Prognosis Studies tool (QUIPS tool) [31]. Finally, we assessed the quality of the evidence using the Grading of Recommendations Assessment Development and Evaluations (GRADE) approach using the five criteria of the GRADE system.

Statistical analysis
For the studies that were relatively homogeneous in terms of methodology and outcomes, a meta-analysis of the data was performed. Sufficiently, similar data was pooled using the inverse variance approach to accommodate crude and adjusted odds ratios, where possible. Additionally, the meta-analysis was summarized using pooled estimates, the 95% confidence interval, and the between-study variance was estimated using Tau 2 . We extracted all unadjusted and adjusted measures of the association from all included studies and converted effect sizes as necessary to possible selection bias, thus allowing us to use the data from as many studies as possible. We anticipated that results from multivariate analyses would have been reported as odds ratios (ORs), risk ratios (RRs), and hazard ratios (HRs), if so, we would use ORs as the common measure of the association, using RRs and HRs to estimates ORs at a particular time point [32]. Furthermore, measures of effect were analyzed using RevMan statistical software for systematic reviews. Statistical heterogeneity was quantified using the I 2 statistic [33]. If the I 2 statistic is high (75 to 100%-as suggested by Higgins et al.) indicating high heterogeneity [33], a random effect model was used.

PRISMA flow chart
We retrieved 2418 articles regarding treatment failure among ART users in poor resource setting as identified in MEDLINE (PubMed); EMBASE (OVID); LILACS (BI-REME); Science Citation Index Expanded (SCI-EX-PANDED, Web of Science), Social Sciences citation index (SSCI, Web of Science), and Conference Proceedings Citation Index-Social Science & Humanities (CPCI-SSH, Web of Science), and CINAHL (EBSCOHost). These are shown in Fig. 1.
Of these initial articles, 3 articles were duplicates; 2158 articles were excluded after reviewing their titles and abstracts and confirmed irrelevant to this review. Thus, 237 potential full-text articles were assessed for eligibility, which resulted in further exclusion of 100 articles.  19 assessed HIV drug-resistant mutations, 12 had the wrong study design, 7 had a wrong patient population, 2 were not in English 1 and was a duplicate, 1 had a wrong setting, and 1 was pediatric population. Finally, 137 studies met the eligibility criteria. These are shown in Table 1.

Meta-analysis
The association between adherence and treatment failure was based on six cross-sectional studies [14,35,37,40,42,47]. The results as presented in Fig. 2 showed a strong relationship between treatment failure and poor treatment adherence. The odds of treatment failure were nearly 6 times higher among patients who had poor adherence (OR = 5.90, 95% CI 3.50, 9.94, moderate strength of evidence). The test statistics, however, showed a substantial heterogeneity (I 2 = 65% and p = 0.02).
Similarly, the association between poor adherence and treatment failure was examined using four cohort studies [36,39,41,46]. The results as presented in Fig. 3 showed that the hazard ratio of treatment failure was nearly 2.5 higher among patients who had poor adherence (HR = Here too, a random effect meta-analysis model was used to determine the association with the outcome. Furthermore, the association between CD4 and treatment failure was examined by using three crosssectional studies [35,40,47]. The results as presented in Fig. 4 showed that treatment failure was strongly associated with CD4 count. The odds of treatment failure were nearly 5 times higher among patients who had a CD4 cell count of 200 cells/mm 3 (OR = 4.82, 95% CI 2.44, 9.52, low strength of evidence). However, the test statistics showed substantial heterogeneity (I 2 = 71% and p = 0.03). Hence, a random effect meta-analysis model was used to determine the association with the outcome.
Likewise, the association between low CD4 count and treatment failure was also observed using four cohort studies [36,38,45,46]. Results presented in Fig. 5 showed that the hazard ratio of treatment failure was nearly 3 times higher among patients who had CD4 lower than 200 cells/mm 3 (HR = 2.98, 95% CI 2.23, 4.00, moderate strength of evidence). The result of the test statistics showed no evidence of heterogeneity (I 2 = 0% and p = 0.55). A random effect meta-analysis model was used to determine the association with the outcome.
Our study also demonstrated similar findings to the above through data abstracted from two cross-sectional studies [34,44]. We also found that treatment failure was significantly associated with low CD4 count, where the odds of treatment failure were 1.14 times higher among patients with CD4 lower than 100 cells/mm 3 (OR = 1.14, 95% CI 0.52, 2.47, low strength of evidence). The test statistics showed moderate heterogeneity (I 2 = 49% and p = 0.75), see Fig. 6. Consequently, a random effect meta-analysis model was computed to determine the association.

Risk of bias assessment
Most of the studies had a low risk of bias on prognostic factors that accounted for 125/137, followed by study participants (123/135), statistical analysis and reporting (116/137), and outcome measurement (115/137). Moreover, 109/137 studies had a low risk of bias on study confounding and 103/137 studies had a low risk of bias on study participant attrition. The full table of results is shown in Appendix 3: risk of bias assessment.

Discussion
This review was aimed at identifying factors associated with antiretroviral treatment failure among individuals living with HIV and showed that low CD4 T cell count (≤ 200 cells/mm 3 ) and poor adherence to ART were significantly associated with virological failure.
In this review, the odds of virological failure were higher among those who had a CD4 cell count of ≤ The finding is supported by the studies conducted in SSA [35,43], while a retrospective analysis of a large ART program in Cambodia showed that previous ART experience, nevirapine-based regimen, and CD4 count ≤ 200 cells/mm 3 were independently associated with an increased risk of treatment [48]. Similar findings were reported in a meta-analysis data from India, where CD4 count ≤ 200 had a significantly greater risk of treatment failure [49]. As CD4 cell count increases, viral replication decreases, which means it has an inverse relationship with viral load. As patients' immune status drops, and the rate of viral load increases compared to the immuno-competent individuals with HIV infection. In addition, users with compromised immunity are more susceptible to different opportunistic infections that endure the cruel cycle of immunity depletion and viral replication [50]. Moreover, the results found from case-control studies shown that the odds of virological failure were 6 times more among those who had poor adherence compared with those who had good adherence to antiretroviral treatment. Likewise, the finding from cohort studies showed that the odds of virological failure were higher among those who had poor adherence compared with those who had good adherence to antiretroviral treatment. This finding is supported by findings from primary studies conducted in African countries [11,51,52], but also consistent with the finding from a study conducted in Vietnam and other developed countries [53][54][55]. It is obvious that poor adherence to medication compromises treatment response due to suboptimal drug concentration hence creates a conducive environment for viral replication leading to virological failure [56,57]. This reaffirms the need for reinforcement of drug adherence counseling for HIV patients before and during their life course of taking ART.
Poor adherence may lead to a number of adverse consequences on both individual and public HIV healthcare levels. Therefore, the measured efforts are immediately needed in HIV care by responsive bodies like ART case managers, adherence counselors in the hospitals on patients with low current CD4 count through improving poor adherence to ART treatment by strengthening enhanced adherence counseling. Each low-income country national HIV program should give attention to improving HIV services to strengthen adherence among patients on ART in order to reduce the proportion of patients who are failing the treatment.
Our systematic review has some strengths. We planned the review a priori with clearly defined selection criteria. We conducted a comprehensive and exhaustive search, using many additional sources to identify relevant studies, including reference searches of other HIV/ AIDS conferences (IAS and CROI) for the past 20 years.
This review had several limitations mainly related to the quality of the evidence available. To our knowledge, we suspect publication or reporting biases, or both, suggesting that our results may be overestimated. Positive study bias is likely to be problematic in this review. Our literature search for relevant and potential studies included focused searches, i.e., including search terms related to the "less CD4 count," "viral load" in our electronic search. Studies that report a relationship between the prognostic factors and common outcomes are therefore more likely to have been identified in these searches due to reporting of positive results in the study abstract.
In addition, we also observed that some studies reported positive unadjusted association of factors with outcomes of interest, but did not report the association adjusted for other important covariates. This may contribute to a likely overestimation of the adjusted results. Therefore, future research is required to investigate the impact and potential strategies to alleviate reporting and publication bias, as well as initiatives to require registration of protocols and publication of prognostic studies.
Furthermore, our review was the pooling of the adjusted the results despite studies did not include identical sets of covariates. Studies included in this review were homogenous; therefore, pooling of the adjusted results was feasible. However, comparison and interpretation may be challenging in this case. Our review only focused on studies conducted in poor resource settings limiting its generalizability to high-income settings.

Strength of evidence
The strength of evidence contributing to several outcomes in this review was graded as low, moderate, or high. We used the GRADE approach to assess the strength of evidence as shown in the summary of the finding table, Appendix 4. The certainty of evidence was downgraded in most instances due to a high risk of bias as well as inconsistency.

Conclusion
ART failure among individuals living with HIV is a public health concern; the timing and accuracy of identifying treatment failure in resource-limited settings are fundamental but challenging. The findings of this review highlighted that low CD4 counts and poor adherence to ART were associated to ART treatment failure. There is an urgent need that health professionals and HIV programs should focus on novel approaches for patients who have these characteristics in order to prevent ART failure. Further review is required to be done in multiple ART centers and a broader community as well as the different factors associated with treatment failure to decide whether there are discrepancies in virological and immunological responses to antiretroviral therapy at different stages of HIV infection.

6) Statistical analysis and presentation
The statistical analysis is appropriate, and all primary outcomes are reported Summary a. Sufficient presentation of data to assess the adequacy of the analytic strategy