Undisclosed antiretroviral (ARV) use among virally suppressed individuals may underestimate programmatic ARV therapy (ART) coverage estimates, affect interpretability of clinical trials results [1–10], and/or inflate estimates of viremic controllers [11–15]. Undisclosed ARV use has been reported in previous studies [16–18] including studies in Africa [8–10,19]. Although self-report is commonly used to measure ART uptake [20–23], its accuracy could be affected by undisclosed ART use.
As of 2016, Botswana was one of seven countries in the world and the only African country that was reported to have achieved targeted levels of viral suppression defined by UNAIDS [24,25]. The goal of the study was to evaluate the extent of undisclosed ART use in Botswana and assess how lack of disclosure might alter national estimates of UNAIDS 90–90–90 targets [26,27].
Blood specimens were collected in the Botswana Combination Prevention Project (BCPP) study  in 2013–2015. The participants in this study represent a 20% random sampling of households in the 30 communities. People living with HIV (PLHIV) participating in the BCPP study verbally reported prior and current ART receipt . Participants aged 18–64 years provided written informed consent (ascent for participants aged 16–17 years).
Following positive double rapid HIV testing, venous blood was collected by phlebotomy in households. The HIV-1 RNA load in plasma was quantified by Abbott m2000sp/Abbott m2000rt (Wiesbaden, Germany).
Plasma from 134 of 135 participants who reported no ART use and had undetectable HIV-1 RNA (≤400 copies/ml) was screened for ARV drugs by high-throughput liquid chromatography coupled with Q-Exactive high-resolution mass spectrometry using data-dependent fragmentation and selected reaction monitoring at resolution of 17 500 . To obtain qualitative results, each specimen was compared with positive and negative controls for each of 20 drugs tested. The limit of identification ranged from 5 to 10 ng/ml and is presented elsewhere .
Adjusted prevalence ratios (aPR) and 95% confidence intervals (CIs) were estimated for factors associated with undisclosed ART use accounting for clustering, age, and sex. P values less than 0.05 were considered statistically significant. Statistical analyses were performed in STATA, version 14.2 (College Station, Texas, USA) and SAS, version 9.4 (SAS Institute, Cary, North Carolina, USA).
Of 12 610 adult BCPP baseline household survey participants, 3596 (29%) were HIV-infected, and 953 (27%, 95% CI = 24–30%) self-reported no prior use of ART. Of those with an available viral load (N = 951), 136 (14%) had HIV-1 RNA less than 400 copies/ml. Multiple ARV drugs were detected in 52 (39%, 95% CI = 30–50%) of the 134 virologically suppressed individuals tested for ARV drugs. Three ARV drugs were detected in 42 participants, two drugs in nine participants, and one participant had a single drug detected (efavirenz). The most commonly identified ARV combinations detected were (efavirenz/nevirapine)/emtricitabine/tenofovir which were the first-line treatment regimens most commonly prescribed in Botswana's national ART program at the time of sampling. Among 52 individuals with ARV drugs detected, 36 (69%) stated that they did not know their HIV status.
Among virologially suppressed participants with evidence of current ART use either through self-report or detection of ARV drugs (N = 2569), nondisclosure of ART use was associated with being less than 35 years old (aPR = 4.38; 95% CI = 2.51–7.63) and sex with a younger partner (PR = 1.63; 95% CI = 1.01–2.63). No significant differences were found according to sex, employment status, income, education, alcohol use, and history of concurrent sexual partnerships or transactional sex.
We found that among HIV-infected individuals who reported not being on ART, 14% had undetectable HIV-1 RNA (≤400 copies/ml), 39% of whom had detectable plasma ARV levels. Undisclosed ART use was also reported in Partners in Prevention study , HPTN 052 study , in Kenya  and South Africa . After adjusting for undisclosed ARV use in BCPP study communities, the estimated proportion of PLHIV who have undetectable HIV-1 RNA on ART in Botswana increased by 1.4%, from 70.2%  to 71.6%. Adjusting for undisclosed ARV use provided more accurate estimates of the country progress toward the UNAIDS 90–90–90 targets [26,27].
Testing for ARV drugs in blood is the only biomedical verification method able to either confirm or reject self-report of no ART use. Although feasible in research settings, it is not practical to conduct ARV level testing in programmatic settings. However, testing may represent a viable surveillance measure in a proportion of virally suppressed persons who self-report being ART-naïve in population surveys. ART use could also be ascertained from national ARV data systems in which such systems exist and ethical considerations are taken into account.
The underlying reasons of unreported ARV use could include stigma, nonadherence, or desire for confirmation of HIV infection, or may represent use of nonprescribed ARVs including sharing of drugs. We found that undisclosed ARV use was associated with younger age (similar to reports from KwaZulu-Natal, South Africa , and Kenya ) and sex with a younger partner. No significant difference was found in undisclosed ARV use by sex (similar to a report by Kahle et al.), employment status, income level, educational level, alcohol use, and history of concurrent sexual partnerships or transactional sex.
We tested for presence or absence of ARV drugs (at low thresholds), but did not measure ARV drug concentrations, nor could we ascertain the timing of most recent ARV dosing. ARV drug levels are affected by individual drug metabolism and timing of sample collection in relation to drug ingestion. Plasma half-life for non-nucleoside reverse-transcriptase inhibitors is much longer than for nucleoside reverse-transcriptase inhibitors. We therefore cannot exclude that some ARV drugs could not be detected due to unknown time between ARV intake and sampling. Another limitation of this study is that we did not screen for ARV drugs among individuals with detectable viral load, or individuals who said that they were receiving ART.
Among household survey participants in Botswana who reported no prior use of ART and had no detectable virus, undisclosed ARV use was found in 39%. Accounting for undisclosed ART increased the estimated proportion of virologically suppressed individuals among HIV-infected people in Botswana by 1.4–71.6%. Testing for ARV drugs in virologically suppressed individuals could supplement self-report of ART use and inform estimates of ART coverage, as well as providing valuable information to clinicians and clinical trials investigators.
We thank the study participants and entire BCPP staff including all the field study teams for making this study a success. We thank the BCPP team members for their contribution to this study. We thank Lendsey Melton for excellent editorial assistance. We thank the Ministry of Health and CDC Botswana for their excellent support and contributions to the study. We thank Michelle Roland for helpful critique and discussion. This study was supported by the US President's Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention (CDC) under the terms of cooperative agreement U01 GH000447. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies. S.M. was supported by the Fogarty International Center and National Institute of Mental Health, of the National Institutes of Health under Award Number D43 TW010543. S.M. and S.G. were partially supported by sub-Saharan African Network for TB/HIV Research Excellence (SANTHE), a DELTAS Africa Initiative (grant # DEL-15-006). The DELTAS Africa Initiative is an independent funding scheme of the African Academy of Sciences (AAS)'s Alliance for Accelerating Excellence in Science in Africa (AESA) and supported by the New Partnership for Africa's Development Planning and Coordinating Agency (NEPAD Agency) with funding from the Wellcome Trust (grant #107752/Z/15/Z) and the UK government. The views expressed in this publication are those of the authors and not necessarily those of AAS, NEPAD Agency, Wellcome Trust, or the UK government. The funders had no role in the study design, data collection, and decision to publish, or in the preparation of the article.
Conflicts of interest
There are no conflicts of interest.
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