Prevalence and Predictors of Persistent Human Immunodeficiency Virus Viremia and Viral Rebound after Universal Test and Treat: A Population-Based Study

Background: There are limited data on individual human immunodeficiency virus (HIV) viral load (VL) trajectories at the population-level after the introduction of universal test and treat (UTT) in sub-Saharan Africa. Methods: Human immunodeficiency virus VLs were assessed among HIV-positive participants through 3 population-based surveys in 4 Ugandan fishing communities surveyed between November 2011 and August 2017. The unit of analysis was a visit-pair (2 consecutive person-visits), which were categorized as exhibiting durable VL suppression, new/renewed VL suppression, viral rebound, or persistent viremia. Adjusted relative risks (adjRRs) and 95% confidence intervals (CIs) of persistent viremia were estimated using multivariate Poisson regression. Results: There were 1346 HIV-positive participants (n†=†1883 visit-pairs). The population-level prevalence of durable VL suppression increased from 29.7% to 67.9% during UTT rollout, viral rebound declined from 4.4% to 2.7%, and persistent viremia declined from 20.8% to 13.3%. Younger age (15-29 vs 40-49 years; adjRR†=†1.80; 95% CI†=†1.19-2.71), male sex (adjRR†=†2.09, 95% CI†=†1.47-2.95), never being married (vs currently married; adjRR†=†1.88, 95% CI†=†1.34-2.62), and recent migration to the community (vs long-term resident; adjRR†=†1.91, 95% CI†=†1.34-2.73) were factors associated with persistent viremia. Conclusions: Despite increases in durable VL suppression during roll out of UTT in hyperendemic communities, a substantial fraction of the population, whose risk profile tended to be younger, male, and mobile, remained persistently viremic.