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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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Jordan MR, Hamunime N, Bikinesi L, Sawadogo S, Agolory S, Shiningavamwe AN, Negussie T, Fisher-Walker CL, Raizes EG, Mutenda N, Hunter CJ, Dean N, Steegen K, Kana V, Carmona S, Yang C, Tang AM, Parkin N, Hong SY. High levels of HIV drug resistance among adults failing second-line antiretroviral therapy in Namibia. Medicine (Baltimore) 2020; 99:e21661. [PMID: 32925712 PMCID: PMC7489739 DOI: 10.1097/md.0000000000021661] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To support optimal third-line antiretroviral therapy (ART) selection in Namibia, we investigated the prevalence of HIV drug resistance (HIVDR) at time of failure of second-line ART. A cross-sectional study was conducted between August 2016 and February 2017. HIV-infected people ≥15 years of age with confirmed virological failure while receiving ritonavir-boosted protease inhibitor (PI/r)-based second-line ART were identified at 15 high-volume ART clinics representing over >70% of the total population receiving second-line ART. HIVDR genotyping of dried blood spots obtained from these individuals was performed using standard population sequencing methods. The Stanford HIVDR algorithm was used to identify sequences with predicted resistance; genotypic susceptibility scores for potential third-line regimens were calculated. Two hundred thirty-eight individuals were enrolled; 57.6% were female. The median age and duration on PI/r-based ART at time of enrolment were 37 years and 3.46 years, respectively. 97.5% received lopinavir/ritonavir-based regimens. The prevalence of nucleoside reverse transcriptase inhibitor (NRTI), non-nucleoside reverse transcriptase inhibitor (NNRTI), and PI/r resistance was 50.6%, 63.1%, and 13.1%, respectively. No significant association was observed between HIVDR prevalence and age or sex. This study demonstrates high levels of NRTI and NNRTI resistance and moderate levels of PI resistance in people receiving PI/r-based second-line ART in Namibia. Findings underscore the need for objective and inexpensive measures of adherence to identify those in need of intensive adherence counselling, routine viral load monitoring to promptly detect virological failure, and HIVDR genotyping to optimize selection of third-line drugs in Namibia.
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Affiliation(s)
- Michael R. Jordan
- Division of Geographic Medicine and Infectious Disease, Tufts Medical Center
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Ndapewa Hamunime
- Directorate of Special Programmes, Ministry of Health and Social Services, Windhoek, Namibia
| | - Leonard Bikinesi
- Directorate of Special Programmes, Ministry of Health and Social Services, Windhoek, Namibia
| | | | - Simon Agolory
- United States Centers for Disease Control and Prevention
| | | | - Taffa Negussie
- Directorate of Special Programmes, Ministry of Health and Social Services, Windhoek, Namibia
| | | | | | - Nicholus Mutenda
- Directorate of Special Programmes, Ministry of Health and Social Services, Windhoek, Namibia
| | | | - Natalie Dean
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | - Kim Steegen
- Department of Molecular Medicine and Haematology, University of Witwatersrand, Johannesburg, South Africa
| | - Vibha Kana
- Department of Molecular Medicine and Haematology, University of Witwatersrand, Johannesburg, South Africa
| | - Sergio Carmona
- Department of Molecular Medicine and Haematology, University of Witwatersrand, Johannesburg, South Africa
| | - Chunfu Yang
- United States Centers for Disease Control and Prevention, Atlanta, GA
| | - Alice M. Tang
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Neil Parkin
- Data First Consulting, Inc., Sebastopol, CA, USA
| | - Steven Y. Hong
- Division of Geographic Medicine and Infectious Disease, Tufts Medical Center
- United States Centers for Disease Control and Prevention
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Heller T, Ganesh P, Gumulira J, Nkhoma L, Chipingu C, Kanyama C, Kalua T, Nyrienda R, Phiri S, Schooley A. Successful establishment of third-line antiretroviral therapy in Malawi: lessons learned. Public Health Action 2019; 9:169-173. [PMID: 32042610 DOI: 10.5588/pha.19.0043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 08/15/2019] [Indexed: 11/10/2022] Open
Abstract
SETTING Malawi has an extensive national antiretroviral treatment (ART) program, and although less than 2% of all patients receive second-line ART, there are increasingly more patients failing on these regimens. OBJECTIVE To establish a virtual ART committee using limited available local facilities and expertise to recommend third-line regimens based on genotype resistance of samples sent abroad. DESIGN A secretariat and a laboratory sample hub were established. The committee started work after locally organizing training courses. Decisions about ART regimens were mainly based on a relatively simple, previously described algorithm, which allowed decisions to be taken without extensive expert knowledge. RESULTS Of the 25 applications assessed, 23 samples were sent for resistance testing from June 2017 to April 2018. Major protease inhibitor (PI) resistance was detected in 65% of the samples. PI resistance was found even in patients exposed to PIs for short periods. In particular, patients who received co-administration of PIs and rifampicin frequently showed resistance mutations. CONCLUSION Third-line ART using genotypic resistance testing and algorithm-based treatment regimens are feasible in low-resource settings. Our model can serve as a base for similar programs initiating programmatic third-line ART in other African countries.
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Affiliation(s)
- T Heller
- Lighthouse Trust, Lilongwe, Malawi
| | - P Ganesh
- Lighthouse Trust, Lilongwe, Malawi.,International Training and Education Center for Health, Department of Global Health, University of Washington, Seattle, WA, USA
| | | | - L Nkhoma
- Lighthouse Trust, Lilongwe, Malawi
| | - C Chipingu
- Partners in Hope Medical Centre, Lilongwe, Malawi
| | - C Kanyama
- University of North Carolina Project, Lilongwe, Malawi
| | - T Kalua
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - R Nyrienda
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - S Phiri
- Lighthouse Trust, Lilongwe, Malawi.,Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA.,Department of Public Health, College of Medicine, School of Public Health and Family Medicine, University of Malawi, Blantyre, Malawi
| | - A Schooley
- Partners in Hope Medical Centre, Lilongwe, Malawi.,Department of Medicine, Division of Infectious Disease, David Geffen School of Medicine at the University of California, Los Angeles, CA, USA
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Grinsztejn B, Hughes MD, Ritz J, Salata R, Mugyenyi P, Hogg E, Wieclaw L, Gross R, Godfrey C, Cardoso SW, Bukuru A, Makanga M, Faesen S, Mave V, Wangari Ndege B, Nerette Fontain S, Samaneka W, Secours R, van Schalkwyk M, Mngqibisa R, Mohapi L, Valencia J, Sugandhavesa P, Montalban E, Avihingsanon A, Santos BR, Kumarasamy N, Kanyama C, Schooley RT, Mellors JW, Wallis CL, Collier AC. Third-line antiretroviral therapy in low-income and middle-income countries (ACTG A5288): a prospective strategy study. Lancet HIV 2019; 6:e588-e600. [PMID: 31371262 PMCID: PMC6857629 DOI: 10.1016/s2352-3018(19)30146-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 03/22/2019] [Accepted: 04/26/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Antiretroviral therapy (ART) management is challenging for individuals in resource-limited settings presenting for third-line treatment because of complex resistance patterns, partly due to reduced access to viral load monitoring. We aimed to evaluate use of newer antiretroviral drugs and contemporary management approaches, including population-based sequencing, to select appropriate antiretrovirals, plasma viral load monitoring, and interventions to improve adherence in individuals presenting with second-line viral failure. METHODS A5288 was a phase 4, third-line ART strategy study done at 19 urban sites in ten countries that enrolled adult participants with confirmed plasma HIV-1 RNA (viral load) of 1000 copies per mL or more after more than 24 weeks of protease inhibitor-based second-line ART. The primary objective was to use antiretrovirals (raltegravir, etravirine, and ritonavir-boosted darunavir) and diagnostic monitoring technologies, including viral load, genotyping, and adherence support to achieve viral load suppression (defined as ≤200 copies per mL) in 65% or more of participants. ART history and real-time drug resistance genotypes were used to assign participants to one of four cohorts: cohort A (no lopinavir resistance) stayed on second-line ART and cohorts B (B1, best available nucleoside reverse transcriptase inhibitors [NRTIs] plus ritonavir-boosted darunavir plus raltegravir; B2, ritonavir-boosted darunavir plus raltegravir plus etravirine; B3, ritonavir-boosted darunavir, raltegravir, and either tenofovir plus emtricitabine or tenofovir plus lamivudine), C (ritonavir-boosted darunavir plus raltegravir plus tenofovir-emtricitabine or tenofovir plus lamivudine), and D (best available NRTIs plus ritonavir-boosted darunavir plus raltegravir) were defined by increasing levels of resistance and received appropriate regimens, including new antiretrovirals. Participants in Cohort B without detectable hepatitis B surface antigen were assigned by blocked randomisation to cohorts B1 and B2, and those with detectable hepatitis B surface antigen were assigned to cohort B3. The trial is registered with ClinicalTrials.gov, number NCT01641367. FINDINGS From Jan 10, 2013, to Sept 10, 2015, 545 participants were enrolled. 287 (53%) were assigned to cohort A, 74 (14%) to B1, 72 (13%) to B2, eight (1%) to B3, 70 (13%) to C, and 34 (6%) to D. Overall, 349 (64%, 95% CI 60-68) participants achieved viral suppression at week 48, with proportions varying from 125 (44%) of 287 in cohort A to 65 (88%) of 74 in cohort B1, 63 (88%) of 72 in B2, eight (100%) of eight in B3, 63 (90%) of 70 in C, and 25 (74%) of 34 in D. Participants in cohort A remained on their second-line protease inhibitor, and had the most participants with grade 3 or higher adverse events (147 [51%]). INTERPRETATION Targeted real-time genotyping to select third-line ART can appropriately allocate more costly antiretrovirals to those with greater levels of HIV drug resistance. FUNDING National Institutes of Health.
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Affiliation(s)
- Beatriz Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil.
| | | | - Justin Ritz
- Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Robert Salata
- Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | | | - Evelyn Hogg
- Social & Scientific Systems, Inc, Silver Spring, MD, USA
| | - Linda Wieclaw
- Frontier Science & Technology Research Foundation, Amherst, NY, USA
| | - Robert Gross
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - Catherine Godfrey
- Division of AIDS, National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Sandra W Cardoso
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | | | - Mumbi Makanga
- Kenya Medical Research Institute, Kisumu, Kenya; Center of Disease Control, Kisumu, Kenya
| | - Sharlaa Faesen
- Wits HIV Clinical Research Site, Johannesburg, South Africa
| | - Vidya Mave
- BJ Medical College Clinical Research Site, Pune, India
| | | | | | - Wadzanai Samaneka
- University of Zimbabwe College of Health Sciences Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Rode Secours
- Les Centres GHESKIO Clinical Research Site, Port-au-Prince, Haiti
| | - Marije van Schalkwyk
- Family Clinical Research Unit Clinical Research Site, Stellenbosch University, Cape Town, South Africa
| | - Rosie Mngqibisa
- Durban Adult HIV Clinical Research Site, Enhancing Care Foundation, Durban, South Africa
| | - Lerato Mohapi
- Soweto AIDS Clinical Trials Group Clinical Research Site, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | | | - Anchalee Avihingsanon
- Thai Red Cross AIDS Research Center Treatment Clinical Research Site, Bangkok, Thailand
| | - Breno R Santos
- Serviço de Infectologia, Hospital Nossa Senhora da Conceicao, Grupo Hospitalar Conceição, Porto Alegre, Brazil
| | | | - Cecilia Kanyama
- University of North Carolina Project, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Robert T Schooley
- Division of Infectious Disease, University of California, San Diego, CA, USA
| | - John W Mellors
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Carole L Wallis
- Bio Analytical Research Corporation South Africa, Lancet Laboratories, Johannesburg, South Africa
| | - Ann C Collier
- University of Washington School of Medicine, University of Washington, Seattle, WA, USA
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Zhang G, DeVos J, Medina-Moreno S, Wagar N, Diallo K, Beard RS, Zheng DP, Mwachari C, Riwa C, Jullu B, Wangari NE, Kibona MS, Ng'Ang'A LW, Raizes E, Yang C. Utilization of dried blood spot specimens can expedite nationwide surveillance of HIV drug resistance in resource-limited settings. PLoS One 2018; 13:e0203296. [PMID: 30192818 PMCID: PMC6128523 DOI: 10.1371/journal.pone.0203296] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 08/14/2018] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Surveillance of HIV drug resistance (HIVDR) is crucial to ensuring the continued success of antiretroviral therapy (ART) programs. With the concern of reduced genotyping sensitivity of HIV on dried blood spots (DBS), DBS for HIVDR surveillance have been limited to ART-naïve populations. To investigate if DBS under certain conditions may also be a feasible sample type for HIVDR testing in ART patients, we piloted nationwide surveys for HIVDR among ART patients using DBS in two African countries with rapid scale-up of ART. METHODS EDTA-venous blood was collected to prepare DBS from adult and pediatric ART patients receiving treatment during the previous 12-36 months. DBS were stored at ambient temperature for two weeks and then at -80°C until shipment at ambient temperature to the WHO-designated Specialized HIVDR Laboratory at CDC in Atlanta. Viral load (VL) was determined using NucliSENS EasyQ® HIV-1 v2.0 kits; HIVDR genotyping was performed using the ATCC HIV-1 Drug Resistance Genotyping kits. RESULTS DBS were collected from 1,368 and 1,202 ART patients; 244 and 255 these specimens had VL ≥1,000 copies/mL in Kenya and Tanzania, respectively. The overall genotyping rate of those DBS with VL ≥1,000 copies/mL was 93.0% (95% CI: 89.1%-95.6%) in Kenya and 91.8% (87.7%-94.6%) in Tanzania. The turnaround times for the HIVDR surveys from the time of collecting DBS to completing laboratory testing were 6.5 months and 9.3 months for the Kenya and Tanzania surveys, respectively. CONCLUSIONS The study demonstrates a favorable outcome of using DBS for nationwide surveillance of HIVDR in ART patients. Our results confirm that DBS collected and stored at ambient temperature for two weeks, and shipped with routine courier services are a reliable sample type for large-scale surveillance of acquired HIVDR.
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Affiliation(s)
- Guoqing Zhang
- International Laboratory Branch, Division of Global HIV & TB, Center for Global Health, CDC, Atlanta, GA, United States of America
| | - Joshua DeVos
- International Laboratory Branch, Division of Global HIV & TB, Center for Global Health, CDC, Atlanta, GA, United States of America
| | - Sandra Medina-Moreno
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Nicholas Wagar
- International Laboratory Branch, Division of Global HIV & TB, Center for Global Health, CDC, Atlanta, GA, United States of America
| | - Karidia Diallo
- International Laboratory Branch, Division of Global HIV & TB, Center for Global Health, CDC, Atlanta, GA, United States of America
| | - R. Suzanne Beard
- International Laboratory Branch, Division of Global HIV & TB, Center for Global Health, CDC, Atlanta, GA, United States of America
| | - Du-Ping Zheng
- International Laboratory Branch, Division of Global HIV & TB, Center for Global Health, CDC, Atlanta, GA, United States of America
| | | | - Carolyn Riwa
- The Ministry of Health Tanzania, Dar es Salaam, Tanzania
| | - Boniface Jullu
- The Ministry of Health Tanzania, Dar es Salaam, Tanzania
| | | | | | | | - Elliot Raizes
- Adult Care and Treatment Branch, Division of Global HIV & TB, Center for Global Health, CDC, Atlanta, GA, United States of America
| | - Chunfu Yang
- International Laboratory Branch, Division of Global HIV & TB, Center for Global Health, CDC, Atlanta, GA, United States of America
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