Integrase inhibitors in children and adolescents: clinical use and resistance

Early Effects of Scaling Up Dolutegravir-Based ARV Regimens Among Children Living with HIV in Malawi

Viral suppression (VS) in children has remained suboptimal compared to that in adults. We evaluated the impact of transitioning children weighing < 20 kg to a pediatric formulation of dolutegravir (pDTG) on VS in Malawi. We analyzed routine retrospective program data from electronic medical record systems pooled across 169 healthcare facilities in Malawi supported by the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF). We included children who weighed < 20 kg and received antiretroviral therapy (ART) between July 2021-June 2022. Using descriptive statistics, we summarized demographic and clinical characteristics, ART regimens, ART adherence, and VS. We used logistic regression to identify factors associated with post-transition VS. A total of 2468 Children Living with HIV (CLHIV) were included, 55.3% of whom were < 60 months old. Most (83.8%) had initiated on non-DTG-based ART; 71.0% of these had a viral load (VL) test result before transitioning to pDTG, and 62.5% had VS. Nearly all (99.9%) CLHIV transitioned to pDTG-based regimens. Six months after the transition, 52.7% had good ART adherence, and 38.6% had routine VL testing results; 81.7% achieved VS. Post-transition VS was associated with good adherence and pre-transition VS: adjusted odds ratios of 2.79 (95% CI 1.65-4.71), p < 0.001 and 5.32 (95% CI 3.23-9.48), p < 0.001, respectively. After transitioning to pDTG, VS was achieved in most children tested within the first 6 months. However, adherence remained suboptimal post-transition and VL testing at 6 months was limited. Interventions to improve VL testing and enhance ART adherence are still needed in CLHIV on pDTG-based regimens.

Effect of dolutegravir-based drug combinations on the level of medication adherence and viral load among adolescents living with HIV in resource-limited setting: a pre-post design

OBJECTIVES

The use of antiretroviral drugs among HIV-infected adolescents has been challenged with poor medication adherence, leading to an unsuppressed viral load and ultimately to drug resistance. Recently, dolutegravir has been approved for use in adolescents with HIV, but the evidence on medication adherence and viral load suppression is limited. The study determined the effect of dolutegravir-based drug regimens on the level of medication adherence and viral load among treatment-experienced adolescents.

METHODS

A longitudinal pre-post design study was done among adolescents living with HIV at a paediatrics clinic in Nigeria. Assessment of medication adherence and viral load testing was done before and at six months of transitioning to dolutegravir-based regimens. McNemar-chi-square was used to determine the effectiveness of the drug on adherence and viral load suppression. Multivariate logistic regression analysis was performed to determine the predictors of drug adherence and viral suppression.

RESULTS

The mean age of the participants was 14.7 years (SD=3.2), and 53.3 % were males. The mean duration of ART use was 10.3 years (SD=3.2). Six months after transitioning to dolutegravir, there was a significant decrease in viral load (Z=-7.947, p<0.001) and an increase in medication adherence score (Z=-7.554, p<0.001), among the treatment-experienced adolescents. Viral suppression was 13 times higher among respondents with good medication adherence as compared to those with poor medication adherence (AOR=13.24, CI=3.25-53.90).

CONCLUSIONS

Dolutegravir is effective in improving medication adherence and viral suppression among Adolescents living with HIV. Thus, the need to transition eligible adolescents to dolutegravir to sustain better treatment outcomes.

Drug resistance in children and adolescents with HIV in Panama

OBJECTIVES

The inadequacy of resistance monitoring in Latin America leads to circulation of HIV strains with drug resistance mutations (DRMs), compromising ART effectiveness. This study describes the DRM prevalence in HIV-infected paediatric patients in Panama.

METHODS

During 2018-19, plasma was collected from 76 HIV-infected children/adolescents (5 ART-naive, 71 treated) in Panama for HIV-1 DRM pol analysis, predicted antiretroviral (ARV) susceptibility by Stanford, and HIV-1 variant phylogenetic characterization.

RESULTS

HIV-1 pol sequences were recovered from 67 (88.2%) of 76 children/adolescents (median age 12 years), carrying 65 subtype B, 1 subtype G and 1 unique recombinant URF_A1B. Five were ART-naive and 62 ART-treated under virological failure (viraemia >50 copies/mL) with previous exposure to NRTIs, (100%), NNRTIs (45.2%), PIs (95.2%) and integrase strand transfer inhibitors (INSTIs, 17.7%). Among the treated patients, 34 (54.8%) carried resistant strains, with major DRMs to one (40.3%), two (9.7%) or three (4.8%) ARV families. Most of them harboured DRMs to NRTIs (58.5%) or NNRTIs (39%), but also major DRMs to PIs (4.9%) and INSTIs (6.5%). We also found dual-class NRTI + NNRTI (12.2%) and NNRTI + PI (2.6%) resistance. Two naive subjects carried viruses with DRMs to NRTIs and NRTI + NNRTI, respectively. Sequenced viruses presented high/intermediate resistance mainly to emtricitabine/lamivudine (48.9% each) and efavirenz/nevirapine (33.3% each). Most participants were susceptible to PIs (91.3%) and INSTIs (88.1%).

CONCLUSIONS

The high DRM prevalence to NRTIs and NNRTIs observed among treated HIV-infected children/adolescents in Panama justifies the need for routine resistance monitoring for optimal rescue therapy selection in this vulnerable population.