Antiretroviral therapy use, and self-reported adherence and viral suppression among women living with HIV in Canada

Background: In Canada, an estimated 62,790 people are living with HIV, 24.6% of which are female. Antiretroviral therapy (ART) suppresses viral replication to undetectable levels, leading to reduced individual-level morbidity, mortality, and risk of onward transmission. Most commonly over the last decade, ART consists of a backbone of two nucleoside reverse transcriptase inhibitors (NRTIs), with a third agent from one of the following classes: an integrase strand transfer inhibitor (INSTI), a non-nucleoside reverse transcriptase inhibitor (NNRTI), or a boosted protease inhibitor (bPI). Viral suppression (VS) is contingent on adherence to ART, but adherence can be affected by intrapersonal and structural barriers. Underlying gender and racial inequities may exacerbate these barriers for women living with HIV. A landmark 2000 study found that at least 95% ART adherence is necessary for VS. With potent and tolerable agents made recently available as therapeutic options, specifically INSTIs, lower adherence may not have the same harmful impact as with older regimens. I aimed to describe ART use among women living with HIV in Canada between 2013 and 2018, and identify the level at which self-reported ART adherence is no longer associated with self-reported VS.Methods: I used data from the Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (CHIWOS), a community-based study conducted across three provinces from 2013 to 2018. Overall, 1,422 women living with HIV completed three waves of questionnaires at 18-month intervals. A Sankey diagram was used to show trends of third agent classes over time. The proportion of self-reported VS (less than 50 copies/mL) at different levels of self-reported adherence was plotted. Multivariable logistic regression was used to determine the association between adherence and VS, adjusting for demographic factors, years with HIV, third agent class, number of medications other than ART, incarceration history, housing stability, current illicit drug use, current mental health condition, and ART interruption between study waves.Results: Overall, 1,187 women living with HIV were included, excluding those who did not indicate ART use status from 2013 to 2018 (n=235). At baseline, the median age was 42 years. With respect to race/ethnicity, 42.0% (n=499) self-identified as white, 29.4% (n=349) as African, Caribbean, and Black, and 21.0% (n=249) as Indigenous. Participants who reported an annual household income of less than $20,000 comprised 62.2% (n=738) of the sample. NNRTIs (26.3%) were the most common class of 3rd agents from 2013 to 2015 but were then surpassed by INSTIs from 2015 to 2017 (23.2%) and 2017 to 2018 (30.8%). Adherence levels of less than 70% [adjusted odds ratio (aOR): 0.06, 95% confidence interval (CI): 0.01, 0.27] and 80 to 89% [aOR: 0.21, 95% CI: 0.05, 0.86] were associated with lower odds of reporting VS, compared to 95% or greater. There was a negative but statistically non-significant association in the odds of reporting VS for 70 to 79% adherence [aOR: 0.29, 95% CI: 0.05, 1.77] relative to 95% or greater. We found no statistical difference in the odds of reporting VS with 90 to 94% [aOR: 1.04, 95% CI: 0.20, 5.32], compared to 95% or greater. Conclusion: Participants in the CHIWOS cohort show increasing adoption of INSTI as 3rd agents between 2013 and 2018, and that adherence levels lower than 90% are less likely to be associated with VS. This study provides current evidence that can guide patient-provider discussions

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