Pachawo Bisani

Background: Consistent engagement in antiretroviral therapy (ART) care is crucial for health outcomes and HIV transmission reduction. This study examined the first two years of ART engagement patterns in two public ART clinics in Lilongwe, Malawi. Routine retention support is provided using ART “Buddies” or a two-way texting (2wT) system for those with phones and interest. Methods: ART engagement patterns were analysed across six-month intervals (>0–6, >6–12, >12–18, >18–24). Patients retained on ART were categorised as continuously engaged (attended all appointments within 13 days), cyclical engagement (returned late (14–59 days) at least once), and re-engaged (missed an appointment by ≥60 days but returned to care). Clients who disengaged (lost to follow-up (LTFU), transferred out, stopped, or died) at any interval were assigned that outcome. Engagement patterns were visualised using a Sankey chart. Results: Among 6,303 clients, 1,030 (16%) were in the Buddy support group with phone access, 4,850 (77%) without phone, and 423 (7%) in the 2wT support group. 5,300 (84%) clients were grouped into 33 common engagement patterns over 24 months; 1,003 (16%) of clients illustrated fewer common patterns. By 24 months, 3,368 (53%) were retained on ART: 296 (70%) of 2wT; 2,793 (58%) of Buddy with phone access; and 3,367 (27%) of Buddy without phone access. Among the 3,368 clients retained on ART at 24 months, 1,836 (55%) were continuously engaged, 1,031 (30%) had cyclical engagement, and 500 (15%) re-engaged after LTFU. Overall, 1836 (29% of the total cohort of 6,303) continuously engaged in care over 24 months. In the six-month interval analysis, clients aged 50+ had the highest proportion (n=184, 70%) of continuous engagement overall, compared to individuals aged 35-49 years (n=832, 58%) and 18-34 years (n=820, 49%). 2wT clients showed the highest continuously engagement up to 18 months (70% at 0–6 months, 72% at >6–12 months, and 81% at >12– 18 months), compared to Buddy groups (with phone access:57%, 58%, 76%; without phone access: 30%, 33%, 62%). Conclusion: A small proportion of clients were continuously on ART over the first 24 months of ART. Older clients and 2wT participants had more favourable ART engagement patterns; those without phone access faired worst. While most ART clients followed similar ART engagement patterns, a few showed varying trajectories. Tailored retention support based on engagement patterns could improve long-term retention in ART care.

Background: Retaining clients on antiretroviral therapy (ART) is challenging especially during the first year on ART. Mobile health (mHealth) interventions show promise to close retention gaps. We aimed to assess reach (who received the intervention?) and effectiveness (did it work?) of a hybrid two-way texting (2wT) intervention to improve ART retention at a large public clinic in Lilongwe, Malawi. Methods: Between August 2021 - June 2023, a quasi-experimental study compared outcomes between two cohorts of new ART clients: 1) those opting into 2wT with combined automated, weekly motivation short messaging service (SMS) messages and response-requested appointment reminders; and 2) a matched historical cohort receiving standard of care (SoC). Reach was defined as “the proportion clients ≤6 months of ART initiation eligible for 2wT”. 2wT effectiveness was assessed in time-to-event analysis comparing Kaplan-Meier plots of 6- and 12-month retention between 2wT and SoC using a log-rank test. The effect of 2wT on ART drop out was estimated using multivariable Cox proportional hazard models, adjusting for sex, age and WHO stage at ART initiation. Results: Of the 1,146 clients screened, 645 were ineligible (56%) largely due to lack of phone access (393/645; 61%) and illiteracy (149/645; 23%): a reach of 44%. Among 468 2wT participants, the 12-month probability of ART retention was 91% (95%CI: 88% - 93%) compared to 75% (95%CI: 71% - 79%) among 468 SoC participants (p<0.0001). Compared to SoC participants, 2wT participants had a 62% lower hazard of dropping out of ART care at all time points (hazard ratio 0.38, 95% CI: 0.26-0.54; p<0.001). Conclusions: Not all clients were reached with 2wT. For those who opted-in, 2wT reduced drop out throughout the first year on ART and significantly increased 12-month retention. The proactive 2wT approach should be expanded as a complement to other interventions in routine, low-resource settings to improve ART retention.

Millions of Africans are on dolutegravir-based antiretroviral therapy (ART), but few detailed descriptions of dolutegravir resistance and its clinical management exist. We reviewed HIV drug resistance (HIVDR) testing application forms submitted between June 2019 and October 2022, data from the national HIVDR database, and genotypic test results. We obtained standardized ART outcomes and virological results of cases with dolutegravir resistance, and explored associations with dolutegravir resistance among individuals with successful integrase sequencing. All cases were on two nucleoside reverse transcriptase inhibitors (NRTIs)/dolutegravir, and had confirmed virological failure, generally with prolonged viremia. Among 89 samples with successful integrase sequencing, 24 showed dolutegravir resistance. Dolutegravir resistance-associated mutations included R263K (16/24), E138K (7/24), and G118R (6/24). In multivariable logistic regression analysis, older age and the presence of high-level NRTI resistance were significantly associated with dolutegravir resistance. After treatment modification recommendations, four individuals (17%) with dolutegravir resistance died, one self-discontinued ART, one defaulted, and one transferred out. Of the 17 remaining individuals, 12 had follow-up VL results, and 11 (92%) were <1000 copies/mL. Twenty-four cases with dolutegravir resistance among 89 individuals with confirmed virological failure suggests a considerable prevalence in the Malawi HIV program. Successful management of dolutegravir resistance was possible, but early mortality was high. More research on the management of treatment-experienced individuals with dolutegravir resistance is needed.