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Sivay MV, Maksimenko LV, Nalimova TM, Nefedova AA, Osipova IP, Kriklivaya NP, Gashnikova MP, Ekushov VE, Totmenin AV, Kapustin DV, Pozdnyakova LL, Skudarnov SE, Ostapova TS, Yaschenko SV, Nazarova OI, Shevchenko VV, Ilyina EA, Novikova OA, Agafonov AP, Gashnikova NM. HIV drug resistance among patients experiencing antiretroviral therapy failure in Russia, 2019-2021. Int J Antimicrob Agents 2024; 63:107074. [PMID: 38154660 DOI: 10.1016/j.ijantimicag.2023.107074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 11/15/2023] [Accepted: 12/20/2023] [Indexed: 12/30/2023]
Abstract
Increasing HIV drug resistance is an important public health concern. The current study aimed to assess HIV drug resistance among people who live with HIV (PLWH) experiencing virological failure. Blood samples and epidemiological characteristics were collected in four Siberian regions from PLWH experiencing ART failure. Partial pol gene sequences were obtained for the study individuals. Drug resistance mutations (DRMs) were predicted using the Stanford HIVdb Program. The association of HIV DRM with epidemiological characteristics was estimated using logistic regression analysis. Further analysis was performed for children (0-14 y old) and adults (≥15 y old) separately. In total, 815 (89.4%) patients were included in the final dataset. Overall, 501 (61.5%) patients had DRM detected. NRTI DRM was more common in children, while NRTI+NNRTI DRM was more frequent in adults (P < 0.001). Krasnoyarsk region, male sex and high viral load were positively associated with the presence of DRM in adults, while higher CD4 cell count and PI/INSTI-based ART had a negative association. No association between epidemiological characteristics and DRM was identified in children. The remaining 38.5% of patients with virological failure had no DRM detected; those patients were likely to have insufficient ART adherence. Most (55.5%) patients had HIV CRF63_02A6, followed by sub-subtype A6 (39.2%). This study revealed poor ART adherence as a main factor driving ART failure among PLWH in the Siberian region. DRM was detected in over 60% of PLWH experiencing ART failure. The current results highlight an urgent need for the introduction of special programs focusing on ART adherence improvement.
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Affiliation(s)
- Mariya V Sivay
- State Research Center of Virology and Biotechnology 'Vector', Novosibirsk region, Russia.
| | - Lada V Maksimenko
- State Research Center of Virology and Biotechnology 'Vector', Novosibirsk region, Russia
| | - Tatiana M Nalimova
- State Research Center of Virology and Biotechnology 'Vector', Novosibirsk region, Russia
| | - Anastasiya A Nefedova
- State Research Center of Virology and Biotechnology 'Vector', Novosibirsk region, Russia
| | - Irina P Osipova
- State Research Center of Virology and Biotechnology 'Vector', Novosibirsk region, Russia
| | - Nadezda P Kriklivaya
- State Research Center of Virology and Biotechnology 'Vector', Novosibirsk region, Russia
| | - Mariya P Gashnikova
- State Research Center of Virology and Biotechnology 'Vector', Novosibirsk region, Russia
| | - Vasiliy E Ekushov
- State Research Center of Virology and Biotechnology 'Vector', Novosibirsk region, Russia
| | - Alexei V Totmenin
- State Research Center of Virology and Biotechnology 'Vector', Novosibirsk region, Russia
| | | | | | - Sergey E Skudarnov
- Krasnoyarsk Regional Center for Prevention and Control of AIDS, Krasnoyarsk, Russia
| | - Tatyana S Ostapova
- Krasnoyarsk Regional Center for Prevention and Control of AIDS, Krasnoyarsk, Russia
| | - Svetlana V Yaschenko
- Krasnoyarsk Regional Center for Prevention and Control of AIDS, Krasnoyarsk, Russia
| | - Olga I Nazarova
- Omsk City Center for Prevention and Control of AIDS and Other Infectious Diseases, Omsk, Russia
| | - Valery V Shevchenko
- Altai Regional Center for Prevention and Control of AIDS and Other Infectious Diseases, Barnaul, Russia
| | - Elena A Ilyina
- Altai Regional Center for Prevention and Control of AIDS and Other Infectious Diseases, Barnaul, Russia
| | - Olga A Novikova
- Altai Regional Center for Prevention and Control of AIDS and Other Infectious Diseases, Barnaul, Russia
| | - Aleksander P Agafonov
- State Research Center of Virology and Biotechnology 'Vector', Novosibirsk region, Russia
| | - Natalya M Gashnikova
- State Research Center of Virology and Biotechnology 'Vector', Novosibirsk region, Russia
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Fokam J, Chenwi CA, Takou D, Santoro MM, Tala V, Teto G, Beloumou G, Semengue ENJ, Dambaya B, Djupsa S, Kembou E, Bouba NP, Ajeh R, Cappelli G, Mbanya D, Colizzi V, Ceccherini-Silberstein F, Perno CF, Ndjolo A. Laboratory Based Surveillance of HIV-1 Acquired Drug Resistance in Cameroon: Implications for Use of Tenofovir-Lamivudine-Dolutegravir (TLD) as Second- or Third-Line Regimens. Viruses 2023; 15:1683. [PMID: 37632026 PMCID: PMC10459610 DOI: 10.3390/v15081683] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 06/01/2023] [Accepted: 06/13/2023] [Indexed: 08/27/2023] Open
Abstract
Increased HIV drug resistance (HIVDR) with antiretroviral therapy (ART) rollout may jeopardize therapeutic options, especially in this era of transition to fixed-dose tenofovir-lamivudine-dolutegravir (TLD). We studied acquired HIVDR (ADR) patterns and describe potentially active drugs after first- and second-line failure in resource-limited settings (RLS) like Cameroon. A laboratory-based study with 759 patients (≥15 years) experiencing virological failure was carried out at the Chantal Biya International Reference Centre (CIRCB), Yaoundé, Cameroon. Socio-demographic, therapeutic and immunovirological data from patient records were analysed according to HIV-1 genotypic profiles. Median (IQR) ART-duration was 63 (50-308) months. Median CD4 and viremia were 153 (IQR:50-308) cells/mm3 and 138,666 (IQR:28,979-533,066) copies/mL, respectively. Overall ADR was high (93.4% first-line; 92.9%-second-line). TDF, potentially active in 35.7% of participants after first-line and 45.1% after second-line, suggested sub-optimal TLD-efficacy in second-line (64.3%) and third-line (54.9%). All PI/r preserved high efficacy after first-line failure while only DRV/r preserved high-level efficacy (87.9%) after second-line failure. In this resource-limited setting (RLS), ADR is high in ART-failing patients. PI/r strategies remain potent backbones for second-line ART, while only DRV/r remains very potent despite second-line failure. Though TLD use would be preferable, blind use for second- and third-line regimens may be sub-optimal (functional monotherapy with dolutegravir) with high risk of further failure, thus suggesting strategies for selective ART switch to TLD in failing patients in RLS.
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Affiliation(s)
- Joseph Fokam
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Messa, Yaoundé P.O. Box 3077, Cameroon; (D.T.)
- Faculty of Medicine and Biomedical Sciences (FMBS), University of Yaoundé I, Yaoundé P.O. Box 1364, Cameroon
- National HIV Drug Resistance Working Group (HIVDRWG), Ministry of Public Health, Yaoundé P.O. Box 3038, Cameroon
- Faculty of Health Sciences, University of Buea, Buea P.O. Box 063, Cameroon
| | - Collins Ambe Chenwi
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Messa, Yaoundé P.O. Box 3077, Cameroon; (D.T.)
- Faculty of Medicine and Biomedical Sciences (FMBS), University of Yaoundé I, Yaoundé P.O. Box 1364, Cameroon
- Department of Experimental Medicine, Faculty of Medicine and Surgery, University of Rome “Tor Vergata”, Via Montpellier 1, 00133 Rome, Italy
| | - Desire Takou
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Messa, Yaoundé P.O. Box 3077, Cameroon; (D.T.)
| | - Maria Mercedes Santoro
- Department of Experimental Medicine, Faculty of Medicine and Surgery, University of Rome “Tor Vergata”, Via Montpellier 1, 00133 Rome, Italy
| | - Valere Tala
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Messa, Yaoundé P.O. Box 3077, Cameroon; (D.T.)
- Faculty of Medicine and Biomedical Sciences (FMBS), University of Yaoundé I, Yaoundé P.O. Box 1364, Cameroon
| | - George Teto
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Messa, Yaoundé P.O. Box 3077, Cameroon; (D.T.)
| | - Grace Beloumou
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Messa, Yaoundé P.O. Box 3077, Cameroon; (D.T.)
| | - Ezechiel Ngoufack Jagni Semengue
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Messa, Yaoundé P.O. Box 3077, Cameroon; (D.T.)
- Department of Experimental Medicine, Faculty of Medicine and Surgery, University of Rome “Tor Vergata”, Via Montpellier 1, 00133 Rome, Italy
| | - Beatrice Dambaya
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Messa, Yaoundé P.O. Box 3077, Cameroon; (D.T.)
| | - Sandrine Djupsa
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Messa, Yaoundé P.O. Box 3077, Cameroon; (D.T.)
| | - Etienne Kembou
- World Health Organisation, Country Office, Yaoundé P.O. Box 155, Cameroon;
| | - Nounouce Pamen Bouba
- Department of Disease, Epidemic and Pandemic Control, Ministry of Public Health, Yaoundé P.O. Box 3038, Cameroon
| | - Rogers Ajeh
- Central Technical Group, National AIDS Control Committee, Yaoundé P.O. Box 2005, Cameroon
| | - Giulia Cappelli
- Italian National Research Council, P. le Aldo Moro, 7, 00185 Rome, Italy
| | - Dora Mbanya
- Faculty of Medicine and Biomedical Sciences (FMBS), University of Yaoundé I, Yaoundé P.O. Box 1364, Cameroon
- National Blood Transfusion Service, Ministry of Public Health, Yaoundé P.O. Box 3038, Cameroon
- Haematology and Transfusion Service, Centre Hospitalier et Universitaire (CHU), Yaounde-13, Yaoundé P.O Box 30335, Cameroon
| | - Vittorio Colizzi
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Messa, Yaoundé P.O. Box 3077, Cameroon; (D.T.)
- Department of Experimental Medicine, Faculty of Medicine and Surgery, University of Rome “Tor Vergata”, Via Montpellier 1, 00133 Rome, Italy
| | - Francesca Ceccherini-Silberstein
- Department of Experimental Medicine, Faculty of Medicine and Surgery, University of Rome “Tor Vergata”, Via Montpellier 1, 00133 Rome, Italy
| | - Carlo-Federico Perno
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Messa, Yaoundé P.O. Box 3077, Cameroon; (D.T.)
- Bambino Gesu’ Children’s Research Hospital, Piazza S. Onofrio 4, 00165 Rome, Italy
| | - Alexis Ndjolo
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Messa, Yaoundé P.O. Box 3077, Cameroon; (D.T.)
- Faculty of Medicine and Biomedical Sciences (FMBS), University of Yaoundé I, Yaoundé P.O. Box 1364, Cameroon
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Salata RA, Grinsztejn B, Ritz J, Collier AC, Hogg E, Gross R, Godfrey C, Kumarasamy N, Kanyama C, Mellors JW, Wallis CL, Hughes MD. Predictors of virologic outcome among people living with HIV who continue a protease inhibitor-based antiretroviral regimen following virologic failure with no or limited resistance. AIDS Res Ther 2023; 20:3. [PMID: 36604746 PMCID: PMC9814171 DOI: 10.1186/s12981-022-00494-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 12/19/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Treatment management after repeated failure of antiretroviral therapy (ART) is difficult due to resistance and adherence challenges. For people who have failed non-nucleoside reverse transcriptase inhibitor-(NNRTI-) and protease inhibitor-(PI-) based regimens with no or limited resistance, remaining on PI-based ART is an option. Using data from an ART strategy trial (A5288) in low/middle-income countries which included this option, we explored whether predictors can be identified distinguishing those who experienced further virologic failure from those who achieved and maintained virologic suppression. METHODS A5288 enrolled people with confirmed HIV-1 RNA ≥ 1000 copies/mL after ≥ 24 weeks of PI-based ART and prior failure on NNRTI-based ART. This analysis focused on the 278 participants with no resistance to the PI being taken and no or limited nucleoside reverse transcriptase inhibitor (NRTI) resistance, who continued their PI with flexibility to change NRTIs. Proportional hazards models were used to evaluate predictors of virologic failure during follow-up (VF: confirmed HIV-1 RNA ≥ 1000 copies/mL at ≥ 24 weeks of follow-up). RESULTS 56% of participants were female. At study entry, median age was 40 years, time on ART 7.8 years, CD4 count 169 cells/mm3, HIV-1 RNA 20,444 copies/mL; and 37% had NRTI resistance. The estimated proportion experiencing VF increased from 39% at week 24 to 60% at week 96. In multivariable analysis, significant predictors at study entry of VF were higher HIV-1 RNA (adjusted hazard ratio: 2.20 for ≥ 10,000 versus < 10,000 copies/mL), lower age (1.96 for < 30 versus ≥ 30 years), NRTI resistance (1.74 for present versus absent), lower CD4 count (1.73 for < 200 versus ≥ 200 cells/mm3), and shorter ART duration (1.62 for < 10 versus ≥ 10 years). There was a strong trend in proportion with VF at week 96 with the number of these five risk factors that a participant had, varying from 8% for zero, to 31%, 40%, 73%, and 100% for one, two, three, and four/five. Only 13% of participants developed new NRTI or PI resistance mutations. CONCLUSION A simple count of five predictors might have value for identifying risk of continued VF. Novel antiretroviral and adherence support interventions are needed to improve virologic outcomes for higher risk individuals.
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Affiliation(s)
- Robert A Salata
- Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH, 44122, USA.
| | - Beatriz Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas, Rio de Janeiro, Brazil
| | - Justin Ritz
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - Evelyn Hogg
- Social & Scientific Systems, A DLH Company, MD, Silver Spring, USA
| | - Robert Gross
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | | | - Cecilia Kanyama
- University of North Carolina Project-Malawi, Lilongwe, Malawi
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Scriven YA, Mulinge MM, Saleri N, Luvai EA, Nyachieo A, Maina EN, Mwau M. Prevalence and factors associated with HIV-1 drug resistance mutations in treatment-experienced patients in Nairobi, Kenya: A cross-sectional study. Medicine (Baltimore) 2021; 100:e27460. [PMID: 34622871 PMCID: PMC8500620 DOI: 10.1097/md.0000000000027460] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/20/2021] [Indexed: 01/05/2023] Open
Abstract
ABSTRACT An estimated 1.5 million Kenyans are HIV-seropositive, with 1.1 million on antiretroviral therapy (ART), with the majority of them unaware of their drug resistance status. In this study, we assessed the prevalence of drug resistance to nucleoside reverse transcriptase inhibitors (NRTIs), nucleoside reverse transcriptase inhibitors (NNRTIs), and protease inhibitors, and the variables associated with drug resistance in patients failing treatment in Nairobi, Kenya.This cross-sectional study utilized 128 HIV-positive plasma samples obtained from patients enrolled for routine viral monitoring in Nairobi clinics between 2015 and 2017. The primary outcome was human immunodeficiency virus type 1 (HIV-1) drug resistance mutation counts determined by Sanger sequencing of the polymerase (pol) gene followed by interpretation using Stanford's HIV Drug Resistance Database. Poisson regression was used to determine the effects of sex, viral load, age, HIV-subtype, treatment duration, and ART-regimen on the primary outcome.HIV-1 drug resistance mutations were found in 82.3% of the subjects, with 15.3% of subjects having triple-class ART resistance and 45.2% having dual-class resistance. NRTI primary mutations M184 V/I and K65R/E/N were found in 28.8% and 8.9% of subjects respectively, while NNRTI primary mutations K103N/S, G190A, and Y181C were found in 21.0%, 14.6%, and 10.9% of subjects. We found statistically significant evidence (P = .013) that the association between treatment duration and drug resistance mutations differed by sex. An increase of one natural-log transformed viral load unit was associated with 11% increase in drug resistance mutation counts (incidence rate ratio [IRR] 1.11; 95% CI 1.06-1.16; P < .001) after adjusting for age, HIV-1 subtype, and the sex-treatment duration interaction. Subjects who had been on treatment for 31 to 60 months had 63% higher resistance mutation counts (IRR 1.63; 95% CI 1.12-2.43; P = .013) compared to the reference group (<30 months). Similarly, patients on ART for 61 to 90 months were associated with 133% higher mutation counts than the reference group (IRR 2.33; 95% CI 1.59-3.49; P < .001). HIV-1 subtype, age, or ART-regimen were not associated with resistance mutation counts.Drug resistance mutations were found in alarmingly high numbers, and they were associated with viral load and treatment time. This finding emphasizes the importance of targeted resistance monitoring as a tool for addressing the problem.
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Affiliation(s)
- Yvonne A Scriven
- Centre for Infectious and Parasitic Diseases Control Research, Kenya Medical Research Institute, Busia, Kenya
| | - Martin M Mulinge
- Department of Biochemistry, School of Medicine, University of Nairobi, Nairobi, Kenya
- Kenya AIDS Vaccine Initiative - Institute of Clinical Research, University of Nairobi, Nairobi, Kenya
| | - Norah Saleri
- Centre for Infectious and Parasitic Diseases Control Research, Kenya Medical Research Institute, Busia, Kenya
| | - Elizabeth A Luvai
- Centre for Infectious and Parasitic Diseases Control Research, Kenya Medical Research Institute, Busia, Kenya
| | - Atunga Nyachieo
- Department of Biochemistry, School of Medicine, University of Nairobi, Nairobi, Kenya
| | - Esther N Maina
- Department of Biochemistry, School of Medicine, University of Nairobi, Nairobi, Kenya
| | - Matilu Mwau
- Centre for Infectious and Parasitic Diseases Control Research, Kenya Medical Research Institute, Busia, Kenya
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Obasa AE, Ambikan AT, Gupta S, Neogi U, Jacobs GB. Increased acquired protease inhibitor drug resistance mutations in minor HIV-1 quasispecies from infected patients suspected of failing on national second-line therapy in South Africa. BMC Infect Dis 2021; 21:214. [PMID: 33632139 PMCID: PMC7908688 DOI: 10.1186/s12879-021-05905-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 02/16/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND HIV-1C has been shown to have a greater risk of virological failure and reduced susceptibility towards boosted protease inhibitors (bPIs), a component of second-line combination antiretroviral therapy (cART) in South Africa. This study entailed an evaluation of HIV-1 drug resistance-associated mutations (RAMs) among minor viral populations through high-throughput sequencing genotypic resistance testing (HTS-GRT) in patients on the South African national second-line cART regimen receiving bPIs. METHODS During 2017 and 2018, 67 patient samples were sequenced using high-throughput sequencing (HTS), of which 56 samples were included in the final analysis because the patient's treatment regimen was available at the time of sampling. All patients were receiving bPIs as part of their cART. Viral RNA was extracted, and complete pol genes were amplified and sequenced using Illumina HiSeq2500, followed by bioinformatics analysis to quantify the RAMs according to the Stanford HIV Drug Resistance Database. RESULTS Statistically significantly higher PI RAMs were observed in minor viral quasispecies (25%; 14/56) compared to non-nucleoside reverse transcriptase inhibitors (9%; 5/56; p = 0.042) and integrase inhibitor RAM (4%; 2/56; p = 0.002). The majority of the drug resistance mutations in the minor viral quasispecies were observed in the V82A mutation (n = 13) in protease and K65R (n = 5), K103N (n = 7) and M184V (n = 5) in reverse transcriptase. CONCLUSIONS HTS-GRT improved the identification of PI and reverse transcriptase inhibitor (RTI) RAMs in second-line cART patients from South Africa compared to the conventional GRT with ≥20% used in Sanger-based sequencing. Several RTI RAMs, such as K65R, M184V or K103N and PI RAM V82A, were identified in < 20% of the population. Deep sequencing could be of greater value in detecting acquired resistance mutations early.
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Affiliation(s)
- Adetayo Emmanuel Obasa
- Department of Pathology, Division of Medical Virology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, Cape Town, 7505, South Africa.
- Department of Laboratory Medicine, Division of Clinical Microbiology, Karolinska Institute, Stockholm, Sweden.
| | - Anoop T Ambikan
- Department of Laboratory Medicine, Division of Clinical Microbiology, Karolinska Institute, Stockholm, Sweden
| | - Soham Gupta
- Department of Laboratory Medicine, Division of Clinical Microbiology, Karolinska Institute, Stockholm, Sweden
| | - Ujjwal Neogi
- Department of Laboratory Medicine, Division of Clinical Microbiology, Karolinska Institute, Stockholm, Sweden
| | - Graeme Brendon Jacobs
- Department of Pathology, Division of Medical Virology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, Cape Town, 7505, South Africa
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Ross J, Jiamsakul A, Kumarasamy N, Azwa I, Merati TP, Do CD, Lee MP, Ly PS, Yunihastuti E, Nguyen KV, Ditangco R, Ng OT, Choi JY, Oka S, Sohn AH, Law M. Virological failure and HIV drug resistance among adults living with HIV on second-line antiretroviral therapy in the Asia-Pacific. HIV Med 2020; 22:201-211. [PMID: 33151020 DOI: 10.1111/hiv.13006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/30/2020] [Accepted: 10/03/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To assess second-line antiretroviral therapy (ART) virological failure and HIV drug resistance-associated mutations (RAMs), in support of third-line regimen planning in Asia. METHODS Adults > 18 years of age on second-line ART for ≥ 6 months were eligible. Cross-sectional data on HIV viral load (VL) and genotypic resistance testing were collected or testing was conducted between July 2015 and May 2017 at 12 Asia-Pacific sites. Virological failure (VF) was defined as VL > 1000 copies/mL with a second VL > 1000 copies/mL within 3-6 months. FASTA files were submitted to Stanford University HIV Drug Resistance Database and RAMs were compared against the IAS-USA 2019 mutations list. VF risk factors were analysed using logistic regression. RESULTS Of 1378 patients, 74% were male and 70% acquired HIV through heterosexual exposure. At second-line switch, median [interquartile range (IQR)] age was 37 (32-42) years and median (IQR) CD4 count was 103 (43.5-229.5) cells/µL; 93% received regimens with boosted protease inhibitors (PIs). Median duration on second line was 3 years. Among 101 patients (7%) with VF, CD4 count > 200 cells/µL at switch [odds ratio (OR) = 0.36, 95% confidence interval (CI): 0.17-0.77 vs. CD4 ≤ 50) and HIV exposure through male-male sex (OR = 0.32, 95% CI: 0.17-0.64 vs. heterosexual) or injecting drug use (OR = 0.24, 95% CI: 0.12-0.49) were associated with reduced VF. Of 41 (41%) patients with resistance data, 80% had at least one RAM to nonnucleoside reverse transcriptase inhibitors (NNRTIs), 63% to NRTIs, and 35% to PIs. Of those with PI RAMs, 71% had two or more. CONCLUSIONS There were low proportions with VF and significant RAMs in our cohort, reflecting the durability of current second-line regimens.
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Affiliation(s)
- J Ross
- TREAT Asia/amfAR -The Foundation for AIDS Research, Bangkok, Thailand
| | - A Jiamsakul
- The Kirby Institute, UNSW Sydney, Kensington, NSW, Australia
| | - N Kumarasamy
- Chennai Antiviral Research and Treatment Clinical Research Site (CART CRS), VHS-Infectious Diseases Medical Centre, VHS, Chennai, India
| | - I Azwa
- Infectious Diseases Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - T P Merati
- Faculty of Medicine Udayana University & Sanglah Hospital, Bali, Indonesia
| | - C D Do
- Bach Mai Hospital, Hanoi, Vietnam
| | - M P Lee
- Queen Elizabeth Hospital, Hong Kong SAR, Hong Kong
| | - P S Ly
- National Center for HIV/AIDS, Dermatology & STDs, Phnom Penh, Cambodia
| | - E Yunihastuti
- Faculty of Medicine, Universitas Indonesia - Dr Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - K V Nguyen
- National Hospital for Tropical Diseases, Hanoi, Vietnam
| | - R Ditangco
- Research Institute for Tropical Medicine, Muntinlupa City, Philippines
| | - O T Ng
- Tan Tock Seng Hospital, Singapore, Singapore
| | - J Y Choi
- Division of Infectious Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - S Oka
- National Center for Global Health and Medicine, Tokyo, Japan
| | - A H Sohn
- TREAT Asia/amfAR -The Foundation for AIDS Research, Bangkok, Thailand
| | - M Law
- The Kirby Institute, UNSW Sydney, Kensington, NSW, Australia
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7
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Thompson JA, Kityo C, Dunn D, Hoppe A, Ndashimye E, Hakim J, Kambugu A, van Oosterhout JJ, Arribas J, Mugyenyi P, Walker AS, Paton NI. Evolution of Protease Inhibitor Resistance in Human Immunodeficiency Virus Type 1 Infected Patients Failing Protease Inhibitor Monotherapy as Second-line Therapy in Low-income Countries: An Observational Analysis Within the EARNEST Randomized Trial. Clin Infect Dis 2020; 68:1184-1192. [PMID: 30060027 DOI: 10.1093/cid/ciy589] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 07/24/2018] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Limited viral load (VL) testing in human immunodeficiency virus (HIV) treatment programs in low-income countries often delays detection of treatment failure. The impact of remaining on failing protease inhibitor (PI)-containing regimens is unclear. METHODS We retrospectively tested VL in 2164 stored plasma samples from 386 patients randomized to receive lopinavir monotherapy (after initial raltegravir induction) in the Europe-Africa Research Network for Evaluation of Second-line Therapy (EARNEST) trial. Protease genotypic resistance testing was performed when VL >1000 copies/mL. We assessed evolution of PI resistance mutations from virological failure (confirmed VL >1000 copies/mL) until PI monotherapy discontinuation and examined associations using mixed-effects models. RESULTS Median post-failure follow-up (in 118 patients) was 68 (interquartile range, 48-88) weeks. At failure, 20% had intermediate/high-level resistance to lopinavir. At 40-48 weeks post-failure, 68% and 51% had intermediate/high-level resistance to lopinavir and atazanavir; 17% had intermediate-level resistance (none high) to darunavir. Common PI mutations were M46I, I54V, and V82A. On average, 1.7 (95% confidence interval 1.5-2.0) PI mutations developed per year; increasing after the first mutation; decreasing with subsequent mutations (P < .0001). VL changes were modest, mainly driven by nonadherence (P = .006) and PI mutation development (P = .0002); I47A was associated with a larger increase in VL than other mutations (P = .05). CONCLUSIONS Most patients develop intermediate/high-level lopinavir resistance within 1 year of ongoing viral replication on monotherapy but retain susceptibility to darunavir. Viral load increased slowly after failure, driven by non-adherence and PI mutation development. CLINICAL TRIALS REGISTRATION NCT00988039.
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Affiliation(s)
- Jennifer A Thompson
- Medical Research Council Clinical Trials Unit at University College London, United Kingdom.,Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Cissy Kityo
- Joint Clinical Research Centre, Kampala, Uganda
| | - David Dunn
- Medical Research Council Clinical Trials Unit at University College London, United Kingdom
| | - Anne Hoppe
- Medical Research Council Clinical Trials Unit at University College London, United Kingdom.,Division of Infection and Immunity, University College London, United Kingdom
| | - Emmanuel Ndashimye
- Joint Clinical Research Centre, Kampala, Uganda.,Department of Microbiology and Immunology, University of Western Ontario, London, Ontario, Canada
| | - James Hakim
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | - Andrew Kambugu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Joep J van Oosterhout
- Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi.,Dignitas International, Zomba, Malawi
| | | | | | - A Sarah Walker
- Medical Research Council Clinical Trials Unit at University College London, United Kingdom
| | - Nicholas I Paton
- Medical Research Council Clinical Trials Unit at University College London, United Kingdom.,Yong Loo Lin School of Medicine, National University of Singapore
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Chimbetete C, Shamu T, Keiser O. Zimbabwe's national third-line antiretroviral therapy program: Cohort description and treatment outcomes. PLoS One 2020; 15:e0228601. [PMID: 32119663 PMCID: PMC7051055 DOI: 10.1371/journal.pone.0228601] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 01/18/2020] [Indexed: 12/17/2022] Open
Abstract
Background In 2015, Zimbabwe introduced third-line antiretroviral therapy (ART) through four designated treatment centers; three government clinics in Harare and Bulawayo, and Newlands Clinic (NC), operated by a private voluntary organization in Harare. We describe characteristics of patients receiving third line ART and analyzed treatment outcomes in this national programme as of 31 December 2018. Methods We described the population using proportions for categorical variables, and medians and interquartile ranges for continuous variables. Patients from NC, where data were more complete, were followed from the date of starting third-line ART until death, transfer, loss to follow up or 31 December 2018. Results A total of 209 patients had ever received third-line ART: 124 at NC and 85 from the three government clinics. HIV genotype results were available for 89 (72%) patients at NC and fourteen (16.5%) patients in the government clinics. Median duration of third line ART (years) in the government clinics was 2.3 (IQR:0.6–3.4), 1.3 (IQR: 0.7–1.7) and 1 (0.6–1.9). Of the 67 patients who received third line ART in the government clinics for at least six months, 53 (79%) had most recent viral load (VL) < 1000 copies/ml. Data on other treatment outcomes from government clinics were incomplete. From NC: a total of 109 (88%) patients were still in care, 13 (10.5%) had died and 2 (1.5%) were transferred. Median duration of third-line ART was 1.4 years (IQR: 0.6–2.8). Among the 111 NC patients who had received third-line ART for at least 6 months, 83 (75%) had a VL <50 copies/ml and 106 (95.5%) had a VL <1000 copies/ml. Conclusion Our findings demonstrate that, with comprehensive care, patients failing second-line ART can achieve high rates of virological suppression on third-line regimens. There is need to decentralize the provision of third-line ART in Zimbabwe. More needs to be done to improve completeness of data in the government clinics.
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Affiliation(s)
- Cleophas Chimbetete
- Newlands Clinic, Harare, Zimbabwe.,Institute of Global Health, University of Geneva, Geneva, Switzerland
| | | | - Olivia Keiser
- Institute of Global Health, University of Geneva, Geneva, Switzerland
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9
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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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10
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A Clinical Prediction Rule for Protease Inhibitor Resistance in Patients Failing Second-Line Antiretroviral Therapy. J Acquir Immune Defic Syndr 2019; 80:325-329. [PMID: 30531296 PMCID: PMC6802273 DOI: 10.1097/qai.0000000000001923] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Most adults with virological failure on second-line antiretroviral therapy (ART) in resource-limited settings have no major protease inhibitor (PI) resistance mutations. Therefore, empiric switches to third-line ART would waste resources. Genotypic antiretroviral resistance testing (GART) is expensive and has limited availability. A clinical prediction rule (CPR) for PI resistance could rationalize access to GART. SETTING A private sector ART cohort, South Africa. METHODS We identified adults with virologic failure on ritonavir-boosted lopinavir/atazanavir-based ART and GART. We constructed a multivariate logistic regression model including age, sex, PI duration, short-term adherence (using pharmacy claims), concomitant CYP3A4-inducing drugs, and viral load at time of GART. We selected variables for the CPR using a stepwise approach and internally validated the model by bootstrapping. RESULTS 148/339 (44%) patients had PI resistance (defined as ≥ 1 major resistance mutation to current PI). The median age was 42 years (interquartile range 36-48), 212 (63%) were females, 308 (91%) were on lopinavir/ritonavir, and median PI duration was 2.6 years (interquartile range 1.6-4.7). Variables associated with PI resistance and included in the CPR were age {adjusted odds ratio (aOR) 1.96 (95% confidence interval [CI]: 1.42 to 2.70) for 10-year increase}, PI duration (aOR 1.14 [95% CI: 1.03 to 1.26] per year), and adherence (aOR 1.22 [95% CI: 1.12 to 1.33] per 10% increase). The CPR model had a c-statistic of 0.738 (95% CI: 0.686 to 0.791). CONCLUSIONS Older patients with high adherence and prolonged PI exposure are most likely to benefit from GART to guide selection of a third-line ART regimen. Our CPR to select patients for GART requires external validation before implementation.
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11
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Eholie SP, Moh R, Benalycherif A, Gabillard D, Ello F, Messou E, Zoungrana J, Diallo I, Diallo M, Bado G, Cisse M, Maiga AI, Anzian A, Toni TD, Congo-Ouedraogo M, Toure-Kane C, Seydi M, Minta DK, Sawadogo A, Sangaré L, Drabo J, Karcher S, Le Carrou J, de Monteynard LA, Peytavin G, Gabassi A, Girard PM, Chaix ML, Anglaret X, Landman R. Implementation of an intensive adherence intervention in patients with second-line antiretroviral therapy failure in four west African countries with little access to genotypic resistance testing: a prospective cohort study. Lancet HIV 2019; 6:e750-e759. [PMID: 31601544 DOI: 10.1016/s2352-3018(19)30228-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 06/20/2019] [Accepted: 07/04/2019] [Indexed: 01/27/2023]
Abstract
BACKGROUND The decision about whether to switch to third-line antiretroviral therapy (ART) in patients with treatment failure on second-line therapy is difficult in settings with little access to genotypic resistance testing. In this study, we used a standardised algorithm including a wide range of adherence-enhancing interventions followed by a new viral load measurement to decide whether to switch to third-line therapy in this situation. The decision, made on the basis of effectiveness of the adherence reinforcement to drive viral resuppression, did not use genotypic resistance testing. METHODS In this prospective cohort study, adults in four west African countries with treatment failure of a boosted protease inhibitor ART regimen were offered nine adherence reinforcement interventions, and followed up for 64 weeks. We measured viral load at week 12 and used the results to decide ART treatment at week 16: if successful resuppression (plasma HIV-1 RNA <400 copies per mL or had decreased by ≥2 log10 copies per mL compared with baseline), patients continued the same second-line regimen; otherwise they switched to a third-line regimen based on ritonavir-boosted darunavir and raltegravir. The primary endpoint was virological success at week 64 (plasma HIV-1 RNA <50 copies per mL). After study termination we did genotypic resistance testing on frozen plasma samples collected at baseline, and retrospectively determined the appropriateness of the week 16 decision on the basis of the baseline genotypic susceptibility score. FINDINGS Between March 28, 2013, and May 11, 2015, of the 198 eligible participants, five died before week 16. Of the 193 remaining, 130 (67%) reached viral resuppression and continued with second-line ART, and 63 (33%) switched to third-line ART at week 16. Post-study genotypic resistance testing showed that the baseline genotypic susceptibility score was calculable in 166 patients, of whom 57 (34%) had a score less than 2. We retrospectively concluded that the week 16 decision was appropriate in 145 (75%) patients. At week 64, four patients (2%) were lost to follow-up, ten (5%) had died, and 101 (52%) had a viral load less than 50 copies per mL. INTERPRETATION Poor adherence is the first problem to tackle in patients for whom second-line ART is failing when resistance tests are not routinely available and is effectively a manageable problem. Lack of access to genotypic resistance testing should not be an obstacle to the prescription of third-line ART in patients who do not achieve viral resuppression after adherence reinforcement. FUNDING French Agency for Research on AIDS and Viral Hepatitis.
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Affiliation(s)
- Serge P Eholie
- Département de Dermatologie et d'Infectiologie, UFR des Sciences Médicales, Université Félix Houphouët Boigny, Abidjan, Cote d'Ivoire; Inserm 1219, University of Bordeaux, Bordeaux, France; Programme PACCI/ANRS Research Center, Abidjan, Cote d'Ivoire.
| | - Raoul Moh
- Département de Dermatologie et d'Infectiologie, UFR des Sciences Médicales, Université Félix Houphouët Boigny, Abidjan, Cote d'Ivoire; Inserm 1219, University of Bordeaux, Bordeaux, France; Programme PACCI/ANRS Research Center, Abidjan, Cote d'Ivoire
| | | | - Delphine Gabillard
- Inserm 1219, University of Bordeaux, Bordeaux, France; Programme PACCI/ANRS Research Center, Abidjan, Cote d'Ivoire
| | - Frédéric Ello
- Département de Dermatologie et d'Infectiologie, UFR des Sciences Médicales, Université Félix Houphouët Boigny, Abidjan, Cote d'Ivoire; Programme PACCI/ANRS Research Center, Abidjan, Cote d'Ivoire
| | - Eugène Messou
- Département de Dermatologie et d'Infectiologie, UFR des Sciences Médicales, Université Félix Houphouët Boigny, Abidjan, Cote d'Ivoire; Inserm 1219, University of Bordeaux, Bordeaux, France; Programme PACCI/ANRS Research Center, Abidjan, Cote d'Ivoire; Centre de Prise en charge, de Recherche et de Formation (CePReF), Abidjan, Côte d'Ivoire
| | | | - Ismaël Diallo
- Service de Médecine Interne, Hôpital de Jour, CHU Yalgado Ouedraogo, Ouagadougou, Burkina Faso
| | - Mouhamadou Diallo
- Centre Régional de Recherche et de Formation à la Prise en Charge Clinique (CRCF), Dakar, Senegal
| | - Guillaume Bado
- Unité de Virologie, CHU Sourô Sanou, Bobo-Dioulasso, Burkina Faso
| | - Mamadou Cisse
- Centre d'Ecoute, de Soins, d'Animation et de Conseils (CESAC), Bamako, Mali
| | | | - Amani Anzian
- Centre de Prise en charge, de Recherche et de Formation (CePReF), Abidjan, Côte d'Ivoire
| | - Thomas-d'Aquin Toni
- Centre de Diagnostic et de Recherche sur le SIDA (CeDReS), CHU de Treichville, Abidjan, Côte d'Ivoire
| | - Malika Congo-Ouedraogo
- Service de Bactériologie-Virologie, Département des Laboratoires, CHU Yalgado Ouedraogo, Ouagadougou, Burkina Faso
| | - Coumba Toure-Kane
- Laboratoire de Bactériologie-Virologie, Département GC&BA-ESP/UCAD, CHU A Le Dantec, Dakar, Senegal
| | - Moussa Seydi
- Centre Régional de Recherche et de Formation à la Prise en Charge Clinique (CRCF), Dakar, Senegal; Service des Maladies Infectieuses, CHU Fann, Dakar, Senegal
| | - Daouda K Minta
- Service des Maladies Infectieuses et Tropicales, CHU du Point-G, Bamako, Mali
| | - Adrien Sawadogo
- Hôpital de Jour, CHU Sourô Sanou, Bobo-Dioulasso, Burkina Faso
| | - Lassana Sangaré
- Service de Bactériologie-Virologie, Département des Laboratoires, CHU Yalgado Ouedraogo, Ouagadougou, Burkina Faso
| | - Joseph Drabo
- Service de Médecine Interne, Hôpital de Jour, CHU Yalgado Ouedraogo, Ouagadougou, Burkina Faso
| | - Sophie Karcher
- Inserm 1219, University of Bordeaux, Bordeaux, France; Programme PACCI/ANRS Research Center, Abidjan, Cote d'Ivoire
| | - Jérome Le Carrou
- Inserm 1219, University of Bordeaux, Bordeaux, France; Programme PACCI/ANRS Research Center, Abidjan, Cote d'Ivoire
| | | | - Gilles Peytavin
- Service de Pharmacologie, CHU Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Audrey Gabassi
- Laboratoire de Virologie, CHU Saint Louis, Assistance Publique-Hôpitaux de Paris, Paris, France; Inserm U944, CNR VIH, Université Paris Diderot, Paris, France
| | - Pierre-Marie Girard
- IMEA, Bichat Claude-Bernard University Hospital, Paris, France; Service des Maladies Infectieuses et Tropicales, CHU Saint Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marie-Laure Chaix
- Laboratoire de Virologie, CHU Saint Louis, Assistance Publique-Hôpitaux de Paris, Paris, France; Inserm U944, CNR VIH, Université Paris Diderot, Paris, France
| | - Xavier Anglaret
- Inserm 1219, University of Bordeaux, Bordeaux, France; Programme PACCI/ANRS Research Center, Abidjan, Cote d'Ivoire.
| | - Roland Landman
- IMEA, Bichat Claude-Bernard University Hospital, Paris, France; Service des Maladies Infectieuses et Tropicales, CHU Bichat Claude Bernard, Assistance Publique-Hôpitaux de Paris, Paris, France; IAME, UMR 1137, Inserm, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
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12
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Second-line antiretroviral therapy failure and characterization of HIV-1 drug resistance patterns in children in Mali. Arch Pediatr 2019; 26:254-258. [PMID: 31307909 DOI: 10.1016/j.arcped.2019.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 03/06/2019] [Accepted: 06/12/2019] [Indexed: 11/21/2022]
Abstract
INTRODUCTION In recent years, children born to HIV-infected mothers have been receiving antiretroviral treatment (ART) with limited or no virologic monitoring, which increases the likelihood of development and accumulation of drug resistance mutations, which itself may limit the effectiveness of future ART. The objective of this study was to evaluate the prevalence of resistance mutations in children infected with HIV-1 experiencing virological failure to second-line ART in the Pediatric Department of Gabriel Touré Hospital in Mali. METHODS Children aged from 5 to 18 infected with HIV-1 on second-line antiretroviral therapy and whose viral load was greater than 1000 copies/mL after observance reinforcement were enrolled. The protease and reverse transcriptase genes were sequenced with ViroSeq®. The results were interpreted according to the last version of the Stanford algorithm in 2018. The study was approved by the Ethics Committee of the Faculty of Medicine and Dentistry, University of Sciences, Techniques and Technologies of Bamako (Mali). RESULTS Of 216 children, 33 (15.3%) who had a viral load (VL)>1000 copies/mL in second line were recruited and included in the study. The median plasma viral load was 77,000 copies/mL [IQR (28,000-290,000)] and the median CD4 cell count was 310 cells/mm3 [IQR (152-412)]. The median age was 12 years; 48.5% of patients were treated with a combination of stavudine/lamivudine/nevirapine (Triomune®) for first-line treatment and 60.6% with abacavir/lamivudine/lopinavir/ritonavir for the second-line ART. The median treatment duration was 8.5 years [range, 3-13]. Of the 33 children whose treatment failed, the predominant HIV-1 subtype was CRF02_AG (66.7%). The prevalence of resistance to ART classes was 60.61% (20/33) to nucleoside reverse transcriptase inhibitors (NRTIs), 54.51% (18/33) to nonnucleoside reverse transcriptase inhibitors (NNRTIs), and 51.52% (17/33) to protease inhibitors (PIs). Of the patients studied, 90.9% were exposed to lopinavir/ritonavir (LPV/r) but only 15.2% (5/33) developed resistance to LPV/r. CONCLUSIONS This study demonstrated that LPV/r remains active in most patients after second-line ART failure. In children whose second-line ART fails, particular attention should be paid to their ART and adherence history when considering the next treatment option.
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13
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HIV-1 second-line failure and drug resistance at high-level and low-level viremia in Western Kenya. AIDS 2018; 32:2485-2496. [PMID: 30134290 DOI: 10.1097/qad.0000000000001964] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Characterize failure and resistance above and below guidelines-recommended 1000 copies/ml virologic threshold, upon second-line failure. DESIGN Cross-sectional study. METHODS Kenyan adults on lopinavir/ritonavir-based second-line were enrolled at AMPATH (Academic Model Providing Access to Healthcare). Charts were reviewed for demographic/clinical characteristics and CD4/viral load were obtained. Participants with detectable viral load had a second visit and pol genotyping was attempted in both visits. Accumulated resistance was defined as mutations in the second, not the first visit. Low-level viremia (LLV) was detectable viral load less than 1000 copies/ml. Failure and resistance associations were evaluated using logistic and Poisson regression, Fisher Exact and t-tests. RESULTS Of 394 participants (median age 42, 60% women, median 1.9 years on second-line) 48% had detectable viral load; 21% had viral load more than 1000 copies/ml, associated with younger age, tuberculosis treatment, shorter time on second-line, lower CD4count/percentage, longer first-line treatment interruption and pregnancy. In 105 sequences from the first visit (35 with LLV), 79% had resistance (57% dual-class, 7% triple-class; 46% with intermediate-to-high-level resistance to ≥1 future drug option). LLV was associated with more overall and NRTI-associated mutations and with predicted resistance to more next-regimen drugs. In 48 second-visit sequences (after median 55 days; IQR 28-33), 40% accumulated resistance and LLV was associated with more mutation accumulation. CONCLUSION High resistance upon second-line failure exists at levels above and below guideline-recommended virologic-failure threshold, impacting future treatment options. Optimization of care should include increased viral load monitoring, resistance testing and third-line ART access, and consideration of lowering the virologic failure threshold, though this demands further investigation.
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14
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Stockdale AJ, Saunders MJ, Boyd MA, Bonnett LJ, Johnston V, Wandeler G, Schoffelen AF, Ciaffi L, Stafford K, Collier AC, Paton NI, Geretti AM. Effectiveness of Protease Inhibitor/Nucleos(t)ide Reverse Transcriptase Inhibitor-Based Second-line Antiretroviral Therapy for the Treatment of Human Immunodeficiency Virus Type 1 Infection in Sub-Saharan Africa: A Systematic Review and Meta-analysis. Clin Infect Dis 2018; 66:1846-1857. [PMID: 29272346 PMCID: PMC5982734 DOI: 10.1093/cid/cix1108] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 12/18/2017] [Indexed: 02/02/2023] Open
Abstract
Background In sub-Saharan Africa, 25.5 million people are living with human immunodeficiency virus (HIV), representing 70% of the global total. The need for second-line antiretroviral therapy (ART) is projected to increase in the next decade in keeping with the expansion of treatment provision. Outcome data are required to inform policy. Methods We performed a systematic review and meta-analysis of studies reporting the virological outcomes of protease inhibitor (PI)-based second-line ART in sub-Saharan Africa. The primary outcome was virological suppression (HIV-1 RNA <400 copies/mL) after 48 and 96 weeks of treatment. The secondary outcome was the proportion of patients with PI resistance. Pooled aggregate data were analyzed using a DerSimonian-Laird random effects model. Results By intention-to-treat analysis, virological suppression occurred in 69.3% (95% confidence interval [CI], 58.2%-79.3%) of patients at week 48 (4558 participants, 14 studies), and in 61.5% (95% CI, 47.2%-74.9%) at week 96 (2145 participants, 8 studies). Preexisting resistance to nucleos(t)ide reverse transcriptase inhibitors (NRTIs) increased the likelihood of virological suppression. Major protease resistance mutations occurred in a median of 17% (interquartile range, 0-25%) of the virological failure population and increased with duration of second-line ART. Conclusions One-third of patients receiving PI-based second-line ART with continued NRTI use in sub-Saharan Africa did not achieve virological suppression, although among viremic patients, protease resistance was infrequent. Significant challenges remain in implementation of viral load monitoring. Optimizing definitions and strategies for management of second-line ART failure is a research priority. Prospero Registration CRD42016048985.
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Affiliation(s)
- Alexander J Stockdale
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre
- Institute of Infection and Global Health, University of Liverpool
| | - Matthew J Saunders
- Section of Infectious Diseases and Immunity and Wellcome Trust–Imperial College Centre for Global Health Research, Imperial College London, United Kingdom
| | - Mark A Boyd
- Kirby Institute for Infection and Immunity, University of New South Wales, Sydney
- Lyell McEwin Hospital, University of Adelaide, South Australia, Australia
| | | | | | - Gilles Wandeler
- Institute of Social and Preventative Medicine, University of Bern
- Department of Infectious Diseases, Bern University Hospital, Switzerland
| | - Annelot F Schoffelen
- Department of Infectious Diseases, University Medical Centre Utrecht, The Netherlands
| | - Laura Ciaffi
- Unité Mixte de Recherche de l’Institut de Rech (UMI), Institute de Recherche pour le Développement, Institute National de la Santé et de la Recherche Medicale, University of Montpellier, France
| | - Kristen Stafford
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore
| | - Ann C Collier
- University of Washington School of Medicine, Seattle
| | - Nicholas I Paton
- Yong Loo Lin School of Medicine, National University of Singapore
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Chimbetete C, Katzenstein D, Shamu T, Spoerri A, Estill J, Egger M, Keiser O. HIV-1 Drug Resistance and Third-Line Therapy Outcomes in Patients Failing Second-Line Therapy in Zimbabwe. Open Forum Infect Dis 2018; 5:ofy005. [PMID: 29435471 PMCID: PMC5801603 DOI: 10.1093/ofid/ofy005] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 01/23/2018] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES To analyze the patterns and risk factors of HIV drug resistance mutations among patients failing second-line treatment and to describe early treatment responses to recommended third-line antiretroviral therapy (ART) in a national referral HIV clinic in Zimbabwe. METHODS Patients on boosted protease inhibitor (PI) regimens for more than 6 months with treatment failure confirmed by 2 viral load (VL) tests >1000 copies/mL were genotyped, and susceptibility to available antiretroviral drugs was estimated by the Stanford HIVdb program. Risk factors for major PI resistance were assessed by logistic regression. Third-line treatment was provided as Darunavir/r, Raltegravir, or Dolutegravir and Zidovudine, Abacavir Lamivudine, or Tenofovir. RESULTS Genotypes were performed on 86 patients who had good adherence to treatment. The median duration of first- and second-line ART was 3.8 years (interquartile range [IQR], 2.3-5.1) and 2.6 years (IQR, 1.6-4.9), respectively. The median HIV viral load and CD4 cell count were 65 210 copies/mL (IQR, 8728-208 920 copies/mL) and 201 cells/mm3 (IQR, 49-333 cells/mm3). Major PI resistance-associated mutations (RAMs) were demonstrated in 44 (51%) non-nucleoside reverse transcriptase inhibitor RAMs in 72 patients (83%) and nucleoside reverse transcriptase inhibitors RAMs in 62 patients (72%). PI resistance was associated with age >24 years (P = .003) and CD4 cell count <200 cells/mm3 (P = .007). In multivariable analysis, only age >24 years was significantly associated (adjusted odds ratio, 4.75; 95% confidence interval, 1.69-13.38; P = .003) with major PI mutations. Third-line DRV/r- and InSTI-based therapy achieved virologic suppression in 29/36 patients (81%) after 6 months. CONCLUSIONS The prevelance of PI mutations was high. Adolescents and young adults had a lower risk of acquiring major PI resistance mutations, possibly due to poor adherence to ART. Third-line treatment with a regimen of Darunavir/r, Raltegravir/Dolutegravir, and optimized nucleoside reverse transcriptase inhibitors was effective.
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Affiliation(s)
- Cleophas Chimbetete
- Institute of Global Health, University of Geneva, Geneva, Switzerl
- Newlands Clinic, Harare, Zimbabwe
| | | | | | - Adrian Spoerri
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerl
| | - Janne Estill
- Institute of Global Health, University of Geneva, Geneva, Switzerl
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerl
- Institute of Mathematical Statistics and Actuarial Science, University of Bern, Bern, Switzerl
| | - Matthias Egger
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerl
| | - Olivia Keiser
- Institute of Global Health, University of Geneva, Geneva, Switzerl
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerl
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16
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Tsai HC, Chen IT, Wu KS, Tseng YT, Sy CL, Chen JK, Lee SSJ, Chen YS. High rate of HIV-1 drug resistance in treatment failure patients in Taiwan, 2009-2014. Infect Drug Resist 2017; 10:343-352. [PMID: 29081666 PMCID: PMC5652926 DOI: 10.2147/idr.s146584] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Drug resistance to nucleoside reverse transcriptase inhibitors (NRTIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), and protease inhibitors (PIs) has been associated with loss of viral suppression measured by a rise in HIV-1 RNA levels, a decline in CD4 cell counts, persistence on a failing treatment regimen, and lack of adherence to combination antiretroviral therapy. Objectives This study aimed to monitor the prevalence and risk factors associated with drug resistance in Taiwan after failure of first-line therapy. Materials and methods Data from the Veterans General Hospital Surveillance and Monitor Network for the period 2009–2014 were analyzed. Plasma samples from patients diagnosed with virologic failure and an HIV-1 RNA viral load >1000 copies/mL were analyzed by the ViroSeq™ HIV-1 genotyping system for drug susceptibility. Hazard ratios (HRs) for drug resistance were calculated using a Cox proportional hazard model. Results From 2009 to 2014, 359 patients were tested for resistance. The median CD4 count and viral load (log) were 214 cells/μL (interquartile range [IQR]: 71–367) and 4.5 (IQR: 3.9–5.0), respectively. Subtype B HIV-1 strains were found in 90% of individuals. The resistance rate to any of the three classes of antiretroviral drugs (NRTI, NNRTI, and PI) was 75.5%. The percentage of NRTI, NNRTI, and PI resistance was 58.6%, 61.4%, and 11.4%, respectively. The risk factors for any class of drug resistance included age ≤35 years (adjusted HR: 2.30, CI: 1.48–3.56; p<0.0001), initial NNRTI-based antiretroviral regimens (adjusted HR: 1.70, CI: 1.10–2.63; p=0.018), and current NNRTI-based antiretroviral regimens when treatment failure occurs (odds ratio: 4.04, CI: 2.47–6.59; p<0.001). There was no association between HIV-1 subtype, viral load, and resistance. Conclusion This study demonstrated a high level of resistance to NRTI and NNRTI in patients with virologic failure to first-line antiretroviral therapy despite routine viral load monitoring. Educating younger men who have sex with men to maintain good adherence is crucial, as PI use is associated with lower possibility of drug resistance.
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Affiliation(s)
- Hung-Chin Tsai
- Department of Medicine, Division of Infectious Diseases, Kaohsiung Veterans General Hospital, Kaohsiung.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei.,Department of Parasitology, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - I-Tzu Chen
- Department of Medicine, Division of Infectious Diseases, Kaohsiung Veterans General Hospital, Kaohsiung
| | - Kuan-Sheng Wu
- Department of Medicine, Division of Infectious Diseases, Kaohsiung Veterans General Hospital, Kaohsiung.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei
| | - Yu-Ting Tseng
- Department of Medicine, Division of Infectious Diseases, Kaohsiung Veterans General Hospital, Kaohsiung
| | - Cheng-Len Sy
- Department of Medicine, Division of Infectious Diseases, Kaohsiung Veterans General Hospital, Kaohsiung
| | - Jui-Kuang Chen
- Department of Medicine, Division of Infectious Diseases, Kaohsiung Veterans General Hospital, Kaohsiung
| | - Susan Shin-Jung Lee
- Department of Medicine, Division of Infectious Diseases, Kaohsiung Veterans General Hospital, Kaohsiung.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei
| | - Yao-Shen Chen
- Department of Medicine, Division of Infectious Diseases, Kaohsiung Veterans General Hospital, Kaohsiung.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei
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Emergence of untreatable, multidrug-resistant HIV-1 in patients failing second-line therapy in Kenya. AIDS 2017; 31:1495-1498. [PMID: 28398959 DOI: 10.1097/qad.0000000000001500] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
: We performed a countrywide assessment of HIV drug resistance among 123 patients with virological failure on second-line antiretroviral therapy (ART) in Kenya. The percentage of patients harbouring intermediate-to-high-level resistance was 27% for lopinavir-ritonavir, 24% for atazanavir-ritonavir and 7% for darunavir-ritonavir, and 25% had complete loss of activity to all available first and second-line drugs. Overall, one in four patients failing second-line ART have completely exhausted available antiretrovirals in Kenya, highlighting the need for increased access to third-line drugs.
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de Truchis P, Lê MP, Daou M, Madougou B, Nouhou Y, Moussa Saley S, Sani A, Adehossi E, Rouveix E, Saidou M, Peytavin G, Delaugerre C. High efficacy of first-line ART in a West African cohort, assessed by dried blood spot virological and pharmacological measurements. J Antimicrob Chemother 2016; 71:3222-3227. [PMID: 27439522 DOI: 10.1093/jac/dkw286] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 05/19/2016] [Accepted: 06/14/2016] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES The objectives of this study were to determine the rate of viral success in HIV-infected patients on first-line ART by the assessment of dried blood spot (DBS) viral load (VL) and to assess the performance of DBS sampling for VL measurement, genotypic resistance and antiretroviral concentration determinations. METHODS HIV-infected patients treated for >1 year with first-line ART in Niamey, Niger were included. VL based on nucleic acid sequence-based amplification (NASBA) assay (limit of quantification <800 copies/mL) was measured on DBS capillary samples. Resistance genotype was assessed for all detectable VLs (limit of detection >100 copies/mL); antiretroviral concentrations were interpreted using standard plasma cut-offs after extrapolation of blood to plasma results. Median (IQR) results are presented. RESULTS Two hundred and eighteen patients (61% women), aged 41 (34-46) years, with 138 (56-235) CD4 cells/mm3 at baseline were included. After 4 (2-6) years of follow-up under therapy, CD4 gain was +197 (98-372) cells/mm3; 81% had VL <800 copies/mL. Antiretroviral concentrations were adequate in 87% of patients and nevirapine/efavirenz concentrations were related to viral success (P < 0.001). DBS genotypic resistance amplification succeeded in 71% of failing patients: NRTI drug resistance mutations were identified in 73% including resistance to lamivudine/emtricitabine (67%), abacavir (30%) and tenofovir (21%); and NNRTI drug resistance mutations were identified in 82% including resistance to rilpivirine (39%) and etravirine (15%). CONCLUSIONS This study demonstrated a good response after 4 years of first-line ART in Niger. Adherence was high, according to antiretroviral concentrations, and the majority of failures were explained by selection of drug resistance mutations detected in the DBS genotype. Using DBS might improve the assessment of ART failure in HIV-infected patients in low-income countries.
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Affiliation(s)
- Pierre de Truchis
- Hôpitaux Universitaires Paris IdF-Ouest, APHP, France .,GIP-ESTHER, Expertise France, Paris, France.,Entraide Sante 92, France
| | - Minh Patrick Lê
- Pharmaco-Toxicology Department, Hôpital Bichat - Claude Bernard, APHP, INSERM IAME UMR 1137, Paris, France
| | - Mamane Daou
- GIP-ESTHER, Expertise France, Paris, France.,Hôpital National de Niamey, Niger
| | - Boubacar Madougou
- GIP-ESTHER, Expertise France, Paris, France.,Hôpital National de Niamey, Niger
| | | | | | | | | | - Elisabeth Rouveix
- Hôpitaux Universitaires Paris IdF-Ouest, APHP, France.,GIP-ESTHER, Expertise France, Paris, France.,Entraide Sante 92, France
| | - Mamadou Saidou
- Laboratoire National de Virologie, CHU Lamordé, Niamey, Niger
| | - Gilles Peytavin
- Pharmaco-Toxicology Department, Hôpital Bichat - Claude Bernard, APHP, INSERM IAME UMR 1137, Paris, France
| | - Constance Delaugerre
- Laboratoire de Virologie-INSERM U941, Hôpital Saint Louis-APHP, Université Paris Diderot, Paris, France
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Raguin G. The ESTHER hospital partnership initiative: a powerful levy for building capacities to combat the HIV pandemic in low-resource countries. Global Health 2016; 12:12. [PMID: 27036882 PMCID: PMC4818518 DOI: 10.1186/s12992-016-0149-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 03/16/2016] [Indexed: 11/05/2022] Open
Abstract
Partnerships between hospitals in high income countries and low resource countries are uniquely capable of fulfilling the tripartite needs of care, training, and research required to address health care crises in low resource countries. Of particular interest, at a time when the EBOLA crisis highlights the weaknesses of health systems in resource-poor settings, the institutional resources and expertise of hospitals can also contribute to strengthening health systems with long-term sustainability. We describe a partnership network between French Hospitals and hospitals/health structures in 19 countries that demonstrates the power and efficacy of health partnership in the response to the HIV/AIDS pandemic in sub-Saharan Africa and south East Asia. Through the ESTHER initiative, the partnership network currently provides capacity development, care and treatment to over 165,000 HIV-positive patients at 87 urban and 92 peripheral sites in 17 countries and enrolls 19,000 new HIV positive patients, delivers psychosocial services to 120 000 people and tests more than 35,000 pregnant women for HIV annually. It also, engages communities and assists with the development of a robust electronic information system. Launched in 2002, the ESTHER (Ensemble pour une Solidarite Thérapeutique Hospitalière En Reseau) initiative has grown from small projects with a focus on access to antiretroviral treatment in a limited number of West African countries at its outset into a large and comprehensive HIV/AIDS-control system in Western and Central Africa. The partnership’s rapid achievements in the fight against HIV/AIDS, combined with the comprehensive and long-term approach to countries’ health care needs, suggest that this “twinning” and medical mentoring model can and should be duplicated and developed to address the ever more pressing demand for response to global health needs in low resource countries.
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Affiliation(s)
- Gilles Raguin
- Expertise France, 73 rue de Vaugirard, Paris, 75006, France.
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20
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Thao VP, Quang VM, Day JN, Chinh NT, Shikuma CM, Farrar J, Van Vinh Chau N, Thwaites GE, Dunstan SJ, Le T. High prevalence of PI resistance in patients failing second-line ART in Vietnam. J Antimicrob Chemother 2015; 71:762-74. [PMID: 26661398 PMCID: PMC4743698 DOI: 10.1093/jac/dkv385] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 10/16/2015] [Indexed: 01/11/2023] Open
Abstract
Background There are limited data from resource-limited settings on antiretroviral resistance mutations that develop in patients failing second-line PI ART. Methods We performed a cross-sectional virological assessment of adults on second-line ART for ≥6 months between November 2006 and December 2011, followed by a prospective follow-up over 2 years of patients with virological failure (VF) at the Hospital for Tropical Diseases, Vietnam. VF was defined as HIV RNA concentrations ≥1000 copies/mL. Resistance mutations were identified by population sequencing of the pol gene and interpreted using the 2014 IAS-USA mutation list and the Stanford algorithm. Logistic regression modelling was performed to identify predictors of VF. Results Two hundred and thirty-one patients were enrolled in the study. The median age was 32 years; 81.0% were male, 95.7% were on a lopinavir/ritonavir-containing regimen and 22 (9.5%) patients had VF. Of the patients with VF, 14 (64%) carried at least one major protease mutation [median: 2 (IQR: 1–3)]; 13 (59%) had multiple protease mutations conferring intermediate- to high-level resistance to lopinavir/ritonavir. Mutations conferring cross-resistance to etravirine, rilpivirine, tipranavir and darunavir were identified in 55%, 55%, 45% and 27% of patients, respectively. Higher viral load, adherence <95% and previous indinavir use were independent predictors of VF. The 2 year outcomes of the patients maintained on lopinavir/ritonavir included: death, 7 (35%); worsening virological/immunological control, 6 (30%); and virological re-suppression, 5 (25%). Two patients were switched to raltegravir and darunavir/ritonavir with good HIV control. Conclusions High-prevalence PI resistance was associated with previous indinavir exposure. Darunavir plus an integrase inhibitor and lamivudine might be a promising third-line regimen in Vietnam.
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Affiliation(s)
- Vu Phuong Thao
- Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Vo Minh Quang
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Jeremy N Day
- Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Cecilia M Shikuma
- Hawaii Center for AIDS, University of Hawaii at Manoa, Honolulu, HI, USA
| | - Jeremy Farrar
- Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Guy E Thwaites
- Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sarah J Dunstan
- The Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
| | - Thuy Le
- Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK Hawaii Center for AIDS, University of Hawaii at Manoa, Honolulu, HI, USA
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21
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Ndahimana JD, Riedel DJ, Muhayimpundu R, Nsanzimana S, Niyibizi G, Mutaganzwa E, Mulindabigwi A, Baribwira C, Kiromera A, Jagodzinski LL, Peel SA, Redfield RR. HIV drug resistance mutations among patients failing second-line antiretroviral therapy in Rwanda. Antivir Ther 2015; 21:253-9. [PMID: 26562173 DOI: 10.3851/imp3005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Studies of patients failing second-line antiretroviral therapy (ART) in resource-limited settings (RLS) are few. Evidence suggests most patients who appear to be virologically failing do so not due to drug resistance but to poor adherence, which, if properly addressed, could allow continued use of less expensive first- and second-line regimens. Drug resistant mutations (DRMs) were characterized among patients virologically failing second-line ART in Rwanda. METHODS A total of 128 adult patients receiving second-line ART for at least 6 months were invited to participate; 74 agreed and had HIV-1 viral load (VL) measured. Resistance genotypes were conducted in patients with virological failure (VF; that is, VL ≥1,000 copies/ml). RESULTS In total, 35 patients met the criteria for VF. The median time on lopinavir/ritonavir-based second-line ART was 2.7 years. Of 30 successful resistance genotype analyses, 13 (43%) had ≥1 nucleoside reverse transcriptase inhibitor (NRTI) mutation, 18 (60%) had at least 1 non-NRTI mutation and 5 (17%) had at least 1 major protease inhibitor mutation. Eleven (37%) had virus without significant mutations that would be fully sensitive to first-line ART; 12 (40%) had DRM to first-line ART but sensitive to second-line ART. Only 7 patients (23%) demonstrated a DRM profile requiring third-line ART. CONCLUSIONS Among 30 genotyped samples of patients with VF on second-line ART, more than one-third had no significant DRMs, implicating poor adherence as the primary cause of VF. The majority of patients (77%) would not have required third-line ART. These findings reinforce the need for intensive adherence assessment and counselling for patients who appear to be failing second-line ART in RLS.
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Rossouw TM, Feucht UD, Melikian G, van Dyk G, Thomas W, du Plessis NM, Avenant T. Factors Associated with the Development of Drug Resistance Mutations in HIV-1 Infected Children Failing Protease Inhibitor-Based Antiretroviral Therapy in South Africa. PLoS One 2015. [PMID: 26196688 PMCID: PMC4510388 DOI: 10.1371/journal.pone.0133452] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE Limited data are available from the developing world on antiretroviral drug resistance in HIV-1 infected children failing protease inhibitor-based antiretroviral therapy, especially in the context of a high tuberculosis burden. We describe the proportion of children with drug resistance mutations after failed protease inhibitor-based antiretroviral therapy as well as associated factors. METHODS Data from children initiated on protease inhibitor-based antiretroviral therapy with subsequent virological failure referred for genotypic drug resistance testing between 2008 and 2012 were retrospectively analysed. Frequencies of drug resistance mutations were determined and associations with these mutations identified through logistic regression analysis. RESULTS The study included 65 young children (median age 16.8 months [IQR 7.8; 23.3]) with mostly advanced clinical disease (88.5% WHO stage 3 or 4 disease), severe malnutrition (median weight-for-age Z-score -2.4 [IQR -3.7;-1.5]; median height-for-age Z-score -3.1 [IQR -4.3;-2.4]), high baseline HIV viral load (median 6.04 log10, IQR 5.34;6.47) and frequent tuberculosis co-infection (66%) at antiretroviral therapy initiation. Major protease inhibitor mutations were found in 49% of children and associated with low weight-for-age and height-for-age (p = 0.039; p = 0.05); longer duration of protease inhibitor regimens and virological failure (p = 0.001; p = 0.005); unsuppressed HIV viral load at 12 months of antiretroviral therapy (p = 0.001); tuberculosis treatment at antiretroviral therapy initiation (p = 0.048) and use of ritonavir as single protease inhibitor (p = 0.038). On multivariate analysis, cumulative months on protease inhibitor regimens and use of ritonavir as single protease inhibitor remained significant (p = 0.008; p = 0.033). CONCLUSION Major protease inhibitor resistance mutations were common in this study of HIV-1-infected children, with the timing of tuberculosis treatment and subsequent protease inhibitor dosing strategy proving to be important associated factors. There is an urgent need for safe, effective, and practicable HIV/tuberculosis co-treatment in young children and the optimal timing of treatment, optimal dosing of antiretroviral therapy, and alternative tuberculosis treatment strategies should be urgently addressed.
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Affiliation(s)
- Theresa M. Rossouw
- Institute for Cellular and Molecular Medicine, Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
- * E-mail:
| | - Ute D. Feucht
- Department of Paediatrics, Kalafong Provincial Tertiary Hospital, University of Pretoria, Pretoria, South Africa
| | - George Melikian
- AIDS Healthcare Foundation, Los Angeles, CA, United States of America
| | - Gisela van Dyk
- Institute for Cellular and Molecular Medicine, Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Winifred Thomas
- Department of Paediatrics, Kalafong Provincial Tertiary Hospital, University of Pretoria, Pretoria, South Africa
| | - Nicolette M. du Plessis
- Department of Paediatrics, Kalafong Provincial Tertiary Hospital, University of Pretoria, Pretoria, South Africa
| | - Theunis Avenant
- Department of Paediatrics, Kalafong Provincial Tertiary Hospital, University of Pretoria, Pretoria, South Africa
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HIV multi-drug resistance at first-line antiretroviral failure and subsequent virological response in Asia. J Int AIDS Soc 2014; 17:19053. [PMID: 25141905 PMCID: PMC4139921 DOI: 10.7448/ias.17.1.19053] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 06/01/2014] [Accepted: 06/20/2014] [Indexed: 11/08/2022] Open
Abstract
Introduction First-line antiretroviral therapy (ART) failure often results from the development of resistance-associated mutations (RAMs). Three patterns, including thymidine analogue mutations (TAMs), 69 Insertion (69Ins) and the Q151M complex, are associated with resistance to multiple-nucleoside reverse transcriptase inhibitors (NRTIs) and may compromise treatment options for second-line ART. Methods We investigated patterns and factors associated with multi-NRTI RAMs at first-line failure in patients from The TREAT Asia Studies to Evaluate Resistance – Monitoring study (TASER-M), and evaluated their impact on virological responses at 12 months after switching to second-line ART. RAMs were compared with the IAS-USA 2013 mutations list. We defined multi-NRTI RAMs as the presence of either Q151M; 69Ins; ≥2 TAMs; or M184V+≥1 TAM. Virological suppression was defined as viral load (VL) <400 copies/ml at 12 months from switch to second-line. Logistic regression was used to analyze (1) factors associated with multi-NRTI RAMs at first-line failure and (2) factors associated with virological suppression after 12 months on second-line. Results A total of 105 patients from 10 sites in Thailand, Hong Kong, Indonesia, Malaysia and Philippines were included. There were 97/105 (92%) patients harbouring ≥1 RAMs at first-line failure, 39/105 with multi-NRTI RAMs: six with Q151M; 24 with ≥2 TAMs; and 32 with M184V+≥1 TAM. Factors associated with multi-NRTI RAMs were CD4 ≤200 cells/µL at genotyping (OR=4.43, 95% CI [1.59–12.37], p=0.004) and ART duration >2 years (OR=6.25, 95% CI [2.39–16.36], p<0.001). Among 87/105 patients with available VL at 12 months after switch to second-line ART, virological suppression was achieved in 85%. The median genotypic susceptibility score (GSS) for the second-line regimen was 2.00. Patients with ART adherence ≥95% were more likely to be virologically suppressed (OR=9.33, 95% CI (2.43–35.81), p=0.001). Measures of patient resistance to second-line ART, including the GSS, were not significantly associated with virological outcome. Conclusions Multi-NRTI RAMs at first-line failure were associated with low CD4 level and longer duration of ART. With many patients switching to highly susceptible regimens, good adherence was still crucial in achieving virological response. This emphasizes the importance of continued adherence counselling well into second-line therapy.
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Fofana DB, Soulié C, Baldé A, Lambert-Niclot S, Sylla M, Ait-Arkoub Z, Diallo F, Sangaré B, Cissé M, Maïga IA, Fourati S, Koita O, Calvez V, Marcelin AG, Maïga AI. High level of HIV-1 resistance in patients failing long-term first-line antiretroviral therapy in Mali. J Antimicrob Chemother 2014; 69:2531-5. [PMID: 24855120 DOI: 10.1093/jac/dku153] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES In resource-limited settings, few data are available on virological failure after long-term first-line antiretroviral therapy. This study characterized the genotypic resistance patterns at the time of failure after at least 36 months of a first-line regimen in Mali, West Africa. METHODS Plasma samples from 84 patients who were receiving first-line antiretroviral treatment and with an HIV-1 RNA viral load (VL) >1000 copies/mL were analysed. Genotypic resistance testing was performed and HIV-1 drug resistance was interpreted according to the latest version of the National Agency for HIV and Hepatitis Research algorithm. RESULTS At the time of resistance testing, patients had been treated for a median of 60 months (IQR 36-132 months) and had a median CD4 cell count of 292 cells/mm(3) (IQR 6-1319 cells/mm(3)), a median HIV-1 RNA level of 28266 copies/mL (IQR 1000-2 93 495 copies/mL) and a median genotypic susceptibility score of 1 (IQR 1-4). The prevalence of nucleoside reverse transcriptase inhibitor (NRTI) and non-nucleoside reverse transcriptase inhibitor (NNRTI) resistance mutations was 78% and 82%, respectively. Viruses were resistant to at least one drug in 92% of cases. Although etravirine and rilpivirine were not used in the first-line regimens, viruses were resistant to etravirine in 34% of cases and to rilpivirine in 49% of cases. The treatment duration, median number of NRTI and NNRTI mutations and some reverse transcriptase mutations (T215Y/F/N, L210W, L74I, M41L and H221Y) were associated with the VL at virological failure. CONCLUSIONS This study demonstrated a high level of resistance to NRTIs and NNRTIs, compromising second-generation NNRTIs, for patients who stayed on long-term first-line regimens. It is crucial to expand the accessibility of virological testing in resource-limited settings to limit the expansion of resistance and preserve second-line treatment efficacy.
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Affiliation(s)
- D B Fofana
- Sorbonne Universités, UPMC Univ Paris 06, UMR_S1136, F-75005 Paris, France Inserm, UMR_S 1136, F-75005 Paris, France AP-HP, Hôpital Pitié-Salpêtrière, Service de Virologie, F-75013 Paris, France
| | - C Soulié
- Sorbonne Universités, UPMC Univ Paris 06, UMR_S1136, F-75005 Paris, France Inserm, UMR_S 1136, F-75005 Paris, France AP-HP, Hôpital Pitié-Salpêtrière, Service de Virologie, F-75013 Paris, France
| | - A Baldé
- Unité d'Epidémiologie Moléculaire de la Résistance du VIH, SEREFO-FMOS/FAPH, Université des Sciences Techniques et des Technologies, Bamako, Mali
| | - S Lambert-Niclot
- Sorbonne Universités, UPMC Univ Paris 06, UMR_S1136, F-75005 Paris, France Inserm, UMR_S 1136, F-75005 Paris, France AP-HP, Hôpital Pitié-Salpêtrière, Service de Virologie, F-75013 Paris, France
| | - M Sylla
- Service de Pédiatrie, CHU Gabriel Toure, Université des Sciences Techniques et des Technologies, Bamako, Mali
| | - Z Ait-Arkoub
- Sorbonne Universités, UPMC Univ Paris 06, UMR_S1136, F-75005 Paris, France Inserm, UMR_S 1136, F-75005 Paris, France AP-HP, Hôpital Pitié-Salpêtrière, Service de Virologie, F-75013 Paris, France
| | | | | | | | | | - S Fourati
- Sorbonne Universités, UPMC Univ Paris 06, UMR_S1136, F-75005 Paris, France Inserm, UMR_S 1136, F-75005 Paris, France AP-HP, Hôpital Pitié-Salpêtrière, Service de Virologie, F-75013 Paris, France
| | - O Koita
- Unité d'Epidémiologie Moléculaire de la Résistance du VIH, SEREFO-FMOS/FAPH, Université des Sciences Techniques et des Technologies, Bamako, Mali
| | - V Calvez
- Sorbonne Universités, UPMC Univ Paris 06, UMR_S1136, F-75005 Paris, France Inserm, UMR_S 1136, F-75005 Paris, France AP-HP, Hôpital Pitié-Salpêtrière, Service de Virologie, F-75013 Paris, France
| | - A G Marcelin
- Sorbonne Universités, UPMC Univ Paris 06, UMR_S1136, F-75005 Paris, France Inserm, UMR_S 1136, F-75005 Paris, France AP-HP, Hôpital Pitié-Salpêtrière, Service de Virologie, F-75013 Paris, France
| | - A I Maïga
- Unité d'Epidémiologie Moléculaire de la Résistance du VIH, SEREFO-FMOS/FAPH, Université des Sciences Techniques et des Technologies, Bamako, Mali Laboratoire d'Analyses Médicales, CHU Gabriel Toure, Université des Sciences Techniques et des Technologies, Bamako, Mali
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Beyond first-line HIV treatment regimens: the current state of antiretroviral regimens, viral load monitoring, and resistance testing in resource-limited settings. Curr Opin HIV AIDS 2014; 8:586-90. [PMID: 24100872 DOI: 10.1097/coh.0000000000000004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW With the availability of antiretroviral drugs in resource-limited settings, there is a rapid scale-up of antiretroviral therapy in developing countries. RECENT FINDINGS The review focuses on the issues faced while patients are on first-line antiretroviral therapy in the absence of viral load monitoring, and the availability and progress of the second-line antiretroviral drugs and the salvage regimens in resource-limited settings. SUMMARY There is an urgent need for low-cost, low-tech viral load monitoring in resource-limited settings. Fixed-dose combination of antiretrovirals for first-line and second-line therapy will result in better effectiveness. There is a need for newer antiretroviral drugs in resource-limited settings.
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Short-term effectiveness and safety of third-line antiretroviral regimens among patients in Western India. J Acquir Immune Defic Syndr 2014; 65:e82-4. [PMID: 24442229 DOI: 10.1097/qai.0b013e3182a6104a] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Fall-Malick FZ, Tchiakpé E, Ould Soufiane S, Diop-Ndiaye H, Mouhamedoune Baye A, Ould Horma Babana A, Touré Kane C, Lo B, Mboup S. Drug resistance mutations and genetic diversity in adults treated for HIV type 1 infection in Mauritania. J Med Virol 2013; 86:404-10. [PMID: 24318486 DOI: 10.1002/jmv.23860] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2013] [Indexed: 11/06/2022]
Abstract
The aim of this cross-sectional study was to evaluate the drug resistance mutationprofile observed in patients receiving antiretroviral therapy with virological failure and to document the HIV-1 genetic diversity in Mauritania. Eighty-six subjects were included and 65 samples were amplified successfully and sequenced. HIV-1 genotyping was performed using the Agence Nationale de Recherche sur le SIDA AC11 resistance procedure. The median treatment duration was 32 months (range: 6-88) and the median viral load, 5 log10 copies/ml (range: 3.13-7). Fifty-nine patients (90.8%) were on first line regimens including 32.0% (19/59) on triomune fixed-dose and six on second-line therapy with NonNucleoside Reverse Transcriptase plus a protease inhibitor. Forty-seven patients (72.3%) had at least one drug resistance mutation including 73.0% (43/59) on first-line therapy. For the second-line, one out of six patients presented resistance mutations and only one presented PI DRM. Overall, the most common DRMs detected were M184V/I (n = 32; 49.2%), K103N (n = 28; 43%), and Y181C (n = 13; 20%). Thymidine Analog Mutations (TAMs) were found in 26.0% (n = 17) of strains and the most common was T215Y (n = 11, 16.9%). Phylogenetic analysis revealed 17 HIV-1 variants with the predominance of CRF02_AG (n = 42; 64.6%). A high rate of DRM was found in this study and shows the potential need for a structured virological surveillance including viral load quantification and genotyping. Further studies may also be needed in regards to the great variability of HIV-1 strains in Mauritania.
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Affiliation(s)
- F-Zahra Fall-Malick
- Laboratory of Virology, Public Health National Institute (INRSP), Nouakchott, Mauritania
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Increasing rate of TAMs and etravirine resistance in HIV-1-infected adults between 12 and 24 months of treatment: the VOLTART cohort study in Côte d'Ivoire, West Africa. J Acquir Immune Defic Syndr 2013; 64:211-9. [PMID: 23797690 DOI: 10.1097/qai.0b013e3182a009e4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND In sub-Saharan Africa, most HIV-infected patients receive antiretroviral therapy (ART) without virological monitoring. Longitudinal data on secondary resistance are rare. METHODS We conducted a prospective cohort study of HIV-1-infected adults initiating ART in 3 clinics using computerized monitoring systems. Patients had plasma HIV-1 RNA viral load (VL) tests at months 12 (M12) and 24 (M24) after ART initiation and HIV-1 resistance genotype tests if VL was detectable (≥300 copies/mL). RESULTS Overall, 1573 patients initiated ART with stavudine/zidovudine plus lamivudine plus nevirapine/efavirenz. At M12 and M24, 944 and 844 patients, respectively, remained in active follow-up. Among them, 25% (M12) and 27% (M24) had detectable VLs and 12% (M12) and 19% (M24) had virus resistant to at least 1 antiretroviral drug, accounting for 54% (M12) and 75% (M24) of patients with detectable VLs. Among the resistant strains, 95% (M12) and 97% (M24) were resistant to lamivudine/emtricitabine, efavirenz, and/or nevirapine, the frequency of thymidine analog mutations increased from 8.1% (M12) to 14.7% (M24) and etravirine resistance increased from 13.5% (M12) to 24.5% (M24). CONCLUSIONS Of the patients with detectable VLs at M24, 25% still did not harbor resistant virus. Preventing mutations from emerging with adherence reinforcement in patients with detectable VLs remains important beyond M24. Switching therapy early in patients with resistance to 3 TC/FTC and/or to nonnucleoside reverse transcriptase inhibitors to prevent extended resistance to nucleoside reverse transcriptase inhibitors and etravirine resistance from occurring is also a major challenge.
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Rawizza HE, Chaplin B, Meloni ST, Darin KM, Olaitan O, Scarsi KK, Onwuamah CK, Audu RA, Chebu PR, Imade GE, Okonkwo P, Kanki PJ. Accumulation of protease mutations among patients failing second-line antiretroviral therapy and response to salvage therapy in Nigeria. PLoS One 2013; 8:e73582. [PMID: 24069209 PMCID: PMC3775797 DOI: 10.1371/journal.pone.0073582] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 07/19/2013] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND To date, antiretroviral therapy (ART) guidelines and programs in resource-limited settings (RLS) have focused on 1(st)- and 2(nd)-line (2 L) therapy. As programs approach a decade of implementation, policy regarding access to 3(rd)-line (3 L) ART is needed. We aimed to examine the impact of maintaining patients on failing 2 L ART on the accumulation of protease (PR) mutations. METHODS AND FINDINGS From 2004-2011, the Harvard/APIN PEPFAR Program provided ART to >100,000 people in Nigeria. Genotypic resistance testing was performed on a subset of patients experiencing 2 L failure, defined as 2 consecutive viral loads (VL)>1000 copies/mL after ≥6 months on 2 L. Of 6714 patients who received protease inhibitor (PI)-based ART, 673 (10.0%) met virologic failure criteria. Genotypes were performed on 61 samples. Patients on non-suppressive 2 L therapy for <12 months prior to genotyping had a median of 2 (IQR: 0-5) International AIDS Society (IAS) PR mutations compared with 5 (IQR: 0-6) among patients failing for >24 months. Patients developed a median of 0.6 (IQR: 0-1.4) IAS PR mutations per 6 months on failing 2 L therapy. In 38% of failing patients no PR mutations were present. For patients failing >24 months, high- or intermediate-level resistance to lopinavir and atazanavir was present in 63%, with 5% to darunavir. CONCLUSIONS This is the first report assessing the impact of duration of non-suppressive 2 L therapy on the accumulation of PR resistance in a RLS. This information provides insight into the resistance cost of failing to switch non-suppressive 2 L regimens and highlights the issue of 3 L access.
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Affiliation(s)
- Holly E. Rawizza
- Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Beth Chaplin
- Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Seema T. Meloni
- Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Kristin M. Darin
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | | | - Kimberly K. Scarsi
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | | | | | | | | | | | - Phyllis J. Kanki
- Harvard School of Public Health, Boston, Massachusetts, United States of America
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Hosseinipour MC, Gupta RK, Van Zyl G, Eron JJ, Nachega JB. Emergence of HIV drug resistance during first- and second-line antiretroviral therapy in resource-limited settings. J Infect Dis 2013; 207 Suppl 2:S49-56. [PMID: 23687289 DOI: 10.1093/infdis/jit107] [Citation(s) in RCA: 105] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
INTRODUCTION Antiretroviral therapy (ART) in resource-limited settings has expanded in the last decade, reaching >8 million individuals and reducing AIDS mortality and morbidity. Continued success of ART programs will require understanding the emergence of HIV drug resistance patterns among individuals in whom treatment has failed and managing ART from both an individual and public health perspective. We review data on the emergence of HIV drug resistance among individuals in whom first-line therapy has failed and clinical and resistance outcomes of those receiving second-line therapy in resource-limited settings. RESULTS Resistance surveys among patients initiating first-line nonnucleoside reverse-transcriptase inhibitor (NNRTI)-based therapy suggest that 76%-90% of living patients achieve HIV RNA suppression by 12 months after ART initiation. Among patients with detectable HIV RNA at 12 months, HIV drug resistance, primarily due to M184V and NNRTI mutations, has been identified in 60%-72%, although the antiretroviral activity of proposed second-line regimens has been preserved. Complex mutation patterns, including thymidine-analog mutations, K65R, and multinucleoside mutations, are prevalent among cases of treatment failure identified by clinical or immunologic methods. Approximately 22% of patients receiving second-line therapy do not achieve HIV RNA suppression by 6 months, with poor adherence, rather than HIV drug resistance, driving most failures. Major protease inhibitor resistance at the time of second-line failure ranges from 0% to 50%, but studies are limited. CONCLUSIONS Resistance of HIV to first-line therapy is predictable at 12 months when evaluated by means of HIV RNA monitoring and, when detected, largely preserves second-line therapy options. Optimizing adherence, performing resistance surveillance, and improving treatment monitoring are critical for long-term prevention of drug resistance.
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De Luca A, Hamers RL, Schapiro JM. Antiretroviral treatment sequencing strategies to overcome HIV type 1 drug resistance in adolescents and adults in low-middle-income countries. J Infect Dis 2013; 207 Suppl 2:S63-9. [PMID: 23687291 DOI: 10.1093/infdis/jit109] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Antiretroviral treatment (ART) is expanding to human immunodeficiency virus type 1 (HIV-1)-infected persons in low-middle income countries, thanks to a public health approach. With 3 available drug classes, 2 ART sequencing lines are programmatically foreseen. The emergence and transmission of viral drug resistance represents a challenge to the efficacy of ART. Knowledge of HIV-1 drug resistance selection associated with specific drugs and regimens and the consequent activity of residual drug options are essential in programming ART sequencing options aimed at preserving ART efficacy for as long as possible. This article determines optimal ART sequencing options for overcoming HIV-1 drug resistance in resource-limited settings, using currently available drugs and treatment monitoring opportunities. From the perspective of drug resistance and on the basis of limited virologic monitoring data, optimal sequencing seems to involve use of a tenofovir-containing nonnucleoside reverse-transcriptase inhibitor-based first-line regimen, followed by a zidovudine-containing, protease inhibitor (PI)-based second-line regimen. Other options and their consequences are explored by considering within-class and between-class sequencing opportunities, including boosted PI monotherapies and future options with integrase inhibitors. Nucleoside reverse-transcriptase inhibitor resistance pathways in HIV-1 subtype C suggest an additional reason for accelerating stavudine phase out. Viral load monitoring avoids the accumulation of resistance mutations that significantly reduce the activity of next-line options. Rational use of resources, including broader access to viral load monitoring, will help ensure 3 lines of fully active treatment options, thereby increasing the duration of ART success.
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Affiliation(s)
- Andrea De Luca
- Department of Internal and Specialty Medicine, University Infectious Diseases Unit, Azienda Ospedaliera Universitaria Senese, Siena, Italy.
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