1
|
Gonçalves P, Barreto J, Santos M, Leal S, Marcelino J, Abecasis A, Palladino C, Taveira N. HIV-1 drug resistance and genetic diversity in people with HIV-1 in Cape Verde. AIDS 2024; 38:1101-1110. [PMID: 38349224 DOI: 10.1097/qad.0000000000003866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
OBJECTIVES To characterize the genetic diversity and drug resistance profiles of people with HIV-1 failing ART in Cape Verde (CV). DESIGN Cross-sectional study conducted between January 2019 and December 2021 in 24 health centres on the islands of Santiago and São Vicente. METHODS The HIV-1 pol gene was sequenced in individuals with a detectable viral load. HIV-1 genetic diversity was determined by phylogenetic analysis. Drug resistance mutation patterns and resistance phenotypes were estimated using the Stanford algorithm. RESULTS Viral load was detected in 73 of 252 (29%) enrolled participants and sequencing data were produced for 58 (79%) participants. CRF02 AG strains predominated (46.5%), followed by subtype G (22.4%). Most patients (80%) had mutations conferring resistance to nonnucleoside reverse transcriptase inhibitors (NNRTIs) (67%), nucleoside reverse transcriptase inhibitors (55%), integrase inhibitors (10%) and/or protease inhibitors (7%) used in Cape Verde, a significant increase compared with a study conducted in 2010-2011. The most common mutations were M184V/I (43%), K103N/S (36%) and G190A/S (19%). NNRTI resistance was associated with younger age and exposure to two or more drug regimens. CONCLUSION The HIV-1 epidemic in Cape Verde is mainly driven by CRF02_AG and subtype G. Resistance to NNRTIs and/or NRTIs is highly prevalent and resistance to LPV/r and DTG is emerging. Our results support the use of DTG-based first-line ART and protease inhibitor-based regimens for patients with virological failure, but emerging resistance to LPV/r and DTG is a concern. Continued monitoring of drug resistance is essential to ensure adequate healthcare for PWH in Cape Verde.
Collapse
Affiliation(s)
- Paloma Gonçalves
- Instituto de Investigação do Medicamento (iMed.Ulisboa), Faculdade de Farmácia de Lisboa, Lisbon, Portugal
| | | | - Menilita Santos
- Instituto Nacional de Saúde Pública de Cabo Verde, Praia, Cape Verde
| | - Silvania Leal
- Instituto Nacional de Saúde Pública de Cabo Verde, Praia, Cape Verde
| | - José Marcelino
- Instituto de Investigação do Medicamento (iMed.Ulisboa), Faculdade de Farmácia de Lisboa, Lisbon, Portugal
- Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), Instituto Superior de Ciências da Saúde Egas Moniz, Monte de Caparica
| | - Ana Abecasis
- Global Health and Tropical Medicine (GHTM), Instituto de Higiene e Medicina Tropical/Universidade Nova de Lisboa (IHMT/UNL), Lisboa, Portugal
| | - Claudia Palladino
- Instituto de Investigação do Medicamento (iMed.Ulisboa), Faculdade de Farmácia de Lisboa, Lisbon, Portugal
| | - Nuno Taveira
- Instituto de Investigação do Medicamento (iMed.Ulisboa), Faculdade de Farmácia de Lisboa, Lisbon, Portugal
- Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), Instituto Superior de Ciências da Saúde Egas Moniz, Monte de Caparica
| |
Collapse
|
2
|
Scallon AJ, Hassan SA, Qian SR, Gao Y, Oyaro P, Brown E, Wagude J, Mukui I, Kinywa E, Oluoch F, Odhiambo F, Oyaro B, Kingwara L, Yongo N, Karauki E, Otieno L, John-Stewart GC, Abuogi LL, Patel RC. "I feel drug resistance testing allowed us to make an informed decision": qualitative insights on the role of HIV drug resistance mutation testing among children and pregnant women living with HIV in western Kenya. BMC Health Serv Res 2023; 23:908. [PMID: 37620855 PMCID: PMC10463841 DOI: 10.1186/s12913-023-09804-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 07/10/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Pregnant women and children living with HIV in Kenya achieve viral suppression (VS) at lower rates than other adults. While many factors contribute to these low rates, the acquisition and development of HIV drug resistance mutations (DRMs) are a contributing factor. Recognizing the significance of DRMs in treatment decisions, resource-limited settings are scaling up national DRM testing programs. From provider and patient perspectives, however, optimal ways to operationalize and scale-up DRM testing in such settings remain unclear. METHODS Our mixed methods study evaluates the attitudes towards, facilitators to, and barriers to DRM testing approaches among children and pregnant women on antiretroviral therapy (ART) in five HIV treatment facilities in Kenya. We conducted 68 key informant interviews (KIIs) from December 2019 to December 2020 with adolescents, caregivers, pregnant women newly initiating ART or with a high viral load, and providers, laboratory/facility leadership, and policy makers. Our KII guides covered the following domains: (1) DRM testing experiences in routine care and through our intervention and (2) barriers and facilitators to routine and point-of-care DRM testing scale-up. We used inductive coding and thematic analysis to identify dominant themes with convergent and divergent subthemes. RESULTS The following themes emerged from our analysis: (1) DRM testing and counseling were valuable to clinical decision-making and reassuring to patients, with timely results allowing providers to change patient ART regimens faster; (2) providers and policymakers desired an amended and potentially decentralized DRM testing process that incorporates quicker sample-to-results turn-around-time, less burdensome procedures, and greater patient and provider "empowerment" to increase comfort with testing protocols; (3) facility-level delays, deriving from overworked facilities and sample tracking difficulties, were highlighted as areas for improvement. CONCLUSIONS DRM testing has the potential to considerably improve patient health outcomes. Key informants recognized several obstacles to implementation and desired a more simplified, time-efficient, and potentially decentralized DRM testing process that builds provider comfort and confidence with DRM testing protocols. Further investigating the implementation, endurance, and effectiveness of DRM testing training is critical to addressing the barriers and areas of improvement highlighted in our study. TRIAL REGISTRATION NCT03820323.
Collapse
Affiliation(s)
- Andrea J Scallon
- Jackson School of International Studies, University of Washington, Seattle, USA
| | - Shukri A Hassan
- Department of Medicine, University of Washington, 325 9th Ave, Seattle, WA, 98105, USA
| | | | - Yuandi Gao
- School of Public Health, University of Washington, Seattle, USA
| | | | | | | | - Irene Mukui
- Drugs for Neglected Diseases Initiative, Nairobi, Kenya
| | | | | | - Francesca Odhiambo
- Family AIDS Care and Education Services, Kenya Medical Research Institute, Kisumu, Kenya
| | - Boaz Oyaro
- Kenya Medical Research Institute-CDC, Kisian, Kenya
| | - Leonard Kingwara
- National HIV Reference Laboratory, Ministry of Health, Nairobi, Kenya
| | | | | | - Lindah Otieno
- Family AIDS Care and Education Services, Kenya Medical Research Institute, Kisumu, Kenya
| | - Grace C John-Stewart
- Department of Medicine, University of Washington, 325 9th Ave, Seattle, WA, 98105, USA
- Departments of Global Health, University of Washington, 325 9th Ave, WA, 98105, Seattle, USA
- Department of Pediatrics, University of Washington, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
| | - Lisa L Abuogi
- Department of Pediatrics, University of Colorado, Denver, USA
| | - Rena C Patel
- Department of Medicine, University of Washington, 325 9th Ave, Seattle, WA, 98105, USA.
- Departments of Global Health, University of Washington, 325 9th Ave, WA, 98105, Seattle, USA.
| |
Collapse
|
3
|
Steegen K, van Zyl GU, Claassen M, Khan A, Pillay M, Govender S, Bester PA, van Straaten JM, Kana V, Cutler E, Kalimashe MN, Lebelo RL, Moloi MBH, Hans L. Advancing HIV Drug Resistance Technologies and Strategies: Insights from South Africa's Experience and Future Directions for Resource-Limited Settings. Diagnostics (Basel) 2023; 13:2209. [PMID: 37443603 DOI: 10.3390/diagnostics13132209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/23/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
Monitoring of HIV drug resistance (HIVDR) remains critical for ensuring countries attain and sustain the global goals for ending HIV as a public health threat by 2030. On an individual patient level, drug resistance results assist in ensuring unnecessary treatment switches are avoided and subsequent regimens are tailored on a case-by-case basis, should resistance be detected. Although there is a disparity in access to HIVDR testing in high-income countries compared to low- and middle-income countries (LMICS), more LMICs have now included HIVDR testing for individual patient management in some groups of patients. In this review, we describe different strategies for surveillance as well as where HIVDR testing can be implemented for individual patient management. In addition, we briefly review available technologies for HIVDR testing in LMICs, including Sanger sequencing, next-generation sequencing, and some point-of-care options. Finally, we describe how South Africa has implemented HIVDR testing in the public sector.
Collapse
Affiliation(s)
- Kim Steegen
- Department of Molecular Medicine and Haematology, National Health Laboratory Service, Charlotte Maxeke Johannesburg Hospital, Johannesburg 2193, South Africa
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2000, South Africa
- Wits Diagnostic Innovation Hub, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2000, South Africa
| | - Gert U van Zyl
- Division of Medical Virology, Stellenbosh University, Stellenbosh 7602, South Africa
- Division of Medical Virology, Stellenbosh National Health Laboratory Service, Tygerberg Hospital, Tygerberg 7505, South Africa
| | - Mathilda Claassen
- Division of Medical Virology, Stellenbosh University, Stellenbosh 7602, South Africa
- Division of Medical Virology, Stellenbosh National Health Laboratory Service, Tygerberg Hospital, Tygerberg 7505, South Africa
| | - Aabida Khan
- Department of Virology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban 4041, South Africa
- Department of Virology, National Health Laboratory Service, Inkosi Albert Luthuli Central Hospital, Durban 4058, South Africa
| | - Melendhran Pillay
- Department of Virology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban 4041, South Africa
- Department of Virology, National Health Laboratory Service, Inkosi Albert Luthuli Central Hospital, Durban 4058, South Africa
| | - Subitha Govender
- Department of Virology, National Health Laboratory Service, Inkosi Albert Luthuli Central Hospital, Durban 4058, South Africa
| | - Phillip A Bester
- Department of Medical Microbiology and Virology, University of the Free State, Bloemfontein 9300, South Africa
- Department of Medical Microbiology and Virology, National Health Laboratory Service, Universitas Academic Hospital, Bloemfontein 9301, South Africa
| | - Johanna M van Straaten
- Department of Medical Microbiology and Virology, National Health Laboratory Service, Universitas Academic Hospital, Bloemfontein 9301, South Africa
| | - Vibha Kana
- Centre for HIV and STIs, National Institute for Communicable Diseases, Johannesburg 2192, South Africa
| | - Ewaldé Cutler
- Centre for HIV and STIs, National Institute for Communicable Diseases, Johannesburg 2192, South Africa
| | - Monalisa N Kalimashe
- Centre for HIV and STIs, National Institute for Communicable Diseases, Johannesburg 2192, South Africa
| | - Ramokone L Lebelo
- Department of Virological Pathology, Sefako Makgatho Health Sciences University, Pretoria 0204, South Africa
- Department of Virological Pathology, National Health Laboratory Service, Sefako Makgatho Health Sciences University, Pretoria 0204, South Africa
| | - Mokopi B H Moloi
- Department of Virological Pathology, Sefako Makgatho Health Sciences University, Pretoria 0204, South Africa
- Department of Virological Pathology, National Health Laboratory Service, Sefako Makgatho Health Sciences University, Pretoria 0204, South Africa
| | - Lucia Hans
- Department of Molecular Medicine and Haematology, National Health Laboratory Service, Charlotte Maxeke Johannesburg Hospital, Johannesburg 2193, South Africa
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2000, South Africa
- Wits Diagnostic Innovation Hub, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2000, South Africa
| |
Collapse
|
4
|
McCluskey SM, Govender K, Adamson J, Gandhi M, Spinelli MA, Moosa MY, Muyindike W, Moodley P, Pillay M, Masette G, Sunpath H, Pillay S, Chen G, Hedt-Gauthier B, Marconi VC, Siedner MJ. Point-of-care urine tenofovir testing to predict HIV drug resistance among individuals with virologic failure. AIDS 2023; 37:1109-1113. [PMID: 36928169 PMCID: PMC10164085 DOI: 10.1097/qad.0000000000003520] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
OBJECTIVE We sought to evaluate the utility of a point-of-care (POC) urine tenofovir (TFV) assay, developed to objectively assess adherence, to predict HIV drug resistance (HIVDR) in people failing first-line antiretroviral therapy (ART). DESIGN We retrospectively analyzed TFV levels as a biomarker of adherence in urine specimens collected during a clinical trial that enrolled adults with virologic failure on first-line ART in Uganda and South Africa. METHODS Urine specimens were analyzed from participants on TFV-containing regimens who had a viral load >1000 copies/ml and paired genotypic resistance test (GRT) results. We assessed recent ART TFV adherence with a qualitative POC lateral flow urine assay with a cut-off value of 1500 ng/ml. We then calculated performance characteristics of the POC urine TFV assay to predict HIVDR, defined as intermediate or high-level resistance to any component of the current ART regimen. RESULTS Urine specimens with paired plasma GRT results were available from 283 participants. The most common ART regimen during study conduct was emtricitabine, tenofovir disoproxil fumarate, and efavirenz. The overall prevalence of HIVDR was 86% ( n = 243/283). Of those with TFV detected on the POC assay, 91% ( n = 204/224) had HIVDR, vs. only 66% ( n = 39/59) among those with no TFV detected ( P- value < 0.001). Positive and negative predictive values of the assay to predict HIVDR were 91% and 34%, respectively. CONCLUSIONS In populations with a high prevalence of HIVDR, the POC urine TFV assay can provide a low-cost, rapid method to guide requirements for confirmatory resistance testing and inform the need for regimen change.
Collapse
Affiliation(s)
- Suzanne M McCluskey
- Medical Practice Evaluation Center
- Division of Infectious Diseases, Massachusetts General Hospital
- Harvard Medical School, Boston, MA, USA
| | | | - John Adamson
- Africa Health Research Institute, Durban, South Africa
| | - Monica Gandhi
- Division of HIV, ID, and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Matthew A Spinelli
- Division of HIV, ID, and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Pravi Moodley
- University of KwaZulu-Natal, Durban, South Africa
- National Health Laboratory Service
| | | | - Godfrey Masette
- Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Selvan Pillay
- Adrenergy Research Innovations, Durban, South Africa
| | | | - Bethany Hedt-Gauthier
- Harvard Medical School, Boston, MA, USA
- Harvard T. H. Chan School of Public Health, Boston, MA
| | - Vincent C Marconi
- Emory University School of Medicine
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Mark J Siedner
- Medical Practice Evaluation Center
- Division of Infectious Diseases, Massachusetts General Hospital
- Harvard Medical School, Boston, MA, USA
- Africa Health Research Institute, Durban, South Africa
- University of KwaZulu-Natal, Durban, South Africa
- Mbarara University of Science and Technology, Mbarara, Uganda
| |
Collapse
|
5
|
Hermans LE, Ter Heine R, Schuurman R, Tempelman HA, Burger DM, Vervoort SC, Deville WL, De Jong D, Venter WD, Nijhuis M, Wensing AM. A randomized study of intensified antiretroviral treatment monitoring versus standard-of-care for prevention of drug resistance and antiretroviral treatment switch. AIDS 2022; 36:1959-1968. [PMID: 35950949 PMCID: PMC9612712 DOI: 10.1097/qad.0000000000003349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/19/2022] [Accepted: 07/23/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Standard-of-care antiretroviral treatment (ART) monitoring in low and middle-income countries consists of annual determination of HIV-RNA viral load with confirmatory viral load testing in case of viral rebound. We evaluated an intensified monitoring strategy of three-monthly viral load testing with additional drug exposure and drug resistance testing in case of viral rebound. METHODS We performed an open-label randomized controlled trial (RCT) at a rural South African healthcare clinic, enrolling adults already receiving or newly initiating first-line ART. During 96 weeks follow-up, intervention participants received three-monthly viral load testing and sequential point-of-care drug exposure testing and DBS-based drug resistance testing in case of rebound above 1000 copies/ml. Control participants received standard-of-care monitoring according to the WHO guidelines. RESULTS Five hundred one participants were included, of whom 416 (83.0%) were randomized at 24 weeks. Four hundred one participants were available for intention-to-treat analysis. Viral rebound occurred in 9.0% (18/199) of intervention participants and in 11.9% (24/202) of controls ( P = 0.445). Time to detection of rebound was 375 days [interquartile range (IQR): 348-515] in intervention participants and 360 days [IQR: 338-464] in controls [hazard ratio: 0.88 (95% confidence interval (95% CI): 0.46-1.66]; P = 0.683]. Duration of viral rebound was 87 days [IQR: 70-110] in intervention participants and 101 days [IQR: 78-213] in controls ( P = 0.423). In the control arm, three patients with confirmed failure were switched to second-line ART. In the intervention arm, of three patients with confirmed failure, switch could initially be avoided in two cases. CONCLUSION Three-monthly viral load testing did not significantly reduce the duration of viraemia when compared with standard-of-care annual viral load testing, providing randomized trial evidence in support of annual viral load monitoring.
Collapse
Affiliation(s)
- Lucas E. Hermans
- Virology, Department of Medical Microbiology, University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
- Ezintsha, University of Witwatersrand, Johannesburg
- Infectious Diseases & HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Rob Ter Heine
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Rob Schuurman
- Virology, Department of Medical Microbiology, University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
| | - Hugo A. Tempelman
- Ezintsha, University of Witwatersrand, Johannesburg
- Ndlovu Research Consortium, Elandsdoorn, South Africa
| | - David M. Burger
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Walter L.J.M. Deville
- Ndlovu Research Consortium, Elandsdoorn, South Africa
- Julius Global Health, The Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - Dorien De Jong
- Virology, Department of Medical Microbiology, University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
| | - Willem D.F. Venter
- Ezintsha, University of Witwatersrand, Johannesburg
- Ndlovu Research Consortium, Elandsdoorn, South Africa
| | - Monique Nijhuis
- Virology, Department of Medical Microbiology, University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
- Ndlovu Research Consortium, Elandsdoorn, South Africa
- HIV Pathogenesis Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Annemarie M.J. Wensing
- Virology, Department of Medical Microbiology, University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
- Ezintsha, University of Witwatersrand, Johannesburg
- Ndlovu Research Consortium, Elandsdoorn, South Africa
| |
Collapse
|
6
|
Keene CM, Ragunathan A, Euvrard J, English M, McKnight J, Orrell C. Measuring patient engagement with HIV care in sub-Saharan Africa: a scoping study. J Int AIDS Soc 2022; 25:e26025. [PMID: 36285618 PMCID: PMC9597383 DOI: 10.1002/jia2.26025] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 09/27/2022] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Engagement with HIV care is a multi-dimensional, dynamic process, critical to maintaining successful treatment outcomes. However, measures of engagement are not standardized nor comprehensive. This undermines our understanding of the scope of challenges with engagement and whether interventions have an impact, complicating patient and programme-level decision-making. This study identified and characterized measures of engagement to support more consistent and comprehensive evaluation. METHODS We conducted a scoping study to systematically categorize measures the health system could use to evaluate engagement with HIV care for those on antiretroviral treatment. Key terms were used to search literature databases (Embase, PsychINFO, Ovid Global-Health, PubMed, Scopus, CINAHL, Cochrane and the World Health Organization Index Medicus), Google Scholar and stakeholder-identified manuscripts, ultimately including English evidence published from sub-Saharan Africa from 2014 to 2021. Measures were extracted, organized, then reviewed with key stakeholders. RESULTS AND DISCUSSION We screened 14,885 titles/abstracts, included 118 full-texts and identified 110 measures of engagement, categorized into three engagement dimensions ("retention," "adherence" and "active self-management"), a combination category ("multi-dimensional engagement") and "treatment outcomes" category (e.g. viral load as an end-result reflecting that engagement occurred). Retention reflected status in care, continuity of attendance and visit timing. Adherence was assessed by a variety of measures categorized into primary (prescription not filled) and secondary measures (medication not taken as directed). Active self-management reflected involvement in care and self-management. Three overarching use cases were identified: research to make recommendations, routine monitoring for quality improvement and strategic decision-making and assessment of individual patients. CONCLUSIONS Heterogeneity in conceptualizing engagement with HIV care is reflected by the broad range of measures identified and the lack of consensus on "gold-standard" indicators. This review organized metrics into five categories based on the dimensions of engagement; further work could identify a standardized, minimum set of measures useful for comprehensive evaluation of engagement for different use cases. In the interim, measurement of engagement could be advanced through the assessment of multiple categories for a more thorough evaluation, conducting sensitivity analyses with commonly used measures for more comparable outputs and using longitudinal measures to evaluate engagement patterns. This could improve research, programme evaluation and nuanced assessment of individual patient engagement in HIV care.
Collapse
Affiliation(s)
- Claire M. Keene
- Health Systems CollaborativeOxford Centre for Global Health ResearchNuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Ayesha Ragunathan
- Health Systems CollaborativeOxford Centre for Global Health ResearchNuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Mike English
- Health Systems CollaborativeOxford Centre for Global Health ResearchNuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Jacob McKnight
- Health Systems CollaborativeOxford Centre for Global Health ResearchNuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Catherine Orrell
- Department of MedicineFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | | |
Collapse
|
7
|
Keene CM, Ragunathan A, Euvrard J, English M, McKnight J, Orrell C. Measuring patient engagement with HIV care in sub-Saharan Africa: a scoping study. J Int AIDS Soc 2022; 25:e26025. [PMID: 36285618 PMCID: PMC9597383 DOI: 10.1002/jia2.26025/full|10.1002/jia2.26025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 09/27/2022] [Indexed: 05/22/2023] Open
Abstract
INTRODUCTION Engagement with HIV care is a multi-dimensional, dynamic process, critical to maintaining successful treatment outcomes. However, measures of engagement are not standardized nor comprehensive. This undermines our understanding of the scope of challenges with engagement and whether interventions have an impact, complicating patient and programme-level decision-making. This study identified and characterized measures of engagement to support more consistent and comprehensive evaluation. METHODS We conducted a scoping study to systematically categorize measures the health system could use to evaluate engagement with HIV care for those on antiretroviral treatment. Key terms were used to search literature databases (Embase, PsychINFO, Ovid Global-Health, PubMed, Scopus, CINAHL, Cochrane and the World Health Organization Index Medicus), Google Scholar and stakeholder-identified manuscripts, ultimately including English evidence published from sub-Saharan Africa from 2014 to 2021. Measures were extracted, organized, then reviewed with key stakeholders. RESULTS AND DISCUSSION We screened 14,885 titles/abstracts, included 118 full-texts and identified 110 measures of engagement, categorized into three engagement dimensions ("retention," "adherence" and "active self-management"), a combination category ("multi-dimensional engagement") and "treatment outcomes" category (e.g. viral load as an end-result reflecting that engagement occurred). Retention reflected status in care, continuity of attendance and visit timing. Adherence was assessed by a variety of measures categorized into primary (prescription not filled) and secondary measures (medication not taken as directed). Active self-management reflected involvement in care and self-management. Three overarching use cases were identified: research to make recommendations, routine monitoring for quality improvement and strategic decision-making and assessment of individual patients. CONCLUSIONS Heterogeneity in conceptualizing engagement with HIV care is reflected by the broad range of measures identified and the lack of consensus on "gold-standard" indicators. This review organized metrics into five categories based on the dimensions of engagement; further work could identify a standardized, minimum set of measures useful for comprehensive evaluation of engagement for different use cases. In the interim, measurement of engagement could be advanced through the assessment of multiple categories for a more thorough evaluation, conducting sensitivity analyses with commonly used measures for more comparable outputs and using longitudinal measures to evaluate engagement patterns. This could improve research, programme evaluation and nuanced assessment of individual patient engagement in HIV care.
Collapse
Affiliation(s)
- Claire M. Keene
- Health Systems CollaborativeOxford Centre for Global Health ResearchNuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Ayesha Ragunathan
- Health Systems CollaborativeOxford Centre for Global Health ResearchNuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Mike English
- Health Systems CollaborativeOxford Centre for Global Health ResearchNuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Jacob McKnight
- Health Systems CollaborativeOxford Centre for Global Health ResearchNuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Catherine Orrell
- Department of MedicineFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | | |
Collapse
|
8
|
Mesic A, Decroo T, Mar HT, Jacobs BKM, Thandar MP, Thwe TT, Kyaw AA, Sangma M, Beversluis D, Bermudez-Aza E, Spina A, Aung DPP, Piriou E, Ritmeijer K, Van Olmen J, Oo HN, Lynen L. Viraemic-time predicts mortality among people living with HIV on second-line antiretroviral treatment in Myanmar: A retrospective cohort study. PLoS One 2022; 17:e0271910. [PMID: 35905123 PMCID: PMC9337705 DOI: 10.1371/journal.pone.0271910] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 07/08/2022] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Despite HIV viral load (VL) monitoring being serial, most studies use a cross-sectional design to evaluate the virological status of a cohort. The objective of our study was to use a simplified approach to calculate viraemic-time: the proportion of follow-up time with unsuppressed VL above the limit of detection. We estimated risk factors for higher viraemic-time and whether viraemic-time predicted mortality in a second-line antiretroviral treatment (ART) cohort in Myanmar. METHODS We conducted a retrospective cohort analysis of people living with HIV (PLHIV) who received second-line ART for a period >6 months and who had at least two HIV VL test results between 01 January 2014 and 30 April 2018. Fractional logistic regression assessed risk factors for having higher viraemic-time and Cox proportional hazards regression assessed the association between viraemic-time and mortality. Kaplan-Meier curves were plotted to illustrate survival probability for different viraemic-time categories. RESULTS Among 1,352 participants, 815 (60.3%) never experienced viraemia, and 172 (12.7%), 214 (15.8%), and 80 (5.9%) participants were viraemic <20%, 20-49%, and 50-79% of their total follow-up time, respectively. Few (71; 5.3%) participants were ≥80% of their total follow-up time viraemic. The odds for having higher viraemic-time were higher among people with a history of injecting drug use (aOR 2.01, 95% CI 1.30-3.10, p = 0.002), sex workers (aOR 2.10, 95% CI 1.11-4.00, p = 0.02) and patients treated with lopinavir/ritonavir (vs. atazanavir; aOR 1.53, 95% CI 1.12-2.10, p = 0.008). Viraemic-time was strongly associated with mortality hazard among those with 50-79% and ≥80% viraemic-time (aHR 2.92, 95% CI 1.21-7.10, p = 0.02 and aHR 2.71, 95% CI 1.22-6.01, p = 0.01). This association was not observed in those with viraemic-time <50%. CONCLUSIONS Key populations were at risk for having a higher viraemic-time on second-line ART. Viraemic-time predicts clinical outcomes. Differentiated services should target subgroups at risk for a higher viraemic-time to control both HIV transmission and mortality.
Collapse
Affiliation(s)
- Anita Mesic
- Public Health Department, Médecins Sans Frontières, Amsterdam, The Netherlands
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Tom Decroo
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Research Foundation Flanders, Brussels, Belgium
| | - Htay Thet Mar
- Medical Department, Médecins Sans Frontières, Yangon, Myanmar
| | - Bart K. M. Jacobs
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Thin Thin Thwe
- Medical Department, Médecins Sans Frontières, Yangon, Myanmar
| | - Aung Aung Kyaw
- Medical Department, Médecins Sans Frontières, Yangon, Myanmar
| | - Mitchell Sangma
- Medical Department, Médecins Sans Frontières, Yangon, Myanmar
| | - David Beversluis
- Public Health Department, Médecins Sans Frontières, Amsterdam, The Netherlands
| | - Elkin Bermudez-Aza
- Public Health Department, Médecins Sans Frontières, Amsterdam, The Netherlands
| | - Alexander Spina
- Public Health Department, Médecins Sans Frontières, Amsterdam, The Netherlands
- University of Exeter Medical School, Exeter, United Kingdom
| | | | - Erwan Piriou
- Public Health Department, Médecins Sans Frontières, Amsterdam, The Netherlands
| | - Koert Ritmeijer
- Public Health Department, Médecins Sans Frontières, Amsterdam, The Netherlands
| | - Josefien Van Olmen
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Family Medicine and Population Health, University of Antwerp, Antwerpen, Belgium
| | - Htun Nyunt Oo
- National AIDS Programme, Ministry of Health and Sport, Naypyidaw, Myanmar
| | - Lutgarde Lynen
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| |
Collapse
|
9
|
Abstract
PURPOSE OF REVIEW HIV-1 drug resistance (HIV DR) testing is routinely performed by genotyping plasma viruses using Sanger population sequencing. Next-generation sequencing (NGS) is increasingly replacing standardized Sanger sequencing. This opens up new opportunities, but also brings challenges. RECENT FINDINGS The number of NGS applications and protocols for HIV DR testing is increasing. All of them are noninferior to Sanger sequencing when comparing NGS-derived consensus sequences to Sanger sequencing-derived sequences. In addition, NGS enables high-throughput sequencing of near full-length HIV-1 genomes and detection of low-abundance drug-resistant HIV-1 variants, although their clinical implications need further investigation. Several groups have defined remaining challenges in implementing NGS protocols for HIV-1 resistance testing. Some of them are already being addressed. One of the most important needs is quality management and consequently, if possible, standardization. SUMMARY The use of NGS technologies on HIV DR testing will allow unprecedented insights into genomic structures of virus populations that may be of immediate relevance to both clinical and research areas such as personalized antiretroviral treatment. Efforts continue to tackle the remaining challenges in NGS-based HIV DR testing.
Collapse
|
10
|
Castillo‐Mancilla JR, Edwards JA, Brijkumar J, Moosa M, Zhao Y, Ofotokun I, Johnson BA, Lee MH, Pillay S, Pillay M, Moodley P, Kuritzkes DR, Sunpath H, Bushman LR, Ellison L, Anderson PL, Marconi VC. Tenofovir diphosphate levels in dried blood spots are associated with virologic failure and resistance to first-line therapy in South Africa: a case-control cohort study. J Int AIDS Soc 2021; 24:e25849. [PMID: 34910844 PMCID: PMC8673924 DOI: 10.1002/jia2.25849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 11/02/2021] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Tenofovir diphosphate (TFV-DP) in dried blood spots (DBS), a measure of cumulative antiretroviral therapy (ART) adherence, is associated with viral suppression and predicts future viremia in persons with HIV (PWH). However, its utility to identify those at risk for virologic failure (VF) and drug resistance is unknown. To address this, we aimed to establish the association between this adherence biomarker and VF with drug resistance in a cohort of PWH initiating first-line ART in KwaZulu-Natal, South Africa. METHODS PWH initiating TFV disoproxil fumarate (TDF)-based ART within a parent prospective cohort were evaluated. Using a nested design, DBS for TFV-DP were collected from cases who developed VF (HIV-1 RNA ≥1000 copies/ml) after ≥5 months on ART versus controls, matched 1:2 by site, age, gender, race and ART duration. Cases were categorized as having VF with or without resistance using genotyping. One-way analysis of variance (ANOVA) was used to compare TFV-DP for controls, cases with VF and resistance, and cases with VF without resistance. Data are presented as mean (standard deviation, SD) or geometric mean [95% confidence interval, 95% CI]. RESULTS AND DISCUSSION One thousand participants were enrolled in the parent study between 2014 and 2016, of which 288 (29%) had DBS available. Of these, 94 (33%) were cases and 194 (67%) were controls; 59% were women. Mean age of our population was 33 (SD 8) years. Genotyping was available in 50 (53%) of the 94 cases. Geometric mean TFV-DP in DBS from controls was 708 [95% CI; 647-773] fmol/punch, which was higher compared to participants having VF with resistance (n = 36), 386 [95% CI; 241-617] fmol/punch and VF without resistance (n = 14), 61 [95% CI; 22-164] fmol/punch; p<0.001. Genotype could not be obtained in 44 (47%) cases. CONCLUSIONS TFV-DP in DBS showed a stepwise association with VF and drug resistance in South African PWH. Participants having VF with resistance had mid-range concentrations of TFV-DP, which were higher than those for PWH without resistance. Future research on the clinical utility of TFV-DP concentrations in DBS to predict and prevent the development of VF and drug resistance is needed.
Collapse
Affiliation(s)
- Jose R. Castillo‐Mancilla
- Division of Infectious DiseasesDepartment of MedicineUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Johnathan A. Edwards
- Division of Infectious DiseasesDepartment of MedicineEmory University School of MedicineAtlantaGeorgiaUSA
- School of Health and Social CareUniversity of LincolnLincolnUK
| | | | | | - Yuan Zhao
- Division of Infectious DiseasesDepartment of MedicineEmory University School of MedicineAtlantaGeorgiaUSA
| | - Igho Ofotokun
- Division of Infectious DiseasesDepartment of MedicineEmory University School of MedicineAtlantaGeorgiaUSA
| | - Brent A. Johnson
- Department of Biostatistics and Computational BiologyUniversity of RochesterRochesterNew YorkUSA
| | - Mitchell H. Lee
- Division of Infectious DiseasesDepartment of MedicineEmory University School of MedicineAtlantaGeorgiaUSA
| | - Selvan Pillay
- National Health Laboratory ServiceDurbanSouth Africa
| | | | - Pravi Moodley
- National Health Laboratory ServiceDurbanSouth Africa
- University of KwaZulu‐NatalDurbanSouth Africa
| | - Daniel R. Kuritzkes
- Divison of Infectious DiseasesBrigham and Women's HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Henry Sunpath
- National Health Laboratory ServiceDurbanSouth Africa
| | - Lane R. Bushman
- Division of Infectious DiseasesDepartment of MedicineUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Lucas Ellison
- Division of Infectious DiseasesDepartment of MedicineUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Peter L. Anderson
- Division of Infectious DiseasesDepartment of MedicineUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Vincent C. Marconi
- Division of Infectious DiseasesDepartment of MedicineEmory University School of MedicineAtlantaGeorgiaUSA
- Rollins School of Public HealthEmory UniversityAtlantaGeorgiaUSA
- Emory Vaccine CenterEmory UniversityAtlantaGeorgiaUSA
| |
Collapse
|
11
|
Chimukangara B, Lessells RJ, Singh L, Grigalionyte I, Yende-Zuma N, Adams R, Dawood H, Dlamini L, Buthelezi S, Chetty S, Diallo K, Duffus WA, Mogashoa M, Hagen MB, Giandhari J, de Oliveira T, Moodley P, Padayatchi N, Naidoo K. Acquired HIV drug resistance and virologic monitoring in a HIV hyper-endemic setting in KwaZulu-Natal Province, South Africa. AIDS Res Ther 2021; 18:74. [PMID: 34656129 PMCID: PMC8520607 DOI: 10.1186/s12981-021-00393-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 09/22/2021] [Indexed: 11/17/2022] Open
Abstract
Background Introduction of tenofovir (TDF) plus lamivudine (3TC) and dolutegravir (DTG) in first- and second-line HIV treatment regimens in South Africa warrants characterization of acquired HIV-1 drug resistance (ADR) mutations that could impact DTG-based antiretroviral therapy (ART). In this study, we sought to determine prevalence of ADR mutations and their potential impact on susceptibility to drugs used in combination with DTG among HIV-positive adults (≥ 18 years) accessing routine care at a selected ART facility in KwaZulu-Natal, South Africa. Methods We enrolled adult participants in a cross-sectional study between May and September 2019. Eligible participants had a most recent documented viral load (VL) ≥ 1000 copies/mL after at least 6 months on ART. We genotyped HIV-1 reverse transcriptase and protease genes by Sanger sequencing and assessed ADR. We characterized the effect of ADR mutations on the predicted susceptibility to drugs used in combination with DTG. Results From 143 participants enrolled, we obtained sequence data for 115 (80%), and 92.2% (95% CI 85.7–96.4) had ADR. The proportion with ADR was similar for participants on first-line ART (65/70, 92.9%, 95% CI 84.1–97.6) and those on second-line ART (40/44, 90.9%, 95% CI 78.3–97.5), and was present for the single participant on third-line ART. Approximately 89% (62/70) of those on first-line ART had dual class NRTI and NNRTI resistance and only six (13.6%) of those on second-line ART had major PI mutations. Most participants (82%) with first-line viraemia maintained susceptibility to Zidovudine (AZT), and the majority of them had lost susceptibility to TDF (71%) and 3TC (84%). Approximately two in every five TDF-treated individuals had thymidine analogue mutations (TAMs). Conclusions Susceptibility to AZT among most participants with first-line viraemia suggests that a new second-line regimen of AZT + 3TC + DTG could be effective. However, atypical occurrence of TAMs in TDF-treated individuals suggests a less effective AZT + 3TC + DTG regimen in a subpopulation of patients. As most patients with first-line viraemia had at least low-level resistance to TDF and 3TC, identifying viraemia before switch to TDF + 3TC + DTG is important to avoid DTG functional monotherapy. These findings highlight a need for close monitoring of outcomes on new standardized treatment regimens. Supplementary Information The online version contains supplementary material available at 10.1186/s12981-021-00393-5.
Collapse
|
12
|
Johnson KA, Okochi H, Glidden DV, Gandhi M, Spinelli M. Brief Report: No Difference in Urine Tenofovir Levels in Patients Living With HIV on Unboosted Versus Dose-Adjusted Boosted Tenofovir Alafenamide. J Acquir Immune Defic Syndr 2021; 88:57-60. [PMID: 33990489 PMCID: PMC8373700 DOI: 10.1097/qai.0000000000002727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 04/28/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Tenofovir alafenamide (TAF) is increasingly used in HIV treatment, with or without agents that require pharmacologic boosters such as ritonavir/cobicistat. Boosters increase TAF levels, so the TAF dose is lowered in single-pill combinations. We hypothesized that individuals on dose-adjusted boosted TAF would have similar urine tenofovir (TFV) concentrations to those on unboosted TAF. SETTING/METHODS We collected urine samples from patients with HIV on TAF, with evidence of virologic suppression and high self-reported adherence at 2 San Francisco clinics from June 2019 to January 2020. We measured urine TFV levels by liquid chromatography/tandem mass spectrometry and used linear regression to compare natural log-transformed urine TFV levels for patients on boosted versus unboosted TAF. RESULTS Our analysis included 30 patients on unboosted TAF (25 mg daily TAF) and 15 on boosted TAF (12 on 10 mg daily TAF and 3 on 25 mg daily TAF). Patients on unboosted vs. boosted TAF had similar baseline age, weight, sex, and creatinine. In unadjusted univariate linear regression, there were no significant differences in urine TFV levels based on presence/absence of boosting after TAF dose reduction to 10 mg (geometric mean ratio 1.07; 95% confidence interval: 0.53 to 2.16). This finding was unchanged in adjusted analysis. CONCLUSIONS No significant differences in urine TFV levels were seen for patients on unboosted vs. boosted dose-reduced TAF. These results have important implications for our forthcoming point-of-care urine immunoassay for TAF, implying that separate adherence cutoffs will not be necessary for patients on boosters and dose-reduced TAF. A single POC TAF immunoassay will, thus, support monitoring on most TAF-based antiretroviral therapy.
Collapse
Affiliation(s)
- Kelly A. Johnson
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Hideaki Okochi
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - David V. Glidden
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA
| | - Monica Gandhi
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Matthew Spinelli
- Department of Medicine, University of California San Francisco, San Francisco, CA
| |
Collapse
|
13
|
Hermans LE, Nijhuis M, Tempelman HA, Houts T, Schuurman R, Burger DM, Wensing AMJ, ter Heine R. Point-of-Care Detection of Nonadherence to Antiretroviral Treatment for HIV-1 in Resource-Limited Settings Using Drug Level Testing for Efavirenz, Lopinavir, and Dolutegravir: A Validation and Pharmacokinetic Simulation Study. J Acquir Immune Defic Syndr 2021; 87:1072-1078. [PMID: 34153013 DOI: 10.1097/qai.0000000000002681] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 12/30/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Virological failure during antiretroviral treatment (ART) may indicate the presence of drug resistance, but may also originate from nonadherence. Qualitative detection of ART components using drug level testing may be used to differentiate between these scenarios. We aimed to validate and implement qualitative point-of-care drug level tests for efavirenz (EFV), lopinavir (LPV), and dolutegravir (DTG) in rural South Africa. METHODS Qualitative performance of immunoassays for EFV, LPV, and DTG was assessed by calculating limit of detection (LoD), region of uncertainty, and qualitative agreement with a reference test. Minimum duration of nonadherence resulting in a negative drug level test was assessed by simulation of treatment cessation using validated population pharmacokinetic models. RESULTS LoD was 0.05 mg/L for EFV, 0.06 mg/L for LPV, and 0.02 mg/L for DTG. Region of uncertainty was 0.01-0.06 mg/L for EFV, 0.01-0.07 mg/L for LPV, and 0.01-0.02 mg/L for DTG. Qualitative agreement with reference testing at the LoD in patient samples was 95.2% (79/83) for EFV, 99.3% (140/141) for LPV, and 100% (118/118) for DTG. After simulated treatment cessation, median time to undetectability below LoD was 7 days [interquartile range (IQR) 4-13] for EFV, 30 hours (IQR 24-36) for LPV, and 6 days (IQR 4-7) for DTG. CONCLUSIONS We demonstrate that qualitative ART drug level testing using immunoassays is feasible in a rural resource-limited setting. Implementation of this technology enables reliable detection of recent nonadherence and may allow for rapid and cost-effective differentiation between patients in need for adherence counseling and patients who require drug resistance testing or alternative treatment.
Collapse
Affiliation(s)
- Lucas E Hermans
- Virology, Department of Medical Microbiology, University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
- Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
- Ndlovu Research Consortium, Elandsdoorn, South Africa
| | - Monique Nijhuis
- Virology, Department of Medical Microbiology, University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
- Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
- Ndlovu Research Consortium, Elandsdoorn, South Africa
| | | | - Tom Houts
- ARK Diagnostics, Inc., Fremont, CA; and
| | - Rob Schuurman
- Virology, Department of Medical Microbiology, University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
| | - David M Burger
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Annemarie M J Wensing
- Virology, Department of Medical Microbiology, University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
- Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
- Ndlovu Research Consortium, Elandsdoorn, South Africa
| | - Rob ter Heine
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| |
Collapse
|