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Desmonde S, Dame J, Malateste K, David A, Amorissani-Folquet M, N'Gbeche S, Sylla M, Takassi E, Kouakou K, Tossa LB, Yonaba C, Leroy V. Disparities in access to Dolutegravir in West African children, adolescents and young adults aged 0-24 years living with HIV. A IeDEA Pediatric West African cohort analysis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.05.24.24307900. [PMID: 38826257 PMCID: PMC11142258 DOI: 10.1101/2024.05.24.24307900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2024]
Abstract
Introduction We describe the 24-month incidence of Dolutegravir (DTG)-containing antiretroviral treatment (ART) initiation since its introduction in 2019 in the pediatric West African IeDEA cohorts. Methods We included all patients aged 0-24 years on ART, from nine clinics in Côte d'Ivoire (n=4), Ghana, Nigeria, Mali, Benin, and Burkina Faso. Baseline varied by clinic and was defined as date of first DTG prescription; patients were followed-up until database closure/death/loss to follow-up (LTFU, no visit ≥ 7 months), whichever came first. We computed the cumulative incidence function for DTG initiation; associated factors were explored in a shared frailty model, accounting for clinic heterogeneity. Results Since 2019, 3,350 patients were included; 49% were female;79% had been on ART ≥ 12 months. Median baseline age was 12.9 years (IQR: 9-17). Median follow-up was 14 months (IQR: 7-22). The overall cumulative incidence of DTG initiation reached 35.5% (95% CI: 33.7-37.2) and 56.4% (95% CI: 54.4-58.4) at 12 and 24 months, respectively. In univariate analyses, those aged <5 years and females were overall less likely to switch. Adjusted on ART line and available viral load (VL) at baseline, females >10 years were less likely to initiate DTG compared to males of the same age (aHR among 10-14 years: 0.62, 95% CI: 0.54-0.72; among ≥15 years: 0.43, 95% CI: 0.36-0.50), as were those with detectable VL (> 50 copies/mL) compared to those in viral suppression (aHR: 0.86, 95% CI: 0.77-0.97) and those on PIs compared to those on NNRTIs (aHR after 12 months of roll-out: 0.75, 95% CI: 0.65-0.86). Conclusion: Access to paediatric DTG was incomplete and unequitable in West African settings: children <5years, females ≥ 10 years and those with detectable viral load were least likely to access DTG. Maintained monitoring and support of treatment practices is required to better ensure universal and equal access. Key messages What is already known on this topic?: Dolutegravir (DTG)-based ART regimens are recommended as the preferred first-line ART regimens recommended by the World Health Organisation in all people living with HIV since 2018, with a note of caution for pregnant women, then confirmed in all children with approved DTG dosing and adolescents since 2019.Deployment of universal DTG access in adults in West Africa has faced challenges such as infrastructure challenges, and healthcare system disparities, and was hindered by initial perinatal safety concerns affecting greatly women of childbearing age.Specific data on access to DTG in children, adolescents and young adults in West Africa is limited.What this study adds ?: This study describes the dynamic of the DTG roll-out over the first 24 months and its correlates since 2019 in a large West African multicentric cohort of children, adolescents and youth.We observed a rapid scale-up of DTG among children, adolescents and young adults living with HIV in West Africa, despite the COVID-19 pandemic.However, DTG access after 24 months was incomplete and unequitable, with adolescent girls and young women being less likely to initiate DTG compared to males, as were those with a detectable viral load (> 50 copies/mL) compared to those in success.Younger children < 5 years were also less likely to initiate DTG, explained by the later approval of paediatric formulations and their low availability.How this study might affect research, practice or policy?: Maintained monitoring, training and updating guidance for healthcare workers is essential to ensure universal access to DTG, especially for females, for whom inequity begins age 10 years.Efforts to improve access to universal DTG in West Africa require multifaceted interventions including healthcare infrastructure improvement and facilitation of paediatric antiretroviral forecasting and planification.
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Ghassan W, Basem A, Hawra A, Ahmad A, Muaddi AAH, Mestouri A, Elaraby R, Mahon J. Estimating the cost due to resistance against antiretroviral therapies in individuals with HIV: Perspective of the Kingdom of Saudi Arabia. IJID REGIONS 2024; 11:100371. [PMID: 38808154 PMCID: PMC11130718 DOI: 10.1016/j.ijregi.2024.100371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/23/2024] [Accepted: 04/23/2024] [Indexed: 05/30/2024]
Abstract
Objectives The emergence of resistance to antiretroviral therapy (ART) has an impact on the cost of HIV care. This study aimed to estimate the direct and indirect costs associated with the first episode of drug resistance in individuals with HIV receiving first-line ART. Methods We developed a cost calculator to estimate the cost of drug resistance over a period of 12 months in the Kingdom of Saudi Arabia. The model inputs (estimated using expert opinion and publicly available sources) included costs associated with testing for resistance, adverse events of a new regimen, and indirect costs. Results The direct and indirect medical expenses for the year resistance developed were 6980 Saudi Arabian riyal (SAR) and SAR 2862, respectively. The addition of the cost of new ARTs would increase the total annual costs (between SAR 5174 and SAR 34,265 per patient). One-way sensitivity analysis also reported significant impact of initial and switching therapies used after resistance develops on the total costs of resistance per year. Conclusions There is a significant cost burden associated with drug resistance, which emphasizes the need to select an appropriate initial ART regimen that has a strong genetic barrier and conduct pre-treatment resistance tests (if possible).
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Affiliation(s)
- Wali Ghassan
- King Faisal Specialist Hospital & Research Centre, Jeddah, Saudi Arabia
| | - Alraddadi Basem
- King Faisal Specialist Hospital & Research Centre, Jeddah, Saudi Arabia
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Aprilianti S, Utami AM, Suwantika AA, Zakiyah N, Azis VI. The Cost-Effectiveness of Dolutegravir in Combination with Tenofovir and Lamivudine for HIV Therapy: A Systematic Review. CLINICOECONOMICS AND OUTCOMES RESEARCH 2024; 16:25-34. [PMID: 38293254 PMCID: PMC10826517 DOI: 10.2147/ceor.s439725] [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: 09/11/2023] [Accepted: 01/20/2024] [Indexed: 02/01/2024] Open
Abstract
The World Health Organization (WHO) recommends dolutegravir (DTG), a human immunodeficiency virus (HIV) medicine, as the first- and second-line treatment for all populations because, when compared to an efavirenz (EFV) regimen, plus two nucleoside reverse transcriptase inhibitors (NRTIs) has demonstrated significant effectiveness in HIV suppression in persons. This study aims to review evidence of the cost-effectiveness of DTG in combination with tenofovir and lamivudine compared with the standard of care for HIV therapy. The systematic review involved searching electronic databases for articles published between January 2018 and May 2022. Electronic database sources include PubMed, ScienceDirect, and EBSCO for articles on DTG in combination with tenofovir and lamivudine as subjects with cost-effectiveness outcomes. The inclusion criteria in this systematic review were studies about the cost-effectiveness analysis (CEA) of DTG in combination with tenofovir and lamivudine, written in English. A total of 145 articles were identified from three databases. After removing nine duplicates, 142 articles were screened by title and abstract, excluding 123 articles. After a full-text screening of 19 articles, five articles were selected for further analysis. Five articles reviewed in sub-Saharan Africa, India, and China implemented different modelling methods for CEA but produced similar results. The results of these studies demonstrate that it is more cost-effective than standard care for HIV treatment. The study conducted in sub-Saharan Africa from 2018 to 2020 showed a cost-effective result with disability-adjusted life years averted (DALY averted) by 83%; in India, it resulted in incremental cost-effectiveness ratio (ICER) $130 per year of live-saved (YLS); and a study in China found that dolutegravir plus tenofovir and lamivudine led to 0.006 incremental quality-adjusted life years (QALYs) with cost savings of $64. The DTG regimen is cost-effective and recommended for HIV therapy in all studies that provide results.
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Affiliation(s)
- Santi Aprilianti
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
| | - Auliasari M Utami
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
| | - Auliya A Suwantika
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
- Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia
- Center for Health Technology Assessment, Universitas Padjadjaran, Bandung, Indonesia
| | - Neily Zakiyah
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
- Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia
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Gumede SB, Wensing AMJ, Lalla-Edward ST, de Wit JBF, Francois Venter WD, Tempelman HA, Hermans LE. Predictors of Treatment Adherence and Virological Failure Among People Living with HIV Receiving Antiretroviral Therapy in a South African Rural Community: A Sub-study of the ITREMA Randomised Clinical Trial. AIDS Behav 2023; 27:3863-3885. [PMID: 37382825 PMCID: PMC10598166 DOI: 10.1007/s10461-023-04103-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2023] [Indexed: 06/30/2023]
Abstract
A large proportion of people living with HIV (PLHIV) in sub-Saharan Africa reside in rural areas. Knowledge of enablers and barriers of adherence to antiretroviral treatment (ART) in these populations is limited. We conducted a cohort study of 501 adult PLHIV on ART at a rural South African treatment facility as a sub-study of a clinical trial (ClinicalTrials.gov NCT03357588). Socio-economic, psychosocial and behavioral characteristics were assessed as covariates of self-reported adherence difficulties, suboptimal pill count adherence and virological failure during 96 weeks of follow-up. Male gender was an independent risk factor for all outcomes. Food insecurity was associated with virological failure in males. Depressive symptoms were independently associated with virological failure in both males and females. Household income and task-oriented coping score were protective against suboptimal pill-count adherence. These results underscore the impact of low household income, food insecurity and depression on outcomes of ART in rural settings and confirm other previously described risk factors. Recognition of these factors and targeted adherence support strategies may improve patient health and treatment outcomes.
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Affiliation(s)
- Siphamandla B Gumede
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa.
- Department of Interdisciplinary Social Science, Utrecht University, Utrecht, The Netherlands.
| | - Annemarie M J Wensing
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
- Ndlovu Research Consortium, Elandsdoorn, South Africa
| | - Samanta T Lalla-Edward
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa
| | - John B F de Wit
- Department of Interdisciplinary Social Science, Utrecht University, Utrecht, The Netherlands
- Centre for Social Research in Health, UNSW, Sydney, Australia
| | - W D Francois Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa
| | - Hugo A Tempelman
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa
- Ndlovu Research Consortium, Elandsdoorn, South Africa
| | - Lucas E Hermans
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
- Ndlovu Research Consortium, Elandsdoorn, South Africa
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Bousmah MAQ, Protopopescu C, Mpoudi-Etame M, Omgba Bassega P, Maradan G, Olinga J, Varloteaux M, Tovar-Sanchez T, Delaporte É, Kouanfack C, Boyer S. Improvements in Patient-Reported Outcomes Following Initiation of Dolutegravir-Based or Low-Dose Efavirenz-Based First-Line Antiretroviral Therapy: A Four-Year Longitudinal Analysis in Cameroon (NAMSAL ANRS 12313 Trial). J Acquir Immune Defic Syndr 2023; 94:262-272. [PMID: 37851566 DOI: 10.1097/qai.0000000000003273] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 07/10/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND We provide new and comprehensive evidence on the evolution of a wide range of patient-reported outcomes (PROs) in the NAMSAL ANRS 12313 trial in Cameroon (2016-2021)-the first randomized comparison of dolutegravir 50 mg (DTG) and low-dose efavirenz (ie, 400 mg; EFV400) in treatment-naive adults living with HIV-1 in sub-Saharan Africa. METHODS We first described the evolution of PROs between baseline and week 192. Then, we used random-effects models to measure the effect of time since the initiation of antiretroviral therapy and the differential effect of DTG versus EFV400 on each PRO, adjusting for clinical, demographic, and socioeconomic factors, while accounting for unobserved heterogeneity and missing data. RESULTS Among the 613 patients randomized (DTG arm, n = 310; EFV400 arm, n = 303), (1) physical and mental health-related quality of life improved by 13.3% and 6.8%, respectively, (2) the percentage of patients with depression, anxiety, and stress decreased from 23.3%, 23.0%, and 7.7% to 3.1%, 3.5%, and 0.4%, respectively, and (3) the mean number of HIV-related symptoms decreased from 7.2 to 3.0 ( P < 0.001). For most PROs, no significant difference was found between both arms, even when accounting for the effect of DTG on weight gain. Nevertheless, our results suggest smaller improvements in mental health outcomes in the DTG arm, with a 5 percentage point higher adjusted probability of having anxiety at week 192 ( P < 0.01). CONCLUSIONS Although supporting the current World Health Organization guidelines recommending DTG-based and EFV400-based regimens as preferred and alternative first-line antiretroviral therapy, further studies should investigate medium-term mental health outcomes in patients on DTG. TRIAL REGISTRATION ClinicalTrials.gov : NCT02777229.
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Affiliation(s)
- Marwân-Al-Qays Bousmah
- Aix Marseille Univ, Inserm, IRD, SESSTIM, Sciences Économiques & Sociales de la Santé & Traitement de l'Information Médicale, ISSPAM, Marseille, France
- Université Paris Cité, IRD, Inserm, Ceped, Paris, France
| | - Camelia Protopopescu
- Aix Marseille Univ, Inserm, IRD, SESSTIM, Sciences Économiques & Sociales de la Santé & Traitement de l'Information Médicale, ISSPAM, Marseille, France
| | | | | | - Gwenaëlle Maradan
- ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, Marseille, France
| | - Justin Olinga
- ANRS Cameroon Site, Yaoundé Central Hospital, Yaoundé, Cameroon
| | | | - Tamara Tovar-Sanchez
- TransVIHMI, University of Montpellier, IRD-UMI233, INSERM-U1175, Montpellier, France
| | - Éric Delaporte
- TransVIHMI, University of Montpellier, IRD-UMI233, INSERM-U1175, Montpellier, France
| | - Charles Kouanfack
- Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
- Centre for Research on Emerging and Re-emerging Diseases (CREMER), Yaoundé, Cameroon; and
- Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Sylvie Boyer
- Aix Marseille Univ, Inserm, IRD, SESSTIM, Sciences Économiques & Sociales de la Santé & Traitement de l'Information Médicale, ISSPAM, Marseille, France
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Moolla H, Phillips A, Ten Brink D, Mudimu E, Stover J, Bansi-Matharu L, Martin-Hughes R, Wulan N, Cambiano V, Smith J, Bershteyn A, Meyer-Rath G, Jamieson L, Johnson LF. A quantitative assessment of the consistency of projections from five mathematical models of the HIV epidemic in South Africa: a model comparison study. BMC Public Health 2023; 23:2119. [PMID: 37891514 PMCID: PMC10612295 DOI: 10.1186/s12889-023-16995-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 10/14/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Mathematical models are increasingly used to inform HIV policy and planning. Comparing estimates obtained using different mathematical models can test the robustness of estimates and highlight research gaps. As part of a larger project aiming to determine the optimal allocation of funding for HIV services, in this study we compare projections from five mathematical models of the HIV epidemic in South Africa: EMOD-HIV, Goals, HIV-Synthesis, Optima, and Thembisa. METHODS The five modelling groups produced estimates of the total population, HIV incidence, HIV prevalence, proportion of people living with HIV who are diagnosed, ART coverage, proportion of those on ART who are virally suppressed, AIDS-related deaths, total deaths, and the proportion of adult males who are circumcised. Estimates were made under a "status quo" scenario for the period 1990 to 2040. For each output variable we assessed the consistency of model estimates by calculating the coefficient of variation and examining the trend over time. RESULTS For most outputs there was significant inter-model variability between 1990 and 2005, when limited data was available for calibration, good consistency from 2005 to 2025, and increasing variability towards the end of the projection period. Estimates of HIV incidence, deaths in people living with HIV, and total deaths displayed the largest long-term variability, with standard deviations between 35 and 65% of the cross-model means. Despite this variability, all models predicted a gradual decline in HIV incidence in the long-term. Projections related to the UNAIDS 95-95-95 targets were more consistent, with the coefficients of variation below 0.1 for all groups except children. CONCLUSIONS While models produced consistent estimates for several outputs, there are areas of variability that should be investigated. This is important if projections are to be used in subsequent cost-effectiveness studies.
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Affiliation(s)
- Haroon Moolla
- Centre for Infectious Disease Epidemiology and Research, Faculty of Health Sciences, University of Cape Town, Anzio Road, Cape Town, 7925, Observatory, South Africa.
| | | | | | - Edinah Mudimu
- Department of Decision Sciences, University of South Africa, Pretoria, South Africa
| | | | | | | | | | | | | | - Anna Bershteyn
- Department of Population Health, NYU Grossman School of Medicine, New York, USA
| | - Gesine Meyer-Rath
- Center for Global Health and Development, Boston University, Boston, USA
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa
| | - Lise Jamieson
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa
- Department of Medical Microbiology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Leigh F Johnson
- Centre for Infectious Disease Epidemiology and Research, Faculty of Health Sciences, University of Cape Town, Anzio Road, Cape Town, 7925, Observatory, South Africa
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Manyana S, Pillay M, Gounder L, Khan A, Moodley P, Naidoo K, Chimukangara B. Affordable drug resistance genotyping of HIV-1 reverse transcriptase, protease and integrase genes, for resource limited settings. AIDS Res Ther 2023; 20:9. [PMID: 36759801 PMCID: PMC9912687 DOI: 10.1186/s12981-023-00505-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 02/03/2023] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND As use of dolutegravir (DTG) becomes more common in resource limited settings (RLS), the demand for integrase resistance testing is increasing. Affordable methods for genotyping all relevant HIV-1 pol genes (i.e., protease (PR), reverse transcriptase (RT) and integrase (IN)) are required to guide choice of future antiretroviral therapy (ART). We designed an in-house HIV-1 drug resistance (HIVDR) genotyping method that is affordable and suitable for use in RLS. METHODS We obtained remnant plasma samples from CAPRISA 103 study and amplified HIV-1 PR, RT and IN genes, using an innovative PCR assay. We validated the assay using remnant plasma samples from an external quality assessment (EQA) programme. We genotyped samples by Sanger sequencing and assessed HIVDR mutations using the Stanford HIV drug resistance database. We compared drug resistance mutations with previous genotypes and calculated method cost-estimates. RESULTS From 96 samples processed, we obtained sequence data for 78 (81%), of which 75 (96%) had a least one HIVDR mutation, with no major-IN mutations observed. Only one sample had an E157Q INSTI-accessory mutation. When compared to previous genotypes, 18/78 (23%) had at least one discordant mutation, but only 2/78 (3%) resulted in different phenotypic predictions that could affect choice of subsequent regimen. All CAPRISA 103 study sequences were HIV-1C as confirmed by phylogenetic analysis. Of the 7 EQA samples, 4 were HIV-1C, 2 were HIV-1D, and 1 was HIV-1A. Genotypic resistance data generated using the IDR method were 100% concordant with EQA panel results. Overall genotyping cost per sample was estimated at ~ US$43-$US49, with a processing time of ~ 2 working days. CONCLUSIONS We successfully designed an in-house HIVDR method that is suitable for genotyping HIV-1 PR, RT and IN genes, at an affordable cost and shorter turnaround time. This HIVDR genotyping method accommodates changes in ART regimens and will help to guide HIV-1 treatment decisions in RLS.
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Affiliation(s)
- Sontaga Manyana
- Department of Virology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal and National Health Laboratory Service, 800 Vusi Mzimela Road, Durban, 4058, South Africa
| | - Melendhran Pillay
- Department of Virology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal and National Health Laboratory Service, 800 Vusi Mzimela Road, Durban, 4058, South Africa
| | - Lilishia Gounder
- Department of Virology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal and National Health Laboratory Service, 800 Vusi Mzimela Road, Durban, 4058, South Africa
| | - Aabida Khan
- Department of Virology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal and National Health Laboratory Service, 800 Vusi Mzimela Road, Durban, 4058, South Africa
| | - Pravi Moodley
- Department of Virology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal and National Health Laboratory Service, 800 Vusi Mzimela Road, Durban, 4058, South Africa
| | - Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
- CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, South African Medical Research Council (SAMRC), Durban, South Africa
| | - Benjamin Chimukangara
- Department of Virology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal and National Health Laboratory Service, 800 Vusi Mzimela Road, Durban, 4058, South Africa.
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa.
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD, USA.
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Fokam J, Ngoufack Jagni Semengue E, Molimbou E, Etame NK, Santoro MM, Takou D, Mossiang L, Meledie AP, Chenwi CA, Yagai B, Nka AD, Dambaya B, Teto G, Ka’e AC, Beloumou GA, Ndjeyep SCD, Fainguem N, Abba A, Kengni AMN, Tchouaket MCT, Bouba NP, Billong SC, Djubgang R, Saounde ET, Sosso SM, Kouanfack C, Bissek ACZK, Eben-Moussi E, Colizzi V, Perno CF, Ceccherini-Silberstein F, Ndjolo A. Evaluation of Circulating and Archived HIV-1 Integrase Drug-Resistance Variants among Patients on Third-Line ART in Cameroon: Implications for Dolutegravir-Containing Regimens in Resource-Limited Settings. Microbiol Spectr 2022; 10:e0342022. [PMID: 36259973 PMCID: PMC9769697 DOI: 10.1128/spectrum.03420-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/14/2022] [Indexed: 01/10/2023] Open
Abstract
To ensure the long-term efficacy of dolutegravir (DTG), we evaluated the genotypic profile in viral reservoirs among patients on third-line (3L) antiretroviral therapy (ART) in Cameroon, according to prior exposure to raltegravir (RAL). A facility-based study was conducted from May through December 2021 among patients on 3L ART from HIV treatment centers in Yaoundé and Douala. Viral load was measured, and genotyping was performed on plasma RNA and proviral DNA. HIV-1 drug resistance mutations were interpreted using HIVdb.v9.1 and phylogeny analysis was performed using MEGA.v7, with P < 0.05 considered significant. Of the 12,093 patients on ART, 53 fully met our inclusion criteria. The median (IQR) age was 51 years (40 to 55 years), and the male/female ratio was 4/5. The median duration on integrase strand-transfer inhibitors (INSTI)-containing regimens was 18 months (12 to 32 months), and 15.09% (8/53) were exposed to RAL. The most administered 3L ART was TDF+3TC+DTG+DRV/r (33.96%, 18/53). Only 5.66% (3/53) had unsuppressed viremia (>1000 copies/mL). Resistance testing in proviral DNA was successful for 18/22 participants and revealed 1/18 patients (5.56%, in the RAL-arm) with archived mutations at major resistance positions (G140R and G163R). Five subtypes were identified, CRF02_AG (12/18), CRF22_01AE (3/18), A1 (1/18), G (1/18), and F2 (1/18). In Cameroon, 3L-experienced patients had a good virological response with a low level of archived mutations in the integrase. This finding underscored the use of DTG-containing ART for heavily treated patients in similar programmatic settings. However, patients with prior exposure to RAL should be closely monitored following a stratified or personalized approach to mitigate risks of INSTI-resistance, alongside pharmacovigilance. IMPORTANCE We described the analysis of the genotypes of the population within third-line antiviral therapy in Cameroon, with a focus on defining the effects of prior raltegravir (RAL) treatment and resistance mutations for current dolutegravir (DTG) treatment. While supporting the current transition to DTG-containing ART in resource-limited settings toward the achievement of the UNAIDS' goal of HIV elimination by 2030, our findings suggested that RAL-exposed patients may need a specific monitoring approach either in a stratified or personalized model of third-line ART to ensure the long-term success of DTG-containing regimens.
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Affiliation(s)
- Joseph Fokam
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Management and Care, Yaoundé, Cameroun
- Faculty of Health Sciences, University of Buea, Buea, Cameroon
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroun
- National HIV Drug Resistance Working Group, Ministry of Public Health, Yaoundé, Cameroun
| | - Ezechiel Ngoufack Jagni Semengue
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Management and Care, Yaoundé, Cameroun
- University of Rome Tor Vergata, Rome, Italy
- Evangelical University of Cameroon, Bandjoun, Cameroon
| | - Evariste Molimbou
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Management and Care, Yaoundé, Cameroun
- Evangelical University of Cameroon, Bandjoun, Cameroon
| | - Naomi-Karell Etame
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Management and Care, Yaoundé, Cameroun
- School of Health Sciences, Catholic University of Central Africa, Yaoundé, Cameroun
| | | | - Désiré Takou
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Management and Care, Yaoundé, Cameroun
| | | | | | - Collins Ambe Chenwi
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Management and Care, Yaoundé, Cameroun
- Mvangan District Hospital, Mvangan, Cameroon
| | - Bouba Yagai
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Management and Care, Yaoundé, Cameroun
- University of Rome Tor Vergata, Rome, Italy
| | - Alex Durand Nka
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Management and Care, Yaoundé, Cameroun
- University of Rome Tor Vergata, Rome, Italy
- Evangelical University of Cameroon, Bandjoun, Cameroon
| | - Beatrice Dambaya
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Management and Care, Yaoundé, Cameroun
| | - Georges Teto
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Management and Care, Yaoundé, Cameroun
| | - Aude Christelle Ka’e
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Management and Care, Yaoundé, Cameroun
- PhD Courses in Microbiology, Immunology, Infectious Diseases and Transplants (MIMIT), University of Rome “Tor Vergata”, Rome, Italy
| | - Grâce Angong Beloumou
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Management and Care, Yaoundé, Cameroun
| | | | - Nadine Fainguem
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Management and Care, Yaoundé, Cameroun
- University of Rome Tor Vergata, Rome, Italy
| | - Aissatou Abba
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Management and Care, Yaoundé, Cameroun
| | - Aurelie Minelle Ngueko Kengni
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Management and Care, Yaoundé, Cameroun
- School of Health Sciences, Catholic University of Central Africa, Yaoundé, Cameroun
| | - Michel Carlos Tommo Tchouaket
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Management and Care, Yaoundé, Cameroun
- School of Health Sciences, Catholic University of Central Africa, Yaoundé, Cameroun
| | - Nounouce Pamen Bouba
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroun
- Directorate for Disease, Epidemic and Pandemic Control, Yaounde, Cameroon
| | - Serge-Clotaire Billong
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroun
- National HIV Drug Resistance Working Group, Ministry of Public Health, Yaoundé, Cameroun
- Central Technical Group, National AIDS Control Committee, Yaoundé, Cameroun
| | - Rina Djubgang
- Directorate of Pharmacy, Drug and Laboratory, Ministry of Public Health, Yaoundé, Cameroun
| | | | - Samuel Martin Sosso
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Management and Care, Yaoundé, Cameroun
| | - Charles Kouanfack
- Yaoundé Central Hospital, Yaoundé, Cameroun
- Faculty of Medicine and Pharmaceutical Sciences, University de Dschang, Dschang, Cameroon
| | - Anne-Cecile Zoung-Kanyi Bissek
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroun
- National HIV Drug Resistance Working Group, Ministry of Public Health, Yaoundé, Cameroun
- Division of Operational Health Research, Ministry of Public Health, Yaoundé, Cameroun
| | - Emmanuel Eben-Moussi
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Management and Care, Yaoundé, Cameroun
| | - Vittorio Colizzi
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Management and Care, Yaoundé, Cameroun
- University of Rome Tor Vergata, Rome, Italy
- Evangelical University of Cameroon, Bandjoun, Cameroon
| | - Carlo-Federico Perno
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Management and Care, Yaoundé, Cameroun
- Bambino Gesu Pediatric Hospital, Rome, Italy
| | | | - Alexis Ndjolo
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Management and Care, Yaoundé, Cameroun
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroun
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Mukhatayeva A, Mustafa A, Dzissyuk N, Issanov A, Mukhatayev Z, Bayserkin B, Vermund SH, Ali S. Antiretroviral therapy resistance mutations among HIV infected people in Kazakhstan. Sci Rep 2022; 12:17195. [PMID: 36229577 PMCID: PMC9562405 DOI: 10.1038/s41598-022-22163-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 10/10/2022] [Indexed: 01/05/2023] Open
Abstract
In Kazakhstan, the number of people living with HIV (PLHIV) has increased steadily by 39% since 2010. Development of antiretroviral therapy (ART) resistance mutations (ARTRM) is a major hurdle in achieving effective treatment and prevention against HIV. Using HIV pol sequences from 602 PLHIV from Kazakhstan, we analyzed ARTRMs for their association with factors that may promote development of ARTRMs. 56% PLHIV were infected with HIV subtype A6 and 42% with CRF02_AG. The ARTRM Q174K was associated with increased viral load and decreased CD4+ cell count, while infection with CRF02_AG was associated with a lower likelihood of Q174K. Interestingly, CRF02_AG was positively associated with the ARTRM L10V that, in turn, was observed frequently with darunavir administration. Infection with CRF02_AG was positively associated with the ARTRM S162A that, in turn, was frequently observed with the administration of nevirapine, also associated with lower CD4 counts. Zidovudine or Nevirapine receipt was associated with the development of the ARTRM E138A, that, in turn, was associated with lower CD4 counts. Determination of a patient's HIV variant can help guide ART choice in Kazakhstan. For example, PLHIV infected with CRF02_AG will benefit less from darunavir and nevirapine, and emtricitabine should replace zidovudine.
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Affiliation(s)
- Ainur Mukhatayeva
- Department of Biomedical Sciences, Nazarbayev School of Medicine, Nazarbayev University, Astana, Kazakhstan
| | - Aidana Mustafa
- Department of Biomedical Sciences, Nazarbayev School of Medicine, Nazarbayev University, Astana, Kazakhstan
| | - Natalya Dzissyuk
- Kazakh Scientific Center of Dermatology and Infectious Diseases, Almaty, Kazakhstan
| | - Alpamys Issanov
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Zhussipbek Mukhatayev
- Department of Biomedical Sciences, Nazarbayev School of Medicine, Nazarbayev University, Astana, Kazakhstan
| | - Bauyrzhan Bayserkin
- Kazakh Scientific Center of Dermatology and Infectious Diseases, Almaty, Kazakhstan
| | | | - Syed Ali
- Department of Biomedical Sciences, Nazarbayev School of Medicine, Nazarbayev University, Astana, Kazakhstan.
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10
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Schramm B, Temfack E, Descamps D, Nicholas S, Peytavin G, Bitilinyu-Bangoh JE, Storto A, Lê MP, Abdi B, Ousley J, Kalua T, Calvez V, Jahn A, Marcelin AG, Szumilin E. Viral suppression and HIV-1 drug resistance 1 year after pragmatic transitioning to dolutegravir first-line therapy in Malawi: a prospective cohort study. THE LANCET HIV 2022; 9:e544-e553. [DOI: 10.1016/s2352-3018(22)00136-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 05/02/2022] [Accepted: 05/11/2022] [Indexed: 12/12/2022]
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11
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Gumede SB, de Wit JBF, Venter WDF, Lalla-Edward ST. Study protocol: Strengthening understanding of effective adherence strategies for first-line and second-line antiretroviral therapy (ART) in selected rural and urban communities in South Africa. PLoS One 2021; 16:e0261107. [PMID: 34932588 PMCID: PMC8691643 DOI: 10.1371/journal.pone.0261107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 11/24/2021] [Indexed: 11/19/2022] Open
Abstract
Multiple factors make adherence to antiretroviral therapy (ART) a complex process. This study aims to describe the barriers and facilitators to adherence for patients receiving first-line and second-line ART, identify different adherence strategies utilized and make recommendations for an improved adherence strategy. This mixed method parallel convergent study will be conducted in seven high volume public health facilities in Gauteng and one in Limpopo province in South Africa. The study consists of four phases; a retrospective secondary data analysis of a large cohort of patients on ART (using TIER.Net, an ART patient and data management system for recording and monitoring patients on ART and tuberculosis (TB)) from seven Johannesburg inner-city public health facilities (Gauteng province); a secondary data analysis of the Intensified Treatment Monitoring Accumulation (ITREMA) trial (a randomized control trial which ran from June 2015 to January 2019) conducted at the Ndlovu Medical Center (Limpopo province); in-depth interviews with people living with Human Immunodeficiency Virus (PLHIV) who are taking ART (in both urban and rural settings); and a systematic review of the impact of treatment adherence interventions for chronic conditions in sub-Saharan Africa. Data will be collected on demographics, socio-economic status, treatment support, retention in care status, disclosure, stigma, clinical markers (CD4 count and viral load (VL)), self-reported adherence information, intrapersonal, and interpersonal factors, community networks, and policy level factors. The systematic review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) reporting and Population, Interventions, Comparisons and Outcomes (PICO) criteria. Analyses will involve tests of association (Chi-square and t-test), thematic analysis (deductive and inductive approaches) and network meta-analysis. Using an integrated multilevel socio-ecological framework this study will describe the factors associated with adherence for PLHIV who are taking first-line or second-line ART. Implementing evidence-based adherence approaches, when taken up, will improve patient's overall health outcomes. Our study results will provide guidance regarding context-specific intervention strategies to improve ART adherence.
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Affiliation(s)
- Siphamandla Bonga Gumede
- Ezintsha, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Faculty of Social and Behavioural Sciences, Department of Interdisciplinary Social Science, Utrecht University, The Netherlands
| | - John Benjamin Frank de Wit
- Faculty of Social and Behavioural Sciences, Department of Interdisciplinary Social Science, Utrecht University, The Netherlands
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Kerschberger B, Aung A, Mpala Q, Ntshalintshali N, Mamba C, Schomaker M, Tombo ML, Maphalala G, Sibandze D, Dube L, Kashangura R, Mthethwa-Hleza S, Telnov A, de la Tour R, Gonzalez A, Calmy A, Ciglenecki I. Predicting, Diagnosing, and Treating Acute and Early HIV Infection in a Public Sector Facility in Eswatini. J Acquir Immune Defic Syndr 2021; 88:506-517. [PMID: 34483294 PMCID: PMC8575170 DOI: 10.1097/qai.0000000000002794] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 08/12/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND The lack of acute and early HIV infection (AEHI) diagnosis and care contributes to high HIV incidence in resource-limited settings. We aimed to assess the yield of AEHI, predict and diagnose AEHI, and describe AEHI care outcomes in a public sector setting in Eswatini. SETTING This study was conducted in Nhlangano outpatient department from March 2019 to March 2020. METHODS Adults at risk of AEHI underwent diagnostic testing for AEHI with the quantitative Xpert HIV-1 viral load (VL) assay. AEHI was defined as the detection of HIV-1 VL on Xpert and either an HIV-seronegative or HIV-serodiscordant third-generation antibody-based rapid diagnostic test (RDT) result. First, the cross-sectional analysis obtained the yield of AEHI and established a predictor risk score for the prediction of AEHI using Lasso logistic regression. Second, diagnostic accuracy statistics described the ability of the fourth-generation antibody/p24 antigen-based Alere HIV-Combo RDT to diagnose AEHI (vs Xpert VL testing). Third, we described acute HIV infection care outcomes of AEHI-positive patients using survival analysis. RESULTS Of 795 HIV-seronegative/HIV-serodiscordant outpatients recruited, 30 (3.8%, 95% confidence interval: 2.6% to 5.3%) had AEHI. The predictor risk score contained several factors (HIV-serodiscordant RDT, women, feeling at risk of HIV, swollen glands, and fatigue) and had sensitivity and specificity of 83.3% and 65.8%, respectively, to predict AEHI. The HIV-Combo RDT had sensitivity and specificity of 86.2% and 99.9%, respectively, to diagnose AEHI. Of 30 AEHI-positive patients, the 1-month cumulative treatment initiation was 74% (95% confidence interval: 57% to 88%), and the 3-month viral suppression (<1000 copies/mL) was 87% (67% to 98%). CONCLUSION AEHI diagnosis and care seem possible in resource-limited settings.
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Affiliation(s)
| | - Aung Aung
- Médecins Sans Frontières (OCG), Mbabane, Eswatini
| | | | | | | | - Michael Schomaker
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa;
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT—University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria;
| | | | | | | | - Lenhle Dube
- Ministry of Health (SNAP), Mbabane, Eswatini
| | | | | | - Alex Telnov
- Médecins Sans Frontières (OCG), Geneva, Switzerland;
| | | | - Alan Gonzalez
- Médecins Sans Frontières (OCG), Geneva, Switzerland;
| | - Alexandra Calmy
- HIV/AIDS Unit, Division of Infectious Diseases, Geneva University Hospitals Geneva, Switzerland; and
- Institute of Global Health, University of Geneva, Geneva, Switzerland.
| | - Iza Ciglenecki
- Médecins Sans Frontières (OCG), Geneva, Switzerland;
- Institute of Global Health, University of Geneva, Geneva, Switzerland.
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13
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Jamieson L, Serenata C, Makhubele L, Sokhela S, Mashabane N, Akpomiemie G, Johnson LF, Venter WDF, Meyer-Rath G. Cost and cost-effectiveness of dolutegravir-based antiretroviral regimens: an economic evaluation of a clinical trial. AIDS 2021; 35:S173-S182. [PMID: 34848584 DOI: 10.1097/qad.0000000000003068] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND HIV programmes world-wide currently make decisions regarding new antiretroviral therapy (ART) regimens with less side-effects and higher resistance barriers, which may improve adherence and viral suppression. Economic evaluation helps inform these decisions. METHODS We conducted an economic evaluation of three ART regimens included in the ADVANCE trial from the provider's perspective: tenofovir alafenamide (TAF)/emtricitabine (FTC)+dolutegravir (DTG) and tenofovir disoproxil fumarate (TDF)/FTC+DTG, compared with TDF/FTC/efavirenz (EFV). We used top-down and bottom-up cost analysis with resource utilization based on trial data and adjusted to emulate routine care. We estimated the cost-effectiveness of each regimen as cost per person virally suppressed or retained and per life-year saved, at 48 and 96 weeks. RESULTS Though the DTG-based trial arms were 2% more costly than TDF/FTC/EFV, both had slightly lower cost-per-outcome ($9783 and $9929/patient virally suppressed for TDF/FTC+DTG and TAF/FTC+DTG, respectively) than TDF/FTC/EFV ($10 365). The trial cost per additional virally suppressed patient, compared with TDF/FTC/EFV, was lower in the TDF/FTC+DTG arm ($2967) compared with TAF/FTC+DTG ($3430). In routine care, cost per virally suppressed patient was estimated as similar between TDF/FTC+DTG ($426) and TDF/FTC/EFV ($424) but more costly under TAF/FTC+DTG. Similar results were seen in the cost per additional person retained across scenarios. When modelled over 20 years, TDF/FTC+DTG was more cost-effective than TAF/FTC+DTG ($10 341 vs $41 958/life-year saved). CONCLUSION TDF/FTC+DTG had similar costs per outcome as TDF/FTC/EFV in the routine care scenario but TDF/FTC+DTG was more cost-effective when modelled over 20 years.
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Affiliation(s)
- Lise Jamieson
- Health Economics and Epidemiology Research Office (HE RO), Department of Internal Medicine, School of Clinical Medicine
| | - Celicia Serenata
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | - Lebogang Makhubele
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | - Simiso Sokhela
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | - Nkuli Mashabane
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | - Godspower Akpomiemie
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | - Leigh F Johnson
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Willem D F Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | - Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office (HE RO), Department of Internal Medicine, School of Clinical Medicine
- School of Public Health, Boston University, Boston, MA, USA
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14
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Belay YB, Ali EE, Chung KY, Gebretekle GB, Sander B. Cost-Utility Analysis of Dolutegravir- Versus Efavirenz-Based Regimens as a First-Line Treatment in Adult HIV/AIDS Patients in Ethiopia. PHARMACOECONOMICS - OPEN 2021; 5:655-664. [PMID: 34133017 PMCID: PMC8611130 DOI: 10.1007/s41669-021-00275-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/27/2021] [Indexed: 06/02/2023]
Abstract
BACKGROUND In several countries, the dolutegravir (DTG)-based regimen is generally preferred as first-line antiretroviral therapy (ART) over the efavirenz (EFV)-based regimen, but the evidence in low-income countries is limited. OBJECTIVE Our study aimed to evaluate the cost effectiveness of DTG- versus EFV-based first-line human immunodeficiency virus (HIV) treatment in Ethiopia. METHODS We developed a microsimulation model for the progression of HIV/acquired immune deficiency syndrome (AIDS) to examine the cost effectiveness of DTG-based first-line ART compared with an EFV-based regimen from a healthcare payer perspective. We used a lifetime horizon with a 1-month cycle length and a 3% annual discount rate. The primary outcomes were a lifetime cost in US dollars ($), quality-adjusted life-months (QALMs) that converted to QALYs using the formula QALY = QALM/12, and incremental cost-effectiveness ratio (ICER). Deterministic sensitivity analysis was conducted to account for parameter uncertainty. RESULTS Compared with the EFV-based regimen, the DTG-based regimen was associated with an expected lifetime cost of $12,709 (vs. $12,701) and expected QALYs of 15.3 (vs. 14.7 QALYs) per patient, resulting in an ICER value of $13.33 per QALY. From an alternative analysis with a 5-year time horizon, DTG-based ART was found to be dominant, with expected gains of 0.17 QALYs at a lower cost of $1 per patient. The deterministic sensitivity analysis depicted that the maximum increase in ICER value was $72 per QALY, and all ICER values were below the estimated threshold value. CONCLUSIONS The DTG-based first-line regimen appears to be cost effective compared with the EFV-based regimen for the treatment of HIV/AIDS patients in an Ethiopian setting.
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Affiliation(s)
- Yared Belete Belay
- School of Pharmacy, College of Health Sciences, Mekelle University, PO Box 1871, Mekelle, Ethiopia.
| | - Eskinder Eshetu Ali
- Department of Pharmaceutics and Social Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Karen Y Chung
- Division of Plastic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Torono, ON, Canada
| | - Gebremedhin Beedemariam Gebretekle
- Department of Pharmaceutics and Social Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Torono, ON, Canada
| | - Beate Sander
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Torono, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Public Health Ontario, Toronto, ON, Canada
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15
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Fokam J, Ngoufack Jagni Semengue E, Armenia D, Takou D, Dambaya B, Teto G, Chenwi CA, Nka AD, Beloumou GA, Ndjeyep SCD, Tchouaket MCT, Fainguem N, Sosso SM, Colizzi V, Perno CF, Ndjolo A, Ceccherini-Silberstein F, Santoro MM. High performance of integrase genotyping on diverse HIV-1 clades circulating in Cameroon: toward a successful transition to dolutegravir-based regimens in low and middle-income countries. Diagn Microbiol Infect Dis 2021; 102:115574. [PMID: 34864527 DOI: 10.1016/j.diagmicrobio.2021.115574] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 10/08/2021] [Accepted: 10/17/2021] [Indexed: 11/03/2022]
Abstract
A successful transition to dolutegravir-based regimens in low and middle-income countries (LMICs) requires an integrase genotyping assay effective on diverse HIV-1 clades. We herein developed and validated an in-house integrase genotyping protocol on plasma samples from 195 HIV-infected patients in Cameroon. Median [IQR] viremia was 23,574 (518-109,235) copies/mL; 128/195 participants had ≥1000copies/mL (i.e., WHO-threshold for genotypic resistance testing in LMICs). A total of 18 viral clades were detected: 72(51.1%) CRF02_AG, 38(26.9%) pure subtypes and 31(22.0%) other recombinants. Following WHO-threshold (≥1000copies/ml), sequencing performance was 82.81%(106/128). Regarding viremia, performance was 85.00%(68/80) with ≥100,000copies/mL versus 76.67%(23/30) with 10,000 to 99,999copies/mL (P = 0.22); 83.33%(15/18) with 1,000 to 99,999copies/mL (P = 0.55); 73.68%(14/19) with 500 to 999copies/mL (P = 0.19); 50%(13/26) for 200 to 499copies/mL (P = 0.0005) and 36.36%(8/22) for <200copies/mL (P < 0.0001). The developed in-house integrase-genotyping is highly effective on both pure and recombinant viral clades, even at low-level viremia. This performance underscores its usefulness in monitoring integrase-resistance mutations and supporting the scale-up of dolutegravir-based regimens in LMICs.
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Affiliation(s)
- Joseph Fokam
- Chantal BIYA International Reference Centre for research on HIV/AIDS prevention and management (CIRCB), Yaoundé, Cameroon; Faculty of Health Sciences, University of Buea, Buea, Cameroon; Faculty of Medicine and biomedical Sciences, University of Yaounde I, Yaounde, Cameroon.
| | - Ezechiel Ngoufack Jagni Semengue
- Chantal BIYA International Reference Centre for research on HIV/AIDS prevention and management (CIRCB), Yaoundé, Cameroon; University of Rome Tor Vergata, Rome, Italy; Evangelical University of Cameroon, Bandjoun, Cameroon.
| | - Daniele Armenia
- Saint Camillus International University of Health and Medical Sciences, Rome Italy
| | - Désiré Takou
- Chantal BIYA International Reference Centre for research on HIV/AIDS prevention and management (CIRCB), Yaoundé, Cameroon
| | - Béatrice Dambaya
- Chantal BIYA International Reference Centre for research on HIV/AIDS prevention and management (CIRCB), Yaoundé, Cameroon; Faculty of Sciences, University of Yaounde I, Yaounde, Cameroon
| | - Georges Teto
- Chantal BIYA International Reference Centre for research on HIV/AIDS prevention and management (CIRCB), Yaoundé, Cameroon
| | - Collins Ambe Chenwi
- Chantal BIYA International Reference Centre for research on HIV/AIDS prevention and management (CIRCB), Yaoundé, Cameroon; Faculty of Medicine and biomedical Sciences, University of Yaounde I, Yaounde, Cameroon
| | - Alex Durand Nka
- Chantal BIYA International Reference Centre for research on HIV/AIDS prevention and management (CIRCB), Yaoundé, Cameroon; University of Rome Tor Vergata, Rome, Italy; Evangelical University of Cameroon, Bandjoun, Cameroon
| | - Grâce Angong Beloumou
- Chantal BIYA International Reference Centre for research on HIV/AIDS prevention and management (CIRCB), Yaoundé, Cameroon
| | - Sandrine Claire Djupsa Ndjeyep
- Chantal BIYA International Reference Centre for research on HIV/AIDS prevention and management (CIRCB), Yaoundé, Cameroon
| | - Michel Carlos Tommo Tchouaket
- Chantal BIYA International Reference Centre for research on HIV/AIDS prevention and management (CIRCB), Yaoundé, Cameroon
| | - Nadine Fainguem
- Chantal BIYA International Reference Centre for research on HIV/AIDS prevention and management (CIRCB), Yaoundé, Cameroon
| | - Samuel Martin Sosso
- Chantal BIYA International Reference Centre for research on HIV/AIDS prevention and management (CIRCB), Yaoundé, Cameroon
| | - Vittorio Colizzi
- Chantal BIYA International Reference Centre for research on HIV/AIDS prevention and management (CIRCB), Yaoundé, Cameroon; University of Rome Tor Vergata, Rome, Italy; Evangelical University of Cameroon, Bandjoun, Cameroon
| | - Carlo-Federico Perno
- Chantal BIYA International Reference Centre for research on HIV/AIDS prevention and management (CIRCB), Yaoundé, Cameroon; Bambino Gesu Children's Hospital, Rome, Italy
| | - Alexis Ndjolo
- Chantal BIYA International Reference Centre for research on HIV/AIDS prevention and management (CIRCB), Yaoundé, Cameroon; Faculty of Medicine and biomedical Sciences, University of Yaounde I, Yaounde, Cameroon
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Kouamou V, Mavetera J, Manasa J, Ndhlovu CE, Katzenstein D, McGregor AM. Pretreatment HIV Drug Resistance Among Adults Initiating or Re-Initiating First-Line Antiretroviral Therapy in Zimbabwe: Fast-Tracking the Transition to Dolutegravir-Based First-Line Regimens? AIDS Res Hum Retroviruses 2021; 37:776-783. [PMID: 33430681 DOI: 10.1089/aid.2020.0242] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Pretreatment drug resistance (PDR) can compromise antiretroviral therapy (ART) efficacy and undermine the WHO targets to end the AIDS epidemic as a public health threat by 2030. Thus, we examined the level of PDR in Harare, Zimbabwe. Eligible study participants were adults who were ART naive or individuals with previous ART exposure reinitiating treatment, recruited between October 2018 and February 2020 in a HIV ART treatment clinic, in Harare. HIV drug resistance tests were performed for all specimens with viral load ≥400 copies/mL and interpreted using the Stanford HIVDB Algorithm. Chi-square test or Fisher's exact test was used for comparison of proportions of PDR across ART-naive or prior ART-exposed participants. All statistical analyses were performed using Stata version 14. Overall, 120 samples were genotyped of whom 104 were ART naive and 16 reported previous ART exposure. The overall PDR frequency among all participants was 31% [95% confidence interval (CI): 22.5-39.6]. PDR to any non-nucleotide reverse transcriptase inhibitor (NNRTI) was reported in 29% (95% CI: 21.0-37.9). PDR to nucleotide reverse transcriptase inhibitors (NRTIs) and protease inhibitors were low, found in 3% (95% CI: 0.9-8.2) and 1% (95% CI: 0.02-4.52), respectively. PDR to NNRTIs [efavirenz/nevirapine (EFV/NVP)] was found in 17% (95% CI: 10.5-24.6) and was more than six times higher among people with previous ART exposure than ART-naive people: 63% versus 10%, p < .001. Our study shows that PDR to NNRTIs in Zimbabwe has remarkably increased from the 10.9% prevalence reported in the 2016 WHO survey. Addressing PDR at a national level is a critical need and will be facilitated by fast-tracking the transition to dolutegravir in first-line ART regimens.
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Affiliation(s)
- Vinie Kouamou
- Department of Medicine, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Justice Mavetera
- Department of Medicine, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Justen Manasa
- Department of Medical Microbiology, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | | | - David Katzenstein
- Department of Molecular Biology, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Alan Michael McGregor
- Department of Medicine, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
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17
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Phillips AN, Cambiano V, Johnson L, Nakagawa F, Homan R, Meyer-Rath G, Rehle T, Tanser F, Moyo S, Shahmanesh M, Castor D, Russell E, Jamieson L, Bansi-Matharu L, Shroufi A, Barnabas RV, Parikh UM, Mellors JW, Revill P. Potential Impact and Cost-Effectiveness of Condomless-Sex-Concentrated PrEP in KwaZulu-Natal Accounting for Drug Resistance. J Infect Dis 2021; 223:1345-1355. [PMID: 31851759 PMCID: PMC8064039 DOI: 10.1093/infdis/jiz667] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 12/17/2019] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Oral preexposure prophylaxis (PrEP) in the form of tenofovir-disoproxil-fumarate/emtricitabine is being implemented in selected sites in South Africa. Addressing outstanding questions on PrEP cost-effectiveness can inform further implementation. METHODS We calibrated an individual-based model to KwaZulu-Natal to predict the impact and cost-effectiveness of PrEP, with use concentrated in periods of condomless sex, accounting for effects on drug resistance. We consider (1) PrEP availability for adolescent girls and young women aged 15-24 years and female sex workers, and (2) availability for everyone aged 15-64 years. Our primary analysis represents a level of PrEP use hypothesized to be attainable by future PrEP programs. RESULTS In the context of PrEP use in adults aged 15-64 years, there was a predicted 33% reduction in incidence and 36% reduction in women aged 15-24 years. PrEP was cost-effective, including in a range of sensitivity analyses, although with substantially reduced (cost) effectiveness under a policy of ART initiation with efavirenz- rather than dolutegravir-based regimens due to PrEP undermining ART effectiveness by increasing HIV drug resistance. CONCLUSIONS PrEP use concentrated during time periods of condomless sex has the potential to substantively impact HIV incidence and be cost-effective.
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Affiliation(s)
- Andrew N Phillips
- Institute for Global Health, University College London, London, UK
- Correspondence: Andrew Phillips, PhD, UCL, Royal Free Campus, Rowland Hill Street, London NW3, UK ()
| | | | - Leigh Johnson
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Fumiyo Nakagawa
- Institute for Global Health, University College London, London, UK
| | | | - Gesine Meyer-Rath
- Departmentof Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Thomas Rehle
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Frank Tanser
- Lincoln Institute for Health, University of Lincoln, Lincoln, UK
- Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
| | - Sizulu Moyo
- Human Sciences Research Council, Pretoria, South Africa
| | - Maryam Shahmanesh
- Institute for Global Health, University College London, London, UK
- Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa
| | - Delivette Castor
- United States Agency for International Development, Washington, District of Columbia, USA
| | - Elizabeth Russell
- United States Agency for International Development, Washington, District of Columbia, USA
| | - Lise Jamieson
- Departmentof Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Amir Shroufi
- Medécins Sans Frontières, Cape Town, South Africa
| | | | - Urvi M Parikh
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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18
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Ferguson O, Jo Y, Pennington J, Johnson K, Chaisson RE, Churchyard G, Dowdy D. Cost-effectiveness of one month of daily isoniazid and rifapentine versus three months of weekly isoniazid and rifapentine for prevention of tuberculosis among people receiving antiretroviral therapy in Uganda. J Int AIDS Soc 2021; 23:e25623. [PMID: 33073520 PMCID: PMC7569168 DOI: 10.1002/jia2.25623] [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: 02/27/2020] [Revised: 08/20/2020] [Accepted: 09/08/2020] [Indexed: 11/10/2022] Open
Abstract
Introduction Preventive therapy is essential for reducing tuberculosis (TB) burden among people living with HIV (PLWH) in high‐burden settings. Short‐course preventive therapy regimens, such as three‐month weekly rifapentine and isoniazid (3HP) and one‐month daily rifapentine and isoniazid (1HP), may help facilitate uptake of preventive therapy for latently infected patients, but the comparative cost‐effectiveness of these regimens under different conditions is uncertain. Methods We used a Markov state‐transition model to estimate the incremental costs and effectiveness of 1HP versus 3HP in a simulated cohort of patients attending an HIV clinic in Uganda, as an example of a low‐income, high‐burden setting in which TB preventive therapy might be prescribed to PLWH. Our primary outcome was the incremental cost‐effectiveness ratio, expressed as 2019 US dollars per disability‐adjusted life year (DALY) averted. We estimated cost‐effectiveness under different conditions of treatment completion and efficacy of 1HP versus 3HP, latent TB prevalence and rifapentine price. Results Assuming equivalent clinical outcomes using 1HP and 3HP and a rifapentine price of $0.21 per 150 mg, 1HP would cost an additional $4.66 per patient treated. Assuming equivalent efficacy but 20% higher completion with 1HP versus 3HP, 1HP would cost $1,221 per DALY averted relative to 3HP. This could be reduced to $18 per DALY averted if 1HP had 5% greater efficacy than 3HP and the price of rifapentine were 50% lower. At a rifapentine price of $0.06 per 150 mg, 1HP would become cost‐neutral relative to 3HP. Conclusions 1HP has the potential to be cost‐effective under many realistic circumstances. Cost‐effectiveness depends on rifapentine price, relative completion and efficacy, prevalence of latent TB and local willingness‐to‐pay.
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Affiliation(s)
- Olivia Ferguson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Youngji Jo
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jeff Pennington
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Karl Johnson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Richard E Chaisson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Medicine, Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gavin Churchyard
- Aurum Institute, Parktown, South Africa.,School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - David Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Medicine, Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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19
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Meisner J, Roberts DA, Rodriguez P, Sharma M, Newman Owiredu M, Gomez B, de Mello MB, Bobrik A, Vodianyk A, Storey A, Githuka G, Chidarikire T, Barnabas R, Farid S, Essajee S, Jamil MS, Baggaley R, Johnson C, Drake AL. Optimizing HIV retesting during pregnancy and postpartum in four countries: a cost-effectiveness analysis. J Int AIDS Soc 2021; 24:e25686. [PMID: 33787064 PMCID: PMC8010369 DOI: 10.1002/jia2.25686] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 02/04/2021] [Accepted: 02/17/2021] [Indexed: 01/23/2023] Open
Abstract
INTRODUCTION HIV retesting during late pregnancy and breastfeeding can help detect new maternal infections and prevent mother-to-child HIV transmission (MTCT), but the optimal timing and cost-effectiveness of maternal retesting remain uncertain. METHODS We constructed deterministic models to assess the health and economic impact of maternal HIV retesting on a hypothetical population of pregnant women, following initial testing in pregnancy, on MTCT in four countries: South Africa and Kenya (high/intermediate HIV prevalence), and Colombia and Ukraine (low HIV prevalence). We evaluated six scenarios with varying retesting frequencies from late in antenatal care (ANC) through nine months postpartum. We compared strategies using incremental cost-effectiveness ratios (ICERs) over a 20-year time horizon using country-specific thresholds. RESULTS We found maternal retesting once in late ANC with catch-up testing through six weeks postpartum was cost-effective in Kenya (ICER = $166 per DALY averted) and South Africa (ICER=$289 per DALY averted). This strategy prevented 19% (Kenya) and 12% (South Africa) of infant HIV infections. Adding one or two additional retests postpartum provided smaller benefits (1 to 2 percentage point increase in infections averted versus one retest). Adding three retests during the postpartum period averted additional infections (1 to 3 percentage point increase in infections averted versus one retest) but ICERs ($7639 and in Kenya and $11 985 in South Africa) greatly exceeded the cost-effectiveness thresholds. In Colombia and Ukraine, all retesting strategies exceeded the cost-effectiveness threshold and prevented few infant infections (up to 31 and 5 infections, respectively). CONCLUSIONS In high HIV burden settings with MTCT rates similar to those seen in Kenya and South Africa, HIV retesting once in late ANC, with subsequent intervention, is the most cost-effective strategy for preventing infant HIV infections. In these settings, two HIV retests postpartum marginally reduced MTCT and were less costly than adding three retests. Retesting in low-burden settings with MTCT rates similar to Colombia and Ukraine was not cost-effective at any time point due to very low HIV prevalence and limited breastfeeding.
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Affiliation(s)
| | - D Allen Roberts
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
| | - Patricia Rodriguez
- The Comparative Health Outcomes Policy & Economics InstituteUniversity of WashingtonSeattleWAUSA
| | - Monisha Sharma
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | | | - Bertha Gomez
- Pan American Health Organization/World Health OrganizationColombia OfficeBogotáColombia
| | - Maeve B de Mello
- Department of Communicable Diseases and Environmental Determinants of HealthPan American Health Organization/World Health OrganizationWashingtonDCUSA
| | - Alexey Bobrik
- Global Fund to Fight AIDS, Tuberculosis and MalariaGenevaSwitzerland
| | | | | | | | - Thato Chidarikire
- HIV Prevention ProgrammesNational Department of HealthPretoriaSouth Africa
| | - Ruanne Barnabas
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of MedicineUniversity of WashingtonSeattleWAUSA
| | - Shiza Farid
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | | | - Muhammad S Jamil
- Global HIV, Hepatitis and STI programmeWorld Health OrganizationGenevaSwitzerland
| | - Rachel Baggaley
- Global HIV, Hepatitis and STI programmeWorld Health OrganizationGenevaSwitzerland
| | - Cheryl Johnson
- Global HIV, Hepatitis and STI programmeWorld Health OrganizationGenevaSwitzerland
| | - Alison L Drake
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
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Siriruchatanon M, Liu S, Carlucci JG, Enns EA, Duarte HA. Addressing Pediatric HIV Pretreatment Drug Resistance and Virologic Failure in Sub-Saharan Africa: A Cost-Effectiveness Analysis of Diagnostic-Based Strategies in Children ≥3 Years Old. Diagnostics (Basel) 2021; 11:diagnostics11030567. [PMID: 33801154 PMCID: PMC8004076 DOI: 10.3390/diagnostics11030567] [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: 01/05/2021] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 11/16/2022] Open
Abstract
Improvement of antiretroviral therapy (ART) regimen switching practices and implementation of pretreatment drug resistance (PDR) testing are two potential approaches to improve health outcomes for children living with HIV. We developed a microsimulation model of disease progression and treatment focused on children with perinatally acquired HIV in sub-Saharan Africa who initiate ART at 3 years of age. We evaluated the cost-effectiveness of diagnostic-based strategies (improved switching and PDR testing), over a 10-year time horizon, in settings without and with pediatric dolutegravir (DTG) availability as first-line ART. The improved switching strategy increases the probability of switching to second-line ART when virologic failure is diagnosed through viral load testing. The PDR testing strategy involves a one-time PDR test prior to ART initiation to guide choice of initial regimen. When DTG is not available, PDR testing is dominated by the improved switching strategy, which has an incremental cost-effectiveness ratio (ICER) of USD 579/life-year gained (LY), relative to the status quo. If DTG is available, improved switching has a similar ICER (USD 591/LY) relative to the DTGstatus quo. Even when substantial financial investment is needed to achieve improved regimen switching practices, the improved switching strategy still has the potential to be cost-effective in a wide range of sub-Saharan African countries. Our analysis highlights the importance of strengthening existing laboratory monitoring systems to improve the health of children living with HIV.
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Affiliation(s)
- Mutita Siriruchatanon
- Department of Industrial & Systems Engineering, University of Washington, Seattle, WA 98185, USA; (M.S.); (S.L.)
| | - Shan Liu
- Department of Industrial & Systems Engineering, University of Washington, Seattle, WA 98185, USA; (M.S.); (S.L.)
| | - James G. Carlucci
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, IN 46202, USA;
| | - Eva A. Enns
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN 55408, USA;
| | - Horacio A. Duarte
- Department of Pediatrics, Division of Infectious Diseases, University of Washington, Seattle, WA 98105, USA
- Seattle Children’s Research Institute, Seattle, WA 98101, USA
- Correspondence: ; Tel.: +1-206-884-8233; Fax: +1-206-884-7311
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21
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Bousmah MAQ, Nishimwe ML, Tovar-Sanchez T, Lantche Wandji M, Mpoudi-Etame M, Maradan G, Omgba Bassega P, Varloteaux M, Montoyo A, Kouanfack C, Delaporte E, Boyer S. Cost-Utility Analysis of a Dolutegravir-Based Versus Low-Dose Efavirenz-Based Regimen for the Initial Treatment of HIV-Infected Patients in Cameroon (NAMSAL ANRS 12313 Trial). PHARMACOECONOMICS 2021; 39:331-343. [PMID: 33355914 PMCID: PMC7882571 DOI: 10.1007/s40273-020-00987-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/20/2020] [Indexed: 05/04/2023]
Abstract
OBJECTIVES Evidence comparing the economic and patient values of the World Health Organization's preferred (dolutegravir 50 mg [DTG]-based) and alternative (low-dose [400 mg] efavirenz [EFV400]-based) first-line antiretroviral regimens is limited. We compared patient-reported outcomes (PROs), costs, and the cost-utility of DTG- versus EFV400-based regimens in treatment-naive HIV-1 adults in the randomised NAMSAL ANRS 12313 trial in Yaoundé, Cameroon. METHODS We used clinical data, PROs, and health resource use data collected in the trial's first 96 weeks (2016-2019). Quality-adjusted life-years (QALYs) were computed using utility scores obtained from the 12-item Short Form (SF-12) generic health scale. Other PROs included perceived symptoms, depression, anxiety, and stress. In the 96-week base-case analysis, we estimated the unadjusted and multivariate-adjusted (1) mean costs (in US$, 2016 values) and QALYs/patient, (2) incremental costs and QALYs/patient, and (3) net health benefit (NHB). Outcomes were extrapolated over 5 and 10 years. Uncertainty was assessed using the cost-effectiveness acceptability curve and scenario and cost-effective price threshold analyses. RESULTS In the base-case analysis, the NHB (95% confidence interval) for the DTG-based regimen relative to the EFV400-based regimen was 0.056 (- 0.037 to 0.153), corresponding to an 88% probability of DTG being cost-effective. A 10% decrease in this regimen's price (from $5.2 to $4.7/month) would increase its cost-effectiveness probability to 95%. When extrapolating outcomes over 5 and 10 years, the DTG-based regimen had a 100% probability of being cost-effective for a large range of cost-effectiveness thresholds. CONCLUSIONS At 2020 antiretroviral drug prices, a DTG-based first-line regimen should be preferred over an EFV400-based regimen in sub-Saharan Africa. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02777229.
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Affiliation(s)
- Marwân-Al-Qays Bousmah
- INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de La Santé & Traitement de l'Information Médicale, Aix-Marseille University, Marseille, France
| | - Marie Libérée Nishimwe
- INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de La Santé & Traitement de l'Information Médicale, Aix-Marseille University, Marseille, France
- ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, Marseille, France
| | - Tamara Tovar-Sanchez
- Recherches Translationnelles sur le VIH et les Maladies Infectieuses (TransVIHMI), University of Montpellier, Institut de recherche pour le développement (IRD)-INSERM, and University Hospital of Montpellier, Montpellier, France
| | | | | | - Gwenaëlle Maradan
- ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, Marseille, France
| | | | - Marie Varloteaux
- ANRS Cameroon Site, Central Hospital of Yaoundé, Yaoundé, Cameroon
| | | | - Charles Kouanfack
- ANRS Cameroon Site, Central Hospital of Yaoundé, Yaoundé, Cameroon
- Faculty of Medicine and Pharmaceutical Sciences, University of Dshang, Dshang, Cameroon
| | - Eric Delaporte
- Recherches Translationnelles sur le VIH et les Maladies Infectieuses (TransVIHMI), University of Montpellier, Institut de recherche pour le développement (IRD)-INSERM, and University Hospital of Montpellier, Montpellier, France
| | - Sylvie Boyer
- INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de La Santé & Traitement de l'Information Médicale, Aix-Marseille University, Marseille, France.
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22
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Rodriguez PJ, Roberts DA, Meisner J, Sharma M, Owiredu MN, Gomez B, Mello MB, Bobrik A, Vodianyk A, Storey A, Githuka G, Chidarikire T, Barnabas R, Barr-Dichiara M, Jamil MS, Baggaley R, Johnson C, Taylor MM, Drake AL. Cost-effectiveness of dual maternal HIV and syphilis testing strategies in high and low HIV prevalence countries: a modelling study. Lancet Glob Health 2021; 9:e61-e71. [PMID: 33227254 PMCID: PMC7783487 DOI: 10.1016/s2214-109x(20)30395-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 08/24/2020] [Accepted: 09/02/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Dual HIV and syphilis testing might help to prevent mother-to-child transmission (MTCT) of HIV and syphilis through increased case detection and treatment. We aimed to model and assess the cost-effectiveness of dual testing during antenatal care in four countries with varying HIV and syphilis prevalence. METHODS In this modelling study, we developed Markov models of HIV and syphilis in pregnant women to estimate costs and infant health outcomes of maternal testing at the first antenatal care visit with individual HIV and syphilis tests (base case) and at the first antenatal care visit with a dual rapid diagnostic test (scenario one). We additionally evaluated retesting during late antenatal care and at delivery with either individual tests (scenario two) or a dual rapid diagnosis test (scenario three). We modelled four countries: South Africa, Kenya, Colombia, and Ukraine. Strategies with an incremental cost-effectiveness ratio (ICER) less than the country-specific cost-effectiveness threshold (US$500 in Kenya, $750 in South Africa, $3000 in Colombia, and $1000 in Ukraine) per disability-adjusted life-year averted were considered cost-effective. FINDINGS Routinely offering testing at the first antenatal care visit with a dual rapid diagnosis test was cost-saving compared with the base case in all four countries (ICER: -$26 in Kenya,-$559 in South Africa, -$844 in Colombia, and -$454 in Ukraine). Retesting during late antenatal care with a dual rapid diagnostic test (scenario three) was cost-effective compared with scenario one in all four countries (ICER: $270 in Kenya, $260 in South Africa, $2207 in Colombia, and $205 in Ukraine). INTERPRETATION Incorporating dual rapid diagnostic tests in antenatal care can be cost-saving across countries with varying HIV prevalence. Countries should consider incorporating dual HIV and syphilis rapid diagnostic tests as the first test in antenatal care to support efforts to eliminate MTCT of HIV and syphilis. FUNDING WHO, US Agency for International Development, and the Bill & Melinda Gates Foundation.
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Affiliation(s)
- Patricia J Rodriguez
- The Comparative Health Outcomes Policy & Economics Institute, University of Washington, Seattle, WA, USA
| | - D Allen Roberts
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Julianne Meisner
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Monisha Sharma
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Morkor Newman Owiredu
- Global HIV, Hepatitis and Sexually Transmitted Infections Programme, WHO, Geneva, Switzerland
| | - Bertha Gomez
- Pan American Health Organization and WHO, Colombia Office, Bogotá DC, Colombia
| | - Maeve B Mello
- Department of Communicable Diseases and Environmental Determinants of Health, Pan American Health Organization and WHO, Washington DC, USA
| | - Alexey Bobrik
- Global Fund to Fight AIDS, Tuberculosis and Malaria, Grand-Saconnex, Switzerland
| | - Arkadii Vodianyk
- Department of Infectious Diseases, Ukraine Country Office, WHO, Kiev, Ukraine
| | - Andrew Storey
- Maternal and Neonatal Health, Clinton Health Access Initiative, Boston, MA, USA
| | | | - Thato Chidarikire
- HIV Prevention Programmes, National Department of Health, Pretoria, South Africa
| | - Ruanne Barnabas
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA
| | - Magdalena Barr-Dichiara
- Global HIV, Hepatitis and Sexually Transmitted Infections Programme, WHO, Geneva, Switzerland
| | - Muhammad S Jamil
- Global HIV, Hepatitis and Sexually Transmitted Infections Programme, WHO, Geneva, Switzerland
| | - Rachel Baggaley
- Global HIV, Hepatitis and Sexually Transmitted Infections Programme, WHO, Geneva, Switzerland
| | - Cheryl Johnson
- Global HIV, Hepatitis and Sexually Transmitted Infections Programme, WHO, Geneva, Switzerland; Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Melanie M Taylor
- Global HIV, Hepatitis and Sexually Transmitted Infections Programme, WHO, Geneva, Switzerland; Division of Sexually Transmitted Diseases Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Alison L Drake
- Department of Global Health, University of Washington, Seattle, WA, USA.
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Monaco DC, Zapata L, Hunter E, Salomon H, Dilernia DA. Resistance profile of HIV-1 quasispecies in patients under treatment failure using single molecule, real-time sequencing. AIDS 2020; 34:2201-2210. [PMID: 33196493 DOI: 10.1097/qad.0000000000002697] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Short-read next-generation sequencing (NGS) has been implemented to study the resistance profile of HIV as it provides a higher sensitivity than Sanger sequencing. However, short-reads only generates a consensus view of the viral population rather than a reconstruction of the viral haplotypes. In this study, we evaluated the resistance profile of HIV quasispecies in patients undergoing treatment failure using SMRT sequencing. DESIGN Whole-pol RT-PCR was performed on viral RNA extracted from plasma samples of 38 HIV-positive individuals undergoing treatment failure, and sequenced in the RSII instrument. Error correction and viral haplotype phasing was performed with the Multilayer Directed Phasing and Sequencing (MDPSeq) algorithm. Presence of resistance mutations reported by the IAS-USA in 2017 was assessed using an in-house script. RESULTS The SMRT sequencing-based test detected 131/134 resistance mutations previously detected using a Sanger sequencing-based test. However, the SMRT test also identified seven additional mutations present at an estimated frequency lower than 30%. The intra-host phylogenetic analysis showed that seven samples harbored at least one resistance variant at 20--80% frequency. The haplotype-resolved sequencing revealed viral diversification and selection of new resistance during suboptimal treatment, an overall trend toward selection and accumulation of new resistance mutations, as well as the co-existence of resistant and susceptible variants. CONCLUSION Our results validate the SMRT sequencing-based test for detection of HIV drug resistance. In addition, this method unraveled the complex dynamic of HIV quasispecies during treatment failure, which might have several implications on clinical management.
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Affiliation(s)
| | - Lucas Zapata
- Institute of Biomedical Investigations in Retrovirus and AIDS (INBIRS), School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Eric Hunter
- Emory Vaccine Center, Emory University, Atlanta, Georgia, USA
- Department of Pathology, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Horacio Salomon
- Institute of Biomedical Investigations in Retrovirus and AIDS (INBIRS), School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Dario A Dilernia
- Emory Vaccine Center, Emory University, Atlanta, Georgia, USA
- Department of Pathology, School of Medicine, Emory University, Atlanta, Georgia, USA
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24
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Hauser A, Kusejko K, Johnson LF, Günthard HF, Riou J, Wandeler G, Egger M, Kouyos RD. Impact of scaling up dolutegravir on antiretroviral resistance in South Africa: A modeling study. PLoS Med 2020; 17:e1003397. [PMID: 33315863 PMCID: PMC7735592 DOI: 10.1371/journal.pmed.1003397] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 11/10/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Rising resistance of HIV-1 to non-nucleoside reverse transcriptase inhibitors (NNRTIs) threatens the success of the global scale-up of antiretroviral therapy (ART). The switch to WHO-recommended dolutegravir (DTG)-based regimens could reduce this threat due to DTG's high genetic barrier to resistance. We used mathematical modeling to predict the impact of the scale-up of DTG-based ART on NNRTI pretreatment drug resistance (PDR) in South Africa, 2020 to 2040. METHODS AND FINDINGS We adapted the Modeling Antiretroviral drug Resistance In South Africa (MARISA) model, an epidemiological model of the transmission of NNRTI resistance in South Africa. We modeled the introduction of DTG in 2020 under 2 scenarios: DTG as first-line regimen for ART initiators, or DTG for all patients, including patients on suppressive NNRTI-based ART. Given the safety concerns related to DTG during pregnancy, we assessed the impact of prescribing DTG to all men and in addition to (1) women beyond reproductive age; (2) women beyond reproductive age or using contraception; and (3) all women. The model projections show that, compared to the continuation of NNRTI-based ART, introducing DTG would lead to a reduction in NNRTI PDR in all scenarios if ART initiators are started on a DTG-based regimen, and those on NNRTI-based regimens are rapidly switched to DTG. NNRTI PDR would continue to increase if DTG-based ART was restricted to men. When given to all men and women, DTG-based ART could reduce the level of NNRTI PDR from 52.4% (without DTG) to 10.4% (with universal DTG) in 2040. If only men and women beyond reproductive age or on contraception are started on or switched to DTG-based ART, NNRTI PDR would reach 25.9% in 2040. Limitations include substantial uncertainty due to the long-term predictions and the current scarcity of knowledge about DTG efficacy in South Africa. CONCLUSIONS Our model shows the potential benefit of scaling up DTG-based regimens for halting the rise of NNRTI resistance. Starting or switching all men and women to DTG would lead to a sustained decline in resistance levels, whereas using DTG-based ART in all men, or in men and women beyond childbearing age, would only slow down the increase in levels of NNRTI PDR.
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Affiliation(s)
- Anthony Hauser
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Katharina Kusejko
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Leigh F. Johnson
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
| | - Huldrych F. Günthard
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Julien Riou
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Gilles Wandeler
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- * E-mail: (ME); (RDK)
| | - Roger D. Kouyos
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland
- * E-mail: (ME); (RDK)
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25
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Bertagnolio S, Hermans L, Jordan MR, Avila-Rios S, Iwuji C, Derache A, Delaporte E, Wensing A, Aves T, Borhan ASM, Leenus A, Parkin N, Doherty M, Inzaule S, Mbuagbaw L. Clinical Impact of Pretreatment Human Immunodeficiency Virus Drug Resistance in People Initiating Nonnucleoside Reverse Transcriptase Inhibitor-Containing Antiretroviral Therapy: A Systematic Review and Meta-analysis. J Infect Dis 2020; 224:377-388. [PMID: 33202025 PMCID: PMC8328216 DOI: 10.1093/infdis/jiaa683] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 11/16/2020] [Indexed: 01/15/2023] Open
Abstract
Background Increased access to antiretroviral therapy (ART) has resulted in rising levels of pretreatment human immunodeficiency virus drug resistance (PDR). This is the first systematic review and meta-analysis to assess the impact of PDR on treatment outcomes among people initiating nonnucleoside reverse transcriptase inhibitor (NNRTI)–based ART, including the combination of efavirenz (EFV), tenofovir (TDF), and lamivudine or emtricitabine (XTC). Methods We systematically reviewed studies and conference proceedings comparing treatment outcomes in populations initiating NNRTI-based ART with and without PDR. We conducted subgroup analyses by regimen: (1) NNRTIs + 2 nucleoside reverse transcriptase inhibitors (NRTIs), (2) EFV + 2 NRTIs, or (3) EFV/TDF/XTC; by population (children vs adults); and by definition of resistance (PDR vs NNRTI PDR). Results Among 6197 studies screened, 32 were analyzed (31 441 patients). We found that individuals with PDR initiating NNRTIs across all the subgroups had increased risk of virological failure compared to those without PDR. Risk of acquisition of new resistance mutations and ART switch was also higher in people with PDR. Conclusions This review shows poorer treatment outcomes in the presence of PDR, supporting the World Health Organization’s recommendation to avoid using NNRTIs in countries where levels of PDR are high.
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Affiliation(s)
- Silvia Bertagnolio
- Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Lucas Hermans
- Virology, Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands.,Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Michael R Jordan
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA.,Division of Geographic Medicine and Infectious Disease, Tufts Medical Center, Boston, Massachusetts, USA.,Tufts Center for Integrated Management of Antimicrobial Resistance, Boston, Massachusetts, USA
| | - Santiago Avila-Rios
- Centro de Investigación en Enfermedades Infecciosas, Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico
| | - Collins Iwuji
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, United Kingdom
| | - Anne Derache
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Eric Delaporte
- TransVIHMI, University of Montpellier, Institut de Recherche pour le Développement, Institut national de la santé et de la recherche médicale, Montpellier, France
| | - Annemarie Wensing
- Virology, Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands.,Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Theresa Aves
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - A S M Borhan
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Alvin Leenus
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Neil Parkin
- Data First Consulting, Sebastopol, California, USA
| | - Meg Doherty
- Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Seth Inzaule
- Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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26
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Yan L, Yu F, Zhang H, Zhao H, Wang L, Liang Z, Zhang X, Wu L, Liang H, Yang S, Tang Y, Zhang F. Transmitted and Acquired HIV-1 Drug Resistance from a Family: A Case Study. Infect Drug Resist 2020; 13:3763-3770. [PMID: 33122923 PMCID: PMC7591230 DOI: 10.2147/idr.s272232] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 09/11/2020] [Indexed: 11/23/2022] Open
Affiliation(s)
- Liting Yan
- Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China
- Clinical Center for HIV/AIDS, Capital Medical University, Beijing, People’s Republic of China
| | - Fengting Yu
- Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China
- Clinical Center for HIV/AIDS, Capital Medical University, Beijing, People’s Republic of China
| | - Huimin Zhang
- Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China
- Department of Pediatrics, Beijing Ditan Hospital, Beijing, People’s Republic of China
| | - Hongxin Zhao
- Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China
- Clinical Center for HIV/AIDS, Capital Medical University, Beijing, People’s Republic of China
| | - Linghang Wang
- Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China
- Clinical Center for HIV/AIDS, Capital Medical University, Beijing, People’s Republic of China
| | - Zaiyan Liang
- Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China
- Clinical Center for HIV/AIDS, Capital Medical University, Beijing, People’s Republic of China
| | - Xia Zhang
- Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China
- Clinical Center for HIV/AIDS, Capital Medical University, Beijing, People’s Republic of China
| | - Liang Wu
- Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China
- Clinical Center for HIV/AIDS, Capital Medical University, Beijing, People’s Republic of China
| | - Hongyuan Liang
- Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China
- Clinical Center for HIV/AIDS, Capital Medical University, Beijing, People’s Republic of China
| | - Siyuan Yang
- Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China
- Clinical Center for HIV/AIDS, Capital Medical University, Beijing, People’s Republic of China
| | - Yunxia Tang
- Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China
- Clinical Center for HIV/AIDS, Capital Medical University, Beijing, People’s Republic of China
| | - Fujie Zhang
- Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China
- Clinical Center for HIV/AIDS, Capital Medical University, Beijing, People’s Republic of China
- Correspondence: Fujie Zhang Beijing Ditan Hospital, Capital Medical University, Beijing100015, People’s Republic of ChinaTel +86 10 84322581 Email
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27
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Gachogo RW, Mwai DN, Onyambu FG. Cost analysis of implementing HIV drug resistance testing in Kenya: a case study of a service delivery site at a tertiary level hospital in Kenya. F1000Res 2020; 9:793. [PMID: 32983418 PMCID: PMC7495211 DOI: 10.12688/f1000research.23379.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/15/2020] [Indexed: 01/13/2023] Open
Abstract
Background: HIV drug resistance (HIVDR) threatens progress achieved in response to the HIV epidemic. Understanding the costs of implementing HIVDR testing programs for patient management and surveillance in resource-limited settings is critical in optimizing resource allocation. Here, we estimate the unit cost of HIVDR testing and identify major cost drivers while documenting challenges and lessons learnt in implementation of HIVDR testing at a tertiary level hospital in Kenya. Methods: We employed a mixed costing approach to estimate the costs associated with performing a HIVDR test from the provider's perspective. Data collection involved a time and motion study of laboratory procedures and interviewing laboratory personnel and the management personnel. Cost analysis was based on estimated 1000 HIVDR tests per year. Data entry and analysis were done using Microsoft Excel and costs converted to US dollars (2019). Results: The estimated unit cost for a HIVDR test was $271.78 per test. The main cost drivers included capital ($102.42, 37.68%) and reagents (101.50, 37.35%). Other costs included: personnel ($46.81, 17.22%), utilities ($14.69, 5.41%), equipment maintenance costs ($2.37, 0.87%) and quality assurance program ($4, 1.47%). Costs in relation to specific laboratory processes were as follows: sample collection ($2.41, 0.89%), RNA extraction ($22.79, 8.38%), amplification ($56.14, 20.66%), gel electrophoresis ($10.34, 3.80%), sequencing ($160.94, 59.22%), and sequence analysis ($19.16, 7.05%). A user-initiated modification of halving reagent volumes for some laboratory processes (amplification and sequencing) reduced the unit cost for a HIVDR test to $233.81 (13.97%) reduction. Conclusions: Capital expenditure and reagents remain the most expensive components of HIVDR testing. This cost is bound to change as the sequencing platform is utilized towards maximum capacity or leveraged for use with other tests. Cost saving in offering HIVDR testing services is also possible through reagent volume reduction without compromising on the quality of test results.
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Affiliation(s)
- Rachael W. Gachogo
- Molecular and Infectious Diseases Research Laboratory, University of Nairobi, Nairobi, Kenya
- School of Economics, University of Nairobi, Nairobi, Kenya
| | - Daniel N. Mwai
- School of Economics, University of Nairobi, Nairobi, Kenya
| | - Frank G. Onyambu
- Molecular and Infectious Diseases Research Laboratory, University of Nairobi, Nairobi, Kenya
- School of Health Sciences, Meru University of Science and Technology, Meru, Kenya
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28
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Cowan FM, Chabata ST, Musemburi S, Fearon E, Davey C, Ndori-Mharadze T, Bansi-Matharu L, Cambiano V, Steen R, Busza J, Yekeye R, Mugurungi O, Hargreaves JR, Phillips AN. Strengthening the scale-up and uptake of effective interventions for sex workers for population impact in Zimbabwe. J Int AIDS Soc 2020; 22 Suppl 4:e25320. [PMID: 31328445 PMCID: PMC6643097 DOI: 10.1002/jia2.25320] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 05/13/2019] [Indexed: 12/02/2022] Open
Abstract
Introduction UNAIDS’ goal of ending AIDS by 2030 is unreachable without better targeting of testing, prevention and care. Female sex workers (FSW) in Zimbabwe are at high risk of HIV acquisition and transmission. Here, we report on collated programme and research data from Zimbabwe's national sex work programme. We also assess the potential for wider population impact of FSW programmes by modelling the impact on HIV incidence of eliminating transmission through FSW (i.e. calculate the population attributable fraction of incidence attributable to sex work). Methods Descriptive analyses of individual‐level programme data collected from FSW between 2009 and June 2018 are triangulated with data collected through 37 respondent driven sampling surveys from 19 sites in Zimbabwe 2011 to 2017. We describe programme coverage, uptake, retention and patterns of sex work behaviour and gaps in service provision. An individual‐level stochastic simulation model is used to reconstruct the epidemic and then the incidence compared with the counter‐factual trend in incidence from 2010 had transmission through sex work been eliminated from that date. Results Sisters has reached >67,000 FSW since 2009, increasing attendance as number of sites, programme staff and peer educators were increased. Over 57% of all FSW estimated to be working in Zimbabwe in 2017 (n = 40,000) attended the programme at least once. The proportion of young FSW reached has increased with introduction of the “Young Sisters programme.” There are no clear differences in pattern of sex work across settings. Almost all women report condom use with clients at last sex (95%); however, consistent condom use with clients in the last month varies from 52% to 95% by site. Knowledge of HIV‐positive status has increased from 48 to 78% between 2011 and 2016, as has prevalence of ART use among diagnosed women (29 to 67%). Although subject to uncertainty, modelling suggests that 70% (90% range: 32%, 93%) of all new infections in Zimbabwe from 2010 are directly or indirectly attributable to transmission via sex work. Conclusions It is feasible to increase coverage and impact of sex work programming through community‐led scale‐up of evidence‐based interventions. Eliminating transmission through commercial sex would likely have a substantial impact on new infections occurring more widely across Zimbabwe.
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Affiliation(s)
- Frances M Cowan
- Department of International Public Health, Liverpool School of Medicine, Liverpool, United Kingdom.,Centre for Sexual Health and HIV AIDS Research (CSHHAR) Zimbabwe, Harare, Zimbabwe
| | - Sungai T Chabata
- Centre for Sexual Health and HIV AIDS Research (CSHHAR) Zimbabwe, Harare, Zimbabwe
| | - Sithembile Musemburi
- Centre for Sexual Health and HIV AIDS Research (CSHHAR) Zimbabwe, Harare, Zimbabwe
| | - Elizabeth Fearon
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Calum Davey
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | - Valentina Cambiano
- Institute for Global Health, University College London, London, United Kingdom
| | - Richard Steen
- Department of Public Health, Erasmus University, Rotterdam, The Netherlands
| | - Joanna Busza
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Owen Mugurungi
- AIDS and TB Directorate, Ministry of Health and Child Care, Harare, Zimbabwe
| | - James R Hargreaves
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Andrew N Phillips
- Institute for Global Health, University College London, London, United Kingdom
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29
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van der Galiën R, Ter Heine R, Greupink R, Schalkwijk SJ, van Herwaarden AE, Colbers A, Burger DM. Pharmacokinetics of HIV-Integrase Inhibitors During Pregnancy: Mechanisms, Clinical Implications and Knowledge Gaps. Clin Pharmacokinet 2020; 58:309-323. [PMID: 29915921 PMCID: PMC6373543 DOI: 10.1007/s40262-018-0684-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Prevention of mother-to-child transmission of HIV and optimal maternal treatment are the most important goals of antiretroviral therapy in pregnant women with HIV. These goals may be at risk due to possible reduced exposure during pregnancy caused by physiological changes. Limited information is available on the impact of these physiological changes. This is especially true for HIV-integrase inhibitors, a relatively new class of drugs, recommended first-line agents and hence used by a large proportion of HIV-infected patients. Therefore, the objective of this review is to provide a detailed overview of the pharmacokinetics of HIV-integrase inhibitors in pregnancy. Second, this review defines potential causes for the change in pharmacokinetics of HIV-integrase inhibitors during pregnancy. Despite increased clearance, for raltegravir 400 mg twice daily and dolutegravir 50 mg once daily, exposure during pregnancy seems adequate; however, for elvitegravir, the proposed minimal effective concentration is not reached during pregnancy. Lower exposure to these drugs may be caused by increased hormone levels and, subsequently, enhanced drug metabolism during pregnancy. The pharmacokinetics of bictegravir and cabotegravir, which are under development, have not yet been evaluated in pregnant women. New studies need to prospectively assess whether adequate exposure is reached in pregnant women using these new HIV-integrase inhibitors. To further optimize antiretroviral treatment in pregnant women, studies need to unravel the underlying mechanisms behind the changes in the pharmacokinetics of HIV-integrase inhibitors during pregnancy. More knowledge on altered pharmacokinetics during pregnancy and the underlying mechanisms contribute to the development of effective and safe antiretroviral therapy for HIV-infected pregnant women.
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Affiliation(s)
- Ruben van der Galiën
- Department of Pharmacy, Radboud Institute of Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Rob Ter Heine
- Department of Pharmacy, Radboud Institute of Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Rick Greupink
- Department of Pharmacology and Toxicology, Radboud Institute of Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Stein J Schalkwijk
- Department of Pharmacy, Radboud Institute of Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.,Department of Pharmacology and Toxicology, Radboud Institute of Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Antonius E van Herwaarden
- Department of Laboratory Medicine, Radboud Institute of Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Angela Colbers
- Department of Pharmacy, Radboud Institute of Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - David M Burger
- Department of Pharmacy, Radboud Institute of Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.
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30
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Ngo-Giang-Huong N, Huynh THK, Dagnra AY, Toni TD, Maiga AI, Kania D, Eymard-Duvernay S, Peeters M, Soulie C, Peytavin G, Rekacewicz C, Chaix ML, Aghokeng AF. Prevalence of pretreatment HIV drug resistance in West African and Southeast Asian countries. J Antimicrob Chemother 2020; 74:462-467. [PMID: 30418575 PMCID: PMC6337899 DOI: 10.1093/jac/dky443] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 10/02/2018] [Indexed: 11/13/2022] Open
Abstract
Background ART in the developing world has moved to a new era with the WHO recommendation to test and immediately treat HIV-positive individuals. A high frequency of pretreatment HIV drug resistance (PDR) can compromise ART efficacy. Our study presents updated estimates of PDR in seven countries from West Africa (Burkina Faso, Cameroon, Côte d’Ivoire, Mali and Togo) and Southeast Asia (Thailand and Vietnam). Methods Eligible study participants were adult ART initiators, recruited from December 2015 to November 2016 in major ART clinics in each country. HIV drug resistance (HIVDR) tests were performed for all specimens and interpretation was done using the Stanford algorithm. Results Overall, 1153 participants were recruited and 1020 nt sequences were generated. PDR frequency among all initiators was 15.9% (95% CI: 13.8%–18.3%) overall, ranging from 9.6% and 10.2% in Burkina Faso and Thailand, respectively, 14.7% in Vietnam, 15.4% in Mali, 16.5% in Côte d’Ivoire and 19.3% in Cameroon, to 24.6% in Togo. The prevalence of NNRTI resistance mutations was 12%; NRTI and PI PDR prevalences were 4% and 3%, respectively. Conclusions Our study shows that in most countries PDR exceeded 10%, warranting the conduct of nationally representative surveys to confirm this trend. In the meantime, actions to prevent drug resistance, including transition from NNRTIs to more robust drug classes should be urgently implemented.
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Affiliation(s)
- Nicole Ngo-Giang-Huong
- IRD UMI 174-PHPT-Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Thu H K Huynh
- HIV/AIDS laboratory, Pasteur Institute in Ho Chi Minh City, Vietnam
| | - Anoumou Y Dagnra
- Centre de Biologie moléculaire et d'Immunologie, Faculté des Sciences de la santé, Université de Lomé, Lomé, Togo
| | | | - Almoustapha I Maiga
- UCRC/SEREFO, FMOS, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Dramane Kania
- Virology Laboratory, Department of Biomedical Sciences, Centre MURAZ, Bobo-Dioulasso, Burkina Faso
| | | | - Martine Peeters
- IRD UMI-233, INSERM U1175, Université de Montpellier, Unité TransVIHMI, Montpellier, France
| | - Cathia Soulie
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (iPLESP), AP-HP, Hôpital Pitié Salpêtrière, Laboratoire de virologie, F-75013 Paris, France
| | - Gilles Peytavin
- AP-HP, Hôpital Bichat-Claude Bernard, Laboratoire de Pharmacologie-Toxicologie and IAME, UMR 1137, Université Paris Diderot, Sorbonne Paris Cité et INSERM, Paris, France
| | - Claire Rekacewicz
- Agence Nationale de Recherches sur le Sida et les hépatites virales (ANRS), Paris, France
| | - Marie-Laure Chaix
- INSERM U941, Université Paris Diderot, AP-HP, Hôpital Saint-Louis, Laboratoire de Virologie, Paris, France
| | - Avelin F Aghokeng
- IRD UMI-233, INSERM U1175, Université de Montpellier, Unité TransVIHMI, Montpellier, France.,Centre de Recherche sur les Maladies Emergentes et Reemergentes (CREMER), Virology laboratory IMPM-IRD, Yaoundé, Cameroon
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31
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Duarte HA, Babigumira JB, Enns EA, Stauffer DC, Shafer RW, Beck IA, Garrison LP, Chung MH, Frenkel LM, Bendavid E. Cost-effectiveness analysis of pre-ART HIV drug resistance testing in Kenyan women. EClinicalMedicine 2020; 22:100355. [PMID: 32490370 PMCID: PMC7256304 DOI: 10.1016/j.eclinm.2020.100355] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 04/13/2020] [Accepted: 04/14/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The prevalence of pre-treatment drug resistance (PDR) to non-nucleoside reverse-transcriptase inhibitor (NNRTI) agents is increasing in sub-Saharan Africa, which may decrease the effectiveness of efavirenz-based antiretroviral therapy (ART) programs. However, due to recent safety concerns, there has been hesitancy to replace efavirenz-based ART with dolutegravir in women of reproductive potential. Our objective was to evaluate whether PDR testing for women not initiating dolutegravir-based ART would be a cost-effective strategy to address the challenges posed by PDR. METHODS We developed an HIV drug resistance model that simulates the emergence and transmission of resistance mutations, calibrated to the Kenyan epidemic. We modeled three care strategies for PDR testing among women not initiating dolutegravir-based ART: no PDR testing, PDR testing with a low-cost point mutation assay, known as oligonucleotide ligation assay (OLA), and PDR testing with consensus sequencing. Using a health sector perspective, this model was used to evaluate the health outcomes, lifetime costs, and cost-effectiveness under each strategy over a 15-year time horizon starting in 2019. FINDINGS OLA and CS PDR testing were projected to have incremental cost-effectiveness ratios (ICER) of $10,741/QALY gained and $134,396/QALY gained, respectively, which are not cost-effective by national income standards. Viral suppression rates among women at 12 months after ART initiation were 87·8%, 89·0%, and 89·3% with no testing, OLA testing, and CS testing, respectively. PDR testing with OLA and CS were associated with a 0.5% and 0.6% reduction in incidence rate compared to no PDR testing. Initial PDR prevalence among women was 13.1% in 2019. By 2034, this prevalence was 17·6%, 17·4%, and 17·3% with no testing, OLA testing, and CS testing, respectively. INTERPRETATION PDR testing for women is unlikely to be cost-effective in Kenya whether one uses a low-cost assay, such as OLA, or consensus sequencing. FUNDING National Institutes of Health, Gilead Sciences.
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Affiliation(s)
- Horacio A Duarte
- Department of Pediatrics, Division of Infectious Diseases, University of Washington, Seattle, WA, United States
- Seattle Children's Research Institute, Seattle, WA, United States
| | - Joseph B Babigumira
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Eva A Enns
- School of Public Health, Division of Health Policy and Management, University of Minnesota, Minneapolis, MN, United States
| | - David C Stauffer
- Department of Pediatrics, Division of Infectious Diseases, University of Washington, Seattle, WA, United States
| | - Robert W Shafer
- Department of Medicine, Stanford University, Stanford, CA, United States
| | - Ingrid A Beck
- Seattle Children's Research Institute, Seattle, WA, United States
| | - Louis P Garrison
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, WA, United States
| | | | - Lisa M Frenkel
- Department of Pediatrics, Division of Infectious Diseases, University of Washington, Seattle, WA, United States
- Seattle Children's Research Institute, Seattle, WA, United States
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Laboratory Medicine, University of Washington, Seattle, WA, United States
- Department of Medicine, University of Washington, Seattle, WA, United States
| | - Eran Bendavid
- Department of Medicine, Stanford University, Stanford, CA, United States
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32
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Zhu J, Tian X, Shehu AI, McMahon DK, Ma X. ABCG2 Deficiency Does Not Alter Dolutegravir Metabolism and Pharmacokinetics. J Pharmacol Exp Ther 2020; 374:38-43. [PMID: 32303561 DOI: 10.1124/jpet.119.264424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 04/10/2020] [Indexed: 01/12/2023] Open
Abstract
Dolutegravir (DTG) is a potent integrase inhibitor of human immunodeficiency virus. Because DTG is a substrate of the efflux transporter ABCG2 and ABCG2 is highly polymorphic, we asked whether dose adjustment of DTG is needed for ABCG2-deficient individuals. Using Abcg2-null mice, the current work investigated the impact of ABCG2 deficiency on DTG metabolism and pharmacokinetics. Compared with wild-type mice, no statistically significant difference was found in the systemic and tissue-specific (liver, kidney, and brain) pharmacokinetics of DTG in Abcg2-null mice. In addition, ABCG2 deficiency had no statistically significant impact on the production and excretion of DTG metabolites. In summary, this study demonstrated that deficiency of ABCG2 does not alter DTG metabolism and pharmacokinetics, suggesting that dose adjustment of DTG is not needed for individuals with ABCG2 deficiency. SIGNIFICANCE STATEMENT: The current work demonstrated that deficiency of ATP-binding cassette subfamily G member 2 (ABCG2) does not alter Dolutegravir (DTG) metabolism and pharmacokinetics, suggesting that dose adjustment of DTG is not needed for individuals with ABCG2 deficiency.
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Affiliation(s)
- Junjie Zhu
- Center for Pharmacogenetics, Department of Pharmaceutical Sciences, School of Pharmacy (J.Z., X.T., A.I.S., X.M.) and Division of Infectious Disease, Department of Medicine (D.K.M.), University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Xin Tian
- Center for Pharmacogenetics, Department of Pharmaceutical Sciences, School of Pharmacy (J.Z., X.T., A.I.S., X.M.) and Division of Infectious Disease, Department of Medicine (D.K.M.), University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Amina I Shehu
- Center for Pharmacogenetics, Department of Pharmaceutical Sciences, School of Pharmacy (J.Z., X.T., A.I.S., X.M.) and Division of Infectious Disease, Department of Medicine (D.K.M.), University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Deborah K McMahon
- Center for Pharmacogenetics, Department of Pharmaceutical Sciences, School of Pharmacy (J.Z., X.T., A.I.S., X.M.) and Division of Infectious Disease, Department of Medicine (D.K.M.), University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Xiaochao Ma
- Center for Pharmacogenetics, Department of Pharmaceutical Sciences, School of Pharmacy (J.Z., X.T., A.I.S., X.M.) and Division of Infectious Disease, Department of Medicine (D.K.M.), University of Pittsburgh, Pittsburgh, Pennsylvania
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Shafer RW, Frenkel LM. The Clinical Implications of Pretreatment Drug Resistance-A Moving Target. Clin Infect Dis 2020; 69:215-217. [PMID: 30321316 DOI: 10.1093/cid/ciy895] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 10/10/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- Robert W Shafer
- Division of Infectious Diseases, Department of Medicine, Stanford University, California
| | - Lisa M Frenkel
- Division of Infectious Diseases, Department of Pediatrics, University of Washington, Seattle
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Godman B, McCabe H, D Leong T. Fixed dose drug combinations - are they pharmacoeconomically sound? Findings and implications especially for lower- and middle-income countries. Expert Rev Pharmacoecon Outcomes Res 2020; 20:1-26. [PMID: 32237953 DOI: 10.1080/14737167.2020.1734456] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Introduction: There are positive aspects regarding the prescribing of fixed dose combinations (FDCs) versus prescribing the medicines separately. However, these have to be balanced against concerns including increased costs and their irrationality in some cases. Consequently, there is a need to review their value among lower- and middle-income countries (LMICs) which have the greatest prevalence of both infectious and noninfectious diseases and issues of affordability.Areas covered: Review of potential advantages, disadvantages, cost-effectiveness, and availability of FDCs in high priority disease areas in LMICs and possible initiatives to enhance the prescribing of valued FDCs and limit their use where there are concerns with their value.Expert commentary: FDCs are valued across LMICs. Advantages include potentially improved response rates, reduced adverse reactions, increased adherence rates, and reduced costs. Concerns include increased chances of drug:drug interactions, reduced effectiveness, potential for imprecise diagnoses and higher unjustified prices. Overall certain FDCs including those for malaria, tuberculosis, and hypertension are valued and listed in the country's essential medicine lists, with initiatives needed to enhance their prescribing where currently low prescribing rates. Proposed initiatives include robust clinical and economic data to address the current paucity of pharmacoeconomic data. Irrational FDCs persists in some countries which are being addressed.
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Affiliation(s)
- Brian Godman
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK.,Division of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria, South Africa.,Division of Clinical Pharmacology, Karolinska Institute, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Holly McCabe
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Trudy D Leong
- Division of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria, South Africa
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Abstract
OBJECTIVE Evaluate the potential effectiveness of the implementation of dolutegravir (DTG)-based regimens in patients on failing current antiretroviral treatment (ART) given the high levels of nucleoside reverse transcriptase inhibitor (NRTI) resistance in Togo. DESIGN Patients on ART attending health facilities for routine follow-up visits and for whom HIV viral load test was performed were consecutively included. METHODS Protease, reverse transcriptase and integrase fragments were sequenced and analyzed for presence of drug resistance mutations for patients with viral load more than 1000 copies/ml. RESULTS Among 1681 patients, 320 (19.04%) had viral load more than 1000 copies/ml and 200 were tested for drug resistance mutations. Reverse transcriptase gene was successfully sequenced for 181/200 (90.5%) patients; 140/181 (77.4%) were resistant to NRTIs and non-NRTIs, 4/181 (2.2%) to NRTIs only and 18/181 (9.9%) to non-NRTIs only. Many viral strains accumulated mutations predicting resistance to NRTIs recommended in first and second-line DTG-based ART regimens. ART switch to a DTG-based regimen after viral load testing (viral load >1000 copies/ml) or blind switch without prior viral load testing to a new DTG-based first line, estimated 31% and 47.6% of patients to be potentially on functional DTG monotherapy respectively. CONCLUSION Overall, our results predict that, at the scale of sub-Saharan Africa a significant proportion of patients could be on functional monotherapy. To achieve the third 90 of UNAIDS objectives, implementation of DTG-based regimens should be accompanied with an accelerated scaling up of access to viral load. Studies designed to quantify the implications of use of suboptimal DTG-based regimens are also needed.
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Keita A, Sereme Y, Pillet S, Coulibaly S, Diallo F, Pozzetto B, Thiero TA, Bourlet T. Impact of HIV-1 primary drug resistance on the efficacy of a first-line antiretroviral regimen in the blood of newly diagnosed individuals in Bamako, Mali. J Antimicrob Chemother 2020; 74:165-171. [PMID: 30285106 DOI: 10.1093/jac/dky382] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 08/24/2018] [Indexed: 12/30/2022] Open
Abstract
Background To achieve the 90-90-90 targets assigned by UNAIDS, it is crucial to monitor ART in HIV-1-infected patients, especially in resource-limited countries. Objectives To evaluate the immunovirological response after 12 months of ART in newly HIV-1-diagnosed people in Bamako, Mali; to determine primary and acquired resistance rates to antiretroviral drugs; and to evaluate the impact of primary resistance on the efficacy of ART. Patients and methods One hundred and nineteen HIV-1-infected people (88.2% women; median age 34 years) were enrolled between January and June 2014. HIV-1 RNA loads (Abbott RealTime HIV-1 assay) were tested in the blood before and at months 3, 6 and 12 after initiation of ART. Primary and acquired resistances to ART were evaluated by the Viroseq™ HIV-1 genotyping assay. Results During the study, 8.4% of people died and 37% were lost to follow-up. After 1 year of ART, an undetectable HIV-1 RNA viral load was found in 87.7% of cases. The overall rate of primary drug resistance mutations was 17.5% (3.2%, 15.9% and 0% for NRTIs, NNRTIs and PIs, respectively). These mutations were not associated with either higher mortality rates or larger numbers of virological failures. The acquired resistance rate was estimated at 3.1%. Conclusions Our study showed a high primary resistance level and a huge proportion of people non-adherent to the treatment programme. Reassuringly, almost 90% virological success and a low level of acquired mutations were observed in adherent people at month 12. Reinforced education, regular virological monitoring and early HIV-1 diagnosis may help to improve retention in the care system.
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Affiliation(s)
- Abdelaye Keita
- Institut National de Recherche en Santé Publique (INRSP), Bamako, Mali.,Groupe Immunité des Muqueuses et Agents Pathogènes GIMAP EA3064, University of Saint-Etienne, University of Lyon, Saint-Etienne, France
| | - Youssouf Sereme
- Groupe Immunité des Muqueuses et Agents Pathogènes GIMAP EA3064, University of Saint-Etienne, University of Lyon, Saint-Etienne, France
| | - Sylvie Pillet
- Groupe Immunité des Muqueuses et Agents Pathogènes GIMAP EA3064, University of Saint-Etienne, University of Lyon, Saint-Etienne, France.,Laboratoire des Agents Infectieux et d'Hygiène, University Hospital of Saint-Etienne, Saint Etienne, France
| | | | - Fodié Diallo
- Centre d'écoute de soins et d'accompagnement (CESAC), Bamako, Mali
| | - Bruno Pozzetto
- Groupe Immunité des Muqueuses et Agents Pathogènes GIMAP EA3064, University of Saint-Etienne, University of Lyon, Saint-Etienne, France.,Laboratoire des Agents Infectieux et d'Hygiène, University Hospital of Saint-Etienne, Saint Etienne, France
| | - Tenin Aoua Thiero
- Institut National de Recherche en Santé Publique (INRSP), Bamako, Mali
| | - Thomas Bourlet
- Groupe Immunité des Muqueuses et Agents Pathogènes GIMAP EA3064, University of Saint-Etienne, University of Lyon, Saint-Etienne, France.,Laboratoire des Agents Infectieux et d'Hygiène, University Hospital of Saint-Etienne, Saint Etienne, France
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Bansi-Matharu L, Cambiano V, Apollo T, Yekeye R, Dirawo J, Musemburi S, Davey C, Napierala S, Fearon E, Mpofu A, Mugurungi O, Hargreaves JR, Cowan FM, Phillips AN. 90-90-90 by 2020? Estimation and projection of the adult HIV epidemic and ART programme in Zimbabwe - 2017 to 2020. J Int AIDS Soc 2019; 21:e25205. [PMID: 30465689 PMCID: PMC6250855 DOI: 10.1002/jia2.25205] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 10/16/2018] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION The 90-90-90 targets set by the United Nations aspire to 73% of people living with HIV (PLHIV) being virally suppressed by 2020. Using the HIV Synthesis Model, we aim to mimic the epidemic in Zimbabwe and make projections to assess whether Zimbabwe is on track to meet the 90-90-90 targets and assess whether recently proposed UNAIDS HIV transition metrics are likely to be met. METHODS We used an approximate Bayesian computation approach to identify model parameter values which result in model outputs consistent with observed data, evaluated using a calibration score. These parameter values were then used to make projections to 2020 to compare with the 90-90-90 targets and other key indicators. We also calculated HIV transition metrics proposed by UNAIDS (percentage reduction in new HIV infections and AIDS-related mortality from 2010 to 2020, absolute rate of new infections and AIDS-related mortality, incidence-mortality ratio and incidence-prevalence ratios). RESULTS After calibration, there was general agreement between modelled and observed data. The median predicted outcomes in 2020 were: proportion of PLHIV (aged 15 to 65) diagnosed 0.91 (90% uncertainty range 0.87, 0.94) (0.84 men, 0.95 women); of those diagnosed, proportion on treatment 0.92 (0.90, 0.93); of those receiving treatment, proportion with viral suppression 0.86 (0.81, 0.91). This results in 72% of PLHIV having viral suppression in 2020. We estimated a percentage reduction of 36.5% (13.7% increase to 67.4% reduction) in new infections from 2010 to 2020, and of 30.4% (9.7% increase to 56.6% reduction) in AIDS-related mortality (UNAIDS target 75%). The modelled absolute rates of HIV incidence and AIDS-related mortality in 2020 were 5.48 (2.26, 9.24) and 1.93 (1.31, 2.71) per 1000 person-years respectively. The modelled incidence-mortality ratio and incidence-prevalence ratios in 2020 were 1.05 (0.46, 1.66) and 0.009 (0.004, 0.013) respectively. CONCLUSIONS Our model was able to produce outputs that are simultaneously consistent with an array of observed data and predicted that while the 90-90-90 targets are within reach in Zimbabwe, increased efforts are required in diagnosing men in particular. Calculation of the HIV transition metrics suggest increased efforts are needed to bring the HIV epidemic under control.
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Affiliation(s)
| | | | - Tsitsi Apollo
- Department of HIV/AIDS and STIs, Ministry of Health and Childcare, Harare, Zimbabwe
| | | | - Jeffrey Dirawo
- Centre for Sexual Health, HIV/AIDS Research Zimbabwe, Harare, Zimbabwe
| | | | - Calum Davey
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine (LSHTM), London, UK
| | | | - Elizabeth Fearon
- Department of Social and Environmental Health Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Amon Mpofu
- Zimbabwe National AIDS Council, Harare, Zimbabwe
| | - Owen Mugurungi
- TB and AIDS Unit, Zimbabwe Ministry of Health, Harare, Zimbabwe
| | - James R Hargreaves
- Department of Social and Environmental Health Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Frances M Cowan
- Centre for Sexual Health, HIV/AIDS Research Zimbabwe, Harare, Zimbabwe.,Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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Inzaule SC, Jordan MR, Cournil A, Vitoria M, Ravasi G, Cham F, Le LV, Dzangare J, Hamunime N, Mutenda N, Aghokeng A, Bissek A, Billong S, Kaleebu P, Doherty M, Bertagnolio S. Increasing levels of pretreatment HIV drug resistance and safety concerns for dolutegravir use in women of reproductive age. AIDS 2019; 33:1797-1799. [PMID: 31149946 DOI: 10.1097/qad.0000000000002277] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
: Use of dolutegravir-based first-line antiretroviral therapy (ART) in response to rising levels of pretreatment HIV drug resistance (PDR) to non-nucleoside reverse transcriptase inhibitors (NNRTIs) may be limited, given safety concerns for birth defects in women of child-bearing potential. Pooled data from 11 nationally representative surveys show that NNRTI PDR in women is nearly twice that in men, exceeding 10% in 8 of 11 countries monitored, suggesting the urgent need for a non-NNRTI-based ART regimen in this population.
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Affiliation(s)
- Seth Chekata Inzaule
- Department of HIV and Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
| | | | - Amandine Cournil
- U1058 lab, INSERM, University of Montpellier, Montpellier, France
| | - Marco Vitoria
- Department of HIV and Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
| | | | - Fatim Cham
- World Health Organization, Regional Office for Africa, Brazzaville, Congo
| | - Linh-Vi Le
- World Health Organization, Regional Office for the Western Pacific, Manila, Philippines
| | - Janet Dzangare
- AIDS & TB Unit, Ministry of Health and Child Care, Harare
| | - Ndapewa Hamunime
- Directorate of Special Programes for HIV, TB, and Malaria, Ministry of Health and Social Services, Windhoek, Namibia
| | - Nicholus Mutenda
- Directorate of Special Programes for HIV, TB, and Malaria, Ministry of Health and Social Services, Windhoek, Namibia
| | - Avelin Aghokeng
- Centre de Recherche sur les Maladies Emergentes et Reemergentes (CREMER), Virology laboratory IMPM-IRD, IMPM, Yaoundé, Cameroon and Institut de Recherche pour le Développement (IRD) UMI 233, INSERM U1175, Université de Montpellier, Montpellier, France
| | - Annez Bissek
- Health Operational Research, Ministry of Public Heath, Cameroon
| | | | - Pontiano Kaleebu
- Uganda Virus Research Institute and MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Meg Doherty
- Department of HIV and Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
| | - Silvia Bertagnolio
- Department of HIV and Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
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Abstract
Approximately 20% of people with HIV in the United States prescribed antiretroviral therapy are not virally suppressed. Thus, optimal management of virologic failure has a critical role in the ability to improve viral suppression rates to improve long-term health outcomes for those infected and to achieve epidemic control. This article discusses the causes of virologic failure, the use of resistance testing to guide management after failure, interpretation and relevance of HIV drug resistance patterns, considerations for selection of second-line and salvage therapies, and management of virologic failure in special populations.
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Affiliation(s)
- Suzanne M McCluskey
- Division of Infectious Diseases, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, GRJ5, Boston, MA 02114, USA.
| | - Mark J Siedner
- Division of Infectious Diseases, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, GRJ5, Boston, MA 02114, USA
| | - Vincent C Marconi
- Division of Infectious Diseases, Department of Global Health, Emory University School of Medicine, Rollins School of Public Health, Health Sciences Research Building, 1760 Haygood Dr NE, Room W325, Atlanta, GA 30322, USA
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40
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Venter WDF, Moorhouse M, Sokhela S, Fairlie L, Mashabane N, Masenya M, Serenata C, Akpomiemie G, Qavi A, Chandiwana N, Norris S, Chersich M, Clayden P, Abrams E, Arulappan N, Vos A, McCann K, Simmons B, Hill A. Dolutegravir plus Two Different Prodrugs of Tenofovir to Treat HIV. N Engl J Med 2019; 381:803-815. [PMID: 31339677 DOI: 10.1056/nejmoa1902824] [Citation(s) in RCA: 416] [Impact Index Per Article: 83.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Two drugs under consideration for inclusion in antiretroviral therapy (ART) regimens for human immunodeficiency virus (HIV) infection are dolutegravir (DTG) and tenofovir alafenamide fumarate (TAF). There are limited data on their use in low- and middle-income countries. METHODS We conducted a 96-week, phase 3, investigator-led, open-label, randomized trial in South Africa, in which we compared a triple-therapy combination of emtricitabine (FTC) and DTG plus either of two tenofovir prodrugs - TAF (TAF-based group) or tenofovir disoproxil fumarate (TDF) (TDF-based group) - against the local standard-of-care regimen of TDF-FTC-efavirenz (standard-care group). Inclusion criteria included an age of 12 years or older, no receipt of ART in the previous 6 months, a creatinine clearance of more than 60 ml per minute (>80 ml per minute in patients younger than 19 years of age), and an HIV type 1 (HIV-1) RNA level of 500 copies or more per milliliter. The primary end point was the percentage of patients with a 48-week HIV-1 RNA level of less than 50 copies per milliliter (as determined with the Snapshot algorithm from the Food and Drug Administration; noninferiority margin, -10 percentage points). We report the primary (48-week) efficacy and safety data. RESULTS A total of 1053 patients underwent randomization from February 2017 through May 2018. More than 99% of the patients were black, and 59% were female. The mean age was 32 years, and the mean CD4 count was 337 cells per cubic millimeter. At week 48, the percentage of patients with an HIV-1 RNA level of less than 50 copies per milliliter was 84% in the TAF-based group, 85% in the TDF-based group, and 79% in the standard-care group, findings that indicate that the DTG-containing regimens were noninferior to the standard-care regimen. The number of patients who discontinued the trial regimen was higher in the standard-care group than in the other two groups. In the per-protocol population, the standard-care regimen had equivalent potency to the other two regimens. The TAF-based regimen had less effect on bone density and renal function than the other regimens. Weight increase (both lean and fat mass) was greatest in the TAF-based group and among female patients (mean increase, 6.4 kg in the TAF-based group, 3.2 kg in the TDF-based group, and 1.7 kg in the standard-care group). No resistance to integrase inhibitors was identified in patients receiving the DTG-containing regimens. CONCLUSIONS Treatment with DTG combined with either of two tenofovir prodrugs (TAF and TDF) showed noninferior efficacy to treatment with the standard-care regimen. There was significantly more weight gain with the DTG-containing regimens, especially in combination with TAF, than with the standard-care regimen. (ADVANCE ClinicalTrials.gov number, NCT03122262.).
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Affiliation(s)
- Willem D F Venter
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Michelle Moorhouse
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Simiso Sokhela
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Lee Fairlie
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Nkuli Mashabane
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Masebole Masenya
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Celicia Serenata
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Godspower Akpomiemie
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Ambar Qavi
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Nomathemba Chandiwana
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Shane Norris
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Matthew Chersich
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Polly Clayden
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Elaine Abrams
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Natasha Arulappan
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Alinda Vos
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Kaitlyn McCann
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Bryony Simmons
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Andrew Hill
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
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Shroufi A, Van Cutsem G, Cambiano V, Bansi-Matharu L, Duncan K, Murphy RA, Maman D, Phillips A. Simplifying switch to second-line antiretroviral therapy in sub Saharan Africa: predicted effect of using a single viral load to define efavirenz-based first-line failure. AIDS 2019; 33:1635-1644. [PMID: 31305331 PMCID: PMC6641111 DOI: 10.1097/qad.0000000000002234] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background: Many individuals failing first-line antiretroviral therapy (ART) in sub-Saharan Africa never initiate second-line ART or do so after significant delay. For people on ART with a viral load more than 1000 copies/ml, the WHO recommends a second viral load measurement 3 months after the first viral load and enhanced adherence support. Switch to a second-line regimen is contingent upon a persistently elevated viral load more than 1000 copies/ml. Delayed second-line switch places patients at increased risk for opportunistic infections and mortality. Methods: To assess the potential benefits of a simplified second-line ART switch strategy, we use an individual-based model of HIV transmission, progression and the effect of ART which incorporates consideration of adherence and drug resistance, to compare predicted outcomes of two policies, defining first-line regimen failure for patients on efavirenz-based ART as either two consecutive viral load values more than 1000 copies/ml, with the second after an enhanced adherence intervention (implemented as per current WHO guidelines) or a single viral load value more than 1000 copies/ml. We simulated a range of setting-scenarios reflecting the breadth of the sub-Saharan African HIV epidemic, taking into account potential delays in defining failure and switch to second-line ART. Findings: The use of a single viral load more than 1000 copies/ml to define ART failure would lead to a higher proportion of persons with nonnucleoside reverse-transcriptase inhibitor resistance switched to second-line ART [65 vs. 48%; difference 17% (90% range 14–20%)], resulting in a median 18% reduction in the rate of AIDS-related death over setting scenarios (90% range 6–30%; from a median of 3.1 to 2.5 per 100 person-years) over 3 years. The simplified strategy also is predicted to reduce the rate of AIDS conditions by a median of 31% (90% range 8–49%) among people on first-line ART with a viral load more than 1000 copies/ml in the past 6 months. For a country of 10 million adults (and a median of 880 000 people with HIV), we estimate that this approach would lead to a median of 1322 (90% range 67–3513) AIDS deaths averted per year over 3 years. For South Africa this would represent around 10 215 deaths averted annually. Interpretation: As a step towards reducing unnecessary mortality associated with delayed second-line ART switch, defining failure of first-line efavirenz-based regimens as a single viral load more than 1000 copies/ml should be considered.
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Abbas UL, Glaubius RL, Ding Y, Hood G. Drug resistance from preferred antiretroviral regimens for HIV infection in South Africa: A modeling study. PLoS One 2019; 14:e0218649. [PMID: 31269034 PMCID: PMC6609148 DOI: 10.1371/journal.pone.0218649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 06/06/2019] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Tenofovir-containing regimens comprise the preferred first-line antiretroviral therapy (ART) in many countries including South Africa, where utilization of second-line regimens is limited. Considerable HIV drug resistance has occurred among persons failing tenofovir-containing first-line ART. We evaluated drug resistance at the population level using mathematical modeling. SETTING Heterosexual HIV epidemic in KwaZulu-Natal, South Africa. METHODS We constructed a stochastic individual-based model and simulated scenarios of ART implementation, either CD4-based (threshold < 500 cells/mL) or Fast-track (81% coverage by 2020), with consideration of major drug-associated mutations (M184V, K65R and non-nucleoside reverse transcriptase inhibitor (NNRTI)). Using base case and uncertainty analyses, we assessed (majority) drug resistance levels. RESULTS By 2030, the median total resistance (proportion of HIV-infected persons with drug resistance) is predicted to reach 31.4% (interquartile range (IQR): 16.5%-50.2%) with CD4-based ART, decreasing to 14.5% (IQR: 7.7%-25.8%) with Fast-track implementation. In both scenarios, we find comparably high prevalence (~80%) of acquired NNRTI-associated, M184V and K65R mutations. Over 48% of individuals with acquired resistance harbor dual, 44% triple and 7% just single drug mutations. Drug-resistant HIV is predicted to comprise 40% (IQR: 27%-50%) of incident infections, while 70% of prevalent transmitted resistance is NNRTI-associated. At 2018, the projected total resistance is 15% (IQR: 7.5%-25%), with 18% (IQR: 13%-24%) of incident infections from transmitted drug-resistant HIV. CONCLUSIONS WHO-recommended preferred first-line ART could lead to substantial drug resistance. Effective surveillance of HIV drug resistance and utilization of second-line as well as alternative first-line regimens is crucial.
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Affiliation(s)
- Ume L. Abbas
- Department of Medicine, Section of Infectious Diseases and Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas, United States of America
- Departments of Quantitative Health Sciences and Infectious Disease, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Robert L. Glaubius
- Departments of Quantitative Health Sciences and Infectious Disease, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Yajun Ding
- Department of Medicine, Section of Infectious Diseases and Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas, United States of America
| | - Gregory Hood
- Pittsburgh Supercomputing Center, Carnegie Mellon University, Pittsburgh, Pennsylvania, United States of America
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Point-of-Care HIV Viral Load Testing: an Essential Tool for a Sustainable Global HIV/AIDS Response. Clin Microbiol Rev 2019; 32:32/3/e00097-18. [PMID: 31092508 DOI: 10.1128/cmr.00097-18] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The global public health community has set ambitious treatment targets to end the HIV/AIDS pandemic. With the notable absence of a cure, the goal of HIV treatment is to achieve sustained suppression of an HIV viral load, which allows for immunological recovery and reduces the risk of onward HIV transmission. Monitoring HIV viral load in people living with HIV is therefore central to maintaining effective individual antiretroviral therapy as well as monitoring progress toward achieving population targets for viral suppression. The capacity for laboratory-based HIV viral load testing has increased rapidly in low- and middle-income countries, but implementation of universal viral load monitoring is still hindered by several barriers and delays. New devices for point-of-care HIV viral load testing may be used near patients to improve HIV management by reducing the turnaround time for clinical test results. The implementation of near-patient testing using these new and emerging technologies may be an essential tool for ensuring a sustainable response that will ultimately enable an end to the HIV/AIDS pandemic. In this report, we review the current and emerging technology, the evidence for decentralized viral load monitoring by non-laboratory health care workers, and the additional considerations for expanding point-of-care HIV viral load testing.
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Ávila-Ríos S, García-Morales C, Valenzuela-Lara M, Chaillon A, Tapia-Trejo D, Pérez-García M, López-Sánchez DM, Maza-Sánchez L, del Arenal-Sánchez SJ, Paz-Juárez HE, Quiroz-Morales VS, Mehta SR, Smith DM, León-Juárez EA, Magis-Rodríguez C, Reyes-Terán G. HIV-1 drug resistance before initiation or re-initiation of first-line ART in eight regions of Mexico: a sub-nationally representative survey. J Antimicrob Chemother 2019; 74:1044-1055. [PMID: 30597094 PMCID: PMC7939069 DOI: 10.1093/jac/dky512] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 10/30/2018] [Accepted: 11/12/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND HIV pretreatment drug resistance (PDR) to NNRTIs in persons initiating ART is increasing in Mexico. OBJECTIVES To compare HIV PDR in eight sub-regions of Mexico. PATIENTS AND METHODS A large PDR survey was implemented in Mexico (September 2017-March 2018) across eight sub-regions. All larger clinics (which provide ART to 90% of all initiators) were included, allocating sample size using the probability-proportional-to-size method. Both antiretroviral-naive and prior antiretroviral-exposed persons were included. HIV PDR levels were estimated from pol Sanger sequences obtained at a WHO-designated laboratory. RESULTS A total of 2006 participants were enrolled from 74 clinics. PDR to NNRTIs was higher than to other drug classes (P < 0.0001), crossing the 10% threshold in the North-East, East, South-West and South-East. NNRTI PDR was higher in the South-West (P = 0.02), coinciding with the highest proportion of restarters in this sub-region (14%). We observed higher PDR prevalence to any drug in women compared with men (16.5% versus 12.2%, P = 0.04). After multivariable adjustment, higher NNRTI PDR remained significantly associated with previous antiretroviral exposure in the Centre-North, North-West, South-West and South-East [adjusted OR (aOR): 21, 5, 8 and 25, respectively; P < 0.05]. Genetic network analyses showed high assortativity by sub-region (P < 0.0001), with evidence of drug resistance mutation transmission within local clusters. CONCLUSIONS Diversification of the public health response to HIV drug resistance based on sub-regional characteristics could be considered in Mexico. Higher NNRTI PDR levels were associated with poorer regions, suggesting opportunities to strengthen local HIV programmes. Price and licensing negotiations of drug regimens containing integrase inhibitors are warranted.
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Affiliation(s)
- Santiago Ávila-Ríos
- Centre for Research in Infectious Diseases, National Institute of Respiratory Diseases, Calzada de Tlalpan 4502, Colonia Sección XVI, CP, Mexico City, Mexico
| | - Claudia García-Morales
- Centre for Research in Infectious Diseases, National Institute of Respiratory Diseases, Calzada de Tlalpan 4502, Colonia Sección XVI, CP, Mexico City, Mexico
| | - Marisol Valenzuela-Lara
- National Centre for HIV/AIDS Prevention and Control (CENSIDA), Av. Marina Nacional 60, piso 8, Colonia Tacuba, CP, Mexico City, Mexico
| | - Antoine Chaillon
- University of California San Diego, 9500 Gilman Drive 0679, La Jolla, CA, USA
| | - Daniela Tapia-Trejo
- Centre for Research in Infectious Diseases, National Institute of Respiratory Diseases, Calzada de Tlalpan 4502, Colonia Sección XVI, CP, Mexico City, Mexico
| | - Marissa Pérez-García
- Centre for Research in Infectious Diseases, National Institute of Respiratory Diseases, Calzada de Tlalpan 4502, Colonia Sección XVI, CP, Mexico City, Mexico
| | - Dulce M López-Sánchez
- Centre for Research in Infectious Diseases, National Institute of Respiratory Diseases, Calzada de Tlalpan 4502, Colonia Sección XVI, CP, Mexico City, Mexico
| | - Liliana Maza-Sánchez
- Centre for Research in Infectious Diseases, National Institute of Respiratory Diseases, Calzada de Tlalpan 4502, Colonia Sección XVI, CP, Mexico City, Mexico
| | - Silvia J del Arenal-Sánchez
- Centre for Research in Infectious Diseases, National Institute of Respiratory Diseases, Calzada de Tlalpan 4502, Colonia Sección XVI, CP, Mexico City, Mexico
| | - Héctor E Paz-Juárez
- Centre for Research in Infectious Diseases, National Institute of Respiratory Diseases, Calzada de Tlalpan 4502, Colonia Sección XVI, CP, Mexico City, Mexico
| | - Verónica S Quiroz-Morales
- Centre for Research in Infectious Diseases, National Institute of Respiratory Diseases, Calzada de Tlalpan 4502, Colonia Sección XVI, CP, Mexico City, Mexico
| | - Sanjay R Mehta
- University of California San Diego, 9500 Gilman Drive 0679, La Jolla, CA, USA
| | - David M Smith
- University of California San Diego, 9500 Gilman Drive 0679, La Jolla, CA, USA
| | - Eddie A León-Juárez
- National Centre for HIV/AIDS Prevention and Control (CENSIDA), Av. Marina Nacional 60, piso 8, Colonia Tacuba, CP, Mexico City, Mexico
| | - Carlos Magis-Rodríguez
- National Centre for HIV/AIDS Prevention and Control (CENSIDA), Av. Marina Nacional 60, piso 8, Colonia Tacuba, CP, Mexico City, Mexico
| | - Gustavo Reyes-Terán
- Centre for Research in Infectious Diseases, National Institute of Respiratory Diseases, Calzada de Tlalpan 4502, Colonia Sección XVI, CP, Mexico City, Mexico
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Cambiano V, Johnson CC, Hatzold K, Terris‐Prestholt F, Maheswaran H, Thirumurthy H, Figueroa C, Cowan FM, Sibanda EL, Ncube G, Revill P, Baggaley RC, Corbett EL, Phillips A. The impact and cost-effectiveness of community-based HIV self-testing in sub-Saharan Africa: a health economic and modelling analysis. J Int AIDS Soc 2019; 22 Suppl 1:e25243. [PMID: 30907498 PMCID: PMC6432108 DOI: 10.1002/jia2.25243] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 01/18/2019] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION The prevalence of undiagnosed HIV is declining in Africa, and various HIV testing approaches are finding lower positivity rates. In this context, the epidemiological impact and cost-effectiveness of community-based HIV self-testing (CB-HIVST) is unclear. We aimed to assess this in different sub-populations and across scenarios characterized by different adult HIV prevalence and antiretroviral treatment programmes in sub-Saharan Africa. METHODS The synthesis model was used to address this aim. Three sub-populations were considered for CB-HIVST: (i) women having transactional sex (WTS); (ii) young people (15 to 24 years); and (iii) adult men (25 to 49 years). We assumed uptake of CB-HIVST similar to that reported in epidemiological studies (base case), or assumed people use CB-HIVST only if exposed to risk (condomless sex) since last HIV test. We also considered a five-year time-limited CB-HIVST programme. Cost-effectiveness was defined by an incremental cost-effectiveness ratio (ICER; cost-per-disability-adjusted life-year (DALY) averted) below US$500 over a time horizon of 50 years. The efficiency of targeted CB-HIVST was evaluated using the number of additional tests per infection or death averted. RESULTS In the base case, targeting adult men with CB-HIVST offered the greatest impact, averting 1500 HIV infections and 520 deaths per year in the context of a simulated country with nine million adults, and impact could be enhanced by linkage to voluntary medical male circumcision (VMMC). However, the approach was only cost-effective if the programme was limited to five years or the undiagnosed prevalence was above 3%. CB-HIVST to WTS was the most cost-effective. The main drivers of cost-effectiveness were the cost of CB-HIVST and the prevalence of undiagnosed HIV. All other CB-HIVST scenarios had an ICER above US$500 per DALY averted. CONCLUSIONS CB-HIVST showed an important epidemiological impact. To maximize population health within a fixed budget, CB-HIVST needs to be targeted on the basis of the prevalence of undiagnosed HIV, sub-population and the overall costs of delivering this testing modality. Linkage to VMMC enhances its cost-effectiveness.
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Affiliation(s)
- Valentina Cambiano
- Institute for Global HealthUniversity College LondonLondonUnited Kingdom
| | | | | | - Fern Terris‐Prestholt
- Department of Global Health and DevelopmentLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Hendy Maheswaran
- Institute of Psychology, Health and SocietyUniversity of LiverpoolLiverpoolUnited Kingdom
| | - Harsha Thirumurthy
- Department of Medical Ethics and Health PolicyPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | | | - Frances M Cowan
- Centre for Sexual Health and HIV AIDS Research (CeSHHAR)HarareZimbabwe
- Liverpool School of Tropical MedicineLiverpoolUnited Kingdom
| | - Euphemia L Sibanda
- Centre for Sexual Health and HIV AIDS Research (CeSHHAR)HarareZimbabwe
- Liverpool School of Tropical MedicineLiverpoolUnited Kingdom
| | - Getrude Ncube
- Zimbabwe Ministry of Health and Child CareHarareZimbabwe
| | - Paul Revill
- Centre for Health EconomicsUniversity of YorkYorkUnited Kingdom
| | | | - Elizabeth L Corbett
- Malawi–Liverpool–Wellcome Trust Clinical Research ProgrammeBlantyreMalawi
- Department of Clinical ResearchLondon School of Hygiene& Tropical MedicineLondonUnited Kingdom
| | - Andrew Phillips
- Institute for Global HealthUniversity College LondonLondonUnited Kingdom
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Chimukangara B, Lessells RJ, Rhee SY, Giandhari J, Kharsany AB, Naidoo K, Lewis L, Cawood C, Khanyile D, Ayalew KA, Diallo K, Samuel R, Hunt G, Vandormael A, Stray-Pedersen B, Gordon M, Makadzange T, Kiepiela P, Ramjee G, Ledwaba J, Kalimashe M, Morris L, Parikh UM, Mellors JW, Shafer RW, Katzenstein D, Moodley P, Gupta RK, Pillay D, Abdool Karim SS, de Oliveira T. Trends in Pretreatment HIV-1 Drug Resistance in Antiretroviral Therapy-naive Adults in South Africa, 2000-2016: A Pooled Sequence Analysis. EClinicalMedicine 2019; 9:26-34. [PMID: 31143879 PMCID: PMC6510720 DOI: 10.1016/j.eclinm.2019.03.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 03/01/2019] [Accepted: 03/05/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND South Africa has the largest public antiretroviral therapy (ART) programme in the world. We assessed temporal trends in pretreatment HIV-1 drug resistance (PDR) in ART-naïve adults from South Africa. METHODS We included datasets from studies conducted between 2000 and 2016, with HIV-1 pol sequences from more than ten ART-naïve adults. We analysed sequences for the presence of 101 drug resistance mutations. We pooled sequences by sampling year and performed a sequence-level analysis using a generalized linear mixed model, including the dataset as a random effect. FINDINGS We identified 38 datasets, and retrieved 6880 HIV-1 pol sequences for analysis. The pooled annual prevalence of PDR remained below 5% until 2009, then increased to a peak of 11·9% (95% confidence interval (CI) 9·2-15·0) in 2015. The pooled annual prevalence of non-nucleoside reverse-transcriptase inhibitor (NNRTI) PDR remained below 5% until 2011, then increased to 10.0% (95% CI 8.4-11.8) by 2014. Between 2000 and 2016, there was a 1.18-fold (95% CI 1.13-1.23) annual increase in NNRTI PDR (p < 0.001), and a 1.10-fold (95% CI 1.05-1.16) annual increase in nucleoside reverse-transcriptase inhibitor PDR (p = 0.001). INTERPRETATION Increasing PDR in South Africa presents a threat to the efforts to end the HIV/AIDS epidemic. These findings support the recent decision to modify the standard first-line ART regimen, but also highlights the need for broader public health action to prevent the further emergence and transmission of drug-resistant HIV. SOURCE OF FUNDING This research project was funded by the South African Medical Research Council (MRC) with funds from National Treasury under its Economic Competitiveness and Support Package. DISCLAIMER The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of CDC.
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Affiliation(s)
- Benjamin Chimukangara
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), Department of Laboratory Medicine & Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Department of Virology, National Health Laboratory Service, University of KwaZulu-Natal, Durban, South Africa
- Corresponding authors at: KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), Department of Laboratory Medicine & Medical Science, University of KwaZulu-Natal, 719 Umbilo Road, Durban 4001, South Africa.
| | - Richard J. Lessells
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), Department of Laboratory Medicine & Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Soo-Yon Rhee
- Department of Medicine, Stanford University, Stanford, CA, United States of America
| | - Jennifer Giandhari
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), Department of Laboratory Medicine & Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Ayesha B.M. Kharsany
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- South African Medical Research Council (SAMRC)-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Lara Lewis
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Cherie Cawood
- Epicentre AIDS Risk Management (Pty) Limited, PO Box 3484, Paarl, Cape Town, South Africa
| | - David Khanyile
- Epicentre AIDS Risk Management (Pty) Limited, PO Box 3484, Paarl, Cape Town, South Africa
| | | | - Karidia Diallo
- Centers for Disease Control and Prevention, Pretoria, South Africa
| | - Reshmi Samuel
- Department of Virology, National Health Laboratory Service, University of KwaZulu-Natal, Durban, South Africa
| | - Gillian Hunt
- Centre for HIV and STIs, National Institute for Communicable Diseases (NICD), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Alain Vandormael
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), Department of Laboratory Medicine & Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Babill Stray-Pedersen
- Institute of Clinical Medicine, University of Oslo, Oslo University Hospital, Oslo, Norway
| | - Michelle Gordon
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), Department of Laboratory Medicine & Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Tariro Makadzange
- Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard, Cambridge, MA, United States of America
| | - Photini Kiepiela
- HIV Prevention Research Unit, Medical Research Council, Durban, South Africa
| | - Gita Ramjee
- HIV Prevention Research Unit, Medical Research Council, Durban, South Africa
| | - Johanna Ledwaba
- Centre for HIV and STIs, National Institute for Communicable Diseases (NICD), Johannesburg, South Africa
| | - Monalisa Kalimashe
- Centre for HIV and STIs, National Institute for Communicable Diseases (NICD), Johannesburg, South Africa
| | - Lynn Morris
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Centre for HIV and STIs, National Institute for Communicable Diseases (NICD), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Urvi M. Parikh
- Department of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - John W. Mellors
- Department of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Robert W. Shafer
- Department of Medicine, Stanford University, Stanford, CA, United States of America
| | - David Katzenstein
- Department of Medicine, Stanford University, Stanford, CA, United States of America
| | - Pravi Moodley
- Department of Virology, National Health Laboratory Service, University of KwaZulu-Natal, Durban, South Africa
| | - Ravindra K. Gupta
- Department of Infection, University College London, United Kingdom of Great Britain and Northern Ireland
- Africa Health Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - Deenan Pillay
- Department of Infection, University College London, United Kingdom of Great Britain and Northern Ireland
- Africa Health Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - Salim S. Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Tulio de Oliveira
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), Department of Laboratory Medicine & Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Corresponding authors at: KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), Department of Laboratory Medicine & Medical Science, University of KwaZulu-Natal, 719 Umbilo Road, Durban 4001, South Africa.
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van der Galiën R, Ter Heine R, Greupink R, Schalkwijk SJ, van Herwaarden AE, Colbers A, Burger DM. Pharmacokinetics of HIV-Integrase Inhibitors During Pregnancy: Mechanisms, Clinical Implications and Knowledge Gaps. Clin Pharmacokinet 2019. [PMID: 29915921 DOI: 10.1007/s40262-018-0684-z/tables/4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2023]
Abstract
Prevention of mother-to-child transmission of HIV and optimal maternal treatment are the most important goals of antiretroviral therapy in pregnant women with HIV. These goals may be at risk due to possible reduced exposure during pregnancy caused by physiological changes. Limited information is available on the impact of these physiological changes. This is especially true for HIV-integrase inhibitors, a relatively new class of drugs, recommended first-line agents and hence used by a large proportion of HIV-infected patients. Therefore, the objective of this review is to provide a detailed overview of the pharmacokinetics of HIV-integrase inhibitors in pregnancy. Second, this review defines potential causes for the change in pharmacokinetics of HIV-integrase inhibitors during pregnancy. Despite increased clearance, for raltegravir 400 mg twice daily and dolutegravir 50 mg once daily, exposure during pregnancy seems adequate; however, for elvitegravir, the proposed minimal effective concentration is not reached during pregnancy. Lower exposure to these drugs may be caused by increased hormone levels and, subsequently, enhanced drug metabolism during pregnancy. The pharmacokinetics of bictegravir and cabotegravir, which are under development, have not yet been evaluated in pregnant women. New studies need to prospectively assess whether adequate exposure is reached in pregnant women using these new HIV-integrase inhibitors. To further optimize antiretroviral treatment in pregnant women, studies need to unravel the underlying mechanisms behind the changes in the pharmacokinetics of HIV-integrase inhibitors during pregnancy. More knowledge on altered pharmacokinetics during pregnancy and the underlying mechanisms contribute to the development of effective and safe antiretroviral therapy for HIV-infected pregnant women.
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Affiliation(s)
- Ruben van der Galiën
- Department of Pharmacy, Radboud Institute of Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Rob Ter Heine
- Department of Pharmacy, Radboud Institute of Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Rick Greupink
- Department of Pharmacology and Toxicology, Radboud Institute of Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Stein J Schalkwijk
- Department of Pharmacy, Radboud Institute of Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Department of Pharmacology and Toxicology, Radboud Institute of Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Antonius E van Herwaarden
- Department of Laboratory Medicine, Radboud Institute of Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Angela Colbers
- Department of Pharmacy, Radboud Institute of Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - David M Burger
- Department of Pharmacy, Radboud Institute of Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.
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48
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Rutstein SE, Chen JS, Nelson JAE, Phiri S, Miller WC, Hosseinipour MC. High rates of transmitted NNRTI resistance among persons with acute HIV infection in Malawi: implications for first-line dolutegravir scale-up. AIDS Res Ther 2019; 16:5. [PMID: 30795780 PMCID: PMC6385432 DOI: 10.1186/s12981-019-0220-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 02/07/2019] [Indexed: 11/10/2022] Open
Abstract
High rates of non-nucleoside reverse transcriptase inhibitors (NNRTI) resistance was a key consideration in the WHO policies transitioning first-line regimens to include integrase inhibitors (dolutegravir [DTG]). However, recent data suggests a relationship between DTG and neural tube defects among women exposed during conception, giving providers and policymakers pause regarding the planned regimen changes. We examined HIV drug resistance among a cohort of 46 acutely infected persons in Malawi. Our data demonstrates high levels of transmitted resistance, 11% using standard resistance surveillance mutations and 20% when additional NNRTI polymorphisms that may affect treatment response are included. High resistance rates in this treatment-naïve patient population reinforces the critical nature of DTG-based options in the context of public-health driven treatment programs.
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Affiliation(s)
- Sarah E. Rutstein
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, NC USA
| | - Jane S. Chen
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC USA
| | - Julie A. E. Nelson
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, NC USA
- Department of Microbiology and Immunology, University of North Carolina, Chapel Hill, NC USA
| | | | | | - Mina C. Hosseinipour
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, NC USA
- UNC Project, Lilongwe, Malawi
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49
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Phillips AN, Venter F, Havlir D, Pozniak A, Kuritzkes D, Wensing A, Lundgren JD, De Luca A, Pillay D, Mellors J, Cambiano V, Bansi-Matharu L, Nakagawa F, Kalua T, Jahn A, Apollo T, Mugurungi O, Clayden P, Gupta RK, Barnabas R, Revill P, Cohn J, Bertagnolio S, Calmy A. Risks and benefits of dolutegravir-based antiretroviral drug regimens in sub-Saharan Africa: a modelling study. Lancet HIV 2019; 6:e116-e127. [PMID: 30503325 PMCID: PMC6361866 DOI: 10.1016/s2352-3018(18)30317-5] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 10/15/2018] [Accepted: 10/24/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND The integrase inhibitor dolutegravir could have a major role in future antiretroviral therapy (ART) regimens in sub-Saharan Africa because of its high potency and barrier to resistance, good tolerability, and low cost, but there is uncertainty over appropriate policies for use relating to the potential for drug resistance spread and a possible increased risk of neural tube defects in infants if used in women at the time of conception. We used an existing individual-based model of HIV transmission, progression, and the effect of ART with the aim of informing policy makers on approaches to the use of dolutegravir that are likely to lead to the highest population health gains. METHODS We used an existing individual-based model of HIV transmission and progression in adults, which takes into account the effects of drug resistance and differential drug potency in determining viral suppression and clinical outcomes to compare predicted outcomes of alternative ART regimen policies. We calculated disability adjusted life-years (DALYs) for each policy, assuming that a woman having a child with a neural tube defect incurs an extra DALY per year for the remainder of the time horizon and accounting for mother-to-child transmission. We used a 20 year time horizon, a 3% discount rate, and a cost-effectiveness threshold of US$500 per DALY averted. FINDINGS The greatest number of DALYs is predicted to be averted with use of a policy in which tenofovir, lamivudine, and dolutegravir is used in all people on ART, including switching to tenofovir, lamivudine, and dolutegravir in those currently on ART, regardless of current viral load suppression and intention to have (more) children. This result was consistent in several sensitivity analyses. We predict that this policy would be cost-saving. INTERPRETATION Using a standard DALY framework to compare health outcomes from a public health perspective, the benefits of transition to tenofovir, lamivudine, and dolutegravir for all substantially outweighed the risks. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
| | - Francois Venter
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Diane Havlir
- University of California, San Francisco, CA, USA
| | - Anton Pozniak
- Chelsea and Westminster Hospital, London, UK; London School of Hygiene & Tropical Medicine, London, UK
| | - Daniel Kuritzkes
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Annemarie Wensing
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa; University Medical Center, Utrecht, Netherlands
| | - Jens D Lundgren
- Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Deenan Pillay
- Africa Health Research Institute, Mtubatuba, South Africa
| | | | | | | | | | | | - Andreas Jahn
- Ministry of Health, Lilongwe, Malawi; University of Washington, Seattle, WA, USA
| | | | | | | | | | | | | | - Jennifer Cohn
- Elizabeth Glaser Paediatric AIDS Foundation, Geneva, Switzerland
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50
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Mondi A, Cozzi‐Lepri A, Tavelli A, Rusconi S, Vichi F, Ceccherini‐Silberstein F, Calcagno A, De Luca A, Maggiolo F, Marchetti G, Antinori A, d'Arminio Monforte A. Effectiveness of dolutegravir-based regimens as either first-line or switch antiretroviral therapy: data from the Icona cohort. J Int AIDS Soc 2019; 22:e25227. [PMID: 30663278 PMCID: PMC6340053 DOI: 10.1002/jia2.25227] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 12/19/2018] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Concerns about dolutegravir (DTG) tolerability in the real-life setting have recently arisen. We aimed to estimate the risk of treatment discontinuation and virological failure of DTG-based regimens from a large cohort of HIV-infected individuals. METHODS We performed a multicentre, observational study including all antiretroviral therapy (ART)-naïve and virologically suppressed treatment-experienced (TE) patients from the Icona (Italian Cohort Naïve Antiretrovirals) cohort who started, for the first time, a DTG-based regimen from January 2015 to December 2017. We estimated the cumulative risk of DTG discontinuation regardless of the reason and for toxicity, and of virological failure using Kaplan-Meier curves. We used Cox regression model to investigate predictors of DTG discontinuation. RESULTS About 1679 individuals (932 ART-naïve, 747 TE) were included. The one- and two-year probabilities (95% CI) of DTG discontinuation were 6.7% (4.9 to 8.4) and 11.5% (8.7 to 14.3) for ART-naïve and 6.6% (4.6 to 8.6) and 7.6% (5.4 to 9.8) for TE subjects. In both ART-naïve and TE patients, discontinuations of DTG were mainly driven by toxicity with an estimated risk (95% CI) of 4.0% (2.6 to 5.4) and 2.5% (1.3 to 3.6) by one year and 5.6% (3.8 to 7.5) and 4.0% (2.4 to 5.6) by two years respectively. Neuropsychiatric events were the main reason for stopping DTG in both ART-naïve (2.1%) and TE (1.7%) patients. In ART-naïve, a concomitant AIDS diagnosis predicted the risk of discontinuing DTG for any reason (adjusted relative hazard (aRH) = 3.38, p = 0.001), whereas starting DTG in combination with abacavir (ABC) was associated with a higher risk of discontinuing because of toxicity (aRH = 3.30, p = 0.009). TE patients starting a DTG-based dual therapy compared to a triple therapy had a lower risk of discontinuation for any reason (adjusted hazard ratio (aHR) = 2.50, p = 0.037 for ABC-based triple-therapies, aHR = 3.56, p = 0.012 for tenofovir-based) and for toxicity (aHR = 5.26, p = 0.030 for ABC-based, aHR = 6.60, p = 0.024 for tenofovir-based). The one- and two-year probabilities (95% CI) of virological failure were 1.2% (0.3 to 2.0) and 4.6% (2.7 to 6.5) in the ART naïve group and 2.2% (1.0 to 3.3) and 2.9% (1.5 to 4.3) in the TE group. CONCLUSIONS In this large cohort, DTG showed excellent efficacy and optimal tolerability both as first-line and switching ART. The low risk of treatment-limiting toxicities in ART-naïve as well as in treated individuals reassures on the use of DTG in everyday clinical practice.
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Affiliation(s)
- Annalisa Mondi
- HIV/AIDS DepartmentNational Institute for Infectious Diseases “Lazzaro Spallanzani” IRCCSRomeItaly
| | | | | | - Stefano Rusconi
- Infectious Diseases UnitASST FBF‐Sacco, DIBIC “L. Sacco”University of MilanMilanItaly
| | - Francesca Vichi
- Unit of Infectious DiseasesSanta Maria Annunziata HospitalFirenzeItaly
| | | | - Andrea Calcagno
- Unit of Infectious DiseasesDepartment of Medical SciencesAmedeo di Savoia HospitalUniversity of TorinoTurinItaly
| | | | | | - Giulia Marchetti
- Clinic of Infectious and Tropical DiseasesDepartment of Health SciencesASST Santi Paolo e CarloUniversity of MilanMilanItaly
| | - Andrea Antinori
- HIV/AIDS DepartmentNational Institute for Infectious Diseases “Lazzaro Spallanzani” IRCCSRomeItaly
| | - Antonella d'Arminio Monforte
- Clinic of Infectious and Tropical DiseasesDepartment of Health SciencesASST Santi Paolo e CarloUniversity of MilanMilanItaly
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