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Estill J, Ng’ambi W, Rozanova L, Merzouki A, Keiser O. The spatial spread of HIV in Malawi: An individual-based mathematical model. Heliyon 2023; 9:e21948. [PMID: 38034641 PMCID: PMC10684377 DOI: 10.1016/j.heliyon.2023.e21948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 10/20/2023] [Accepted: 11/01/2023] [Indexed: 12/02/2023] Open
Abstract
Background The prevalence of HIV varies greatly between and within countries. We aimed to build a comprehensive mathematical modelling tool capable of exploring the reasons of this heterogeneity and test its applicability by simulating the Malawian HIV epidemic. Methods We developed a flexible individual-based mathematical model for HIV transmission that comprises a spatial representation and individual-level determinants. We tested this model by calibrating it to the HIV epidemic in Malawi and exploring whether the heterogeneity in HIV prevalence could be reproduced. We ran the model for 1975-2030 with five alternative realizations of the geographical structure and mobility: (I) no geographical structure; 28 administrative districts including (II) only permanent inter-district relocations, (III) inter-district permanent relocations and casual sexual relationships, or (IV) permanent relocations between districts and to/from abroad and inter-district casual sex; and (V) a grid of 10 × 10km2 cells, with permanent relocations and between-cell casual relationships. We assumed HIV was present in 1975 in the districts with >10 % prevalence in 2010. We calibrated the models to national and district-level prevalence estimates. Results Reaching the national prevalence required all adults to have at least 22 casual sex acts/year until 1990. Models II, III and V reproduced the geographical heterogeneity in prevalence in 2010 to some extent if between-district relationships were excluded (Model II; 4.9 %-21.1 %). Long-distance casual partnership mixing mitigated the differences in prevalence substantially (range across districts 4.1%-18.9 % in 2010 in Model III; 4.0%-17.6 % in Model V); with international migration the differences disappeared (Model IV; range across districts 6.9%-13.3 % in 2010). National prevalence decreased to 5 % by 2030. Conclusion Earlier introduction of HIV into the Southern part of Malawi may cause some level of heterogeneity in HIV prevalence. Other factors such as sociobehavioural characteristics are likely to have a major impact and need investigation.
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Affiliation(s)
- Janne Estill
- Institute of Global Health, University of Geneva, Geneva, Switzerland
- School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Wingston Ng’ambi
- College of Medicine, Health Economics and Policy Unit, University of Malawi, Lilongwe, Malawi
| | - Liudmila Rozanova
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Aziza Merzouki
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Olivia Keiser
- Institute of Global Health, University of Geneva, Geneva, Switzerland
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Corlis J, Zhu J, Macul H, Tiberi O, Boothe MAS, Resch SC. Framework for determining the optimal course of action when efficiency and affordability measures differ by perspective in cost-effectiveness analysis-with an illustrative case of HIV treatment in Mozambique. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2023; 21:62. [PMID: 37705101 PMCID: PMC10498553 DOI: 10.1186/s12962-023-00474-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 09/03/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND Cost-effectiveness analysis (CEA) is a standard tool for evaluating health programs and informing decisions about resource allocation and prioritization. Most CEAs evaluating health interventions in low- and middle-income countries adopt a health sector perspective, accounting for resources funded by international donors and country governments, while often excluding out-of-pocket expenditures and time costs borne by program beneficiaries. Even when patients' costs are included, a companion analysis focused on the patient perspective is rarely performed. We view this as a missed opportunity. METHODS We developed methods for assessing intervention affordability and evaluating whether optimal interventions from the health sector perspective also represent efficient and affordable options for patients. We mapped the five different patterns that a comparison of the perspective results can yield into a practical framework, and we provided guidance for researchers and decision-makers on how to use results from multiple perspectives. To illustrate the methodology, we conducted a CEA of six HIV treatment delivery models in Mozambique. We conducted a Monte Carlo microsimulation with probabilistic sensitivity analysis from both patient and health sector perspectives, generating incremental cost-effectiveness ratios for the treatment approaches. We also calculated annualized patient costs for the treatment approaches, comparing the costs with an affordability threshold. We then compared the cost-effectiveness and affordability results from the two perspectives using the framework we developed. RESULTS In this case, the two perspectives did not produce a shared optimal approach for HIV treatment at the willingness-to-pay threshold of 0.3 × Mozambique's annual GDP per capita per DALY averted. However, the clinical 6-month antiretroviral drug distribution strategy, which is optimal from the health sector perspective, is efficient and affordable from the patient perspective. All treatment approaches, except clinical 1-month distributions of antiretroviral drugs which were standard before Covid-19, had an annual cost to patients less than the country's annual average for out-of-pocket health expenditures. CONCLUSION Including a patient perspective in CEAs and explicitly considering affordability offers decision-makers additional insights either by confirming that the optimal strategy from the health sector perspective is also efficient and affordable from the patient perspective or by identifying incongruencies in value or affordability that could affect patient participation.
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Affiliation(s)
| | - Jinyi Zhu
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN USA
| | - Hélder Macul
- Programa Nacional de Controle de ITS-HIV/SIDA, Ministério da Saúde, Maputo, Mozambique
| | - Orrin Tiberi
- Programa Nacional de Controle de ITS-HIV/SIDA, Ministério da Saúde, Maputo, Mozambique
| | | | - Stephen C. Resch
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA USA
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Gidey K, Mache A, Hailu BY, Asgedom SW, Tassew SG, Nirayo YL. Second-Line Antiretroviral Treatment Outcomes and Predictors in Tigray Region, Ethiopia. Infect Drug Resist 2023; 16:4903-4912. [PMID: 37534062 PMCID: PMC10390760 DOI: 10.2147/idr.s419348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 07/21/2023] [Indexed: 08/04/2023] Open
Abstract
Introduction Ethiopia has one of the highest HIV burdens in sub-Saharan Africa. Despite the fact that second-line antiretroviral therapy (ART) has been available for more than ten years, studies on its effectiveness are scarce. Objective To assess treatment outcomes and predictors of unfavorable outcomes in HIV patients receiving second-line ART at Ayder Comprehensive Specialized Hospital and Mekelle Hospital. Materials and Methods An institution-based retrospective cohort study was conducted in two hospitals in Tigray Region, Ethiopia. We evaluated 192 patients aged ≥15 years who were switched to second-line from November 2009 to May 2020 after failure of first-line ART. The primary outcome was the time from the initiation of second-line ART to the occurrence of unfavorable treatment outcomes (treatment failure, death, and loss to follow-up). We performed Kaplan-Meier survival estimates to calculate the cumulative incidence rates of unfavorable outcomes. Results The mean age (SD) at the initiation of second-line ART was 39 (10.03) years, and the median CD4 cell count was 121 cells/microL. During a median follow-up of 4.6 years, 24 (12.5%) patients had died, 11 (5.7%) patients were lost to follow up, and 47 (24,4%) patients were experienced treatment failure. The incidence rates for unfavorable outcomes were 7.8 per 100 patients/years. Predictors for unfavorable outcomes were body mass index (BMI) <18.5 (adjusted hazard ratio [aHR] = 2.51, 95% confidence interval (CI): 1.27-4.95) and CD4 counts ≤100 cells/microL (aHR = 1.74, 95% CI: 1.09-2.79). Despite the failure of second-line ART, none of the patients received third-line ART. Conclusion The incidence rate of unfavorable treatment outcomes for second-line ART was found to be high. A low BMI and a low baseline CD4 count were significant predictors of unfavourable outcomes and should be given special consideration in HIV care. A third-line ART regimen should also be considered for people who have failed second-line ART.
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Affiliation(s)
- Kidu Gidey
- Department of Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Abadi Mache
- Department of Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Berhane Yohannes Hailu
- Department of Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Solomon Weldegebreal Asgedom
- Department of Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Segen Gebremeskel Tassew
- Department of Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Yirga Legesse Nirayo
- Department of Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
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Addisu T, Tilahun M, Wedajo S, Sharew B. Trends Analysis of HIV Infection and Antiretroviral Treatment Outcome in Amhara Regional from 2015 to 2021, Northeast Ethiopia. HIV AIDS (Auckl) 2023; 15:399-410. [PMID: 37426768 PMCID: PMC10329428 DOI: 10.2147/hiv.s411235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 06/30/2023] [Indexed: 07/11/2023] Open
Abstract
Background The persistent efforts of HIV/AIDS epidemiology remain one of the world's most important community health threats. To avoid becoming an epidemic, UNAIDS has set three 90% fast-track targets for 2020, and Ethiopia has also changed its implementation since 2015. However, the achievement targets in the Amhara region have yet to be evaluated at the end of the programme period. Objective The aim of this study was to assess the Trends of HIV Infection and Antiretroviral Treatment outcome in Eastern Amhara Regional from 2015 to 2021, Northeast Ethiopia. Methods A retrospective study was conducted by reviewing the District Health Information System from 2015 to 2021. The collected data includes the trend of HIV testing services, the trend of HIV positivity, the yield of HIV testing approaches, the number of HIV positive patients linked to HIV care and treatment or access to lifelong antiretroviral therapy, viral load testing coverage, and viral suppression. A descriptive statistic and trend analysis were computed. Results A total of 145,639 people accessed antiretroviral therapy. The trend of HIV test positivity has been declining since 2015, peaking at 0.76% in 2015 and declining to 0.60% in 2020. A high level of positivity was reported in volunteer counselling and testing as compared with provider-initiated testing and counselling services. Following an HIV positive, there was an increase in linkage to HIV care and treatment. High suppression rates of viral load indicate testing coverage grew over time. The viral load monitoring coverage was 70% in 2021, with a viral suppression rate of 94%. Conclusion and Recommendations The trend in achievement in the first 90s was not consistent with predefined goals (90%). On the other hand, there was good achievement in the second and third goals. Hence, intensified case-finding approaches to HIV testing should be strengthened.
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Affiliation(s)
- Tseganew Addisu
- Department of Dental Medicine, School of Medicine, College of Medicine and Health Science, Wollo University, Dessie, Ethiopia
| | - Mihret Tilahun
- Department of Medical Laboratory Sciences, College of Medicine and Health Science, Wollo University, Dessie, Ethiopia
| | - Shambel Wedajo
- School of Public Health, College of Medicine and Health Science, Wollo University, Dessie, Ethiopia
| | - Bekele Sharew
- Department of Medical Laboratory Sciences, College of Medicine and Health Science, Wollo University, Dessie, Ethiopia
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Nhemachena T, Späth C, Arendse KD, Lebelo K, Zokufa N, Cassidy T, Whitehouse K, Keene CM, Swartz A. Between empathy and anger: healthcare workers' perspectives on patient disengagement from antiretroviral treatment in Khayelitsha, South Africa - a qualitative study. BMC PRIMARY CARE 2023; 24:34. [PMID: 36698083 PMCID: PMC9878968 DOI: 10.1186/s12875-022-01957-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 12/23/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND & OBJECTIVES The benefits of long-term adherence to antiretroviral therapy (ART) are countered by interruptions in care or disengagement from care. Healthcare workers (HCWs) play an important role in patient engagement and negative or authoritarian attitudes can drive patients to disengage. However, little is known about HCWs' perspectives on disengagement. We explored HCWs' perspectives on ART disengagement in Khayelitsha, a peri-urban area in South Africa with a high HIV burden. METHOD Semi-structured interviews were conducted with 30 HCWs in a primary care HIV clinic to explore their perspectives of patients who disengage from ART. HCWs interviewed included clinical (doctors and nurses) and support staff (counsellors, social workers, data clerks, security guards, and occupational therapists). The interview guide asked HCWs about their experience working with patients who interrupt treatment and return to care. Transcripts were audio-recorded, transcribed, and analysed using an inductive thematic analysis approach. RESULTS Most participants were knowledgeable about the complexities of disengagement and barriers to sustaining engagement with ART, raising their concerns that disengagement poses a significant public health problem. Participants expressed empathy for patients who interrupted treatment, particularly when the challenges that led to their disengagement were considered reasonable by the HCWs. However, many also expressed feelings of anger and frustration towards these patients, partly because they reported an increase in workload as a result. Some staff, mainly those taking chronic medication themselves, perceived patients who disengage from ART as not taking adequate responsibility for their own health. CONCLUSION Lifelong engagement with HIV care is influenced by many factors including disclosure, family support, and HCW interactions. Findings from this study show that HCWs had contradictory feelings towards disengaged patients, experiencing both empathy and anger. Understanding this could contribute to the development of more nuanced interventions to support staff and encourage true person-centred care, to improve patient outcomes.
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Affiliation(s)
- Tsephiso Nhemachena
- grid.7836.a0000 0004 1937 1151School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Carmen Späth
- grid.7836.a0000 0004 1937 1151School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Kirsten D. Arendse
- grid.452731.60000 0004 4687 7174Médecins Sans Frontières, Khayelitsha Project, Cape Town, South Africa
| | - Keitumetse Lebelo
- grid.452731.60000 0004 4687 7174Médecins Sans Frontières, Khayelitsha Project, Cape Town, South Africa
| | - Nompumelelo Zokufa
- grid.452731.60000 0004 4687 7174Médecins Sans Frontières, Khayelitsha Project, Cape Town, South Africa
| | - Tali Cassidy
- grid.7836.a0000 0004 1937 1151School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa ,grid.452731.60000 0004 4687 7174Médecins Sans Frontières, Khayelitsha Project, Cape Town, South Africa
| | - Katherine Whitehouse
- grid.452731.60000 0004 4687 7174Médecins Sans Frontières, Southern African Medical Unit, Cape Town, South Africa
| | - Claire M. Keene
- grid.452731.60000 0004 4687 7174Médecins Sans Frontières, Khayelitsha Project, Cape Town, South Africa ,grid.4991.50000 0004 1936 8948Health Systems Collaborative, Oxford Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Alison Swartz
- grid.7836.a0000 0004 1937 1151School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa ,grid.8356.80000 0001 0942 6946Department of Psychosocial and Psychoanalytic Studies, University of Essex, Essex, England
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Durability of switched therapy after failure of WHO-recommended antiretroviral therapy regimens in a resource-limited setting. AIDS 2022; 36:1791-1800. [PMID: 35876663 DOI: 10.1097/qad.0000000000003340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The study investigated the durability of switched therapy and factors associated with the viral rebound among patients on second-line antiretroviral therapy (ART) in Uganda. DESIGN A retrospective dynamic cohort of adults initiated on second-line ART after virological failure to first-line ART. METHODS Patients on second-line treatment for at least 6 months between 2007 and 2017 were included. Patients were followed, until they experienced a viral rebound (viral load ≥200 copies/ml). Cumulative probability of viral rebounds and factors associated with viral rebound were determined using Kaplan-Meier methods and Cox proportional hazard models. RESULTS One thousand, one hundred and one participants were enrolled of which 64% were women, the median age was 37 years [interquartile range (IQR) 31-43]. The preswitch median CD4 + cell count and viral load were 128 cells/μl (IQR 58-244) and 45 978 copies/ml (IQR 13 827-139 583), respectively. During the 4190.37 person-years, the incidence rate of viral rebound was 83.29 [95% confidence interval (CI) 74.99-92.49] per 1000 person-years. The probability of viral rebound at 5 and 10 years was 0.29 (95% CI 0.26-0.32) and 0.62 (95% CI 0.55-0.69), respectively. The median rebound-free survival was 8.7 years. Young adults (18-24 years) [adjusted hazard ratio (aHR) 2.49, 95% CI 1.32-4.67], preswitch viral load at least 100 000 copies/ml (aHR 1.53, 95% CI 1.22-1.92), and atazanavir/ritonavir (ATV/r)-based second-line (aHR 1.73, 95% CI 1.29-2.32) were associated with an increased risk of viral rebound. CONCLUSION Switched therapies are durable for 8 years after failure of recommended regimens. A high preswitch viral load, ATV/r-based regimens, and young adulthood are risk factors for viral rebound, which underscores the need for more durable regimens and differentiated care services.
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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.
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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
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Pham MD, Nguyen HV, Anderson D, Crowe S, Luchters S. Viral load monitoring for people living with HIV in the era of test and treat: progress made and challenges ahead - a systematic review. BMC Public Health 2022; 22:1203. [PMID: 35710413 PMCID: PMC9202111 DOI: 10.1186/s12889-022-13504-2] [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: 11/18/2021] [Accepted: 05/24/2022] [Indexed: 11/10/2022] Open
Abstract
Background In 2016, we conducted a systematic review to assess the feasibility of treatment monitoring for people living with HIV (PLHIV) receiving antiretroviral therapy (ART) in low and middle-income countries (LMICs), in line with the 90-90-90 treatment target. By 2020, global estimates suggest the 90-90-90 target, particularly the last 90, remains unattainable in many LMICs. This study aims to review the progress and identify needs for public health interventions to improve viral load monitoring and viral suppression for PLHIV in LMICs. Methods A literature search was conducted using an update of the initial search strategy developed for the 2016 review. Electronic databases (Medline and PubMed) were searched to identify relevant literature published in English between Dec 2015 and August 2021. The primary outcome was initial viral load (VL) monitoring (the proportion of PLHIV on ART and eligible for VL monitoring who received a VL test). Secondary outcomes included follow-up VL monitoring (the proportion of PLHIV who received a follow-up VL after an initial elevated VL test), confirmation of treatment failure (the proportion of PLHIV who had two consecutive elevated VL results) and switching treatment regimen rates (the proportion of PLHIV who switched treatment regimen after confirmation of treatment failure). Results The search strategy identified 1984 non-duplicate records, of which 34 studies were included in the review. Marked variations in initial VL monitoring coverage were reported across study settings/countries (range: 12–93% median: 74% IQR: 46–82%) and study populations (adults (range: 25–96%, median: 67% IQR: 50–84%), children, adolescents/young people (range: 2–94%, median: 72% IQR: 47–85%), and pregnant women (range: 32–82%, median: 57% IQR: 43–71%)). Community-based models reported higher VL monitoring (median: 85%, IQR: 82-88%) compared to decentralised care at primary health facility (median: 64%, IRQ: 48-82%). Suboptimal uptake of follow-up VL monitoring and low regimen switching rates were observed. Conclusions Substantial gaps in VL coverage across study settings and study populations were evident, with limited data availability outside of sub-Saharan Africa. Further research is needed to fill the data gaps. Development and implementation of innovative, community-based interventions are required to improve VL monitoring and address the “failure cascade” in PLHIV on ART who fail to achieve viral suppression.
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Affiliation(s)
- Minh D Pham
- Burnet Institute, Melbourne, Australia. .,Department of Epidemiology and Preventive Medicine, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Australia.
| | - Huy V Nguyen
- Health Innovation and Transformation Centre, Federation University, Victoria, Australia.,School of Medicine and Dentistry, Griffith University, Brisbane, Australia
| | - David Anderson
- Burnet Institute, Melbourne, Australia.,Department of Microbiology, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Australia
| | - Suzanne Crowe
- Burnet Institute, Melbourne, Australia.,Central Clinical School, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Australia
| | - Stanley Luchters
- Department of Epidemiology and Preventive Medicine, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Australia.,Centre for Sexual Health and HIV & AIDS Research, Harare, Zimbabwe.,Department of Public health and Primary care, Ghent University, Ghent, Belgium
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Avihingsanon A, Hughes MD, Salata R, Godfrey C, McCarthy C, Mugyenyi P, Hogg E, Gross R, Cardoso SW, Bukuru A, Makanga M, Badal‐aesen S, Mave V, Ndege BW, Fontain SN, Samaneka W, Secours R, Van Schalkwyk M, Mngqibisa R, Mohapi L, Valencia J, Sugandhavesa P, Montalban E, Munyanga C, Chagomerana M, Santos BR, Kumarasamy N, Kanyama C, Schooley RT, Mellors JW, Wallis CL, Collier AC, Grinsztejn B. Third‐line antiretroviral therapy, including raltegravir (RAL), darunavir (DRV/r) and/or etravirine (ETR), is well tolerated and achieves durable virologic suppression over 144 weeks in resource‐limited settings: ACTG A5288 strategy trial. J Int AIDS Soc 2022; 25:e25905. [PMID: 36039892 PMCID: PMC9332128 DOI: 10.1002/jia2.25905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 03/23/2022] [Indexed: 11/22/2022] Open
Abstract
Introduction ACTG A5288 was a strategy trial conducted in diverse populations from multiple continents of people living with HIV (PLWH) failing second‐line protease inhibitor (PI)‐based antiretroviral therapy (ART) from 10 low‐ and middle‐income countries (LMICs). Participants resistant to lopinavir (LPV) and/or multiple nucleotide reverse transcriptase inhibitors started on third‐line regimens that included raltegravir (RAL), darunavir/ritonavir (DRV/r) and/or etravirine (ETR) according to their resistance profiles. At 48 weeks, 87% of these participants achieved HIV‐1 RNA ≤200 copies/ml. We report here long‐term outcomes over 144 weeks. Methods Study participants were enrolled from 2013 to 2015, prior to the availability of dolutegravir in LMICs. “Extended Follow‐up” of the study started after the last participant enrolled had reached 48 weeks and included participants still on antiretroviral (ARV) regimens containing RAL, DRV/r and/or ETR at that time. RAL, DRV/r and ETR were provided for an additional 96 weeks (giving total follow‐up of ≥144 weeks), with HIV‐1 RNA measured at 48 and 96 weeks and CD4 count at 96 weeks after entry into Extended Follow‐up. Proportion of participants with HIV‐1 RNA ≤200 copies/ml was estimated every 24 weeks, using imputation if necessary to handle the different measurement schedule in Extended Follow‐up; mean CD4 count changes were estimated using loess regression. Results and Discussion Of 257 participants (38% females), at study entry, median CD4 count was 179 cells/mm3, and HIV‐1 RNA was 4.6 log10 copies/ml. Median follow‐up was 168 weeks (IQR: 156–204); 15 (6%) participants were lost to follow‐up and 9 (4%) died. 27/246 (11%), 26/246 (11%) and 13/92 (14%) of participants who started RAL, DRV/r and ETR, respectively, discontinued these drugs; only three due to adverse events. 87%, 86%, 83% and 80% of the participants had HIV‐1 RNA ≤200 copies/ml at weeks 48, 96, 144 and 168 (95% CI at week 168: 74–85%), respectively. Mean increase from study entry in CD4 count at week 168 was 265 cells/mm3 (95% CI 247–283). Conclusions Third‐line regimens comprising of RAL, DRV/r and/or ETR were very well tolerated and had high rates of durable virologic suppression among PLWH in LMICs who were failing on second‐line PI‐based ART prior to the availability of dolutegravir.
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Affiliation(s)
- Anchalee Avihingsanon
- HIV‐NAT, Thai Red Cross AIDS Research Centre and Centre of Excellence in Tuberculosis Faculty of Medicine Chulalongkorn University Bangkok Thailand
| | - Michael D. Hughes
- Center for Biostatistics in AIDS Research in the Department of Biostatistics Harvard T H Chan School of Public Health Boston Massachusetts USA
| | | | - Catherine Godfrey
- Division of AIDS National Institutes of Allergy and Infectious Disease National Institutes of Health Bethesda Maryland USA
| | - Caitlyn McCarthy
- Center for Biostatistics in AIDS Research in the Department of Biostatistics Harvard T H Chan School of Public Health Boston Massachusetts USA
| | | | - Evelyn Hogg
- Social & Scientific Systems Inc. a DLH Holdings Company Silver Spring Maryland USA
| | - Robert Gross
- Center for Clinical Epidemiology and Biostatistics University of Pennsylvania Philadelphia Pennsylvania USA
| | - Sandra W. Cardoso
- Instituto Nacional de Infectologia Evandro Chagas Fundacao Oswaldo Cruz Rio de Janeiro Brazil
| | | | - Mumbi Makanga
- Kenya Medical Research Institute/Center of Disease Control Kisumu Kenya
| | - Sharlaa Badal‐aesen
- Clinical HIV Research Unit Helen Joseph Hospital University of Witwatersrand Johannesburg South Africa
| | - Vidya Mave
- BJ Medical College Clinical Research Site Pune India
| | | | | | - Wadzanai Samaneka
- University of Zimbabwe Clinical Trials Research Centre Harare Zimbabwe
| | - Rode Secours
- Les Centres GHESKIO Clinical Research Site Port‐au‐Prince Haiti
| | - Marije Van Schalkwyk
- Family Centre for Research with Ubuntu (FAMCRU) Stellenbosch University Cape Town South Africa
| | - Rosie Mngqibisa
- Durban International Clinical Research Site, King Edward Hospital, Enhancing Care Foundation Durban South Africa
| | - Lerato Mohapi
- Soweto AIDS Clinical Trials Group Clinical Research Site, Perinatal HIV Research Unit University of the Witwatersrand Johannesburg South Africa
| | | | | | | | - Cornelius Munyanga
- University of North Carolina Project, Kamazu Central Hospital Lilongwe Malawi
| | | | | | | | - Cecilia Kanyama
- University of North Carolina Project, Kamazu Central Hospital Lilongwe Malawi
| | - Robert T. Schooley
- Division of Infectious Diseases University of California San Diego California USA
| | - John W. Mellors
- Division of Infectious Diseases Department of Medicine University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - Carole L. Wallis
- BARC‐South Africa and Lancet Laboratories Johannesburg South Africa
| | - Ann C. Collier
- University of Washington School of Medicine University of Washington Seattle Washington USA
| | - Beatriz Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas Fundacao Oswaldo Cruz Rio de Janeiro Brazil
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The role of health facility and individual level characteristics on medication adherence among PLHIV on second-line antiretroviral therapy in Northeast Ethiopia: use of multi-level model. AIDS Res Ther 2022; 19:17. [PMID: 35346245 PMCID: PMC8959555 DOI: 10.1186/s12981-022-00441-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 03/16/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Medication adherence plays a pivotal role in achieving the desired treatment outcomes. The proportion of HIV patients on second-line antiretroviral therapy is becoming a growing public health concern. However, to date, little attention has been given to second-line antiretroviral medication adherence. Moreover, the association between health facility characteristics and medication adherence has yet not been tested. Thus, this research was conducted to determine the magnitude of medication adherence and examine the role of facility-level determinants among HIV patients on second-line ART. METHODS A cross-sectional study was conducted on 714 HIV patients on second-line therapy who were selected via systematic random sampling in twenty public health facilities. Medication adherence was measured using the six-item Simplified Medication Adherence Questionnaire (SMAQ) tool. Data were collected in a personal interview as well as document reviews. A multi-level binary logistic regression was used to uncover individual and facility-level determinants. The effect size was presented using an adjusted odds ratio (AOR), and statistical significance was declared at a P value less than 0.05. RESULTS The magnitude of optimal medication adherence among HIV patients on second-line antiretroviral therapy was 69.5% (65.9-72.7%). Medication adherence was positively associated with the use of adherence reminder methods [AOR = 3.37, (95% CI 2.03-5.62)], having social support [AOR = 1.11, (95% CI 1.02-1.23)], and not having clinical depression [AOR = 3.19, (95% CI 1.93-5.27). The number of adherence counselors [AOR = 1.20, (95% CI 1.04-1.40)], teamwork for enhanced adherence support [AOR = 1.82, (95% CI 1.01-3.42)], and caseloads at ART clinics were all significantly correlated with ARV medication adherence at the facility level. CONCLUSIONS A large proportion of HIV patients on second-line antiretroviral therapy had adherence problems. Both facility-level and individual-level were linked with patient medication adherence. Thus, based on the identified factors, individual and system-level interventions should be targeted.
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Designing a Predictive Model for Antiretroviral Regimen at the Antiretroviral Therapy Center in Chiro Hospital, Ethiopia. JOURNAL OF HEALTHCARE ENGINEERING 2021; 2021:1161923. [PMID: 34745487 PMCID: PMC8570855 DOI: 10.1155/2021/1161923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 10/10/2021] [Indexed: 12/02/2022]
Abstract
Nowadays, the huge amount of patient's data significantly increases with respect to the time in repositories and data mining is increasingly used as an emerging research area in medical fields for extracting useful and previously unknown insights/patterns from the repository data. These unknown patterns/hidden insights can help in discovering new knowledge hidden in these data repositories. From the observation, different ARV regimens were ordered for different patients. However, combination of these drugs causes different side effects on the patients. It has been observed that there was a lack of predictive studies and designed models available in hospitals specifically ART Centers that accurately determine or classify the patient's ARV regimen to TDF + 3TC + EFV, TDF + 3TC + NVP, AZT + 3TC + ATV/R, AZT + 3TC + LPV/R, TDF + 3TC + LVP/R, TDF + 3TC + ATV/R, 8888, and ABC + 3TC + LPV/R. In order to solve these kinds of problems, we built an accurate classifier system or model using parameters like Patient Age, Patient Encounter Day, Patient Encounter Month, Patient Encounter Year, Patient Weight, Patient CD4 Count Adult, Patient TB Screen, Patient Following WHO Stage, Patient CD4 Percent Child, Patient Regimen Specify, Patient Regimen, and so on. The general objective of this research was predictive modeling for the patient's ARV regimen class through data mining techniques so as to improve them. The study used the CRIPS-DM methodology to find and interpret patterns in repositories. A decision tree (J48 and Random Forest) algorithm was used for classification. Using all tested classifiers, the investigation of the study shows that the total accuracy was more than 60%. On the other hand, among different classifications, class H (ABC + 3TC + LPV/R) has shown the worst prediction. But it was revealed that the J48 classifier relatively produces higher classification accuracy for the D (AZT-3TC-NVP) regimen. Here, classification depended on the selected parameters, which revealed that prediction accuracy value differed among all classifiers and the selected attributes. Finally, the study concluded that data mining can be used as a significant technique to discover patient regimen based on salient affecting factors with 96.1% precision achieved. Ensemble learning resolves the categorizing models of greater anticipating performance with different learning algorithms. This model aligned with sentimental investigation to magnify the appearances of the dataset either from the social media or from primary data collection. The empirical investigation with different parameters shows the detailed improvement of their learning methods.
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Tufa TB, Fuchs A, Orth HM, Lübke N, Knops E, Heger E, Jarso G, Hurissa Z, Eggers Y, Häussinger D, Luedde T, Jensen BEO, Kaiser R, Feldt T. Characterization of HIV-1 drug resistance among patients with failure of second-line combined antiretroviral therapy in central Ethiopia. HIV Med 2021; 23:159-168. [PMID: 34622550 DOI: 10.1111/hiv.13176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/31/2021] [Accepted: 09/09/2021] [Indexed: 01/25/2023]
Abstract
BACKGROUND As a consequence of the improved availability of combined antiretroviral therapy (cART) in resource-limited countries, an emergence of HIV drug resistance (HIVDR) has been observed. We assessed the prevalence and spectrum of HIVDR in patients with failure of second-line cART at two HIV clinics in central Ethiopia. METHODS HIV drug resistance was analysed in HIV-1-infected patients with virological failure of second-line cART using the geno2pheno application. RESULTS Among 714 patients receiving second-line cART, 44 (6.2%) fulfilled the criteria for treatment failure and 37 were eligible for study inclusion. Median age was 42 years [interquartile range (IQR): 20-45] and 62.2% were male. At initiation of first-line cART, 23 (62.2%) were WHO stage III, mean CD4 cell count was 170.6 (range: 16-496) cells/µL and median (IQR) HIV-1 viral load was 30 220 (7963-82 598) copies/mL. Most common second-line cART regimens at the time of failure were tenofovir disoproxil fumarate (TDF)-lamivudine (3TC)-ritonavir-boosted atazanavir (ATV/r) (19/37, 51.4%) and zidovudine (ZDV)-3TC-ATV/r (9/37, 24.3%). Genotypic HIV-1 resistance testing was successful in 35 (94.6%) participants. We found at least one resistance mutation in 80% of patients and 40% carried a protease inhibitor (PI)-associated mutation. Most common mutations were M184V (57.1%), Y188C (25.7%), M46I/L (25.7%) and V82A/M (25.7%). High-level resistance against the PI ATV (10/35, 28.6%) and lopinavir (LPV) (5/35, 14.3%) was reported. As expected, no resistance mutations conferring integrase inhibitor resistance were detected. CONCLUSIONS We found a high prevalence of resistance mutations, also against PIs (40%), as the national standard second-line cART components. Resistance testing before switching to second- or third-line cART is warranted.
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Affiliation(s)
- Tafese Beyene Tufa
- College of Health Sciences, Arsi University, Asella, Ethiopia.,Hirsch Institute of Tropical Medicine, Asella, Ethiopia.,Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Duesseldorf, Medical Faculty, Heinrich Heine University, Duesseldorf, Germany
| | - Andre Fuchs
- Hirsch Institute of Tropical Medicine, Asella, Ethiopia.,Internal Medicine III - Gastroenterology and Infectious Diseases, University Hospital of Augsburg, Augsburg, Germany
| | - Hans Martin Orth
- Hirsch Institute of Tropical Medicine, Asella, Ethiopia.,Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Duesseldorf, Medical Faculty, Heinrich Heine University, Duesseldorf, Germany
| | - Nadine Lübke
- Institute of Virology, University Hospital Duesseldorf, Medical Faculty, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Elena Knops
- Institute of Virology, University of Cologne, Cologne, Germany
| | - Eva Heger
- Institute of Virology, University of Cologne, Cologne, Germany
| | - Godana Jarso
- Adama Hospital Medical College, Adama, Oromia, Ethiopia
| | - Zewdu Hurissa
- College of Health Sciences, Arsi University, Asella, Ethiopia
| | - Yannik Eggers
- Hirsch Institute of Tropical Medicine, Asella, Ethiopia.,Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Duesseldorf, Medical Faculty, Heinrich Heine University, Duesseldorf, Germany
| | - Dieter Häussinger
- Hirsch Institute of Tropical Medicine, Asella, Ethiopia.,Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Duesseldorf, Medical Faculty, Heinrich Heine University, Duesseldorf, Germany
| | - Tom Luedde
- Hirsch Institute of Tropical Medicine, Asella, Ethiopia.,Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Duesseldorf, Medical Faculty, Heinrich Heine University, Duesseldorf, Germany
| | - Björn-Erik Ole Jensen
- Hirsch Institute of Tropical Medicine, Asella, Ethiopia.,Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Duesseldorf, Medical Faculty, Heinrich Heine University, Duesseldorf, Germany
| | - Rolf Kaiser
- Institute of Virology, University of Cologne, Cologne, Germany
| | - Torsten Feldt
- Hirsch Institute of Tropical Medicine, Asella, Ethiopia.,Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Duesseldorf, Medical Faculty, Heinrich Heine University, Duesseldorf, Germany
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Wedajo S, Degu G, Deribew A, Ambaw F. Rate of Viral Re-Suppression and Retention to Care Among PLHIV on Second-Line Antiretroviral Therapy at Dessie Comprehensive Specialized Hospital, Northeast Ethiopia: A Retrospective Cohort Study. HIV AIDS-RESEARCH AND PALLIATIVE CARE 2021; 13:877-887. [PMID: 34526824 PMCID: PMC8435530 DOI: 10.2147/hiv.s323445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/21/2021] [Indexed: 12/22/2022]
Abstract
Background In Ethiopia, first-line antiretroviral therapy failure is growing rapidly. However, unlike first-line therapy, to date, very little is known about the outcomes of second-line therapy. Thus, this study assessed the rate of viral re-suppression and attrition to care and their predictors among people living with HIV on second-line therapy. Methods A retrospective cohort study was conducted on 642 people living with HIV at Dessie Comprehensive Specialized Hospital from October 2016 to November 2019. A proportional Cox regression model was computed to explore predictors of viral re-suppression (viral load less than 1000 copies/mL) and attrition to care. Results Out of 642 subjects, 19 (3%), 44 (6.9%), 70 (10.9%), and 509 (79.3%) patients were lost to follow up, died, transferred out, and alive on care, respectively. Similarly, 82.39% (95% CI: 79.24–85.16%) of patients had achieved viral re-suppression, with 96 per 100 person-year rate of re-suppression. Patients who switched timely to second-line therapy were at a higher rate of viral re-suppression than delayed patients [adjusted hazard rate, AHR = 1.43 (95% CI: 1.17–1.74)]. Not having drug substitution history [AHR = 1.25 (95% CI: 1.02–1.52)] was positively associated with viral re-suppression. In contrast, being on anti-TB treatment [AHR = 0.67 (95% CI: 0.49–0.91)] had lower likelihood with viral re-suppression. In the current study, attrition to care was 11% (95% CI: 8.7–13.9%). Ambulatory or bedridden patients were more at risk of attrition to care as compared with workable patients [AHR = 2.61 (95% CI: 1.40–4.87)]. Similarly, being not virally re-suppressed [AHR = 6.87 (95% CI: 3.86–12.23)] and CD4 count ≤450 cells/mm3 [AHR = 2.61 (95% CI: 1.40–4.87)] were also positively associated with attrition to care. Conclusion A significant number of patients failed to achieve viral re-suppression and attrition from care. Most identified factors related to patient monitoring. Hence, patient-centered intervention should be strengthened, besides treatment switch.
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Affiliation(s)
- Shambel Wedajo
- School of Public Health, CMHS, Wollo University, Dessie, Ethiopia
| | - Getu Degu
- School of Public Health, CMHS, Bahir Dar University, Bahir Dar, Ethiopia
| | - Amare Deribew
- Nutrition International (NI) in Ethiopia, Addis Ababa, Ethiopia
| | - Fentie Ambaw
- School of Public Health, CMHS, Bahir Dar University, Bahir Dar, Ethiopia
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Abstract
PURPOSE OF REVIEW People living with HIV (PLWH) are commonly coinfected with Mycobacterium tuberculosis, particularly in high-transmission resource-limited regions. Despite expanded access to antiretroviral therapy and tuberculosis (TB) treatment, TB remains the leading cause of death among PLWH. This review discusses recent advances in the management of TB in PLWH and examines emerging therapeutic approaches to improve outcomes of HIV-associated TB. RECENT FINDINGS Three recent key developments have transformed the management of HIV-associated TB. First, the scaling-up of rapid point-of-care urine-based tests for screening and diagnosis of TB in PLWH has facilitated early case detection and treatment. Second, increasing the availability of potent new and repurposed drugs to treat drug-resistant TB has generated optimism about the treatment and outcome of multidrug-resistant and extensively drug-resistant TB. Third, expanded access to the integrase inhibitor dolutegravir to treat HIV in resource-limited regions has simplified the management of TB/HIV coinfected patients and minimized serious adverse events. SUMMARY While it is unequivocal that substantial progress has been made in early detection and treatment of HIV-associated TB, significant therapeutic challenges persist. To optimize the management and outcomes of TB in HIV, therapeutic approaches that target the pathogen as well as enhance the host response should be explored.
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Musana H, Ssensamba JT, Nakafeero M, Mugerwa H, Kiweewa FM, Serwadda D, Ssali F. Predictors of failure on second-line antiretroviral therapy with protease inhibitor mutations in Uganda. AIDS Res Ther 2021; 18:17. [PMID: 33882938 PMCID: PMC8059285 DOI: 10.1186/s12981-021-00338-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 04/08/2021] [Indexed: 11/10/2022] Open
Abstract
Introduction Failure on second-line antiretroviral therapy (ART) with protease inhibitor (PI) mutations (VF-M) is on the rise. However, there is a paucity of information on the factors associated with this observation in low-income countries. Knowledge of underlying factors is critical if we are to minimize the number of PLHIV switched to costly third-line ART. Our study investigated the factors associated with VF-M. Methods We conducted a matched case–control analysis of patients' records kept at the Joint Clinical Research Center, starting from January 2008 to May 2018. We matched records of patients who failed the second-line ART with major PI mutations (cases) with records of patients who were virologically suppressed (controls) by a ratio of 1:3. Data analysis was conducted using STATA Version 14. Categorical variables were compared with the outcomes failure on second-line ART with PI mutations using the Chi-square and Fisher's exact tests where appropriate. Conditional logistic regression for paired data was used to assess the association between the outcome and exposure variables, employing the backward model building procedure. Results Of the 340 reviewed patients' records, 53% were women, and 6.2% had previous tuberculosis treatment. Males (aOR = 2.58, [CI 1.42–4.69]), and patients concurrently on tuberculosis treatment while on second-line ART (aOR = 5.65, [CI 1.76–18.09]) had higher odds of VF-M. ART initiation between 2001 and 2015 had lower odds of VF-M relative to initiation before the year 2001. Conclusion Males and patients concomitantly on tuberculosis treatment while on second-line ART are at a higher risk of VF-M. HIV/AIDS response programs should give special attention to this group of people if we are to minimize the need for expensive third-line ART. We recommend more extensive, explorative studies to ascertain underlying factors.
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Nuwagira E, Lumori BAE, Muhindo R, Kanyesigye M, Amir A, Muyindike W, Muzoora C. Incidence and predictors of early loss to follow up among patients initiated on protease inhibitor-based second-line antiretroviral therapy in southwestern Uganda. AIDS Res Ther 2021; 18:7. [PMID: 33743748 PMCID: PMC7980600 DOI: 10.1186/s12981-021-00331-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 03/12/2021] [Indexed: 01/05/2023] Open
Abstract
Background Good adherence to antiretroviral therapy (ART) and retention in care are essential for the effectiveness of an HIV care program. With the current increase in numbers of people living with HIV taking second-line ART in sub-Saharan Africa, there is a need to establish their treatment outcomes and the rate of loss to follow up. In this study, we determined the incidence and predictors of loss to follow up among patients taking second-line ART at an experienced HIV treatment center in southwestern Uganda. Methods This was a retrospective review of an electronic database at Mbarara Regional Referral Hospital HIV clinic in southwestern Uganda. Second-line ART included at least two of the nucleoside reverse transcriptase inhibitors and a boosted protease inhibitor. Loss to follow-up was defined as failure to return to the health facility for care or treatment refill for 180 days or more from the previous visit. After excluding children less than 15 years, we pooled data that included socio-demographic, clinical, and laboratory data for patients who started second-line ART between 2002 and 2017. Multiple imputation was done for variables with missing data. Variables that had a p < 0.05 in unadjusted bivariate analyses were included in a multivariate binomial regression model using a stepwise backward selection procedure to describe the factors that independently predicted loss to follow-up. Results Between 2002 and 2017, 1121 patients had been initiated on second-line ART. We included data from 924 participants and of these, 518 (56.1%) were female, the mean age (SD) was 38.4 (± 10.5) years, and 433 (52.4%) had a CD4 count less than 100 cells/µl at the start of second-line ART. The incidence of loss to follow-up was 26.7 per 100 person-years. Male gender (Adjusted risk ratio (ARR) = 1.8, 95% CI 1.5–2.0) p < 0.001 and anemia ARR 1.4, 95% CI 1.1–1.6) p < 0.001 were strongly associated with loss to follow up. Conclusions There is a high incidence of loss to follow up among patients taking protease-inhibitor based second-line ART at a tertiary HIV center in southwestern Uganda. There is a need to routinely measure hemoglobin during clinic reviews, and establish mechanisms to retain males initiated on second-line ART in care. The association of anemia and loss to follow up needs to be investigated.
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Mabeya S, Nyamache A, Ngugi C, Nyerere A, Lihana R. Characterization of HIV-1 Integrase Gene and Resistance Associated Mutations Prior to Roll out of Integrase Inhibitors by Kenyan National HIV-Treatment Program in Kenya. Ethiop J Health Sci 2020; 30:37-44. [PMID: 32116431 PMCID: PMC7036466 DOI: 10.4314/ejhs.v30i1.6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Background Antiretroviral therapy containing an integrase strand transfer inhibitor plus two Nucleoside Reverse Transcriptase inhibitors has now been recommended for treatment of HIV-1-infected patients. This thus determined possible pre-existing integrase resistance-associated mutations in the integrase gene prior to introduction of integrase inhibitors combination therapy in Kenya. Methods Drug experienced HIV patients were enrolled at Kisii Teaching and Referral in Kenya. Blood specimens from (33) patients were collected for direct sequencing of HIV-1 polintegrase genes. Drug resistance mutations were interpreted according to the Stanford algorithm and phylogenetically analysed using insilico tools. Results From pooled 188 Kenyan HIV integrase sequences that were analysed for drug resistance, no major mutations conferring resistance to integrase inhibitors were detected. However, polymorphic accessory mutations associated with reduced susceptibility of integrase inhibitors were observed in low frequency; M50I (12.2%), T97A (3.7%), S153YG, E92G (1.6%), G140S/A/C (1.1%) and E157Q (0.5%). Phylogenetic analysis (330 sequences revealed that HIV-1 subtype A1 accounted for majority of the infections, 26 (78.8%), followed by D, 5 (15.2%) and C, 2 (6%). Conclusion The integrase inhibitors will be effective in Kenya where HIV-1 subtype A1 is still the most predominant. However, occurring polymorphisms may warrant further investigation among drug experienced individuals on dolutegravir combination or integrase inhibitor treatment.
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Affiliation(s)
- Sepha Mabeya
- Department of Medical Microbiology, school of Biomedical Sciences, Jomo Kenyatta University of Agriculture & Technology, Nairobi, Kenya
| | - Anthony Nyamache
- Department of Biochemistry Microbiology & Biotechnology, School of Pure & Applied Sciences, Kenyatta University, Nairobi, Kenya
| | - Caroline Ngugi
- Department of Medical Microbiology, school of Biomedical Sciences, Jomo Kenyatta University of Agriculture & Technology, Nairobi, Kenya
| | - Andrew Nyerere
- Department of Medical Microbiology, school of Biomedical Sciences, Jomo Kenyatta University of Agriculture & Technology, Nairobi, Kenya
| | - Raphael Lihana
- Centre for Virus Research, Kenya Medical Research Institute, Nairobi, Kenya
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Mulisa D, Tolossa T, Wakuma B, Etafa W, Yadesa G. Magnitude of first line antiretroviral therapy treatment failure and associated factors among adult patients on ART in South West Shoa, Central Ethiopia. PLoS One 2020; 15:e0241768. [PMID: 33175902 PMCID: PMC7657481 DOI: 10.1371/journal.pone.0241768] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 10/21/2020] [Indexed: 12/02/2022] Open
Abstract
Background First-line antiretroviral treatment failure has become a public health concern in high, low and middle-income countries with high mortality and morbidity In Ethiopia, around 710,000 peoples were living with HIV and 420,000 of them were receiving ART in 2017. Little is known about the magnitude of first-line ART treatment failure and its associated factors in Ethiopia, particularly in the study area. Therefore, this study was aimed to find the magnitude of first-line ART treatment failure and its associated factors among adult patients attending ART clinic at Southwest shoa zone public hospitals. Methods Institutions based cross-sectional study was employed from February 1 to April 2, 2019. An interviewer administered questionnaire was used to collect data from 350 adult patients on ART using a systematic random sampling technique. The collected data were coded and entered into Epidata version 3 and exported to STATA SE version 14 for analysis. Bivariable and multivariable logistic regression was done to identify factors associated with first-line ART treatment failure. At 95% confidence level strength of association was measured using Odds ratio. Variables with a p-value of ≤ 0.25 in the bivariable analysis were considered as a candidate variable for multivariable analysis. To get the final variables step-wise backward selection procedure was used and those in the final model were selected at a p-value <0.05. Finally, texts, simple frequency tables, and figures were used to present the findings. Results In this study the magnitude of first-line ART treatment failure was 33.42%. Absence of baseline opportunistic infection AOR = 0.362 (95%CI0.178, 0.735), Staying on first-line ART for <5 years AOR = 0.47 (95%CI 0.252, 0.878), Nevirapine containing ART regimen AOR = 3.07 (95%CI 1.677, 5.63), Baseline CD4 count ≥100 cells/mm3 AOR = 0.299 (95%CI 0.152 0.591), absence of opportunistic infections after ART initiation AOR = 0.257 (95%CI 0.142, .467), time taking greater than an one-hour to reach health facility AOR 1.85 (95%CI 1.022 3.367) were significantly associated with first-line ART treatment failure. Conclusion The magnitude of first-line ART treatment failure was high in the study area. Base-line opportunistic infection, duration on first-line ART, NVP based ART, Baseline CD4 count level, OI after ART initiation, and time it takes to reach health facility were independent determinants of first-line ART treatment failure.
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Affiliation(s)
- Diriba Mulisa
- School of Nursing and Midwifery, Institutes of Health Sciences, Wollega University, Nekemte, Ethiopia
- * E-mail:
| | - Tadesse Tolossa
- Department of Public Health, Institutes of Health Sciences, Wollega University, Nekemte, Ethiopia
| | - Bizuneh Wakuma
- Department of Pediatric Nursing, Institutes of Health Sciences, Wollega University, Nekemte, Ethiopia
| | - Werku Etafa
- Department of Pediatric Nursing, Institutes of Health Sciences, Wollega University, Nekemte, Ethiopia
| | - Girma Yadesa
- Department of Nursing, College of Health Sciences, Diredawa University, Diredawa, Ethiopia
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Increased Mortality With Delayed and Missed Switch to Second-Line Antiretroviral Therapy in South Africa. J Acquir Immune Defic Syndr 2020; 84:107-113. [PMID: 32032304 DOI: 10.1097/qai.0000000000002313] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND After failure of first-line antiretroviral therapy (ART) in the public sector, delayed or missed second-line ART switch is linked with poor outcomes in patients with advanced HIV. SETTING We investigated delayed or missed second-line ART switch after confirmed virologic failure in the largest private sector HIV cohort in Africa. METHODS We included HIV-infected adults with confirmed virologic failure after 6 months of nonnucleoside reverse-transcriptase inhibitor-based ART. We estimated the effect of timing of switch on the hazard of death using inverse probability of treatment weighting of marginal structural models. We adjusted for time-dependent confounding of CD4 count, viral load, and visit frequency. RESULTS Five thousand seven hundred forty-eight patients (53% female) with confirmed virologic failure met inclusion criteria; the median age was 40 [interquartile range (IQR): 35-47], advanced HIV was present in 48% and the prior duration of nonnucleoside reverse-transcriptase inhibitor-based ART was 1083 days (IQR: 665-1770). Median time to confirmation of virologic failure and to second-line switch was 196 (IQR: 136-316) and 220 days (IQR: 65-542), respectively. Switching to second-line ART after confirmed failure compared with remaining on first-line ART reduced risk of subsequent death [adjusted hazard ratio: 0.47 (95% confidence interval: 0.36 to 0.63)]. Compared with patients who experienced delayed switch, those switched immediately had a lower risk of death, regardless of CD4 cell count. CONCLUSIONS Delayed or missed switch to second-line ART after confirmed first-line ART failure is common in the South African private sector and associated with mortality. Novel interventions to minimize switch delay should be tested and not limited to those with advanced disease at treatment failure.
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Cavalcanti ATDAE, de Alencar Ximenes RA, Montarroyos UR, d’Albuquerque PM, Fonseca RA, de Barros Miranda-Filho D. Effectiveness of four antiretroviral regimens for treating people living with HIV. PLoS One 2020; 15:e0239527. [PMID: 32986730 PMCID: PMC7521729 DOI: 10.1371/journal.pone.0239527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 09/08/2020] [Indexed: 12/22/2022] Open
Abstract
The aim of this study was to compare 4 different ARV regimens in a clinical cohort in Brazil, with regard to the virologic and immunologic responses, clinical failure and reasons for changing. To compare the virologic response and clinical failure between groups we used the Cox and Kaplan Meier proportional hazard models. To analyze the immunologic outcome, we used multilevel GLLAMM and mixed effect linear regression models. To compare regimen change outcomes we used the Pearson's chi-square test. We included 840 participants distributed across the groups according to the initial ART regimen. The mean follow-up period was 27.8 months. Almost half the sample initiated ART with AIDS-related signs/symptoms. Virologic response was effective in 79.6% of participants within 12 months. The tenofovir/lamivudine/efavirenz group presented a higher proportion of virologic response (VL<50 at 6 months) when compared to the zidovudine/lamivudine/efavirenz group. There was no difference between the regimens regarding the immunologic response. A total of 17.3% of individuals changed regimen because of failure and 46.5% due to adverse events. Changes due to adverse events were more frequent in the group using zidovudine/lamivudine/efavirenz. The proportion of hospitalizations at 1 year was higher in the zidovudine/lamivudine/efavirenz group when compared to the tenofovir/lamivudine/efavirenz group. The effectiveness outcomes between the regimens were similar. Some differences may be due to the individual characteristics of patients, toxicity and acceptability of drugs. Studies are needed that compare similarly effective regimens and their respective treatment costs and financial impacts on SUS (Integrated Healthcare System).
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Affiliation(s)
| | - Ricardo Arraes de Alencar Ximenes
- Postgraduate Program in Health Sciences, University of Pernambuco, Recife, Brazil
- Tropical Medicine, Federal University of Pernambuco, Recife, Brazil
| | | | | | | | - Demócrito de Barros Miranda-Filho
- Postgraduate Program in Health Sciences, University of Pernambuco, Recife, Brazil
- Internal Medicine, University of Pernambuco, Recife, Brazil
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Assefa Y, Gilks CF. Ending the epidemic of HIV/AIDS by 2030: Will there be an endgame to HIV, or an endemic HIV requiring an integrated health systems response in many countries? Int J Infect Dis 2020; 100:273-277. [PMID: 32920236 DOI: 10.1016/j.ijid.2020.09.011] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 09/03/2020] [Accepted: 09/04/2020] [Indexed: 11/30/2022] Open
Abstract
The third Sustainable Development Goal (SDG-3) has a target to end the epidemic of HIV/AIDS by 2030 (Project 2030). This will be achieved when the number of new HIV infections and 'AIDS-related deaths' decline by 90% between 2010 and 2030. So far, the rate of drop in AIDS-related deaths is on track, whereas the rate of drop in new HIV infections is off track to achieve Project 2030. Even if Project 2030 was achieved, HIV would be an endemic health problem. Hence, HIV prevention and control programmes cannot close down for the foreseeable future. This rather demands a paradigm shift from a fully vertical to an integrated health systems response that provides services according to disease burden towards universal health coverage. This will ensure the sustainability of HIV services in the post-2030 era. These all entail unrelenting political commitment, and increased and sustainable funding from both national and global sources.
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Affiliation(s)
- Yibeltal Assefa
- School of Public Health, the University of Queensland, Brisbane, Australia.
| | - Charles F Gilks
- School of Public Health, the University of Queensland, Brisbane, Australia
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22
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Thompson JA, Kityo C, Dunn D, Hoppe A, Ndashimye E, Hakim J, Kambugu A, van Oosterhout JJ, Arribas J, Mugyenyi P, Walker AS, Paton NI. Evolution of Protease Inhibitor Resistance in Human Immunodeficiency Virus Type 1 Infected Patients Failing Protease Inhibitor Monotherapy as Second-line Therapy in Low-income Countries: An Observational Analysis Within the EARNEST Randomized Trial. Clin Infect Dis 2020; 68:1184-1192. [PMID: 30060027 DOI: 10.1093/cid/ciy589] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 07/24/2018] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Limited viral load (VL) testing in human immunodeficiency virus (HIV) treatment programs in low-income countries often delays detection of treatment failure. The impact of remaining on failing protease inhibitor (PI)-containing regimens is unclear. METHODS We retrospectively tested VL in 2164 stored plasma samples from 386 patients randomized to receive lopinavir monotherapy (after initial raltegravir induction) in the Europe-Africa Research Network for Evaluation of Second-line Therapy (EARNEST) trial. Protease genotypic resistance testing was performed when VL >1000 copies/mL. We assessed evolution of PI resistance mutations from virological failure (confirmed VL >1000 copies/mL) until PI monotherapy discontinuation and examined associations using mixed-effects models. RESULTS Median post-failure follow-up (in 118 patients) was 68 (interquartile range, 48-88) weeks. At failure, 20% had intermediate/high-level resistance to lopinavir. At 40-48 weeks post-failure, 68% and 51% had intermediate/high-level resistance to lopinavir and atazanavir; 17% had intermediate-level resistance (none high) to darunavir. Common PI mutations were M46I, I54V, and V82A. On average, 1.7 (95% confidence interval 1.5-2.0) PI mutations developed per year; increasing after the first mutation; decreasing with subsequent mutations (P < .0001). VL changes were modest, mainly driven by nonadherence (P = .006) and PI mutation development (P = .0002); I47A was associated with a larger increase in VL than other mutations (P = .05). CONCLUSIONS Most patients develop intermediate/high-level lopinavir resistance within 1 year of ongoing viral replication on monotherapy but retain susceptibility to darunavir. Viral load increased slowly after failure, driven by non-adherence and PI mutation development. CLINICAL TRIALS REGISTRATION NCT00988039.
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Affiliation(s)
- Jennifer A Thompson
- Medical Research Council Clinical Trials Unit at University College London, United Kingdom.,Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Cissy Kityo
- Joint Clinical Research Centre, Kampala, Uganda
| | - David Dunn
- Medical Research Council Clinical Trials Unit at University College London, United Kingdom
| | - Anne Hoppe
- Medical Research Council Clinical Trials Unit at University College London, United Kingdom.,Division of Infection and Immunity, University College London, United Kingdom
| | - Emmanuel Ndashimye
- Joint Clinical Research Centre, Kampala, Uganda.,Department of Microbiology and Immunology, University of Western Ontario, London, Ontario, Canada
| | - James Hakim
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | - Andrew Kambugu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Joep J van Oosterhout
- Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi.,Dignitas International, Zomba, Malawi
| | | | | | - A Sarah Walker
- Medical Research Council Clinical Trials Unit at University College London, United Kingdom
| | - Nicholas I Paton
- Medical Research Council Clinical Trials Unit at University College London, United Kingdom.,Yong Loo Lin School of Medicine, National University of Singapore
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Chimbetete C, Shamu T, Keiser O. Zimbabwe's national third-line antiretroviral therapy program: Cohort description and treatment outcomes. PLoS One 2020; 15:e0228601. [PMID: 32119663 PMCID: PMC7051055 DOI: 10.1371/journal.pone.0228601] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 01/18/2020] [Indexed: 12/17/2022] Open
Abstract
Background In 2015, Zimbabwe introduced third-line antiretroviral therapy (ART) through four designated treatment centers; three government clinics in Harare and Bulawayo, and Newlands Clinic (NC), operated by a private voluntary organization in Harare. We describe characteristics of patients receiving third line ART and analyzed treatment outcomes in this national programme as of 31 December 2018. Methods We described the population using proportions for categorical variables, and medians and interquartile ranges for continuous variables. Patients from NC, where data were more complete, were followed from the date of starting third-line ART until death, transfer, loss to follow up or 31 December 2018. Results A total of 209 patients had ever received third-line ART: 124 at NC and 85 from the three government clinics. HIV genotype results were available for 89 (72%) patients at NC and fourteen (16.5%) patients in the government clinics. Median duration of third line ART (years) in the government clinics was 2.3 (IQR:0.6–3.4), 1.3 (IQR: 0.7–1.7) and 1 (0.6–1.9). Of the 67 patients who received third line ART in the government clinics for at least six months, 53 (79%) had most recent viral load (VL) < 1000 copies/ml. Data on other treatment outcomes from government clinics were incomplete. From NC: a total of 109 (88%) patients were still in care, 13 (10.5%) had died and 2 (1.5%) were transferred. Median duration of third-line ART was 1.4 years (IQR: 0.6–2.8). Among the 111 NC patients who had received third-line ART for at least 6 months, 83 (75%) had a VL <50 copies/ml and 106 (95.5%) had a VL <1000 copies/ml. Conclusion Our findings demonstrate that, with comprehensive care, patients failing second-line ART can achieve high rates of virological suppression on third-line regimens. There is need to decentralize the provision of third-line ART in Zimbabwe. More needs to be done to improve completeness of data in the government clinics.
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Affiliation(s)
- Cleophas Chimbetete
- Newlands Clinic, Harare, Zimbabwe.,Institute of Global Health, University of Geneva, Geneva, Switzerland
| | | | - Olivia Keiser
- Institute of Global Health, University of Geneva, Geneva, Switzerland
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Molla Tigabu B, Doyore Agide F, Mohraz M, Nikfar S. Atazanavir / ritonavir versus Lopinavir / ritonavir-based combined antiretroviral therapy (cART) for HIV-1 infection: a systematic review and meta-analysis. Afr Health Sci 2020; 20:91-101. [PMID: 33402897 PMCID: PMC7750062 DOI: 10.4314/ahs.v20i1.14] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND This systematic review and meta-analysis was conducted to evaluate the safety and effectiveness of Atazanavir/ritonavir over lopinavir/ritonavir in human immunodeficiency virus-1 (HIV-1) infection. METHODS Clinical trials with a head-to-head comparison of atazanavir/ritonavir and lopinavir/ritonavir in HIV-1 were included. Electronic databases: PubMed/Medline CENTRAL, Embase, Scopus, and Web of Science were searched. Viral suppression below 50 copies/ml at the longest follow-up period was the primary outcome measure. Grade 2-4 treatment-related adverse drug events, lipid profile changes and grade 3-4 bilirubin elevations were used as secondary outcome measures. RESULTS A total of nine articles from seven trials with 1938 HIV-1 patients were included in the current study. Atazanavir/ritonavir has 13% lower overall risk of failure to suppress the virus level < 50 copies/ml than lopinavir/ritonavir in fixed effect model (pooled RR: 0.87; CI: 0.78, 0.96; P=0.006). The overall risk of hyperbilirubinemia is very high for atazanavir/ritonavir than lopinavir/ritonavir in the random effects model (pooled RR: 45.03; CI: 16.03, 126.47; P< 0.0001). CONCLUSION Atazanavir/ritonavir has a better viral suppression at lower risk of lipid abnormality than lopinavir/ritonavir. The risk and development of hyperbilirubinemia from atazanavir-based regimens should be taken into consideration both at the time of prescribing and patient follow-up.
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Kroidl A, Burger T, Urio A, Mugeniwalwo R, Mgaya J, Mlagalila F, Hoelscher M, Däumer M, Salehe O, Sangare A, Lennemann T, Maganga L. High turnaround times and low viral resuppression rates after reinforced adherence counselling following a confirmed virological failure diagnostic algorithm in HIV-infected patients on first-line antiretroviral therapy from Tanzania. Trop Med Int Health 2020; 25:579-589. [PMID: 31984634 DOI: 10.1111/tmi.13373] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Early identification of confirmed virological failure is paramount to avoid accumulation of drug resistance in patients on antiretroviral therapy (ART). Scale-up of HIV-RNA monitoring in Africa and timely switch to second-line regimens are challenged. METHODS A WHO adapted confirmed virological treatment screening algorithm (HIV-RNA screening, enhanced adherence counselling, confirmatory HIV-RNA testing) was evaluated in HIV-infected patients on first-line ART from Tanzania. The main endpoints included viral resuppression and virological failure rates, retention and turnaround time of the screening algorithm until second-line ART initiation. Secondary endpoints included risk factors for virological treatment failure and patterns of genotypic drug resistance. RESULTS HIV-RNA >1000 copies/ml at first screening was detected in 58/356 (16.3%) patients (median time-on-treatment 6.3 years, 25% immunological treatment failure). Adjusted risk factors for virological failure were age <30 years (RR 5.2 [95% CI: 2.5-10.8]), years on ART ≥3 years (RR 3.0 [1.0-8.9]), CD4-counts <200 cells/µl (RR 9.3 [4.0-21.8]) and poor self-reported treatment adherence (RR 2.0 [1.2-3.4]). Resuppression of HIV-RNA <1000 copies/ml was observed in 5/50 (10%) cases after enhanced adherence counselling. Confirmatory testing within 3 months was performed in only 46.6% and switch to second-line ART within 6 months in 60.4% of patients. Major NNRTI-mutation were detected in all of 30 patients, NRTI mutations in 96.7% and ≥3 thymidine-analogue mutations in 40%. No remaining NRTI options were predicted in 57% and limited susceptibility in 23% of patients. CONCLUSION We observed low levels of viral resuppression following adherence counselling, associated with high levels of accumulated drug resistance. High visit burden and turnaround times for confirmed virological failure diagnosis further delayed switching to second-line treatment which could be improved using novel point-of-care viral load monitoring systems.
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Affiliation(s)
- Arne Kroidl
- Division of Infectious Diseases and Tropical Medicine, Medical Center of the University of Munich, Munich, Germany.,German Center for Infection Research, Partner site Munich, Munich, Germany
| | - Tassilo Burger
- Division of Infectious Diseases and Tropical Medicine, Medical Center of the University of Munich, Munich, Germany
| | - Agatha Urio
- NIMR-Mbeya Medical Research Center, Mbeya, Tanzania
| | | | - Jimson Mgaya
- NIMR-Mbeya Medical Research Center, Mbeya, Tanzania
| | | | - Michael Hoelscher
- Division of Infectious Diseases and Tropical Medicine, Medical Center of the University of Munich, Munich, Germany.,German Center for Infection Research, Partner site Munich, Munich, Germany
| | - Martin Däumer
- Institute of Immunology and Genetics, Kaiserslautern, Germany
| | - Omar Salehe
- Mbeya Zonal Referral Hospital, Mbeya, Tanzania
| | | | - Tessa Lennemann
- Division of Infectious Diseases and Tropical Medicine, Medical Center of the University of Munich, Munich, Germany.,NIMR-Mbeya Medical Research Center, Mbeya, Tanzania
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Ford N, Geng E, Ellman T, Orrell C, Ehrenkranz P, Sikazwe I, Jahn A, Rabkin M, Ayisi Addo S, Grimsrud A, Rosen S, Zulu I, Reidy W, Lejone T, Apollo T, Holmes C, Kolling AF, Phate Lesihla R, Nguyen HH, Bakashaba B, Chitembo L, Tiriste G, Doherty M, Bygrave H. Emerging priorities for HIV service delivery. PLoS Med 2020; 17:e1003028. [PMID: 32059023 PMCID: PMC7021280 DOI: 10.1371/journal.pmed.1003028] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Nathan Ford and co-authors discuss global priorities in the provision of HIV prevention and treatment services.
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Affiliation(s)
- Nathan Ford
- Department HIV & Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, South Africa
- * E-mail:
| | - Elvin Geng
- Center for Dissemination and Implementation, Institute for Public Health, Washington University, St. Louis, Missouri, United States of America
| | - Tom Ellman
- Southern African Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
| | - Catherine Orrell
- Department of Medicine, Faculty of Health Sciences, Cape Town, South Africa
| | - Peter Ehrenkranz
- Bill and Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | | | - Miriam Rabkin
- ICAP, Columbia University Mailman School of Public Health, New York, New York, United States of America
| | | | | | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Isaac Zulu
- Division of Global HIV & TB, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - William Reidy
- ICAP, Columbia University Mailman School of Public Health, New York, New York, United States of America
| | - Thabo Lejone
- SolidarMed, Swiss Organization for Health in Africa, Butha-Buthe, Lesotho
| | - Tsitsi Apollo
- Ministry of Health and Child Care Zimbabwe, Harare, Zimbabwe
| | - Charles Holmes
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Georgetown University, Washington, DC, United States of America
| | - Ana Francisca Kolling
- Department of Surveillance, Prevention and Control of STIs, HIV/AIDS and Viral Hepatitis, Ministry of Health, Brasilia, Brazil
| | | | - Huu Hai Nguyen
- Treatment and Care Department, Viet Nam Authority of HIV/AIDS Control, Ministry of Health, Hanoi, Vietnam
| | | | | | - Ghion Tiriste
- Department HIV, World Health Organization, Addis Ababa, Ethiopia
| | - Meg Doherty
- Department HIV & Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
| | - Helen Bygrave
- Southern African Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
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Virological Outcome of Patients With HIV Drug Resistance Attending an Urban Outpatient Clinic in Uganda: A Need for Structured Adherence Counseling and Third-Line Treatment Options. J Acquir Immune Defic Syndr 2019; 80:481-487. [PMID: 30633041 DOI: 10.1097/qai.0000000000001943] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND HIV drug resistance and suboptimal adherence are the main reasons for treatment failure among HIV-infected individuals. As genotypic resistance testing is not routinely available in resource-limited settings such as Uganda, data on transmitted and acquired resistance are sparse. METHODS This observational follow-up study assessed the virological outcomes of patients diagnosed with virological failure or transmitted HIV drug resistance in 2015 at the adults' outpatient clinic of the Infectious Diseases Institute in Kampala, Uganda. Initially, 2430 patients on antiretroviral therapy (ART) underwent virological monitoring, of which 190 had virological failure and were subsequently eligible for this follow-up study. Nine patients diagnosed with transmitted drug resistance were eligible. In patients with a viral load > 1000 copies/mL, genotypic resistance testing was performed. RESULTS Of 190 eligible patients, 30 (15.8%) had either died or were lost to follow-up. A total of 148 (77.9%) were included, of which 98 had had a change of ART regimen, and 50 had received adherence counseling only. The majority was now on second-line ART (N = 130, 87.8%). The median age was 39 years (interquartile range: 32-46), and 109 (73.6%) were women. Virological failure was diagnosed in 29 (19.6%) patients, of which 24 (82.8%) were on second-line ART. Relevant drug resistance was found in 25 (86.2%) cases, of which 12 (41.3%) carried dual and 7 (24.1%) triple drug resistance. CONCLUSION Two years after initial virological failure, most patients followed up by this study had a successful virological outcome. However, a significant proportion either continued to fail or died or was lost to follow-up.
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Mulisa D, Tesfa M, Mullu Kassa G, Tolossa T. Determinants of first line antiretroviral therapy treatment failure among adult patients on ART at central Ethiopia: un-matched case control study. BMC Infect Dis 2019; 19:1024. [PMID: 31795955 PMCID: PMC6889620 DOI: 10.1186/s12879-019-4651-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 11/22/2019] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND In 2018 in Ethiopia, magnitude of human immunodeficiency virus Acquired Immunodeficiency Syndrome treatment failure was 15.9% and currently the number of patient receiving second line antiretroviral therapy (ART) is more increasing than those taking first line ART. Little is known about the predictors of treatment failure in the study area. Therefore; more factors that can be risk for first line ART failure have to identified to make the patients stay on first line ART for long times. Consequently, the aim of this study was to identify determinants of first line ART treatment failure among patients on ART at St. Luke referral hospital and Tulubolo General Hospital, 2019. METHODS A 1:2 un-matched case-control study was conducted among adult patients on active follow up. One new group variables was formed as group 1 for cases and group 0 for controls and then data was entered in to Epi data version 3 and exported to STATA SE version 14 for analysis. From binary logistic regression variables with p value ≤0.25 were a candidate for multiple logistic regression. At the end variables with a p-value ≤0.05 were considered as statistically significant. RESULT A total of 350 (117 cases and 233 controls) patients were participated in the study. Starting ART after 2 years of being confirmed HIV positive (AOR = 3.82 95% CI 1.37,10.6), nevirapine (NVP) based initial ART (AOR = 2.77,95%CI 1.22,6.28) having history of lost to follow up (AOR 3.66,95%CI 1.44,9.27) and base line opportunistic infection (AOR = 1.97,95%CI 1.06,3.63), staying on first line ART for greater than 5 years (AOR = 3.42,95%CI 1.63,7.19) and CD4 less than100cell/ul (AOR = 2.72,95%CI 1.46,5.07) were independent determinants of first line ART treatment failure. CONCLUSION Lost to follow up, staying on first line ART for greater than 5 years, presence of opportunistic infections, NVP based NNRT, late initiation of ART are determinant factors for first line ART treatment failure. The concerned bodies have to focus and act on those identified factors to maintain the patient on first line ART.
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Affiliation(s)
- Diriba Mulisa
- School of Nursing and Midwifery, Wollega University, P.O.BOX: 395, Nekemte, Ethiopia.
| | - Mulugeta Tesfa
- Department of Midwifery, College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | - Getachew Mullu Kassa
- Department of Midwifery, College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | - Tadesse Tolossa
- School of Nursing and Midwifery, Wollega University, P.O.BOX: 395, Nekemte, Ethiopia
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Third-Line Antiretroviral Therapy Program in the South African Public Sector: Cohort Description and Virological Outcomes. J Acquir Immune Defic Syndr 2019; 80:73-78. [PMID: 30334876 PMCID: PMC6319697 DOI: 10.1097/qai.0000000000001883] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background: The World Health Organization recommends that antiretroviral therapy (ART) programs in resource-limited settings develop third-line ART policies. South Africa developed a national third-line ART program for patients who have failed both first-line non-nucleoside reverse transcriptase inhibitor–based ART and second-line protease inhibitor (PI)-based ART. We report on this program. Methods: Third-line ART in South Africa is accessed through a national committee that assesses eligibility and makes individual regimen recommendations. Criteria for third-line include the following: ≥1 year on PI-based ART with virologic failure, despite adherence optimization, and genotypic antiretroviral resistance test showing PI resistance. We describe baseline characteristics and resistance patterns of this cohort and present longitudinal data on virological suppression rates. Results: Between August 2013 and July 2014, 144 patients were approved for third-line ART. Median age was 41 years [interquartile range (IQR): 19–47]; 60% were women (N = 85). Median CD4+ count and viral load were 172 (IQR: 128–351) and 14,759 (IQR: 314–90,378), respectively. About 2.8% started PI-based ART before 2004; 11.1% from 2004 to 2007; 31.3% from 2008 to 2011; and 6.3% from 2012 to 2014 (48.6% unknown start date). Of the 144 patients, 97% and 98% had resistance to lopinavir and atazanavir, respectively; 57% had resistance to darunavir. All were initiated on a regimen containing darunavir, with raltegravir in 101, and etravirine in 33. Among those with at least 1 viral load at least 6 months after third-line approval (n = 118), a large proportion (83%, n = 98) suppressed to <1000 copies per milliliter, and 79% (n = 93) to <400 copies per milliliter. Conclusion: A high proportion of third-line patients with follow-up viral loads are virologically suppressed.
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Eholie SP, Moh R, Benalycherif A, Gabillard D, Ello F, Messou E, Zoungrana J, Diallo I, Diallo M, Bado G, Cisse M, Maiga AI, Anzian A, Toni TD, Congo-Ouedraogo M, Toure-Kane C, Seydi M, Minta DK, Sawadogo A, Sangaré L, Drabo J, Karcher S, Le Carrou J, de Monteynard LA, Peytavin G, Gabassi A, Girard PM, Chaix ML, Anglaret X, Landman R. Implementation of an intensive adherence intervention in patients with second-line antiretroviral therapy failure in four west African countries with little access to genotypic resistance testing: a prospective cohort study. Lancet HIV 2019; 6:e750-e759. [PMID: 31601544 DOI: 10.1016/s2352-3018(19)30228-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 06/20/2019] [Accepted: 07/04/2019] [Indexed: 01/27/2023]
Abstract
BACKGROUND The decision about whether to switch to third-line antiretroviral therapy (ART) in patients with treatment failure on second-line therapy is difficult in settings with little access to genotypic resistance testing. In this study, we used a standardised algorithm including a wide range of adherence-enhancing interventions followed by a new viral load measurement to decide whether to switch to third-line therapy in this situation. The decision, made on the basis of effectiveness of the adherence reinforcement to drive viral resuppression, did not use genotypic resistance testing. METHODS In this prospective cohort study, adults in four west African countries with treatment failure of a boosted protease inhibitor ART regimen were offered nine adherence reinforcement interventions, and followed up for 64 weeks. We measured viral load at week 12 and used the results to decide ART treatment at week 16: if successful resuppression (plasma HIV-1 RNA <400 copies per mL or had decreased by ≥2 log10 copies per mL compared with baseline), patients continued the same second-line regimen; otherwise they switched to a third-line regimen based on ritonavir-boosted darunavir and raltegravir. The primary endpoint was virological success at week 64 (plasma HIV-1 RNA <50 copies per mL). After study termination we did genotypic resistance testing on frozen plasma samples collected at baseline, and retrospectively determined the appropriateness of the week 16 decision on the basis of the baseline genotypic susceptibility score. FINDINGS Between March 28, 2013, and May 11, 2015, of the 198 eligible participants, five died before week 16. Of the 193 remaining, 130 (67%) reached viral resuppression and continued with second-line ART, and 63 (33%) switched to third-line ART at week 16. Post-study genotypic resistance testing showed that the baseline genotypic susceptibility score was calculable in 166 patients, of whom 57 (34%) had a score less than 2. We retrospectively concluded that the week 16 decision was appropriate in 145 (75%) patients. At week 64, four patients (2%) were lost to follow-up, ten (5%) had died, and 101 (52%) had a viral load less than 50 copies per mL. INTERPRETATION Poor adherence is the first problem to tackle in patients for whom second-line ART is failing when resistance tests are not routinely available and is effectively a manageable problem. Lack of access to genotypic resistance testing should not be an obstacle to the prescription of third-line ART in patients who do not achieve viral resuppression after adherence reinforcement. FUNDING French Agency for Research on AIDS and Viral Hepatitis.
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Affiliation(s)
- Serge P Eholie
- Département de Dermatologie et d'Infectiologie, UFR des Sciences Médicales, Université Félix Houphouët Boigny, Abidjan, Cote d'Ivoire; Inserm 1219, University of Bordeaux, Bordeaux, France; Programme PACCI/ANRS Research Center, Abidjan, Cote d'Ivoire.
| | - Raoul Moh
- Département de Dermatologie et d'Infectiologie, UFR des Sciences Médicales, Université Félix Houphouët Boigny, Abidjan, Cote d'Ivoire; Inserm 1219, University of Bordeaux, Bordeaux, France; Programme PACCI/ANRS Research Center, Abidjan, Cote d'Ivoire
| | | | - Delphine Gabillard
- Inserm 1219, University of Bordeaux, Bordeaux, France; Programme PACCI/ANRS Research Center, Abidjan, Cote d'Ivoire
| | - Frédéric Ello
- Département de Dermatologie et d'Infectiologie, UFR des Sciences Médicales, Université Félix Houphouët Boigny, Abidjan, Cote d'Ivoire; Programme PACCI/ANRS Research Center, Abidjan, Cote d'Ivoire
| | - Eugène Messou
- Département de Dermatologie et d'Infectiologie, UFR des Sciences Médicales, Université Félix Houphouët Boigny, Abidjan, Cote d'Ivoire; Inserm 1219, University of Bordeaux, Bordeaux, France; Programme PACCI/ANRS Research Center, Abidjan, Cote d'Ivoire; Centre de Prise en charge, de Recherche et de Formation (CePReF), Abidjan, Côte d'Ivoire
| | | | - Ismaël Diallo
- Service de Médecine Interne, Hôpital de Jour, CHU Yalgado Ouedraogo, Ouagadougou, Burkina Faso
| | - Mouhamadou Diallo
- Centre Régional de Recherche et de Formation à la Prise en Charge Clinique (CRCF), Dakar, Senegal
| | - Guillaume Bado
- Unité de Virologie, CHU Sourô Sanou, Bobo-Dioulasso, Burkina Faso
| | - Mamadou Cisse
- Centre d'Ecoute, de Soins, d'Animation et de Conseils (CESAC), Bamako, Mali
| | | | - Amani Anzian
- Centre de Prise en charge, de Recherche et de Formation (CePReF), Abidjan, Côte d'Ivoire
| | - Thomas-d'Aquin Toni
- Centre de Diagnostic et de Recherche sur le SIDA (CeDReS), CHU de Treichville, Abidjan, Côte d'Ivoire
| | - Malika Congo-Ouedraogo
- Service de Bactériologie-Virologie, Département des Laboratoires, CHU Yalgado Ouedraogo, Ouagadougou, Burkina Faso
| | - Coumba Toure-Kane
- Laboratoire de Bactériologie-Virologie, Département GC&BA-ESP/UCAD, CHU A Le Dantec, Dakar, Senegal
| | - Moussa Seydi
- Centre Régional de Recherche et de Formation à la Prise en Charge Clinique (CRCF), Dakar, Senegal; Service des Maladies Infectieuses, CHU Fann, Dakar, Senegal
| | - Daouda K Minta
- Service des Maladies Infectieuses et Tropicales, CHU du Point-G, Bamako, Mali
| | - Adrien Sawadogo
- Hôpital de Jour, CHU Sourô Sanou, Bobo-Dioulasso, Burkina Faso
| | - Lassana Sangaré
- Service de Bactériologie-Virologie, Département des Laboratoires, CHU Yalgado Ouedraogo, Ouagadougou, Burkina Faso
| | - Joseph Drabo
- Service de Médecine Interne, Hôpital de Jour, CHU Yalgado Ouedraogo, Ouagadougou, Burkina Faso
| | - Sophie Karcher
- Inserm 1219, University of Bordeaux, Bordeaux, France; Programme PACCI/ANRS Research Center, Abidjan, Cote d'Ivoire
| | - Jérome Le Carrou
- Inserm 1219, University of Bordeaux, Bordeaux, France; Programme PACCI/ANRS Research Center, Abidjan, Cote d'Ivoire
| | | | - Gilles Peytavin
- Service de Pharmacologie, CHU Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Audrey Gabassi
- Laboratoire de Virologie, CHU Saint Louis, Assistance Publique-Hôpitaux de Paris, Paris, France; Inserm U944, CNR VIH, Université Paris Diderot, Paris, France
| | - Pierre-Marie Girard
- IMEA, Bichat Claude-Bernard University Hospital, Paris, France; Service des Maladies Infectieuses et Tropicales, CHU Saint Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marie-Laure Chaix
- Laboratoire de Virologie, CHU Saint Louis, Assistance Publique-Hôpitaux de Paris, Paris, France; Inserm U944, CNR VIH, Université Paris Diderot, Paris, France
| | - Xavier Anglaret
- Inserm 1219, University of Bordeaux, Bordeaux, France; Programme PACCI/ANRS Research Center, Abidjan, Cote d'Ivoire.
| | - Roland Landman
- IMEA, Bichat Claude-Bernard University Hospital, Paris, France; Service des Maladies Infectieuses et Tropicales, CHU Bichat Claude Bernard, Assistance Publique-Hôpitaux de Paris, Paris, France; IAME, UMR 1137, Inserm, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
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Yao AH, Moore CL, Lim PL, Molina JM, Madero JS, Kerr S, Mallon PW, Emery S, Cooper DA, Boyd MA. Metabolic profiles of individuals switched to second-line antiretroviral therapy after failing standard first-line therapy for treatment of HIV-1 infection in a randomized, controlled trial. Antivir Ther 2019; 23:21-32. [PMID: 28447585 DOI: 10.3851/imp3171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND To investigate metabolic changes associated with second-line antiretroviral therapy (ART) following virological failure of first-line ART. METHODS SECOND-LINE was an open-label randomized controlled trial. Participants were randomized 1:1 to receive ritonavir-boosted lopinavir (LPV/r) with 2-3 nucleoside/nucleotide reverse transcriptase inhibitors (N[t]RTI group) or raltegravir (RAL group). 210 participants had a dual energy X-ray absorptiometry (DXA)-scan at baseline, week 48 and 96. We categorized participants according to second-line ART backbone: thymidine analogue (ta-NRTI) + lamivudine/emtricitabine (3[F]TC; ta-NRTI group); tenofovir (TDF)+3(F)TC (TDF group); TDF+ta-NRTI ±3(F)TC (TDF+ta-NRTI group); RAL. Changes in fasted total cholesterol (TC), low-density lipoprotein (LDL)-cholesterol, high-density lipoprotein (HDL)-cholesterol, TC/HDL-cholesterol ratio, triglycerides and glucose from baseline to week 96 were examined. We explored the association between metabolic and DXA-assessed soft-tissue changes. Linear regression methods were used. RESULTS We analysed 454 participants. Participants in RAL group had greater TC increases, TC (adjusted mean difference [aMD]=0.65, 95% CI 0.33, 0.96), LDL-c (aMD=0.38, 95% CI 0.15, 0.61) and glucose (aMD=0.47, 95% CI -0.01, 0.92) compared to TDF group, and had greater increases in TC (aMD=0.65, 95% CI 0.28, 1.03), HDL-c (aMD=0.12, 95% CI 0.02, 0.23) and LDL-c (aMD=0.41, 95% CI 0.13, 0.69) compared to TDF+ta-NRTI group. TC/HDL ratio and triglycerides increased in all groups without significant differences between groups. A 1 kg increase in trunk fat mass was associated with an increase in TC. CONCLUSIONS We observed metabolic changes of limited clinical significance in the relatively young population enrolled in this study. However, the metabolic changes observed may have greater clinical significance in older people living with HIV or those with other concomitant cardiovascular risks.
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Affiliation(s)
| | - Cecilia L Moore
- The Kirby Institute, UNSW, Sydney, Australia.,MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, London, United Kingdom
| | - Poh Lian Lim
- Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore
| | - Jean-Michel Molina
- Department of Infectious Diseases, Hôpital Saint-Louis, Paris, France.,University of Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Juan Sierra Madero
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Stephen Kerr
- The Kirby Institute, UNSW, Sydney, Australia.,HIV-NAT, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Paddy Wg Mallon
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Sean Emery
- The Kirby Institute, UNSW, Sydney, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | | | - Mark A Boyd
- The Kirby Institute, UNSW, Sydney, Australia.,Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
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Incidence of switching to second-line antiretroviral therapy and associated factors in children with HIV: an international cohort collaboration. Lancet HIV 2019; 6:e105-e115. [PMID: 30723008 DOI: 10.1016/s2352-3018(18)30319-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 10/19/2018] [Accepted: 10/26/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Estimates of incidence of switching to second-line antiretroviral therapy (ART) among children with HIV are necessary to inform the need for paediatric second-line formulations. We aimed to quantify the cumulative incidence of switching to second-line ART among children in an international cohort collaboration. METHODS In this international cohort collaboration study, we pooled individual patient-level data for children younger than 18 years who initiated ART (two or more nucleoside reverse-transcriptase inhibitors [NRTI] plus a non-NRTI [NNRTI] or boosted protease inhibitor) between 1993 and 2015 from 12 observational cohort networks in the Collaborative Initiative for Paediatric HIV Education and Research (CIPHER) Global Cohort Collaboration. Patients who were reported to be horizontally infected with HIV and those who were enrolled in trials of treatment monitoring, switching, or interruption strategies were excluded. Switch to second-line ART was defined as change of one or more NRTI plus either change in drug class (NNRTI to protease inhibitor or vice versa) or protease inhibitor change, change from single to dual protease inhibitor, or addition of a new drug class. We used cumulative incidence curves to assess time to switching, and multivariable proportional hazards models to explore patient-level and cohort-level factors associated with switching, with death and loss to follow-up as competing risks. FINDINGS At the data cutoff of Sept 16, 2015, 182 747 children with HIV were included in the CIPHER dataset, of whom 93 351 were eligible, with 83 984 (90·0%) from sub-Saharan Africa. At ART initiation, the median patient age was 3·9 years (IQR 1·6-6·9) and 82 885 (88·8%) patients initiated NNRTI-based and 10 466 (11·2%) initiated protease inhibitor-based regimens. Median duration of follow-up after ART initiation was 26 months (IQR 9-52). 3883 (4·2%) patients switched to second-line ART after a median of 35 months (IQR 20-57) of ART. The cumulative incidence of switching at 3 years was 3·1% (95% CI 3·0-3·2), but this estimate varied widely depending on the cohort monitoring strategy, from 6·8% (6·5-7·2) in settings with routine monitoring of CD4 (CD4% or CD4 count) and viral load to 0·8% (0·6-1·0) in settings with clinical only monitoring. In multivariable analyses, patient-level factors associated with an increased likelihood of switching were male sex, older age at ART initiation, and initial NNRTI-based regimen (p<0·0001). Cohort-level factors that increased the likelihood of switching were higher-income country (p=0·0017) and routine or targeted monitoring of CD4 and viral load (p<0·0001), which was associated with a 166% increase in likelihood of switching compared with CD4 only monitoring (subdistributional hazard ratio 2·66, 95% CI 2·22-3·19). INTERPRETATION Our global paediatric analysis found wide variations in the incidence of switching to second-line ART across monitoring strategies. These findings suggest the scale-up of viral load monitoring would probably increase demand for paediatric second-line ART formulations. FUNDING International AIDS Society-CIPHER.
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Fily F, Ayikobua E, Ssemwanga D, Nicholas S, Kaleebu P, Delaugerre C, Pasquier E, Amoros Quiles I, Balkan S, Schramm B. HIV-1 drug resistance testing at second-line regimen failure in Arua, Uganda: avoiding unnecessary switch to an empiric third-line. Trop Med Int Health 2019; 23:1075-1083. [PMID: 30058269 DOI: 10.1111/tmi.13131] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES The number of patients on second-line antiretroviral therapy is growing, but data on HIV drug resistance patterns at failure in resource-constrained settings are scarce. We aimed to describe drug resistance and investigate the factors associated with extensive resistance to nucleoside/nucleotide reverse transcriptase inhibitors (NRTI), in patients failing second-line therapy in the HIV outpatient clinic at Arua Regional Referral Hospital, Uganda. METHODS We included patients who failed on second-line therapy (two consecutive viral loads ≥1000 copies/mm3 by SAMBA-1 point-of-care test) and who had a drug resistance test performed between September 2014 and March 2017. Logistic regression was used to investigate factors associated with NRTI genotypic sensitivity score (GSS) ≤1. RESULTS Seventy-eight patients were included: 42% female, median age 31 years and median time of 29 months on second-line therapy. Among 70 cases with drug resistance test results, predominant subtypes were A (47%) and D (40%); 18.5% had ≥1 major protease inhibitor mutation; 82.8% had ≥1 NRTI mutation and 38.5% had extensive NRTI resistance (NRTI GSS ≤1). A nadir CD4 count ≤100/ml was associated with NRTI GSS ≤1 (OR 4.2, 95% CI [1.3-15.1]). Thirty (42.8%) patients were switched to third-line therapy, composed of integrase inhibitor and protease inhibitor (60% darunavir/r) +/- NRTI. A follow-up viral load was available for 19 third-line patients at 12 months: 84.2% were undetectable. CONCLUSIONS Our study highlights the need for access to drug resistance tests to avoid unnecessary switches to third-line therapy, but also for access to third-line drugs, in particular integrase inhibitors. Low nadir CD4 count might be an indicator of third-line drug requirement for patients failing second-line therapy.
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Affiliation(s)
- F Fily
- Epicentre, Paris, France.,Service des Maladies Respiratoires et Infectieuses, Hôpital Broussais, Saint-Malo, France
| | - E Ayikobua
- Médecins Sans Frontières-France, Paris, France
| | - D Ssemwanga
- MRC/UVRI Uganda Virus Research Unit, Entebbe, Uganda
| | | | - P Kaleebu
- MRC/UVRI Uganda Virus Research Unit, Entebbe, Uganda
| | - C Delaugerre
- Laboratoire de Virologie, Hôpital Saint Louis, AP-HP, Paris, France.,Université Paris-Diderot, Paris, France
| | - E Pasquier
- Epicentre, Paris, France.,Médecins Sans Frontières-France, Paris, France
| | | | - S Balkan
- Médecins Sans Frontières-France, Paris, France
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Abstract
Introduction Understanding the occurrence of antiretroviral (ARV)-related adverse events (AEs) among patients receiving second-line antiretroviral therapy (ART) is important in preventing switches to more limited and expensive third-line regimens. Objective This study aimed to estimate the rates and examine predictors of AEs among adult HIV-1-infected patients receiving second-line ART in the Right to Care (RTC) clinical cohort in South Africa. Methods This was a cohort study of HIV-1-infected adult patients (≥ 18 years of age) initiating standard second-line ART in South Africa from 1 April 2004 to 10 January 2016. Our primary outcome was the development of an AE within 24 months of initiating second-line therapy. We used Kaplan–Meier survival analysis to determine AE incidence in the first 24 months of second-line ART. Predictors of AEs were modelled using a Cox proportional hazards model. Results A total of 7708 patients initiated second-line ART, with 44.5% developing at least one AE over the first 24 months of second-line treatment. The highest AE incidence was observed among patients receiving abacavir (ABC) + lamivudine (3TC) + ritonavir-boosted lopinavir/atazanavir (LPVr/ATVr) (52.7/100 person-years (PYs), 95% confidence interval (CI): 42.9–64.8), while patients initiated on a tenofovir (TDF) + emtricitabine (FTC)/3TC + LPVr regimen had the lowest rate of AEs (26.4/100 PYs, 95% CI: 24.9–28.3). Clinical predictors of AEs included experiencing AEs when receiving first-line ART (adjusted hazard ratio (aHR) 2.3, 95% CI: 1.9–2.8), lower CD4 cell count (0–199 vs. ≥ 350 cells/mm3; aHR 1.4, 95% CI: 1.4–1.8), and switching to second-line therapy from an ABC-base first-line regimen (ABC + 3TC + efavirenz/nevirapine [EFV/NVP] vs. TDF + 3TC/FTC + EFV/NVP; aHR 3.4, 95% CI: 1.1–11.1). Conclusions The rates of AEs were lowest among patients receiving a TDF-based second-line regimen. Patients with poorer health at the time of switch were at higher risk of AEs when receiving second-line ART and may require closer monitoring to improve the durability of second-line therapy.
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Menon S, Rossi R, Kariisa M, Acharya SD, Zdraveska N, Mahmood S, Callens S, Ndizeye Z. Relationship between Highly Active Antiretroviral Therapy (HAART) and human papillomavirus type 16 (HPV 16) infection among women in Sub-Saharan Africa and public health implications: A systematic review. PLoS One 2019; 14:e0213086. [PMID: 30856196 PMCID: PMC6411162 DOI: 10.1371/journal.pone.0213086] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 02/14/2019] [Indexed: 12/17/2022] Open
Abstract
Invasive cervical cancer is the most prevalent cancer among women in Sub-Saharan Africa. In 2013, the World Health Organization (WHO) emitted recommendations to start Highly Active Antiretroviral Therapy (HAART) regardless of CD4 count. Although HAART has been shown to reduce the prevalence of high-risk human papillomavirus (HR-HPV) genotypes, it is unclear whether it confers a protective effect specifically for HPV 16. This review summarizes the existing evidence regarding the effect of HAART on HPV 16 infection, as this genotype may not be influenced by immunity level and explores its implications for Sub Saharan Africa. A comprehensive literature review was undertaken and quality assessment was carried out on the selected papers. Four cohort studies and three cross-sectional studies were identified for which the overall quality score assessment ranged from weak/moderate (Score of 1.8) to strong (Score of 3). The evidence yielded by our review was conflicting. Thus, the high heterogeneity between study populations and results did not allow us to draw any firm conclusions as to whether HAART has an impact on HPV 16 acquisition/prevalence. As only three studies were conducted in Africa, there are insufficient grounds for solid comparison between geographic regions. In light of inadequate data, HPV unvaccinated women on HAART should still receive more frequent follow-up.
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Affiliation(s)
- Sonia Menon
- International Centre for Reproductive Health (ICRH), Ghent University, De Pintelaan, Ghent, Belgium
| | - Rodolfo Rossi
- Primary Health Care Services, International Committee of the Red Cross, Geneva, Switzerland
| | - Mbabazi Kariisa
- March of Dimes Foundation, White Plains, New York, United States of America
| | | | - Natasha Zdraveska
- Faculty of Pharmacy, Department of Clinical Pharmacy, Saints Cyril and Methodius University (Alumni), Skopje, Republic of Macedonia
| | | | - Steven Callens
- Department of Internal Medicine & Infectious Diseases, University Hospital, Ghent, Belgium
| | - Zacharie Ndizeye
- Community Medicine Department, Faculty of Medicine, University of Burundi, Bujumbura, Burundi
- Global Health Institute, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
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Sarfo FS, Castelnuovo B, Fanti I, Feldt T, Incardona F, Kaiser R, Lwanga I, Marrone G, Sonnerborg A, Tufa TB, Zazzi M, De Luca A. Longer-term effectiveness of protease-inhibitor-based second line antiretroviral therapy in four large sub-Saharan African clinics. J Infect 2019; 78:402-408. [PMID: 30849438 DOI: 10.1016/j.jinf.2019.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 02/26/2019] [Accepted: 03/03/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Data on the longer-term effectiveness of second line combination antiretroviral therapy (ART) in sub-Saharan Africa (SSA) are lacking. We sought to assess the probability and determinants of 2nd line ART failure in SSA. METHODS A retrospective, multi-center study of 2nd line ART initiated between 2005 and 2017 at four ART centers in Ethiopia, Ghana and Uganda. Main outcome measure was virologic failure (VF) defined as VL>1000 copies/ml after >6 months on 2nd line therapy. Predictors of VF and virologic re-suppression on 2nd line were evaluated using Cox Proportional Hazards and multivariable logistic regression models, respectively. RESULTS 2191 subjects started 2nd line therapy, 61.5% females. Switching from 1st line (56.4% NVP-based, 70.3% including thymidine-analogues) to 2nd line therapy occurred after mean of 4.1 years. 98.9% of patients started boosted PI with NRTI backbone (TDF+3TC/FTC 67.3%, AZT+3TC 18.5%, others 14.2%). There were 267 (12.0%) VF with a 5-year estimated probability of 15.0% (95% CI 13.2-16.9). Key determinants of VF were concomitant rifampicin use (aHR 2.50 [95% CI 1.54-4.05]) and clinical/immunological failure versus virologic failure as reason for switching therapy (aHR, 0.53 [0.33-0.86]). 138 of 267 (51.7%) subsequently achieved virologic re-suppression and predictors included HIV RNA levels at 2nd-line failure: +1 log higher aOR 0.59 [0.43-0.80], experiencing change within 2nd line ART before VF: aOR 0.17 [0.05-0.56], and more recent calendar year of 2nd line initiation: aOR 0.85 [0.75-0.94]. CONCLUSIONS The effectiveness of current 2nd line ART regimens in SSA is good but challenged by interactions with TB therapy.
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Affiliation(s)
- Fred S Sarfo
- Department of Medicine, Kwame Nkrumah University of Science and Technology, Private Mail Bag, Kumasi, Ghana.
| | | | | | - Torsten Feldt
- Clinic of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Dusseldorf, Germany
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Dolutegravir versus ritonavir-boosted lopinavir both with dual nucleoside reverse transcriptase inhibitor therapy in adults with HIV-1 infection in whom first-line therapy has failed (DAWNING): an open-label, non-inferiority, phase 3b trial. THE LANCET INFECTIOUS DISEASES 2019; 19:253-264. [DOI: 10.1016/s1473-3099(19)30036-2] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 12/08/2018] [Accepted: 12/20/2018] [Indexed: 12/14/2022]
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Limmade Y, Fransisca L, Rodriguez-Fernandez R, Bangs MJ, Rothe C. HIV treatment outcomes following antiretroviral therapy initiation and monitoring: A workplace program in Papua, Indonesia. PLoS One 2019; 14:e0212432. [PMID: 30802257 PMCID: PMC6388914 DOI: 10.1371/journal.pone.0212432] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 02/02/2019] [Indexed: 11/30/2022] Open
Abstract
Background Papua Province, Indonesia is experiencing an on-going epidemic of Human Immunodeficiency Virus (HIV) infection, with an estimated 9-fold greater prevalence than the overall national rate. This study reviewed the treatment outcomes of an HIV-infected cohort on Antiretroviral Therapy (ART) and the predictors in terms of immunological recovery and virological response. Methods ART-naïve individuals in a workplace HIV program in southern Papua were retrospectively analyzed. Patients were assessed at 6, 12 and 36 months after ART initiation for treatment outcomes, and risk factors for virological suppression (viral load (VL) <1,000 copies/ml), poor immune response (CD4 <200 cells/mm3) and immunological failure (CD4 <100 cells/ mm3) after at least 6 months on ART, using a longitudinal Generalized Estimating Equations multivariate model. Results Assessment of 105 patients were included in the final analysis with a median age of 34 years, 88% male, median baseline CD4 236 cells/ mm3, and VL 179,000 copies/ml. There were 74, 73, and 39 patients at 6, 12, and 36 months follow-up, respectively, with 5 deaths over the entire period. For the three observation periods, 68, 80, and 75% of patents achieved virological suppression, poor immune responders decreased from 15, 16 to 10%, whilst 15, 16, 10% met the immunological failure criteria, respectively. Using multivariate analysis, the independent predictor for viral suppression at 12 and 36 months was ≥1 log decrease in VL at 6 months (OR 19.25, p<0.001). Higher baseline CD4 was significantly correlated with better immunological outcomes, and lower likelihood of experiencing immunological failure (p <0.001). Conclusion Virological response at six months after beginning ART is the strongest predictor of viral suppression at 12 and 36 months, and may help in identifying patients needing additional adherence therapy support. Higher baseline CD4 positively affects the immunological outcomes of patients. The findings indicate HIV control programs should prioritize the availability of VL testing and begin ART regardless of CD4 counts in infected patients.
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Affiliation(s)
- Yuriko Limmade
- Institute of Tropical Medicine and International Health, Charité- Universitätsmedizin Berlin, Germany
- * E-mail:
| | - Liony Fransisca
- Kuala Kencana Clinic, PT Freeport Indonesia/International SOS, Papua, Indonesia
| | | | - Michael J. Bangs
- Public Health & Malaria Control Department, PT Freeport Indonesia/International SOS, Papua, Indonesia
| | - Camilla Rothe
- Division of Infectious Diseases and Tropical Medicine, University Hospital, LMU Munich, Germany
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Hamers RL. Dolutegravir for second-line antiretroviral therapy. THE LANCET. INFECTIOUS DISEASES 2019; 19:218-219. [PMID: 30732941 DOI: 10.1016/s1473-3099(19)30035-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 01/10/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Raph L Hamers
- Eijkman-Oxford Clinical Research Unit, Eijkman Institute for Molecular Biology, and Faculty of Medicine Universitas Indonesia, Jakarta 10430, Indonesia; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Amsterdam Institute for Global Health and Development, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.
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Burns R, Borges J, Blasco P, Vandenbulcke A, Mukui I, Magalasi D, Molfino L, Manuel R, Schramm B, Wringe A. 'I saw it as a second chance': A qualitative exploration of experiences of treatment failure and regimen change among people living with HIV on second- and third-line antiretroviral therapy in Kenya, Malawi and Mozambique. Glob Public Health 2019; 14:1112-1124. [PMID: 30632883 DOI: 10.1080/17441692.2018.1561921] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Increasing numbers of people living with HIV (PLHIV) in sub-Saharan Africa are experiencing failure of first-line antiretroviral therapy and transitioning onto second-line regimens. However, there is a dearth of research on their treatment experiences. We conducted in-depth interviews with 43 PLHIV on second- or third-line antiretroviral therapy and 15 HIV health workers in Kenya, Malawi and Mozambique to explore patients' and health workers' perspectives on these transitions. Interviews were audio-recorded, transcribed and translated into English. Data were coded inductively and analysed thematically. In all settings, experiences of treatment failure and associated episodes of ill-health disrupted daily social and economic activities, and recalled earlier fears of dying from HIV. Transitioning onto more effective regimens often represented a second (or third) chance to (re-)engage with HIV care, with patients prioritising their health over other aspects of their lives. However, many patients struggled to maintain these transformations, particularly when faced with persistent social challenges to pill-taking, alongside the burden of more complex regimens and an inability to mobilise sufficient resources to accommodate change. Efforts to identify treatment failure and support regimen change must account for these patients' unique illness and treatment histories, and interventions should incorporate tailored counselling and social and economic support.
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Affiliation(s)
| | - Joana Borges
- b Médecins sans Frontières , Geneva , Switzerland
| | | | | | | | | | | | | | | | - Alison Wringe
- f London School of Hygiene and Tropical Medicine , London , UK
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HIV-1 second-line failure and drug resistance at high-level and low-level viremia in Western Kenya. AIDS 2018; 32:2485-2496. [PMID: 30134290 DOI: 10.1097/qad.0000000000001964] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Characterize failure and resistance above and below guidelines-recommended 1000 copies/ml virologic threshold, upon second-line failure. DESIGN Cross-sectional study. METHODS Kenyan adults on lopinavir/ritonavir-based second-line were enrolled at AMPATH (Academic Model Providing Access to Healthcare). Charts were reviewed for demographic/clinical characteristics and CD4/viral load were obtained. Participants with detectable viral load had a second visit and pol genotyping was attempted in both visits. Accumulated resistance was defined as mutations in the second, not the first visit. Low-level viremia (LLV) was detectable viral load less than 1000 copies/ml. Failure and resistance associations were evaluated using logistic and Poisson regression, Fisher Exact and t-tests. RESULTS Of 394 participants (median age 42, 60% women, median 1.9 years on second-line) 48% had detectable viral load; 21% had viral load more than 1000 copies/ml, associated with younger age, tuberculosis treatment, shorter time on second-line, lower CD4count/percentage, longer first-line treatment interruption and pregnancy. In 105 sequences from the first visit (35 with LLV), 79% had resistance (57% dual-class, 7% triple-class; 46% with intermediate-to-high-level resistance to ≥1 future drug option). LLV was associated with more overall and NRTI-associated mutations and with predicted resistance to more next-regimen drugs. In 48 second-visit sequences (after median 55 days; IQR 28-33), 40% accumulated resistance and LLV was associated with more mutation accumulation. CONCLUSION High resistance upon second-line failure exists at levels above and below guideline-recommended virologic-failure threshold, impacting future treatment options. Optimization of care should include increased viral load monitoring, resistance testing and third-line ART access, and consideration of lowering the virologic failure threshold, though this demands further investigation.
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42
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Estill J, Marsh K, Autenrieth C, Ford N. How to achieve the global 90-90-90 target by 2020 in sub-Saharan Africa? A mathematical modelling study. Trop Med Int Health 2018; 23:1223-1230. [PMID: 30156355 DOI: 10.1111/tmi.13145] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVES The 90-90-90 target states that by 2020, 90% of people living with HIV should be diagnosed, 90% of those diagnosed treated, and 90% of those treated virally suppressed. We assessed the actions needed in each country of sub-Saharan Africa to achieve the 90-90-90 target. METHODS We developed a mathematical model to assess the number of patients needing to start antiretroviral therapy (ART) between 2017 and 2020 to achieve 81% coverage by 2020 in each country, and the proportion of treated patients who are virally suppressed in four scenarios, combining two scenarios of retention (current-level or perfect), and routine viral load monitoring (current or universal coverage). We performed two separate simulations, one using observed failure rates from cohort studies, and one with considerably lower failure rates to set a theoretical lower limit. RESULTS Our model projected that 2.9 million people started ART in 2017 in sub-Saharan Africa. If, depending on scenario, at least 2.2-2.7 million patients continue to start ART annually, 81% ART coverage will be reached in 2020 in sub-Saharan Africa on average. In 37% of the countries, a multiple-fold increase in annual number of patients starting ART is needed. Virological suppression >90% in 2020 could be reached only in the best-case scenario assuming low probability of treatment failure, elimination of treatment interruptions, and universal routine viral load monitoring. CONCLUSION The 90-90-90 target is realistic in sub-Saharan Africa on average, but not necessarily in all individual countries. Each country should identify and focus on the specific gaps needing attention.
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Affiliation(s)
- Janne Estill
- Institute of Global Health, University of Geneva, Geneva, Switzerland.,Institute of Mathematical Statistics and Actuarial Science, University of Bern, Bern, Switzerland
| | - Kimberly Marsh
- Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland
| | | | - Nathan Ford
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
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Hamers RL, Rinke de Wit TF, Holmes CB. HIV drug resistance in low-income and middle-income countries. Lancet HIV 2018; 5:e588-e596. [PMID: 30193863 DOI: 10.1016/s2352-3018(18)30173-5] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 07/02/2018] [Accepted: 07/10/2018] [Indexed: 10/28/2022]
Abstract
After 15 years of global scale-up of antiretroviral therapy (ART), rising prevalence of HIV drug resistance in many low-income and middle-income countries (LMICs) poses a growing threat to the HIV response, with the potential to drive an increase in mortality, HIV incidence, and costs. To achieve UNAIDS global targets, enhanced strategies are needed to improve quality of ART services and durability of available ART regimens, and to curb resistance. These strategies include roll out of drugs with greater efficacy and higher genetic barriers to resistance than those that are currently widely used, universal access to and improved effectiveness of viral load monitoring, patient-centred care delivery models, and reliable drug supply chains, in conjunction with frameworks for resistance monitoring and prevention. In this Review, we assess contemporary data on HIV drug resistance in LMICs and their implications for the HIV response, highlighting the potential impact and resistance risks of novel ART strategies and knowledge gaps.
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Affiliation(s)
- Raph L Hamers
- Eijkman-Oxford Clinical Research Unit, Eijkman Institute for Molecular Biology, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Department of Global Health, Amsterdam UMC, University of Amsterdam and Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands.
| | - Tobias F Rinke de Wit
- Department of Global Health, Amsterdam UMC, University of Amsterdam and Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands; Joep Lange Institute, Amsterdam, Netherlands
| | - Charles B Holmes
- Centre for Infectious Diseases Research Zambia, Lusaka, Zambia; Center for Global Health and Quality, Georgetown University Medical Center, Washington, DC, USA; Johns Hopkins University School of Medicine and Bloomberg School of Public Health, Baltimore, MD, USA
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44
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Stockdale AJ, Saunders MJ, Boyd MA, Bonnett LJ, Johnston V, Wandeler G, Schoffelen AF, Ciaffi L, Stafford K, Collier AC, Paton NI, Geretti AM. Effectiveness of Protease Inhibitor/Nucleos(t)ide Reverse Transcriptase Inhibitor-Based Second-line Antiretroviral Therapy for the Treatment of Human Immunodeficiency Virus Type 1 Infection in Sub-Saharan Africa: A Systematic Review and Meta-analysis. Clin Infect Dis 2018; 66:1846-1857. [PMID: 29272346 PMCID: PMC5982734 DOI: 10.1093/cid/cix1108] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 12/18/2017] [Indexed: 02/02/2023] Open
Abstract
Background In sub-Saharan Africa, 25.5 million people are living with human immunodeficiency virus (HIV), representing 70% of the global total. The need for second-line antiretroviral therapy (ART) is projected to increase in the next decade in keeping with the expansion of treatment provision. Outcome data are required to inform policy. Methods We performed a systematic review and meta-analysis of studies reporting the virological outcomes of protease inhibitor (PI)-based second-line ART in sub-Saharan Africa. The primary outcome was virological suppression (HIV-1 RNA <400 copies/mL) after 48 and 96 weeks of treatment. The secondary outcome was the proportion of patients with PI resistance. Pooled aggregate data were analyzed using a DerSimonian-Laird random effects model. Results By intention-to-treat analysis, virological suppression occurred in 69.3% (95% confidence interval [CI], 58.2%-79.3%) of patients at week 48 (4558 participants, 14 studies), and in 61.5% (95% CI, 47.2%-74.9%) at week 96 (2145 participants, 8 studies). Preexisting resistance to nucleos(t)ide reverse transcriptase inhibitors (NRTIs) increased the likelihood of virological suppression. Major protease resistance mutations occurred in a median of 17% (interquartile range, 0-25%) of the virological failure population and increased with duration of second-line ART. Conclusions One-third of patients receiving PI-based second-line ART with continued NRTI use in sub-Saharan Africa did not achieve virological suppression, although among viremic patients, protease resistance was infrequent. Significant challenges remain in implementation of viral load monitoring. Optimizing definitions and strategies for management of second-line ART failure is a research priority. Prospero Registration CRD42016048985.
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Affiliation(s)
- Alexander J Stockdale
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre
- Institute of Infection and Global Health, University of Liverpool
| | - Matthew J Saunders
- Section of Infectious Diseases and Immunity and Wellcome Trust–Imperial College Centre for Global Health Research, Imperial College London, United Kingdom
| | - Mark A Boyd
- Kirby Institute for Infection and Immunity, University of New South Wales, Sydney
- Lyell McEwin Hospital, University of Adelaide, South Australia, Australia
| | | | | | - Gilles Wandeler
- Institute of Social and Preventative Medicine, University of Bern
- Department of Infectious Diseases, Bern University Hospital, Switzerland
| | - Annelot F Schoffelen
- Department of Infectious Diseases, University Medical Centre Utrecht, The Netherlands
| | - Laura Ciaffi
- Unité Mixte de Recherche de l’Institut de Rech (UMI), Institute de Recherche pour le Développement, Institute National de la Santé et de la Recherche Medicale, University of Montpellier, France
| | - Kristen Stafford
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore
| | - Ann C Collier
- University of Washington School of Medicine, Seattle
| | - Nicholas I Paton
- Yong Loo Lin School of Medicine, National University of Singapore
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45
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Renal health after long-term exposure to tenofovir disoproxil fumarate (TDF) in HIV/HBV positive adults in Ghana. J Infect 2018; 76:515-521. [PMID: 29702139 DOI: 10.1016/j.jinf.2018.03.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 03/11/2018] [Accepted: 03/14/2018] [Indexed: 12/29/2022]
Abstract
OBJECTIVES The study assessed markers of renal health in HIV/HBV co-infected patients receiving TDF-containing antiretroviral therapy in Ghana. METHODS Urinary protein-to-creatinine ratio (uPCR) and albumin-to-protein ratio (uAPR) were measured cross-sectionally after a median of four years of TDF. At this time, alongside extensive laboratory testing, patients underwent evaluation of liver stiffness and blood pressure. The estimated glomerular filtration rate (eGFR) was measured longitudinally before and during TDF therapy. RESULTS Among 101 participants (66% women, median age 44 years, median CD4 count 572 cells/mm3) 21% and 17% had detectable HIV-1 RNA and HBV DNA, respectively. Overall 35% showed hypertension, 6% diabetes, 7% liver stiffness indicative of cirrhosis, and 18% urinary excretion of Schistosoma antigen. Tubular proteinuria occurred in 16% of patients and was independently predicted by female gender and hypertension. The eGFR declined by median 1.8 ml/min/year during TDF exposure (IQR -4.4, -0.0); more pronounced declines (≥ 5 ml/min/year) occurred in 22% of patients and were associated with receiving ritonavir-boosted lopinavir rather than efavirenz. HBV DNA, HBeAg, transaminases, and liver stiffness were not predictive of renal function abnormalities. CONCLUSIONS The findings mandate improved diagnosis and management of hypertension and suggest targeted laboratory monitoring of patients receiving TDF alongside a booster in sub-Saharan Africa.
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46
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Laborde-Balen G, Taverne B, Ndour CT, Kouanfack C, Peeters M, Ndoye I, Delaporte E. The fourth HIV epidemic. THE LANCET. INFECTIOUS DISEASES 2018; 18:379-380. [PMID: 29582762 DOI: 10.1016/s1473-3099(18)30167-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 02/14/2018] [Accepted: 02/15/2018] [Indexed: 12/20/2022]
Affiliation(s)
- Gabrièle Laborde-Balen
- Centre régional de recherche et de formation à la prise en charge clinique de Fann (CRCF), CHNU Fann, 45690 Dakar, Sénégal; Expertise France, Paris, France.
| | - Bernard Taverne
- Centre régional de recherche et de formation à la prise en charge clinique de Fann (CRCF), CHNU Fann, 45690 Dakar, Sénégal; Unité Mixte Internationale de Recherche 233 de l'IRD TransVIHMI (IRD UMI 233-U 1175 INSERM-Université de Montpellier, Montpellier, France
| | - Cheikh Tidiane Ndour
- Division de Lutte contre le Sida et les IST, Ministère de la Santé et de l'Action sociale, Dakar, Sénégal
| | - Charles Kouanfack
- Service des Maladies Infectieuses, Hôpital central de Yaoundé, Cameroon
| | - Martine Peeters
- Unité Mixte Internationale de Recherche 233 de l'IRD TransVIHMI (IRD UMI 233-U 1175 INSERM-Université de Montpellier, Montpellier, France
| | - Ibra Ndoye
- Centre régional de recherche et de formation à la prise en charge clinique de Fann (CRCF), CHNU Fann, 45690 Dakar, Sénégal
| | - Eric Delaporte
- Unité Mixte Internationale de Recherche 233 de l'IRD TransVIHMI (IRD UMI 233-U 1175 INSERM-Université de Montpellier, Montpellier, France
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Nasir IA, Emeribe AU, Ojeamiren I, Aderinsayo Adekola H. Human Immunodeficiency Virus Resistance Testing Technologies and Their Applicability in Resource-Limited Settings of Africa. Infect Dis (Lond) 2017; 10:1178633717749597. [PMID: 29308013 PMCID: PMC5751912 DOI: 10.1177/1178633717749597] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 11/26/2017] [Indexed: 01/03/2023] Open
Abstract
There has been tremendous breakthrough in the development of technologies and protocols for counselling, testing, and surveillance of resistant human immunodeficiency virus strains for efficient prognosis and clinical management aimed at improving the quality of life of infected persons. However, we have not arrived at a point where services rendered using these technologies can be made affordable and accessible to resource-limited settings. There are several technologies for monitoring antiretroviral resistance, each with unique merits and demerits. In this study, we review the strengths and limitations of prospective and affordable technologies with emphasis on those that could be used in resource-limited settings.
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Affiliation(s)
- Idris Abdullahi Nasir
- Department of Medical Microbiology and Parasitology, College of Health Sciences, University of Ilorin, Ilorin, Nigeria.,Department of Medical Laboratory Services, University of Abuja Teaching Hospital, FCT Abuja, Nigeria.,Department of Medical Laboratory Science, College of Medical Sciences, University of Maiduguri, Maiduguri, Nigeria
| | | | - Iduda Ojeamiren
- Department of Virology, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Hafeez Aderinsayo Adekola
- Department of Medical Microbiology and Parasitology, College of Health Sciences, University of Ilorin, Ilorin, Nigeria
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Murphy RA, Court R, Maartens G, Sunpath H. Second-Line Antiretroviral Therapy in Sub-Saharan Africa: It Is Time to Mind the Gaps. AIDS Res Hum Retroviruses 2017; 33:1181-1184. [PMID: 28793781 PMCID: PMC5709698 DOI: 10.1089/aid.2017.0134] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The delay between first-line antiretroviral therapy (ART) failure and initiation of second-line ART in resource-limited settings can be prolonged. Increasing evidence links delayed antiretroviral switch with increased risk for opportunistic infection (OI) and death, particularly in patients with advanced HIV at the time of first-line failure. As access to viral load (VL) monitoring widens beyond a few countries, mechanisms are needed to optimize the use of routine virologic monitoring and assure that first-line regimen failure results in prompt second-line switch. For patients with advanced HIV or OI at the time of first-line failure, a targeted fast track to second-line ART should be considered, involving a switch to second-line ART during a single visit. To derive the maximum benefit from both the current expansion of VL monitoring and the falling costs of second-line ART, clinics and healthcare workers should be given the tools and training to detect and switch patients with regimen failure before HIV disease progression.
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Affiliation(s)
- Richard A. Murphy
- Division of Infectious Diseases, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Richard Court
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Henry Sunpath
- Division of Infectious Diseases, University of KwaZulu-Natal, Durban, South Africa
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De La Mata NL, Kumarasamy N, Ly PS, Ng OT, Nguyen KV, Merati TP, Lee MP, Cuong DD, Choi JY, Ross JL, Law MG. Growing challenges for HIV programmes in Asia: clinic population trends, 2003-2013. AIDS Care 2017; 29:1243-1254. [PMID: 28132544 PMCID: PMC5534184 DOI: 10.1080/09540121.2017.1282108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The scale-up of antiretroviral therapy (ART) has led to a substantial change in the clinical population of HIV-positive patients receiving care. We describe the temporal trends in the demographic and clinical characteristics of HIV-positive patients initiating ART in 2003-13 within an Asian regional cohort. All HIV-positive adult patients that initiated ART between 2003 and 2013 were included. We summarized ART regimen use, age, CD4 cell count, HIV viral load, and HIV-related laboratory monitoring rates during follow-up by calendar year. A total of 16 962 patients were included in the analysis. Patients in active follow-up increased from 695 patients at four sites in 2003 to 11,137 patients at eight sites in 2013. The proportion of patients receiving their second or third ART regimen increased over time (5% in 2003 to 29% in 2013) along with patients aged ≥50 years (8% in 2003 to 18% in 2013). Concurrently, CD4 monitoring has remained stable in recent years, whereas HIV viral load monitoring, although varied among the sites, is increasing. There have been substantial changes in the clinical and demographic characteristics of HIV-positive patients receiving ART in Asia. HIV programmes will need to anticipate the clinical care needs for their aging populations, expanded viral load monitoring, and, the eventual increase in second and third ART regimens that will lead to higher costs and more complex drug procurement needs.
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Affiliation(s)
| | | | - Penh Sun Ly
- National Center for HIV/AIDS, Dermatology & STDs, Phnom Penh, Cambodia
| | | | | | | | - Man Po Lee
- Queen Elizabeth Hospital, Hong Kong SAR, China
| | | | - Jun Yong Choi
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Severance Hospital, Seoul, South Korea
| | - Jeremy L. Ross
- TREAT Asia, amfAR - The Foundation for AIDS Research, Bangkok, Thailand
| | - Matthew G. Law
- The Kirby Institute, UNSW Australia, Sydney, NSW, Australia
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50
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Le NK, Riggi E, Marrone G, Vu TV, Izurieta RO, Nguyen CKT, Larsson M, Do CD. Assessment of WHO criteria for identifying ART treatment failure in Vietnam from 2007 to 2011. PLoS One 2017; 12:e0182688. [PMID: 28877173 PMCID: PMC5587312 DOI: 10.1371/journal.pone.0182688] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 07/20/2017] [Indexed: 11/19/2022] Open
Abstract
Objective We evaluated the sensitivity and specificity of the WHO immunological criteria for detecting antiretroviral therapy (ART) treatment failure in a cohort of Vietnamese patients. We conducted a stratified analysis to determine the effects of BMI, peer support, adherence to antiretroviral (ARV) drugs, age, and gender on the sensitivity and specificity of the WHO criteria. Methods We conducted a retrospective cohort study of 605 HIV-infected patients using data previously collected from a cluster randomized control trial study. We compared the sensitivity and specificity of CD4+ counts to the gold standard of virologic testing as a diagnostic test for ART failure at different time points of 12, 18, and 24 months. Results The sensitivity [95% confidence interval (CI)] of the WHO immunological criteria based on a viral load ≥ 1000 copies/mL was 12% (5%-23%), 14% (2%-43%), and 12.5% (2%-38%) at 12, 18, and 24 months, respectively. In the same order, the specificity was 93% (90%-96%), 98% (96%-99%), and 98% (96%-100%). The positive predictive values (PPV) at 12, 18, and 24 months were 22% (9%-40%), 20% (3%-56%), and 29% (4%-71%); the negative predictive values (NPV) at the same time points were 87% (84%-90%), 97% (95%-98%), and 96% (93%-98%). The stratified analysis revealed similar sensitivities and specificities. Conclusion The sensitivity of the WHO immunological criteria is poor, but the specificity is high. Although testing costs may increase, we recommend that Vietnam and other similar settings adopt viral load testing as the principal method for determining ART failure.
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Affiliation(s)
- Nicole K. Le
- Morsani College of Medicine, University of South Florida, Tampa, FL, United States of America
| | - Emilia Riggi
- Department of Brain and Behavioural Sciences, Medical Statistics Unit, University of Pavia, Pavia, Italy
| | - Gaetano Marrone
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Tam Van Vu
- Department of Infectious Diseases, Uong Bi General Hospital, Uong Bi, Quang Ninh, Vietnam
| | - Ricardo O. Izurieta
- Department of Global Health, College of Public Health, University of South Florida, Tampa, FL, United States of America
| | | | - Mattias Larsson
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Cuong Duy Do
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- Infectious Diseases Department, Bach Mai Hospital, Hanoi, Vietnam
- * E-mail:
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