Viral load versus CD4+ monitoring and 5-year outcomes of antiretroviral therapy in HIV-positive children in Southern Africa: a cohort-based modelling study

Objectives: Many paediatric antiretroviral therapy (ART) programmes in Southern Africa rely on CD4(+) to monitor ART. We assessed the benefit of replacing CD4(+) by viral load monitoring. Design: A mathematical modelling study. Methods: A simulation model of HIV progression over 5 years in children on ART, parameterized by data from seven South African cohorts. We simulated treatment programmes with 6-monthly CD4(+) or 6- or 12-monthly viral load monitoring. We compared mortality, second-line ART use, immunological failure and time spent on failing ART. In further analyses, we varied the rate of virological failure, and assumed that the rate is higher with CD4(+) than with viral load monitoring. Results: About 7% of children were predicted to die within 5 years, independent of the monitoring strategy. Compared with CD4(+) monitoring, 12-monthly viral load monitoring reduced the 5-year risk of immunological failure from 1.6 to 1.0% and the mean time spent on failing ART from 6.6 to 3.6 months; 1% of children with CD4(+) compared with 12% with viral load monitoring switched to second-line ART. Differences became larger when assuming higher rates of virological failure. When assuming higher virological failure rates with CD4(+) than with viral load monitoring, up to 4.2% of children with CD4(+) compared with 1.5% with viral load monitoring experienced immunological failure; the mean time spent on failing ART was 27.3 months with CD4(+) monitoring and 6.0 months with viral load monitoring. Conclusion: Viral load monitoring did not affect 5-year mortality, but reduced time on failing ART, improved immunological response and increased switching to second-line ART. (C) 2014 Wolters Kluwer Health vertical bar Lippincott Williams & Wilkins