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Appiah P, Gbassana G, Adusei-Poku M, Obeng BM, Duedu KO, Sagoe KWC. Genetic landscape for majority and minority HIV-1 drug resistance mutations in antiretroviral therapy naive patients in Accra, Ghana. Heliyon 2024; 10:e33180. [PMID: 39022058 PMCID: PMC11253264 DOI: 10.1016/j.heliyon.2024.e33180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 06/11/2024] [Accepted: 06/15/2024] [Indexed: 07/20/2024] Open
Abstract
Background The successful detection of drug-resistance mutations (DRMs) in HIV-1 infected patients has improved the management of HIV infection. Next-generation sequencing (NGS) to detect low-frequency mutations is predicted to be useful for efficiently testing minority drug resistance mutations, which could contribute to virological failure. This study employed Sanger sequencing and NGS to detect and compare minority and majority drug resistance mutations in HIV-1 strains in treatment-naive patients from Ghana. Method From a previous study, 20 antiretroviral therapy (ART)-naive participants were selected for a cross-sectional study. Sanger sequencing and NGS techniques were used to detect the majority and minority HIV drug resistance (HIVDR) mutations, respectively, in the protease (PR) and partial reverse transcriptase (RT) genes. NGS detected mutations at 1 % and 5 % frequencies and Sanger sequencing at ≥20 % frequencies. The sequences obtained from NGS and Sanger sequencing platforms were submitted to the Stanford HIV drug resistance database for subtyping, mutation identification, and interpretations. Results Sequences from the twenty participants where the CRF02_AG was the predominant strain (16, 80 %) were analyzed. NGS detected 25 mutations in the RT and PR genes, compared to 21 mutations by Sanger sequencing. Minority DRMs were detected at the prevalence of 55.0 % with NGS against 35 % DRMs by Sanger sequencing. One of the patients had eight different HIVDR variants, with two minority variants. These mutations were directed against PI (K20I and D30DN), NNRTI (Y181C, M23LM and V108I) and NRTI (K65R, M184I, and D67N). Conclusion The study affirms the usefulness of genomic sequencing for drug resistance testing in HIV. It further shows that Sanger sequencing alone may not be adequate to detect mutations and that NGS capacity should be developed and deployed in the Ghanaian clinical settings for patients living with HIV.
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Affiliation(s)
- Pious Appiah
- Department of Medical Microbiology, Medical School, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Gaspah Gbassana
- Department of Laboratory Medicine, A. M. Dogliotti School of Medicine, University of Liberia, Monrovia, Liberia
| | - Mildred Adusei-Poku
- Department of Medical Microbiology, Medical School, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Billal Musah Obeng
- Department of Medical Microbiology, Medical School, College of Health Sciences, University of Ghana, Accra, Ghana
- Immunovirology & Pathogenesis Program, Kirby Institute, University of New South Wales, Australia
| | - Kwabena Obeng Duedu
- Department of Biomedical Sciences, University of Health and Allied Sciences, Ho, Ghana
- College of Life Sciences, Birmingham City University, City South Campus, Birmingham, B15 3TN, United Kingdom
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Lao X, Zhang H, Yan L, Zhao H, Zhao Q, Lu H, Chen Y, Li H, Chen J, Ye F, Yu F, Xiao Q, Li Q, Liang X, Yang X, Yan C, Zhang F. Thirteen-year viral suppression and immunologic recovery of LPV/r-based regimens in pediatric HIV treatment: a multicenter cohort study in resource-constrained settings of China. Front Med (Lausanne) 2023; 10:1313734. [PMID: 38188331 PMCID: PMC10771832 DOI: 10.3389/fmed.2023.1313734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 12/07/2023] [Indexed: 01/09/2024] Open
Abstract
Background Antiretroviral Therapy (ART) in children remains challenging due to resource-constrained settings. We conducted a 13-year, prospective, multicenter cohort study on the effectiveness and safety of LPV/r-based regimens in ART-naive and ART-experienced children. Methods From January 2008 to May 2021, children living with HIV-1 were recruited with LPV/r-based regimens from 8 clinical research sites in 6 provinces in China. Effectiveness outcomes were virologic failure (defined as at least two consecutive measurements of VL > 200 copies/mL after 6 months of ART) and immune response (defined as CD4% recovered to more than 25% after 12 months of treatment). The safety outcomes were treatment-related grade 2-4 adverse events and abnormal laboratory test results. Results A total of 345 ART-naïve children and 113 ART-experienced children were included in this cohort study. The median follow-up time was 7.3 (IQR 5.5-10.5) years. The incidence density of virologic failure was 4.1 (95% CI 3.3-4.9) per 100 person-years in ART-naïve children and 5.0 (95% CI 3.5-6.5) per 100 person-years in ART-experienced children. Kaplan Meyer (KM) curve analysis showed children with ART experience were at a higher risk of virologic failure (p < 0.05). The risk factors of virologic failure in ART-naïve children were clinic setting in rural hospitals (aHR = 2.251, 1.108-4.575), annual missed dose times >5 days of LPV intake (aHR = 1.889, 1.004-3.554); The risk factor of virologic failure in ART-experienced children was missed dose times >5 days (aHR = 2.689, 1.299-5.604) and mother as caregivers for ART administration (aHR = 0.475, 0.238-0.948). However, during long-term treatment, viral suppression rates between ART-naïve and ART-experienced children remained similar. No significant differences were observed in the immune response, treatment-related grade 2-4 events, and abnormal laboratory test results between ART-naïve children and ART-experienced children. Conclusion Our research underscores that with consistent, long-term treatment of LPV/r-based regimens, ART-experienced children can achieve therapeutic outcomes comparable to ART-naïve children. It provides crucial insights on LPV/r-based regimens in pediatric HIV treatment, especially in resource-limited settings where high-cost Integrase Strand Transfer Inhibitors (INSTs) are inaccessible. This evidence-based understanding provides an essential addition to the global therapeutic strategies for pediatric HIV treatment.
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Affiliation(s)
- Xiaojie Lao
- Department of Infectious Disease, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Hanxi Zhang
- WHO Collaborating Centre for Comprehensive Management of HIV Treatment and Care, Beijing Ditan Hospital Capital Medical University, Beijing, China
| | - Liting Yan
- Department of Infectious Disease, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Hongxin Zhao
- Department of Infectious Disease, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Qingxia Zhao
- Department of Infectious Disease, The Sixth People's Hospital of Zhengzhou, Zhengzhou, China
| | - Hongyan Lu
- Department of Infectious Disease, Guangxi Zhuang Autonomous Region Center for Disease Control and Prevention, Nanning, China
| | - Yuewu Chen
- Department of Infectious Disease, Shangcai Center for Disease Control and Prevention of Henan Province, Shangcai, China
| | - Huiqin Li
- AIDS Care Center, Yunnan Provincial Hospital of Infectious Disease, Kunming, China
| | - Jinfeng Chen
- Center for Infectious Diseases, Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Fuxiu Ye
- Department of Infectious Disease, The Second People's Hospital of Yining, Xinjiang, China
| | - Fengting Yu
- Department of Infectious Disease, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Qing Xiao
- Department of Infectious Disease, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Qun Li
- Department of Infectious Disease, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Xuelei Liang
- Department of Infectious Disease, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Xiaojie Yang
- Department of Infectious Disease, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Chang Yan
- Department of Infectious Disease, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Fujie Zhang
- Department of Infectious Disease, Beijing Ditan Hospital, Capital Medical University, Beijing, China
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Bareng OT, Moyo S, Zahralban-Steele M, Maruapula D, Ditlhako T, Mokaleng B, Mokgethi P, Choga WT, Moraka NO, Pretorius-Holme M, Mine MO, Raizes E, Molebatsi K, Motswaledi MS, Gobe I, Mohammed T, Gaolathe T, Shapiro R, Mmalane M, Makhema JM, Lockman S, Essex M, Novitsky V, Gaseitsiwe S. HIV-1 drug resistance mutations among individuals with low-level viraemia while taking combination ART in Botswana. J Antimicrob Chemother 2022; 77:1385-1395. [PMID: 35229102 PMCID: PMC9633723 DOI: 10.1093/jac/dkac056] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 02/03/2022] [Indexed: 10/13/2023] Open
Abstract
OBJECTIVES To assess whether a single instance of low-level viraemia (LLV) is associated with the presence of drug resistance mutations (DRMs) and predicts subsequent virological failure (VF) in adults receiving ART in 30 communities participating in the Botswana Combination Prevention Project. METHODS A total of 6078 HIV-1 C pol sequences were generated and analysed using the Stanford HIV drug resistance database. LLV was defined as plasma VL = 51-999 copies/mL and VF was defined as plasma VL ≥ 1000 copies/mL. RESULTS Among 6078 people with HIV (PWH), 4443 (73%) were on ART for at least 6 months. Of the 332 persons on ART with VL > 50 copies/mL, 175 (4%) had VL ≥ 1000 copies/mL and 157 (4%) had LLV at baseline. The prevalence of any DRM was 57 (36%) and 78 (45%) in persons with LLV and VL ≥ 1000 copies/mL, respectively. Major DRMs were found in 31 (20%) with LLV and 53 (30%) with VL ≥ 1000 copies/mL (P = 0.04). Among the 135 PWH with at least one DRM, 17% had NRTI-, 35% NNRTI-, 6% PI- and 3% INSTI-associated mutations. Among the 3596 participants who were followed up, 1709 (48%) were on ART for ≥6 months at entry and had at least one subsequent VL measurement (median 29 months), 43 (3%) of whom had LLV. The OR of experiencing VF in persons with LLV at entry was 36-fold higher than in the virally suppressed group. CONCLUSIONS A single LLV measurement while on ART strongly predicted the risk of future VF, suggesting the use of VL > 50 copies/mL as an indication for more intensive adherence support with more frequent VL monitoring.
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Affiliation(s)
- Ontlametse T Bareng
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- School of Allied Health Professions, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana
| | - Sikhulile Moyo
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Melissa Zahralban-Steele
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Dorcas Maruapula
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Biological Sciences, Faculty of Science, University of Botswana, Gaborone, Botswana
| | | | - Baitshepi Mokaleng
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- School of Allied Health Professions, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana
| | | | - Wonderful T Choga
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Division of Human Genetics, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Natasha O Moraka
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Division of Medical Virology, Stellenbosch University, Cape Town, South Africa
| | - Molly Pretorius-Holme
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Madisa O Mine
- Botswana Ministry of Health and Wellness, Gaborone, Botswana
| | - Elliot Raizes
- U.S. Centers for Disease Control and Prevention, Atlanta, USA
| | - Kesaobaka Molebatsi
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Statistics, University of Botswana, Gaborone, Botswana
| | - Modisa S Motswaledi
- School of Allied Health Professions, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana
| | - Irene Gobe
- School of Allied Health Professions, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana
| | | | | | - Roger Shapiro
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Mompati Mmalane
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Joseph M Makhema
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Shahin Lockman
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA, USA
- Brigham and Women’s Hospital, Boston, MA, USA
| | - Max Essex
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Vlad Novitsky
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Simani Gaseitsiwe
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA, USA
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Chun HM, Obeng-Aduasare YF, Broyles LN, Ellenberger D. Expansion of Viral Load Testing and the Potential Impact on Human Immunodeficiency Virus Drug Resistance. J Infect Dis 2017; 216:S808-S811. [PMID: 29029178 DOI: 10.1093/infdis/jix404] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Increasing the volume, strengthening the quality, and proactively using data of human immunodeficiency virus (HIV) load testing are pivotal to limiting the threat of HIV drug resistance (HIVDR) accumulation,and allow for optimal case-based HIVDR surveillance. Triangulation of viral load (VL) and HIVDR testing data could be pursued to answer key questions and translate data and results for program and public policy. Identification of virologic failure and early management mitigates the greater risk of HIVDR. Routine VL monitoring and evaluation systems are necessary, and countries should consider reviewing system requirements, structural needs, and procedural and technical factors for the entire VL cascade, with special emphasis on post-test result use.
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Affiliation(s)
- Helen M Chun
- Division of Global HIV and TB, Center for Global Health, Centers for Disease Control and Prevention
| | | | - Laura N Broyles
- Division of Global HIV and TB, Center for Global Health, Centers for Disease Control and Prevention
| | - Dennis Ellenberger
- Division of Global HIV and TB, Center for Global Health, Centers for Disease Control and Prevention
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Gibson RM, Nickel G, Crawford M, Kyeyune F, Venner C, Nankya I, Nabulime E, Ndashimye E, Poon AFY, Salata RA, Kityo C, Mugyenyi P, Quiñones-Mateu ME, Arts EJ. Sensitive detection of HIV-1 resistance to Zidovudine and impact on treatment outcomes in low- to middle-income countries. Infect Dis Poverty 2017; 6:163. [PMID: 29202874 PMCID: PMC5716384 DOI: 10.1186/s40249-017-0377-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 11/22/2017] [Indexed: 12/31/2022] Open
Abstract
Background Thymidine analogs, namely AZT (Zidovudine or Retrovir™) and d4T (Stavudine or Zerit™) are antiretroviral drugs still employed in over 75% of first line combination antiretroviral therapy (cART) in Kampala, Uganda despite aversion to prescribing these drugs for cART in high income countries due in part to adverse events. For this study, we explored how the continued use of these thymidine analogs in cART could impact emergence of drug resistance and impact on future treatment success in Uganda, a low-income country. Methods We examined the drug resistance genotypes by Sanger sequencing of 262 HIV-infected patients failing a first line combined antiretroviral treatment containing either AZT or d4T, which represents approximately 5% of the patients at the Joint Clinical Research Center receiving a AZT or d4T containing treatment. Next generation sequencing (DEEPGEN™HIV) and multiplex oligonucleotide ligation assays (AfriPOLA) were then performed on a subset of patient samples to detect low frequency drug resistant mutations. CD4 cell counts, viral RNA loads, and treatment changes were analyzed in a cohort of treatment success and failures. Results Over 80% of patients failing first line AZT/d4T-containing cART had predicted drug resistance to 3TC (Lamivudine) and non-nucleoside RT inhibitors (NNRTIs) in the treatment regimen but only 45% had resistance AZT/d4T associated resistance mutations (TAMs). TAMs were however detected at low frequency within the patients HIV quasispecies (1–20%) in 21 of 34 individuals who were failing first-line AZT-containing cART and lacked TAMs by Sanger. Due to lack of TAMs by Sanger, AZT was typically maintained in second-line therapies and these patients had a low frequency of subsequent virologic success. Conclusions Our findings suggest that continued use of AZT and d4T in first-line treatment in low-to-middle income countries may lead to misdiagnosis of HIV-1 drug resistance and possibly enhance a succession of second- and third-line treatment failures. Electronic supplementary material The online version of this article (doi: 10.1186/s40249-017-0377-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Richard M Gibson
- Department of Microbiology and Immunology, University of Western Ontario, 1151 Richmond St., Dental Sciences Bldg., Rm 3014, London, Ontario, N6A 5C1, Canada
| | - Gabrielle Nickel
- Division of Infectious Diseases, Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Michael Crawford
- Division of Infectious Diseases, Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Fred Kyeyune
- Department of Molecular Biology and Microbiology, Case Western Reserve University, Cleveland, OH, USA.,Department of Pathology, Case Western Reserve University, Cleveland, OH, USA
| | - Colin Venner
- Department of Microbiology and Immunology, University of Western Ontario, 1151 Richmond St., Dental Sciences Bldg., Rm 3014, London, Ontario, N6A 5C1, Canada
| | - Immaculate Nankya
- Department of Molecular Biology and Microbiology, Case Western Reserve University, Cleveland, OH, USA.,Center for AIDS Research Uganda Laboratories, Joint Clinical Research Centre, Kampala, Uganda.,Department of Pathology and Laboratory Medicine, University of Western Ontario, Kampala, Uganda
| | - Eva Nabulime
- Center for AIDS Research Uganda Laboratories, Joint Clinical Research Centre, Kampala, Uganda
| | - Emmanuel Ndashimye
- Center for AIDS Research Uganda Laboratories, Joint Clinical Research Centre, Kampala, Uganda
| | - Art F Y Poon
- Department of Pathology and Laboratory Medicine, University of Western Ontario, Kampala, Uganda
| | - Robert A Salata
- Division of Infectious Diseases, Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Cissy Kityo
- Center for AIDS Research Uganda Laboratories, Joint Clinical Research Centre, Kampala, Uganda
| | - Peter Mugyenyi
- Center for AIDS Research Uganda Laboratories, Joint Clinical Research Centre, Kampala, Uganda
| | - Miguel E Quiñones-Mateu
- Division of Infectious Diseases, Department of Medicine, Case Western Reserve University, Cleveland, OH, USA.,Department of Pathology, Case Western Reserve University, Cleveland, OH, USA.,Center for AIDS Research Uganda Laboratories, Joint Clinical Research Centre, Kampala, Uganda
| | - Eric J Arts
- Department of Microbiology and Immunology, University of Western Ontario, 1151 Richmond St., Dental Sciences Bldg., Rm 3014, London, Ontario, N6A 5C1, Canada. .,TREAT, Joint Clinical Research Centre, Kampala, Uganda.
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Meloni ST, Onwuamah CK, Agbaji O, Chaplin B, Olaleye DO, Audu R, Samuels J, Ezechi O, Imade G, Musa AZ, Odaibo G, Okpokwu J, Rawizza H, Mu’azu MA, Dalhatu I, Ahmed M, Okonkwo P, Raizes E, Ujah IAO, Yang C, Idigbe EO, Kanki PJ. Implication of First-Line Antiretroviral Therapy Choice on Second-Line Options. Open Forum Infect Dis 2017; 4:ofx233. [PMID: 29255731 PMCID: PMC5726477 DOI: 10.1093/ofid/ofx233] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 10/17/2017] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Although there are a number of studies comparing the currently recommended preferred and alternative first-line (1L) antiretroviral therapy (ART) regimens on clinical outcomes, there are limited data examining the impact of 1L regimen choice and duration of virologic failure (VF) on accumulation of drug resistance mutations (DRM). The patterns of DRM from patients failing zidovudine (AZT)-containing versus tenofovir (TDF)-containing ART were assessed to evaluate the predicted susceptibility to second-line (2L) nucleoside reverse-transcriptase inhibitor (NRTI) backbone options in the context of an ongoing programmatic setting that uses viral load (VL) monitoring. METHODS Paired samples from Nigerian ART patients who experienced VF and switched to 2L ART were retrospectively identified. For each sample, the human immunodeficiency virus (HIV)-1 polymerase gene was sequenced at 2 time points, and DRM was analyzed using Stanford University's HIVdb program. RESULTS Sequences were generated for 191 patients. At time of 2L switch, 28.2% of patients on AZT-containing regimens developed resistance to TDF, whereas only 6.8% of patients on TDF-containing 1L had mutations compromising susceptibility to AZT. In a stratified evaluation, patients with 0-6 months between tested VL samples had no difference in proportion compromised to 2L, whereas those with >6 months between samples had a statistically significant difference in proportion with compromised 2L NRTI. In multivariate analyses, patients on 1L AZT had 9.90 times higher odds of having a compromised 2L NRTI option than patients on 1L TDF. CONCLUSIONS In the context of constrained resources, where VL monitoring is limited, we present further evidence to support use of TDF as the preferred 1L NRTI because it allows for preservation of the recommended 2L NRTI option.
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Affiliation(s)
- Seema T Meloni
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Chika K Onwuamah
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Oche Agbaji
- Jos University Teaching Hospital, Plateau State, Nigeria
| | - Beth Chaplin
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | | | - Rosemary Audu
- Nigerian Institute of Medical Research, Lagos, Lagos State, Nigeria
| | - Jay Samuels
- AIDS Prevention Initiative Nigeria, Ltd./Gte., Abuja
| | - Oliver Ezechi
- Nigerian Institute of Medical Research, Lagos, Lagos State, Nigeria
| | - Godwin Imade
- Jos University Teaching Hospital, Plateau State, Nigeria
| | - Adesola Z Musa
- Nigerian Institute of Medical Research, Lagos, Lagos State, Nigeria
| | | | | | - Holly Rawizza
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Brigham and Women’s Hospital, Boston, Massachusetts
| | | | | | | | | | - Elliot Raizes
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Chunfu Yang
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Phyllis J Kanki
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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7
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Field Evaluation of Dried Blood Spots for HIV-1 Viral Load Monitoring in Adults and Children Receiving Antiretroviral Treatment in Kenya: Implications for Scale-up in Resource-Limited Settings. J Acquir Immune Defic Syndr 2017; 74:399-406. [PMID: 28002185 DOI: 10.1097/qai.0000000000001275] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND The World Health Organization recommends viral load (VL) as the preferred method for diagnosing antiretroviral therapy failure; however, operational challenges have hampered the implementation of VL monitoring in most resource-limited settings. This study evaluated the accuracy of dried blood spot (DBS) VL testing under field conditions as a practical alternative to plasma in determining virologic failure (VF). METHODS From May to December 2013, paired plasma and DBS specimens were collected from 416 adults and 377 children on antiretroviral therapy for ≥6 months at 12 clinics in Kenya. DBSs were prepared from venous blood (V-DBS) using disposable transfer pipettes and from finger-prick capillary blood using microcapillary tubes (M-DBS) and directly spotting (D-DBS). All samples were tested on the Abbott m2000 platform; V-DBS was also tested on the Roche COBAS Ampliprep/COBAS TaqMan (CAP/CTM) version 2.0 platform. VF results were compared at 3 DBS thresholds (≥1000, ≥3000, and ≥5000 copies/mL) and a constant plasma threshold of ≥1000 copies/mL. RESULTS On the Abbott platform, at ≥1000-copies/mL threshold, sensitivities, specificities, and kappa values for VF determination were ≥88.1%, ≥93.1%, and ≥0.82%, respectively, for all DBS methods, and it had the lowest percentage of downward misclassification compared with higher thresholds. V-DBS performance on CAP/CTM had significantly poorer specificity at all thresholds (1000%-33.0%, 3000%-60.9%, and 5000%-77.0%). No significant differences were found between adults and children. CONCLUSIONS VL results from V-DBS, M-DBS, and D-DBS were comparable with those from plasma for determining VF using the Abbott platform but not with CAP/CTM. A 1000-copies/mL threshold was optimal and should be considered for VF determination using DBS in adults and children.
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Karade SK, Ghate MV, Chaturbhuj DN, Kadam DB, Shankar S, Gaikwad N, Gurav S, Joshi R, Sane SS, Kulkarni SS, Kurle SN, Paranjape RS, Rewari BB, Gangakhedkar RR. Cross-sectional study of virological failure and multinucleoside reverse transcriptase inhibitor resistance at 12 months of antiretroviral therapy in Western India. Medicine (Baltimore) 2016; 95:e4886. [PMID: 27631260 PMCID: PMC5402603 DOI: 10.1097/md.0000000000004886] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The free antiretroviral therapy (ART) program in India has scaled up to register second largest number of people living with HIV/AIDS across the globe. To assess the effectiveness of current first-line regimen we estimated virological suppression on completion of 1 year of ART. The study describes the correlates of virological failure (VF) and multinucleoside reverse transcriptase inhibitor (NRTI) drug resistance mutations (DRMs).In this cross-sectional study conducted between June and August 2014, consecutive adults from 4 State sponsored ART clinics of western India were recruited for plasma viral load screening at 12 ± 2 months of ART initiation. Individuals with plasma viral load >1000 copies/mL were selected for HIV drug resistance (HIVDR) genotyping. Logistic regression analyses were performed to assess factors associated with VF and multi-NRTI resistance mutations. Criteria adopted for multi-NRTI resistance mutation were either presence of K65R or 3 or more thymidine analog mutations (TAMs) or presence of M184V along with 2 TAMs.Of the 844 study participants, virological suppression at 1 year was achieved in 87.7% of individuals. Factors significantly associated with VF (P < 0.005) were 12 months CD4 count of ≤100 cells/μL (adjusted OR -7.11), low reported adherence (adjusted OR -4.44), and those living without any partner (adjusted OR -1.98). In patients with VF, the prevalence of non-nucleoside reverse transcriptase inhibitor (NNRTI) DRM (78.75%) were higher as compared to NRTI (58.75%). Multi-NRTI DRMs were present in 32.5% of sequences and were significantly associated with CD4 count of ≤100 cells/μL at baseline (adjusted OR -13.00) and TDF-based failing regimen (adjusted OR -20.43). Additionally, low reported adherence was negatively associated with multi-NRTI resistance (adjusted OR -0.11, P = 0.015). K65R mutation was significantly associated with tenofovir (TDF)-based failing regimen (P < 0.001).The study supports early linkage of HIV-infected individuals to the program for ART initiation, adherence improvement, and introduction of viral load monitoring. With recent introduction of TDF-based regimen, the emergence of K65R needs to be monitored closely among HIV-1 subtype C-infected Indian population.
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Affiliation(s)
| | - Manisha V. Ghate
- Department of Clinical Sciences, National AIDS Research Institute
| | | | - Dileep B. Kadam
- Department of Medicine, BJ Medical College and Sasoon General Hospital, Pune
| | | | - Nitin Gaikwad
- Department of Tuberculosis and Chest Diseases, YCM Hospital
| | | | | | | | | | | | | | - Bharat B. Rewari
- Department of AIDS Control, National AIDS Control Organization, New Delhi, India
| | - Raman R. Gangakhedkar
- Department of Clinical Sciences, National AIDS Research Institute
- Correspondence: Raman R. Gangakhedkar, National AIDS Research Institute (ICMR), 73 G Block, MIDC Bhosari, Pune 411026, India (e-mail: )
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9
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Thompson M, Lalezari JP, Kaplan R, Pinedo Y, Sussmann Pena OA, Cahn P, Stock DA, Joshi SR, Hanna GJ, Lataillade M. Safety and efficacy of the HIV-1 attachment inhibitor prodrug fostemsavir in antiretroviral-experienced subjects: week 48 analysis of AI438011, a Phase IIb, randomized controlled trial. Antivir Ther 2016; 22:215-223. [DOI: 10.3851/imp3112] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2016] [Indexed: 10/20/2022]
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10
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Harrison L, Melvin A, Fiscus S, Saidi Y, Nastouli E, Harper L, Compagnucci A, Babiker A, McKinney R, Gibb D, Tudor-Williams G. HIV-1 Drug Resistance and Second-Line Treatment in Children Randomized to Switch at Low Versus Higher RNA Thresholds. J Acquir Immune Defic Syndr 2015; 70:42-53. [PMID: 26322666 PMCID: PMC4556171 DOI: 10.1097/qai.0000000000000671] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND The PENPACT-1 trial compared virologic thresholds to determine when to switch to second-line antiretroviral therapy (ART). Using PENPACT-1 data, we aimed to describe HIV-1 drug resistance accumulation on first-line ART by virologic threshold. METHODS PENPACT-1 had a 2 × 2 factorial design, randomizing HIV-infected children to start protease inhibitor (PI) versus nonnucleoside reverse transcriptase inhibitor (NNRTI)-based ART, and switch at a 1000 copies/mL versus 30,000 copies/mL threshold. Switch criteria were not achieving the threshold by week 24, confirmed rebound above the threshold thereafter, or Center for Disease Control and Prevention stage C event. Resistance tests were performed on samples ≥1000 copies/mL before switch, resuppression, and at 4-years/trial end. RESULTS Sixty-seven children started PI-based ART and were randomized to switch at 1000 copies/mL (PI-1000), 64 PIs and 30,000 copies/mL (PI-30,000), 67 NNRTIs and 1000 copies/mL (NNRTI-1000), and 65 NNRTI and 30,000 copies/mL (NNRTI-30,000). Ninety-four (36%) children reached the 1000 copies/mL switch criteria during 5-year follow-up. In 30,000 copies/mL threshold arms, median time from 1000 to 30,000 copies/mL switch criteria was 58 (PI) versus 80 (NNRTI) weeks (P = 0.81). In NNRTI-30,000, more nucleoside reverse transcriptase inhibitor (NRTI) resistance mutations accumulated than other groups. NNRTI mutations were selected before switching at 1000 copies/mL (23% NNRTI-1000, 27% NNRTI-30,000). Sixty-two children started abacavir + lamivudine, 166 lamivudine + zidovudine or stavudine, and 35 other NRTIs. The abacavir + lamivudine group acquired fewest NRTI mutations. Of 60 switched to second-line, 79% PI-1000, 63% PI-30,000, 64% NNRTI-1000, and 100% NNRTI-30,000 were <400 copies/mL 24 weeks later. CONCLUSIONS Children on first-line NNRTI-based ART who were randomized to switch at a higher virologic threshold developed the most resistance, yet resuppressed on second-line. An abacavir + lamivudine NRTI combination seemed protective against development of NRTI resistance.
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Affiliation(s)
- Linda Harrison
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Ann Melvin
- Seattle Children's Hospital, Seattle, WA
| | - Susan Fiscus
- University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC
| | | | - Eleni Nastouli
- University College London Hospitals, University College London, UK
| | - Lynda Harper
- Medical Research Council Clinical Trials Unit at University College London, UK
| | | | - Abdel Babiker
- Medical Research Council Clinical Trials Unit at University College London, UK
| | | | - Diana Gibb
- Medical Research Council Clinical Trials Unit at University College London, UK
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11
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Huang P, Tan J, Ma W, Zheng H, Lu Y, Wang N, Peng Z, Yu R. Outcomes of antiretroviral treatment in HIV-infected adults: a dynamic and observational cohort study in Shenzhen, China, 2003-2014. BMJ Open 2015; 5:e007508. [PMID: 26002691 PMCID: PMC4442238 DOI: 10.1136/bmjopen-2014-007508] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES To report 10-year outcomes of virological and immunological treatment failure rates and risk factors. DESIGN Prospective cohort study. SETTING Shenzhen, China. PARTICIPANTS 2172 HIV-positive adults in the national treatment database of Shenzhen from December 2003 to January 2014. INTERVENTION Antiretroviral therapy according to the Chinese national treatment guidelines. OUTCOME MEASURES Virological and immunological treatment failure rates. RESULTS Of the 3099 patients surveyed, 2172 (70.1%) were included in the study. The median age was 33 years; 78.2% were male and 51.8% were infected through heterosexual contact. The median follow-up time was 31 months (IQR, 26-38). A total of 81 (3.7%) patients died, whereas 292 (13.4%) and 400 (18.4%) patients experienced virological and immunological failures, respectively. Adjusted Cox regression analysis indicated that baseline viral load (HR=2.19, 95% CI 1.52 to 4.48 for patients with a baseline viral load greater than or equal to 1,000,000 copies/mL compared to those with less than 10,000 copies/mL) and WHO stage (HR=4.16, 95% CI 2.01 to 10.57 for patients in WHO stage IV compared with those in stage I) were significantly associated with virological failure. The strongest risk factors for immunological treatment failure were a low CD4 cell count (HR=0.46, 95% CI 0.32 to 0.66 for patients with CD4 cell counts of 50-99 cells/mm(3) compared to those with less than 50 cells/mm(3)) and higher baseline WHO stage at treatment initiation (HR=2.15, 95% CI 1.38 to 3.34 for patients in WHO stage IV compared to those in stage I). CONCLUSIONS Sustained virological and immunological outcomes show that patients have responded positively to long-term antiretroviral treatment with low mortality. This 10-year data study provides important information for clinicians and policymakers in the region as they begin to evaluate and plan for the future needs of their own rapidly expanding programmes.
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Affiliation(s)
- Peng Huang
- Department of Epidemiology and Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Jingguang Tan
- Department of STDs/AIDS Prevention and Control, Shenzhen Center for Disease Control and Prevention, Shenzhen, China
| | - Wenzhe Ma
- Department of Epidemiology and Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Hui Zheng
- Department of Epidemiology and Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Yan Lu
- Department of STDs/AIDS Prevention and Control, Shenzhen Center for Disease Control and Prevention, Shenzhen, China
| | - Ning Wang
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Zhihang Peng
- Department of Epidemiology and Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Rongbin Yu
- Department of Epidemiology and Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
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Armenia D, Fabeni L, Alteri C, Di Pinto D, Di Carlo D, Bertoli A, Gori C, Carta S, Fedele V, Forbici F, D'Arrigo R, Svicher V, Berno G, Pizzi D, Nicastri E, Sarmati L, Pinnetti C, Ammassari A, D'Offizi G, Latini A, Andreoni M, Antinori A, Ceccherini-Silberstein F, Perno CF, Santoro MM. HIV-1 integrase genotyping is reliable and reproducible for routine clinical detection of integrase resistance mutations even in patients with low-level viraemia. J Antimicrob Chemother 2015; 70:1865-73. [PMID: 25712318 DOI: 10.1093/jac/dkv029] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 01/25/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Integrase drug resistance monitoring deserves attention because of the increasing number of patients being treated with integrase strand-transfer inhibitors. Therefore, we evaluated the integrase genotyping success rate at low-level viraemia (LLV, 51-1000 copies/mL) and resistance in raltegravir-failing patients. METHODS An integrase genotypic resistance test (GRT) was performed on 1734 HIV-1 samples collected during 2006-13. Genotyping success rate was determined according to the following viraemia levels: 51-500, 501-1000, 1001-10 000, 10 001-100 000 and >100 000 copies/mL. The reproducibility of integrase GRT was evaluated in 41 plasma samples processed in duplicate in two reference centres. The relationship between LLV and resistance prevalence was evaluated in a subset of 120 raltegravir-failing patients. RESULTS Overall, the integrase genotyping success rate was 95.7%. For viraemia levels 51-500 and 501-1000 copies/mL, the rate of success was 82.1% and 94.0%, respectively. GRT was reproducible, producing sequences with a high similarity and an equal resistance profile regardless of the sequencing centre or viraemia level. Resistance was detected both at LLV and at viraemia >1000 copies/mL (51-500 copies/mL = 18.2%; 501-1000 = 37.5%; 1001-10 000 = 53.7%; 10 001-100 000 = 30.0%; and >100 000 = 30.8%). At viraemia ≤500 copies/mL, Q148H/K/R and N155H had the same prevalence (9.1%), while the Y143C/H/R was completely absent. At early genotyping (within 3 months of raltegravir treatment), Q148H/K/R and N155H mutations were detected regardless of the viraemia level, while Y143C/H/R was observed only in samples with viraemia >1000 copies/mL. CONCLUSIONS Our findings prove the reliability of HIV-1 integrase genotyping and reinforce the concept that this assay may be useful in the management of failures even at LLV.
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Affiliation(s)
- D Armenia
- University of Rome Tor Vergata, Rome, Italy
| | - L Fabeni
- L. Spallanzani Hospital, Rome, Italy
| | - C Alteri
- University of Rome Tor Vergata, Rome, Italy
| | - D Di Pinto
- University of Rome Tor Vergata, Rome, Italy
| | - D Di Carlo
- University of Rome Tor Vergata, Rome, Italy
| | - A Bertoli
- University of Rome Tor Vergata, Rome, Italy University Hospital Tor Vergata, Rome, Italy
| | - C Gori
- L. Spallanzani Hospital, Rome, Italy
| | - S Carta
- L. Spallanzani Hospital, Rome, Italy
| | - V Fedele
- L. Spallanzani Hospital, Rome, Italy
| | - F Forbici
- L. Spallanzani Hospital, Rome, Italy
| | | | - V Svicher
- University of Rome Tor Vergata, Rome, Italy
| | - G Berno
- L. Spallanzani Hospital, Rome, Italy
| | - D Pizzi
- L. Spallanzani Hospital, Rome, Italy
| | | | - L Sarmati
- University Hospital Tor Vergata, Rome, Italy
| | | | | | | | - A Latini
- San Gallicano Hospital, Rome, Italy
| | - M Andreoni
- University Hospital Tor Vergata, Rome, Italy
| | | | | | - C F Perno
- L. Spallanzani Hospital, Rome, Italy
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Cohen C. Low-Level Viremia in HIV-1 Infection: Consequences and Implications for Switching to a New Regimen. HIV CLINICAL TRIALS 2015; 10:116-24. [DOI: 10.1310/hct1002-116] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Figueroa MI, Sued O, Cahn P. What to do Next? Second-line Antiretroviral Therapy. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2014. [DOI: 10.1007/s40506-014-0013-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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15
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Serrao E, Wang CH, Frederick T, Lee CL, Anthony P, Arribas-Layton D, Baker K, Millstein J, Kovacs A, Neamati N. Alteration of select gene expression patterns in individuals infected with HIV-1. J Med Virol 2014; 86:678-86. [PMID: 24482297 DOI: 10.1002/jmv.23872] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2013] [Indexed: 01/06/2023]
Abstract
Multiple human proteins have been shown to both support and restrict viral replication, and confirmation of virus-associated changes in the expression of these genes is relevant for future therapeutic efforts. In this study a well-characterized panel of 49 individuals either infected with HIV-1 or uninfected was compiled and analyzed for the effect of HIV infection status, viral load, and antiretroviral treatment on specific gene expression. mRNA was extracted and reverse transcribed from purified CD4+ cells, and quantitative real-time PCR was utilized to scrutinize differences in the expression of four host genes that have been demonstrated to either stimulate (HSP90 and LEDGF/p75) or restrict (p21/WAF1 and APOBEC3G) proviral integration. HIV infection status was associated with slight to moderate alterations in the expression of all four genes. After adjusting for age, mRNA expression levels of HSP90, LEDGF/p75 and APOBEC3G were found to all be decreased in infected patients compared to healthy controls by 1.43-, 1.26-, and 4.71-fold, respectively, while p21/WAF1 expression was increased 2.35-fold. Furthermore, individuals receiving raltegravir exhibited a 1.28-fold reduction in LEDGF/p75 compared to those on non-raltegravir antiretroviral treatment. Identification of these and similar HIV-induced changes in gene expression may be valuable for delineating the extent of host cell molecular mechanisms stimulating viral replication.
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Affiliation(s)
- Erik Serrao
- Department of Pharmacology and Pharmaceutical Sciences, School of Pharmacy, University of Southern California, Los Angeles, California
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16
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Cost-effectiveness of newer antiretroviral drugs in treatment-experienced patients with multidrug-resistant HIV disease. J Acquir Immune Defic Syndr 2013; 64:382-91. [PMID: 24129369 DOI: 10.1097/qai.0000000000000002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Newer antiretroviral drugs provide substantial benefits but are expensive. The cost-effectiveness of using antiretroviral drugs in combination for patients with multidrug-resistant HIV disease was determined. DESIGN A cohort state-transition model was built representing treatment-experienced patients with low CD4 counts, high viral load levels, and multidrug-resistant virus. The effectiveness of newer drugs (those approved in 2005 or later) was estimated from published randomized trials. Other parameters were estimated from a randomized trial and from the literature. The model had a lifetime time horizon and used the perspective of an ideal insurer in the United States. The interventions were combination antiretroviral therapy, consisting of 2 newer drugs and 1 conventional drug, compared with 3 conventional drugs. Outcome measures were life-years, quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness. RESULTS Substituting newer antiretroviral drugs increased expected survival by 3.9 years in advanced HIV disease. The incremental cost-effectiveness ratio of newer, compared with conventional, antiretroviral drugs was $75,556/QALY gained. Sensitivity analyses showed that substituting only one newer antiretroviral drug cost $54,559 to $68,732/QALY, depending on assumptions about efficacy. Substituting 3 newer drugs cost $105,956 to $117,477/QALY. Cost-effectiveness ratios were higher if conventional drugs were not discontinued. CONCLUSIONS In treatment-experienced patients with advanced HIV disease, use of newer antiretroviral agents can be cost-effective, given a cost-effectiveness threshold in the range of $50,000 to $75,000 per QALY gained. Newer antiretroviral agents should be used in carefully selected patients for whom less expensive options are clearly inferior.
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Impact of HIV drug resistance on virologic and immunologic failure and mortality in a cohort of patients on antiretroviral therapy in China. AIDS 2013; 27:1815-24. [PMID: 23803794 PMCID: PMC3694318 DOI: 10.1097/qad.0b013e3283611931] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objectives: To study the dynamics of HIV drug resistance (HIVDR) and its association with virologic and immunologic failure as well as mortality among patients on combination antiretroviral therapy (cART) in China. Design: We recruited 365 patients on cART in two rural Chinese counties in 2003–2004 and followed them every 6 months until May 2010. Methods: Virologic failure, HIVDR, immunologic failure and death were documented. We used Kaplan–Meier and the proportional hazards models to identify the timing of the events, and risk factors for mortality. Results: At the end of study, patients had been followed for 1974.3 person-years, a median of 6.1 years. HIVDR mutations were found in 235 (64.4%) patients and 75 died (20.5%, 3.8/100 person-years). Median time from cART to detection of virologic failure was 17.5 months, to HIVDR 36.6 months and to immunologic failure 55.2 months (≈18-month median interval between each adverse milestone). Being male, having a baseline CD4+ cell count of less than 50 cells/μl and HIVDR were associated with higher mortality. Patients who developed HIVDR in the first year of treatment had higher mortality than those developing HIVDR later (adjusted hazard ratio 1.90, 95% confidence interval 1.01–3.48). Conclusion: HIVDR was common and was associated with higher mortality among Chinese patients on cART, particular when HIVDR was detected early in therapy. Our study reinforces the importance of improving patient adherence to cART in order to delay the emergence of HIVDR and obviate the need to switch to costly second-line drug regimens too early.
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Abstract
BACKGROUND There is limited information on antiretroviral (ARV) regimens and outcomes in perinatally HIV (PHIV)-infected youth. Substantial drug resistance after long-term ARV use and nonadherence hinder efforts to design suppressive regimens for PHIV-infected youth. This study compares clinical outcomes by expected activity of the prescribed ARV regimens. METHODS A retrospective cohort study of 13- to 24-year-old PHIV-infected youth on stable ARV regimens for ≥6 months was conducted at a pediatric HIV clinic. ARV regimens were retrospectively categorized as optimal or suboptimal based on accumulated genotypic resistance before study regimen initiation. RESULTS Fifty-two patients with similar baseline characteristics met inclusion criteria (21 optimal and 31 suboptimal regimens). Patients receiving optimal regimens had significantly higher increases in CD4 than those given suboptimal regimens by week 48 of treatment (+62 versus +8 cells/mm, respectively; P = 0.04) and by the end of study period (+93 versus -1 cells/mm, respectively; P = 0.03). There were no significant differences between the groups in decline of viral load, frequency of opportunistic infections or hospitalizations or accumulation of resistance mutations. Overall, 60% of the optimal and 45% of the suboptimal groups had nonadherence during the study regimen (P = 0.3). CONCLUSIONS PHIV-infected youth receiving optimal regimens had greater CD4 improvements but no difference in virologic outcomes compared with those receiving suboptimal regimens. In a patient population with significant nonadherence, providers must weigh the immunologic benefits of initiating an optimal regimen versus the potential risks of further resistance accumulation limiting future treatment options.
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Scherrer AU, Böni J, Yerly S, Klimkait T, Aubert V, Furrer H, Calmy A, Cavassini M, Elzi L, Vernazza PL, Bernasconi E, Ledergerber B, Günthard HF. Long-lasting protection of activity of nucleoside reverse transcriptase inhibitors and protease inhibitors (PIs) by boosted PI containing regimens. PLoS One 2012. [PMID: 23189194 PMCID: PMC3506586 DOI: 10.1371/journal.pone.0050307] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The accumulation of mutations after long-lasting exposure to a failing combination antiretroviral therapy (cART) is problematic and severely reduces the options for further successful treatments. METHODS We studied patients from the Swiss HIV Cohort Study who failed cART with nucleoside reverse transcriptase inhibitors (NRTIs) and either a ritonavir-boosted PI (PI/r) or a non-nucleoside reverse transcriptase inhibitor (NNRTI). The loss of genotypic activity <3, 3-6, >6 months after virological failure was analyzed with Stanford algorithm. Risk factors associated with early emergence of drug resistance mutations (<6 months after failure) were identified with multivariable logistic regression. RESULTS Ninety-nine genotypic resistance tests from PI/r-treated and 129 from NNRTI-treated patients were analyzed. The risk of losing the activity of ≥1 NRTIs was lower among PI/r- compared to NNRTI-treated individuals <3, 3-6, and >6 months after failure: 8.8% vs. 38.2% (p = 0.009), 7.1% vs. 46.9% (p<0.001) and 18.9% vs. 60.9% (p<0.001). The percentages of patients who have lost PI/r activity were 2.9%, 3.6% and 5.4% <3, 3-6, >6 months after failure compared to 41.2%, 49.0% and 63.0% of those who have lost NNRTI activity (all p<0.001). The risk to accumulate an early NRTI mutation was strongly associated with NNRTI-containing cART (adjusted odds ratio: 13.3 (95% CI: 4.1-42.8), p<0.001). CONCLUSIONS The loss of activity of PIs and NRTIs was low among patients treated with PI/r, even after long-lasting exposure to a failing cART. Thus, more options remain for second-line therapy. This finding is potentially of high relevance, in particular for settings with poor or lacking virological monitoring.
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Affiliation(s)
- Alexandra U Scherrer
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zürich, University of Zürich, Zürich, Switzerland.
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Adetunji AA, Achenbach C, Feinglass J, Darin KM, Scarsi KK, Ekong E, Taiwo BO, Adewole IF, Murphy R. Optimizing treatment switch for virologic failure during first-line antiretroviral therapy in resource-limited settings. J Int Assoc Provid AIDS Care 2012; 12:236-40. [PMID: 23128403 DOI: 10.1177/1545109712463733] [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] [Indexed: 11/15/2022] Open
Abstract
We evaluated adult Nigerian patients with antiretroviral switch to second-line treatment with ritonavir-boosted protease inhibitor (PI/r)-based regimens due to virologic failure (confirmed HIV-1 RNA viral load [VL] >1000 copies/mL) during first-line antiretroviral therapy. Proportion of patients with VL >400 copies/mL and characteristics associated with nonsuppression during second-line treatment are described. Approximately 15% of patients (34 of 225) had VL >400 copies/mL at 1-year after treatment switch to PI/r-based regimens. In adjusted analyses, VL ≥5 log10 copies/mL at treatment switch (odds ratio [OR] 2.90 [confidence interval (CI) 1.21-6.93]); duration of first-line treatment after virologic failure >180 days (OR 2.56 [CI 1.0-6.54]); and PI/r regimen adherence <90% (OR 3.27 [CI 1.39-7.68]) were associated with VL >400 copies/mL at 1 year of second-line treatment. We therefore recommend that the maximum permissible time between suspicion of virologic failure and completion of antiretroviral treatment switch should not exceed 6 months when patients develop first-line antiretroviral failure in resource-limited settings.
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Affiliation(s)
- Adedotun A Adetunji
- Department of Family Medicine, University College Hospital, Ibadan, Nigeria.
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Delaugerre C, Gallien S, Flandre P, Mathez D, Amarsy R, Ferret S, Timsit J, Molina JM, de Truchis P. Impact of low-level-viremia on HIV-1 drug-resistance evolution among antiretroviral treated-patients. PLoS One 2012; 7:e36673. [PMID: 22590588 PMCID: PMC3349708 DOI: 10.1371/journal.pone.0036673] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Accepted: 04/10/2012] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Drug-resistance mutations (DRAM) are frequently selected in patients with virological failure defined as viral load (pVL) above 500 copies/ml (c/mL), but few resistance data are available at low-level viremia (LLV). Our objective was to determine the emergence and evolution of DRAM during LLV in HIV-1-infected patients while receiving antiretroviral therapy (ART). METHODS Retrospective analysis of patients presenting a LLV episode defined as pVL between 40 and 500 c/mL on at least 3 occasions during a 6-month period or longer while on the same ART. Resistance genotypic testing was performed at the onset and at the end of LLV period. Emerging DRAM was defined during LLV if never detected on baseline genotype or before. RESULTS 48 patients including 4 naive and 44 pretreated (median 9 years) presented a LLV episode with a median duration of 11 months. Current ART included 2NRTI (94%), ritonavir-boosted PI (94%), NNRTI (23%), and/or raltegravir (19%). Median pVL during LLV was 134 c/mL. Successful resistance testing at both onset and end of the LLV episode were obtained for 37 patients (77%), among who 11 (30%) acquired at least 1 DRAM during the LLV period: for NRTI in 6, for NNRTI in 1, for PI in 4, and for raltegravir in 2. During the LLV period, number of drugs with genotypic resistance increased from a median of 4.5 to 6 drugs. Duration and pVL level of LLV episode, duration of previous ART, current and nadir CD4 count, number of baseline DRAM and GSS were not identified as predictive factors of resistance acquisition during LLV, probably due to limited number of patients. CONCLUSION Persistent LLV episodes below 500 c/ml while receiving ART is associated with emerging DRAM for all drug classes and a decreasing in further therapeutic options, suggesting to earlier consider resistance monitoring and ART optimization in this setting.
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Hamers RL, Sigaloff KCE, Wensing AM, Wallis CL, Kityo C, Siwale M, Mandaliya K, Ive P, Botes ME, Wellington M, Osibogun A, Stevens WS, Rinke de Wit TF, Schuurman R. Patterns of HIV-1 drug resistance after first-line antiretroviral therapy (ART) failure in 6 sub-Saharan African countries: implications for second-line ART strategies. Clin Infect Dis 2012; 54:1660-9. [PMID: 22474222 DOI: 10.1093/cid/cis254] [Citation(s) in RCA: 132] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Human immunodeficiency virus type 1 (HIV-1) drug resistance may limit the benefits of antiretroviral therapy (ART). This cohort study examined patterns of drug-resistance mutations (DRMs) in individuals with virological failure on first-line ART at 13 clinical sites in 6 African countries and predicted their impact on second-line drug susceptibility. METHODS A total of 2588 antiretroviral-naive individuals initiated ART consisting of different nucleoside reverse transcriptase inhibitor (NRTI) backbones (zidovudine, stavudine, tenofovir, or abacavir, plus lamivudine or emtricitabine) with either efavirenz or nevirapine. Population sequencing after 12 months of ART was retrospectively performed if HIV RNA was >1000 copies/mL. The 2010 International Antiviral Society-USA list was used to score major DRMs. The Stanford algorithm was used to predict drug susceptibility. RESULTS HIV-1 sequences were generated for 142 participants who virologically failed ART, of whom 70% carried ≥1 DRM and 49% had dual-class resistance, with an average of 2.4 DRMs per sequence (range, 1-8). The most common DRMs were M184V (53.5%), K103N (28.9%), Y181C (15.5%), and G190A (14.1%). Thymidine analogue mutations were present in 8.5%. K65R was frequently selected by stavudine (15.0%) or tenofovir (27.7%). Among participants with ≥1 DRM, HIV-1 susceptibility was reduced in 93% for efavirenz/nevirapine, in 81% for lamivudine/emtricitabine, in 59% for etravirine/rilpivirine, in 27% for tenofovir, in 18% for stavudine, and in 10% for zidovudine. CONCLUSIONS Early failure detection limited the accumulation of resistance. After stavudine failure in African populations, zidovudine rather than tenofovir may be preferred in second-line ART. Strategies to prevent HIV-1 resistance are a global priority.
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Affiliation(s)
- Raph L Hamers
- PharmAccess Foundation, Academic Medical Center of the University of Amsterdam, The Netherlands.
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23
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Vingerhoets J, Nijs S, Tambuyzer L, Hoogstoel A, Anderson D, Picchio G. Similar predictions of etravirine sensitivity regardless of genotypic testing method used: comparison of available scoring systems. Antivir Ther 2012; 17:1571-9. [DOI: 10.3851/imp2275] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2012] [Indexed: 10/28/2022]
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24
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Rawizza HE, Chaplin B, Meloni ST, Eisen G, Rao T, Sankalé JL, Dieng-Sarr A, Agbaji O, Onwujekwe DI, Gashau W, Nkado R, Ekong E, Okonkwo P, Murphy RL, Kanki PJ. Immunologic criteria are poor predictors of virologic outcome: implications for HIV treatment monitoring in resource-limited settings. Clin Infect Dis 2011; 53:1283-90. [PMID: 22080121 PMCID: PMC3246873 DOI: 10.1093/cid/cir729] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Accepted: 08/17/2011] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Viral load (VL) quantification is considered essential for determining antiretroviral treatment (ART) success in resource-rich countries. However, it is not widely available in resource-limited settings where the burden of human immunodeficiency virus infection is greatest. In the absence of VL monitoring, switches to second-line ART are based on World Health Organization (WHO) clinical or immunologic failure criteria. METHODS We assessed the performance of CD4 cell criteria to predict virologic outcomes in a large ART program in Nigeria. Laboratory monitoring consists of CD4 cell count and VL at baseline, then every 6 months. Failure was defined as 2 consecutive VLs >1000 copies/mL after at least 6 months of ART. Virologic outcomes were compared with the 3 WHO-defined immunologic failure criteria. RESULTS A total of 9690 patients were included in the analysis (median follow-up, 33.2 months). A total of 1225 patients experienced failure by both immunologic and virologic criteria, 872 by virologic criteria only, and 1897 by immunologic criteria only. The sensitivity of CD4 cell criteria to detect viral failure was 58%, specificity was 75%, and the positive-predictive value was 39%. For patients with both virologic and immunologic failure, VL criteria identified failure significantly earlier than CD4 cell criteria (median, 10.4 vs 15.6 months; P < .0001). CONCLUSIONS Because of the low sensitivity of immunologic criteria, a substantial number of failures are missed, potentially resulting in accumulation of resistance mutations. In addition, specificity and predictive values are low, which may result in large numbers of unnecessary ART switches. Monitoring solely by immunologic criteria may result in increased costs because of excess switches to more expensive ART and development of drug-resistant virus.
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Affiliation(s)
- Holly E Rawizza
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.
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Wallis CL, Papathanasopolous MA, Fox M, Conradie F, Ive P, Orrell C, Zeinecker J, Sanne I, Wood R, McIntyre J, Stevens W. Low rates of nucleoside reverse transcriptase inhibitor resistance in a well-monitored cohort in South Africa on antiretroviral therapy. Antivir Ther 2011; 17:313-20. [PMID: 22293461 DOI: 10.3851/imp1985] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2011] [Indexed: 10/15/2022]
Abstract
BACKGROUND The emergence of complex HIV-1 drug resistance mutations has been linked to the duration of time patients are on a failing antiretroviral drug regimen. This study reports on resistance profiles in a closely monitored subtype C infected cohort. METHODS A total of 812 participants were enrolled into the CIPRA-SA 'safeguard the household' study, viral loads were determined at 12-weekly intervals for 96 weeks. Virological failure was defined as either a <1.5 log decrease in viral load at week 12 or two consecutive viral load measurements of >1,000 RNA copies/ml after week 24. Regimens prescribed were in line with the South African roll-out programme (stavudine, lamivudine, efavirenz or nevirapine). Viral RNA was extracted from patients with virological failure, and pol reverse-transcriptase PCR and sequence analysis were performed to determine drug-resistant mutations. RESULTS Virological failure was observed in 83 participants on the first-line regimen during the study period, of which 61 (73%) had HIV-1 drug-resistant mutations. The M184V mutation was the most frequent (n=46; 65%), followed by K103N (46%) and Y181C (21%). Thymidine analogue mutations were infrequent (1%) and Q151M was not observed. CONCLUSIONS Drug resistance profiles were less complex than has been previously reported in South Africa using the same antiretroviral drug regimens. These data suggest that frequent viral load monitoring limits the level and complexity of resistance observed in HIV-1 subtype C, preserving susceptibility to second-line options.
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Affiliation(s)
- Carole L Wallis
- University of the Witwatersrand, Johannesburg, South Africa.
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26
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Mascolini M, Mellors JW, Richman DD, Boucher CAB, Larder BA. HIV and hepatitis virus resistance to antivirals: review of data from the XIX International HIV and Hepatitis Virus Drug Resistance Workshop and curative strategies. Antivir Ther 2011; 16:263-86. [PMID: 21447877 DOI: 10.3851/imp1761] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The XIX International HIV and Hepatitis Virus Drug Resistance Workshop offered scientists, clinical investigators, physicians and others an opportunity to present study results selected in a rigorous peer-review process and to discuss those data in an open forum. In 2010, Workshop organizers expanded the programme to include hepatitis B and C viruses, reasoning that workers in all three fields could benefit from shared experience, positive and negative. Slide sessions at the 2010 Workshop focused on hepatitis virus resistance to current and experimental antivirals; epidemiology of HIV resistance; HIV pathogenesis, fitness and resistance; resistance to new antiretrovirals; markers of response to HIV entry inhibitors; HIV persistence, reservoirs and elimination strategies; application of new viral sequencing techniques; and mechanisms of HIV drug resistance. This article summarizes all slide presentations at the Workshop.
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27
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Zolfo M, Schapiro JM, Phan V, Koole O, Thai S, Vekemans M, Fransen K, Lynen L. Genotypic impact of prolonged detectable HIV type 1 RNA viral load after HAART failure in a CRF01_AE-infected cohort. AIDS Res Hum Retroviruses 2011; 27:727-35. [PMID: 20854169 DOI: 10.1089/aid.2010.0037] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
HIV subtype-specific data on mutation type, rate, and accumulation following HAART treatment failure are limited. We studied patterns and accrual of drug resistance mutations in a Cambodian CRF01_AE-infected cohort continuing a virologically failing first-line, nonnucleoside reverse transcriptase inhibitor- (NNRTI-) based, HAART. Between 2005 and 2007, 837 adult HIV-infected patients had regular plasma HIV-1 RNA viral load measurements at Sihanouk Hospital Centre of Hope (SHCH), Cambodia. Drug resistance testing was performed in all patients with HIV-1 RNA >1000 copies/ml after at least 6 months of HAART. Seventy-one patients with a mean age of 34 years, of whom 68% were male, were retrospectively assessed at virological failure. The median duration of antiretroviral therapy was 12.3 (IQR 7.1-18.23) months, the median CD4 cell count was 173 (IQR 118-256) cells/mm(3), and the mean plasma HIV-1 RNA viral load was 3.9 log (SD 0.72) at failure. NNRTI mutations, M184I/V mutation, thymidine analogue mutations, and K65R were observed in 78.9%, 69%, 20%, and 12.7% of patients, respectively. For 33 patients, genotypic testing was carried out on at least two occasions before the switch to second-line HAART after a median duration of 5.8 (IQR 4.3-6.1) months of virological failure: 54.5% of patients accumulated new mutations with a rate of 1.6 mutations per person-year. Accumulation was seen both for nucleoside and nonnucleoside reverse transcriptase inhibitors, and also in patients with low-level viremia. Subtype-specific data on mutation type, rate, and accumulation after HAART failure are urgently needed to optimize treatment strategies in resource-limited settings.
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Affiliation(s)
- Maria Zolfo
- Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Vichet Phan
- Sihanouk Hospital Center of HOPE, Phnom Penh, Cambodia
| | | | - Sopheak Thai
- Sihanouk Hospital Center of HOPE, Phnom Penh, Cambodia
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Ceccherini-Silberstein F, Cento V, Calvez V, Perno CF. The use of human immunodeficiency virus resistance tests in clinical practice. Clin Microbiol Infect 2011; 16:1511-7. [PMID: 20731678 DOI: 10.1111/j.1469-0691.2010.03353.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Important progress has been made in recent years in the development and clinical use of drugs for the treatment of human immunodeficiency virus type 1 (HIV-1) infection. Nevertheless, when antiretroviral therapy fails to be fully suppressive, new viral variants emerge, thus allowing HIV-1 to escape from drug pressure by accumulating mutations. Between 50% and 70% of treated patients with virological rebound harbour some form of drug-resistant virus; transmitted drug resistance in drug-naïve populations has reached 5-20% in areas of the world with access to treatment. The emergence of drug-resistant viruses remains the limiting factor in HIV-1 management, being a major cause of treatment failure, and being associated with clinical progression and death. All international guidelines focus on the importance of tailoring antiretroviral therapy to the individual patient, on the basis onf HIV-1 genetic data, integrated with clinical, laboratory and therapeutic information. The aim of this review is to provide useful information to clinicians and virologists about how and when to use genotypic resistance testing in clinical practice, especially in the management of the first stages of HIV-1 patient care and treatment decisions.
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Economic evaluation of monitoring virologic responses to antiretroviral therapy in HIV-infected children in resource-limited settings. AIDS 2011; 25:1143-51. [PMID: 21505319 DOI: 10.1097/qad.0b013e3283466fab] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Antiretroviral therapy (ART) management for HIV-infected children is critical in many resource-constrained countries. We investigated the cost-effectiveness and cost-utility of different frequencies of monitoring plasma viral load among HIV-positive children initiating ART in a resource-limited setting. DESIGN/METHODS A stochastic agent-based simulation model was built and directly informed by a cohort of 304 HIV-infected children starting ART in Thailand between 2001 and 2009. The model simulated the expected costs and clinical outcomes over time according to different viral load monitoring frequencies and initiation of second-line therapies when appropriate. RESULTS The optimal frequency of viral load monitoring was found to be annual, after a single screening at 6 months. Associated costs of viral load monitoring and appropriate ART would approximately triple current treatment costs. Compared with current conditions, a single screening during the first year of ART led to a 58.4% reduction in the total person-years of virological failure with annual monitoring leading to a 76.6% reduction. The incremental cost per quality adjusted life year gained from the optimal monitoring frequency was estimated as US$ 68,084 when including costs of ART and US$ 7224 without ART costs. The estimated cost attributed to preventing 1 year of virological failure was US$ 3393 with ART costs and US$ 359 without ART costs. CONCLUSION Even infrequent viral load monitoring is likely to provide substantial clinical benefit to HIV-infected children on ART. Viral load monitoring can be considered cost-effective in many resource-limited settings. However, the costs associated with second-line therapies could be a barrier to its economic feasibility.
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Prosperi MCF, Mackie N, Di Giambenedetto S, Zazzi M, Camacho R, Fanti I, Torti C, Sönnerborg A, Kaiser R, Codoñer FM, Van Laethem K, Bansi L, van de Vijver DAMC, Geretti AM, De Luca A, Giacometti A, Butini L, del Gobbo R, Menzo S, Tacconi D, Corbelli G, Zanussi S, Monno L, Punzi G, Maggiolo F, Callegaro A, Calza L, Carla Re M, Pristerà R, Turconi P, Mandas A, Tini S, Zoncada A, Paolini E, Amadio G, Sighinolfi L, Zuccati G, Morfini M, Manetti R, Corsi P, Galli L, Di Pietro M, Bartalesi F, Colao G, Tosti A, Di Biagio A, Setti M, Bruzzone B, Penco G, Trezzi M, Orani A, Pardelli R, De Gennaro M, Chiodera A, Scalzini A, Palvarini L, Almi P, Todaro G, d'Arminio Monforte A, Cicconi P, Rusconi S, Gismondo MR, Gismondo MR, Micheli V, Biondi ML, Gianotti N, Capetti A, Meraviglia P, Boeri E, Mussini C, Pecorari M, Soria A, Vecchi L, Santirocchi M, Brustia D, Ravanini P, Bello FD, Romano N, Mancuso S, Calzetti C, Maserati R, Filice G, Baldanti F, Francisci D, Parruti G, Polilli E, Sacchini D, Martinelli C, Consolini R, Vatteroni L, Vivarelli A, Dionisio D, Nerli A, Lenzi L, Magnani G, Ortolani P, Andreoni M, Palamara G, Fimiani C, Palmisano L, De Luca A, Fadda G, Vullo V, Turriziani O, Montano M, Cenderello G, Gonnelli A, Zazzi M, Palumbo M, Ghisetti V, Bonora S, Foglie PD, Rossi C, Grossi P, Seminari E, Poletti F, Mondino V, Malena M, Lattuada E, Lengauer T, Däumer M, Hoffmann D, Kaiser R, Schülter E, Müller C, Oette M, Reuter S, Esser S, Fätkenheuer G, Rockstroh J, van de Vijver DAMC, Incardona F, Rosen-Zvi M, Lengauer T, Camacho R, Clotet B, Thalme A, Svedhem V, Bratt G, Gargiulo F, Lapadula G, Manca N, Paraninfo G, Quiros-Roldan E, Carosi G, Castelnuovo F, Vandamme AM, Van Laethem K, Van Wijngaerden E, Ainsworth J, Anderson J, Babiker A, Dunn D, Easterbrook P, Fisher M, Gazzard B, Garrett N, Gilson R, Gompels M, Hill T, Johnson M, Leen C, Orkin C, Phillips A, Pillay D, Porter K, Post F, Sabin C, Sadiq T, Schwenk A, Walsh J, Delpech V, Palfreeman A, Dunn D, Glabay A, Porter K, Bansi L, Hill T, Phillips A, Sabin C, Orkin C, Garrett N, Lynch J, Hand J, de Souza C, Fisher M, Perry N, Tilbury S, Churchill D, Gazzard B, Nelson M, Waxman M, Mandalia S, Delpech V, Anderson J, Kall M, Post F, Korat H, Taylor C, Ibrahim F, Campbell L, Easterbrook P, Babiker A, Dunn D, Glabay A, Porter K, Gilson R, James L, Brima N, Williams I, Schwenk A, Johnson M, Youle M, Lampe F, Smith C, Grabowska H, Chaloner C, Puradiredja DI, Bansi L, Hill T, Phillips A, Sabin C, Walsh J, Weber J, Ramzan F, Carder M, Leen C, Wilson A, Gompels M, Dooley D, Palfreeman A, Anderson J, Asboe D, Pozniak A, Cameron S, Cane P, Chadwick D, Churchill D, Clark D, Collins S, Delpech V, Pillay D, Lazarus L, Dunn D, Dolling D, Fearnhill E, Castro H, Porter K, Coughlin K, Dolling D, Zuckerman M, Anna Maria G, Booth C, Goldberg D, Gompels M, Hale A, Kaye S, Kellam P, Leigh-Brown A, Mackie N, Orkin C, Pillay D, Phillips A, Sabin C, Smit E, Templeton K, Tilston P, Tong W, Williams I, Zhang H, Zhang H, Clark D, Ushiro-Lumb I, Oliver T, Bibby D, Mitchell S, Smit E, Mbisa T, Wildfire A, Tandy R, Shepherd J, Chadwick D, MacLean A, Tong W, Bennett D, Hopkins M, Tilston P, Booth C, Garcia-Diaz A, Kaye S, Kirk S. Detection of drug resistance mutations at low plasma HIV-1 RNA load in a European multicentre cohort study. J Antimicrob Chemother 2011; 66:1886-96. [DOI: 10.1093/jac/dkr171] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Mattia C. F. Prosperi
- Clinic of Infectious Diseases, Catholic University of the Sacred Heart, Rome, Italy
- Informa PRO Contract Research Organization, Rome, Italy
- Department of Pathology, Emerging Pathogens Institute, College of Medicine, University of Florida, Gainesville, USA
| | - Nicola Mackie
- Department of HIV Medicine, Imperial College Healthcare NHS Trust, London, UK
| | | | - Maurizio Zazzi
- Department of Molecular Biology, University of Siena, Siena, Italy
| | - Ricardo Camacho
- Molecular Biology Laboratory, Centro Hospitalar de Lisboa Ocidenta, Lisbon, Portugal
| | - Iuri Fanti
- Clinic of Infectious Diseases, Catholic University of the Sacred Heart, Rome, Italy
| | - Carlo Torti
- Clinic of Infectious and Tropical Diseases, University of Brescia, Brescia, Italy
| | - Anders Sönnerborg
- Division of Infectious Diseases, Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Rolf Kaiser
- Institute of Virology, University of Cologne, Cologne, Germany
| | | | - Kristel Van Laethem
- Rega Institute for Medical Research, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Loveleen Bansi
- Division of Population Health, UCL Medical School, Royal Free Campus, London, UK
| | | | - Anna Maria Geretti
- Department of Virology, University College London Medical School, London, UK
| | - Andrea De Luca
- Clinic of Infectious Diseases, Catholic University of the Sacred Heart, Rome, Italy
- Infectious Diseases Unit, University Hospital of Siena, Siena, Italy
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Dried blood spots in HIV monitoring: applications in resource-limited settings. Bioanalysis 2011; 2:1893-908. [PMID: 21083497 DOI: 10.4155/bio.10.120] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
By the end of 2008, 4 million people were receiving antiretroviral treatment for HIV/AIDS in low- and middle-income countries. In industrialized countries, monitoring of treatment with viral load measurements and drug resistance testing is the standard of care to ensure early detection of treatment failure and a prompt switch to a fully active second-line regimen, before drug-resistant mutations accumulate. These tests, however, require highly specialized laboratories and stringent procedures for storage and shipment of plasma, and are rarely available in resource-limited settings. Therefore, treatment failure in such settings is usually not detected until patients develop severe immunodeficiency, at which stage widespread resistance is likely. Dried blood spots (DBS) are easy to collect and store, and can be a convenient alternative to plasma in settings with limited laboratory capacity. This review provides an overview of possible applications of DBS technologies in the monitoring of HIV treatment, with the main focus on viral load quantification and drug resistance testing.
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Joyce VR, Barnett PG, Chow A, Bayoumi AM, Griffin SC, Sun H, Holodniy M, Brown ST, Kyriakides TC, Cameron DW, Youle M, Sculpher M, Anis AH, Owens DK. Effect of Treatment Interruption and Intensification of Antiretroviral Therapy on Health-Related Quality of Life in Patients with Advanced HIV. Med Decis Making 2011; 32:70-82. [DOI: 10.1177/0272989x10397615] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background. The effect of antiretroviral therapy (ART) interruption or intensification on health-related quality of life (HRQoL) in advanced HIV patients is unknown. Objective. To assess the impact of temporary treatment interruption and intensification of ART on HRQoL. Design. A 2 x 2 factorial open label randomized controlled trial. Setting. Hospitals in the United States, Canada, and the United Kingdom. Patients. Multidrug resistant (MDR) HIV patients. Intervention. Patients were randomized to receive a 12-wk interruption or not, and ART intensification or standard ART. Measurements. The Health Utilities Index (HUI3), EQ-5D, standard gamble (SG), time tradeoff (TTO), visual analog scale (VAS), and the Medical Outcomes Study HIV Health Survey (MOS-HIV). Results. There were no significant differences in HRQoL among the four groups during follow-up; however, there was a temporary significant decline in HRQoL on some measures within the interruption group during interruption (HUI3 −0.05, P = 0.03; VAS −5.9, P = 0.002; physical health summary −2.9, P = 0.001; mental health summary −1.9, P = 0.02). Scores declined slightly overall during follow-up. Multivariate analysis showed significantly lower HRQoL associated with some clinical events. Limitations. The results may not apply to HIV patients who have not experienced multiple treatment failures or who have not developed MDR HIV. Conclusions. Temporary ART interruption and ART intensification provided neither superior nor inferior HRQoL compared with no interruption and standard ART. Among surviving patients, HRQoL scores declined only slightly over years of follow-up in this advanced HIV cohort; however, approximately one-third of patients died during the trial follow up. Lower HRQoL was associated with adverse clinical events.
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Affiliation(s)
- Vilija R. Joyce
- VA Palo Alto Health Care System, VA Cooperative Studies Program Coordinating Center, VA HSR&D Health Economics Resource Center, Menlo Park, California (VRJ, PGB, AC)
- Centre for Research on Inner City Health, The Keenan Research Centre in the Li Ka Shing Knowledge Institute and Division of General Internal Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada and Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (AMB)
- Centre for Health Economics, University of York, York, United Kingdom (SCG, MS)
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, Vancouver, British Columbia, Canada (HS)
- Canadian HIV Trials Network, Vancouver, British Columbia, Canada (HS, AHA)
| | - Paul G. Barnett
- VA Palo Alto Health Care System, VA Cooperative Studies Program Coordinating Center, VA HSR&D Health Economics Resource Center, Menlo Park, California (VRJ, PGB, AC)
- Centre for Research on Inner City Health, The Keenan Research Centre in the Li Ka Shing Knowledge Institute and Division of General Internal Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada and Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (AMB)
- Centre for Health Economics, University of York, York, United Kingdom (SCG, MS)
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, Vancouver, British Columbia, Canada (HS)
- Canadian HIV Trials Network, Vancouver, British Columbia, Canada (HS, AHA)
| | - Adam Chow
- VA Palo Alto Health Care System, VA Cooperative Studies Program Coordinating Center, VA HSR&D Health Economics Resource Center, Menlo Park, California (VRJ, PGB, AC)
- Centre for Research on Inner City Health, The Keenan Research Centre in the Li Ka Shing Knowledge Institute and Division of General Internal Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada and Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (AMB)
- Centre for Health Economics, University of York, York, United Kingdom (SCG, MS)
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, Vancouver, British Columbia, Canada (HS)
- Canadian HIV Trials Network, Vancouver, British Columbia, Canada (HS, AHA)
| | - Ahmed M. Bayoumi
- VA Palo Alto Health Care System, VA Cooperative Studies Program Coordinating Center, VA HSR&D Health Economics Resource Center, Menlo Park, California (VRJ, PGB, AC)
- Centre for Research on Inner City Health, The Keenan Research Centre in the Li Ka Shing Knowledge Institute and Division of General Internal Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada and Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (AMB)
- Centre for Health Economics, University of York, York, United Kingdom (SCG, MS)
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, Vancouver, British Columbia, Canada (HS)
- Canadian HIV Trials Network, Vancouver, British Columbia, Canada (HS, AHA)
| | - Susan C. Griffin
- VA Palo Alto Health Care System, VA Cooperative Studies Program Coordinating Center, VA HSR&D Health Economics Resource Center, Menlo Park, California (VRJ, PGB, AC)
- Centre for Research on Inner City Health, The Keenan Research Centre in the Li Ka Shing Knowledge Institute and Division of General Internal Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada and Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (AMB)
- Centre for Health Economics, University of York, York, United Kingdom (SCG, MS)
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, Vancouver, British Columbia, Canada (HS)
- Canadian HIV Trials Network, Vancouver, British Columbia, Canada (HS, AHA)
| | - Huiying Sun
- VA Palo Alto Health Care System, VA Cooperative Studies Program Coordinating Center, VA HSR&D Health Economics Resource Center, Menlo Park, California (VRJ, PGB, AC)
- Centre for Research on Inner City Health, The Keenan Research Centre in the Li Ka Shing Knowledge Institute and Division of General Internal Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada and Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (AMB)
- Centre for Health Economics, University of York, York, United Kingdom (SCG, MS)
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, Vancouver, British Columbia, Canada (HS)
- Canadian HIV Trials Network, Vancouver, British Columbia, Canada (HS, AHA)
| | - Mark Holodniy
- VA Palo Alto Health Care System, VA Cooperative Studies Program Coordinating Center, VA HSR&D Health Economics Resource Center, Menlo Park, California (VRJ, PGB, AC)
- Centre for Research on Inner City Health, The Keenan Research Centre in the Li Ka Shing Knowledge Institute and Division of General Internal Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada and Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (AMB)
- Centre for Health Economics, University of York, York, United Kingdom (SCG, MS)
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, Vancouver, British Columbia, Canada (HS)
- Canadian HIV Trials Network, Vancouver, British Columbia, Canada (HS, AHA)
| | - Sheldon T. Brown
- VA Palo Alto Health Care System, VA Cooperative Studies Program Coordinating Center, VA HSR&D Health Economics Resource Center, Menlo Park, California (VRJ, PGB, AC)
- Centre for Research on Inner City Health, The Keenan Research Centre in the Li Ka Shing Knowledge Institute and Division of General Internal Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada and Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (AMB)
- Centre for Health Economics, University of York, York, United Kingdom (SCG, MS)
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, Vancouver, British Columbia, Canada (HS)
- Canadian HIV Trials Network, Vancouver, British Columbia, Canada (HS, AHA)
| | - Tassos C. Kyriakides
- VA Palo Alto Health Care System, VA Cooperative Studies Program Coordinating Center, VA HSR&D Health Economics Resource Center, Menlo Park, California (VRJ, PGB, AC)
- Centre for Research on Inner City Health, The Keenan Research Centre in the Li Ka Shing Knowledge Institute and Division of General Internal Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada and Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (AMB)
- Centre for Health Economics, University of York, York, United Kingdom (SCG, MS)
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, Vancouver, British Columbia, Canada (HS)
- Canadian HIV Trials Network, Vancouver, British Columbia, Canada (HS, AHA)
| | - D. William Cameron
- VA Palo Alto Health Care System, VA Cooperative Studies Program Coordinating Center, VA HSR&D Health Economics Resource Center, Menlo Park, California (VRJ, PGB, AC)
- Centre for Research on Inner City Health, The Keenan Research Centre in the Li Ka Shing Knowledge Institute and Division of General Internal Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada and Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (AMB)
- Centre for Health Economics, University of York, York, United Kingdom (SCG, MS)
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, Vancouver, British Columbia, Canada (HS)
- Canadian HIV Trials Network, Vancouver, British Columbia, Canada (HS, AHA)
| | - Mike Youle
- VA Palo Alto Health Care System, VA Cooperative Studies Program Coordinating Center, VA HSR&D Health Economics Resource Center, Menlo Park, California (VRJ, PGB, AC)
- Centre for Research on Inner City Health, The Keenan Research Centre in the Li Ka Shing Knowledge Institute and Division of General Internal Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada and Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (AMB)
- Centre for Health Economics, University of York, York, United Kingdom (SCG, MS)
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, Vancouver, British Columbia, Canada (HS)
- Canadian HIV Trials Network, Vancouver, British Columbia, Canada (HS, AHA)
| | - Mark Sculpher
- VA Palo Alto Health Care System, VA Cooperative Studies Program Coordinating Center, VA HSR&D Health Economics Resource Center, Menlo Park, California (VRJ, PGB, AC)
- Centre for Research on Inner City Health, The Keenan Research Centre in the Li Ka Shing Knowledge Institute and Division of General Internal Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada and Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (AMB)
- Centre for Health Economics, University of York, York, United Kingdom (SCG, MS)
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, Vancouver, British Columbia, Canada (HS)
- Canadian HIV Trials Network, Vancouver, British Columbia, Canada (HS, AHA)
| | - Aslam H. Anis
- VA Palo Alto Health Care System, VA Cooperative Studies Program Coordinating Center, VA HSR&D Health Economics Resource Center, Menlo Park, California (VRJ, PGB, AC)
- Centre for Research on Inner City Health, The Keenan Research Centre in the Li Ka Shing Knowledge Institute and Division of General Internal Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada and Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (AMB)
- Centre for Health Economics, University of York, York, United Kingdom (SCG, MS)
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, Vancouver, British Columbia, Canada (HS)
- Canadian HIV Trials Network, Vancouver, British Columbia, Canada (HS, AHA)
| | - Douglas K. Owens
- VA Palo Alto Health Care System, VA Cooperative Studies Program Coordinating Center, VA HSR&D Health Economics Resource Center, Menlo Park, California (VRJ, PGB, AC)
- Centre for Research on Inner City Health, The Keenan Research Centre in the Li Ka Shing Knowledge Institute and Division of General Internal Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada and Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (AMB)
- Centre for Health Economics, University of York, York, United Kingdom (SCG, MS)
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, Vancouver, British Columbia, Canada (HS)
- Canadian HIV Trials Network, Vancouver, British Columbia, Canada (HS, AHA)
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El-Khatib Z, DeLong AK, Katzenstein D, Ekstrom AM, Ledwaba J, Mohapi L, Laher F, Petzold M, Morris L, Kantor R. Drug resistance patterns and virus re-suppression among HIV-1 subtype C infected patients receiving non-nucleoside reverse transcriptase inhibitors in South Africa. JOURNAL OF AIDS & CLINICAL RESEARCH 2011; 2:1000117. [PMID: 21927716 PMCID: PMC3174802 DOI: 10.4172/2155-6113.1000117] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND: Emergence of HIV-1 drug resistance is at times an inevitable and anticipated consequence of antiretroviral therapy (ART) failure. We examined drug resistance patterns and virus re-suppression among subtype C-infected South African patients receiving first-line ART. METHODS: Treatment records of 431 patients on NNRTI-containing regimens for a median of 45 months were analyzed. Patients with viral load (VL) >400 copies/mL were followed and drug resistance mutations (DRM) were re-assessed. Associations between clinical/demographic measures and drug resistance/virologic outcomes were examined using Fisher exact and ordinal and logistic regression. RESULTS: Ten percent of patients (43/431) were viremic at enrollment (98% previously suppressed); sequences were obtained from 38/43. Of those, 82% had 1-7 DRM. In bivariate analysis remote exposure to single-dose nevirapine or prior ART; higher CD4 counts; lower VL; and >6 months of virologic failure were significantly associated with number of DRM. Of 25 viremic patients followed for a median of 8 months on a continued first-line regimen, 12 (48%) re-suppressed, six with K103N and three with M184V. Thirteen (52%) had continued virologic failure which was significantly associated with detectable VL>6 months prior to enrollment and number of DRM. CONCLUSION: Among these HIV-1 subtype C-infected patients, DRM numbers and patterns were associated with prior exposure to sub-optimal ART, adherence and duration of virologic failure. Viral re-suppression in the presence of K103N and M184V challenges assumptions about drug resistance. In resource-limited settings, where genotyping and alternative drug options are unavailable, continuing first-line treatment, reinforcing adherence and regular virologic monitoring may be effective even after virologic failure.
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Affiliation(s)
- Ziad El-Khatib
- Division of Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden
- AIDS Virus Research Unit, National Institute for Communicable Diseases (NICD), Johannesburg, South Africa
| | - Allison K. DeLong
- Center for Statistical Sciences, Brown University, Providence, Rhode Island, USA
| | - David Katzenstein
- Division of Infectious Diseases, Stanford University, California, USA
| | - Anna Mia Ekstrom
- Division of Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden
| | - Johanna Ledwaba
- AIDS Virus Research Unit, National Institute for Communicable Diseases (NICD), Johannesburg, South Africa
| | - Lerato Mohapi
- Perinatal HIV Research Unit (PHRU), University of the Witwatersrand, Soweto, South Africa
| | - Fatima Laher
- Perinatal HIV Research Unit (PHRU), University of the Witwatersrand, Soweto, South Africa
| | - Max Petzold
- Nordic School of Public Health (NHV), Gothenburg, Sweden
| | - Lynn Morris
- AIDS Virus Research Unit, National Institute for Communicable Diseases (NICD), Johannesburg, South Africa
| | - Rami Kantor
- Division of Infectious Diseases, Brown University Alpert Medical School, Providence, Rhode Island, USA
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Tambuyzer L, Vingerhoets J, Azijn H, Daems B, Nijs S, Béthune MD, Picchio G. Characterization of genotypic and phenotypic changes in HIV-1-infected patients with virologic failure on an etravirine-containing regimen in the DUET-1 and DUET-2 clinical studies. AIDS Res Hum Retroviruses 2010; 26:1197-205. [PMID: 20854144 DOI: 10.1089/aid.2009.0302] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The randomized, placebo-controlled Phase III DUET studies enrolled treatment-experienced, HIV-1-infected patients. We examined the genotypic and phenotypic changes at endpoint relative to baseline, including the emergence of individual reverse transcriptase (RT) mutations, in patients who received the non-nucleoside reverse transcriptase inhibitor (NNRTI) etravirine and experienced virologic failure by rebound by the time of the Week 96 analysis. Patients received etravirine 200 mg twice-daily in combination with a background regimen containing darunavir/ritonavir, investigator-selected nucleoside reverse transcriptase inhibitors, and optional enfuvirtide. Virologic failure by rebound occurred in 93 (15.5%) etravirine-treated patients (compared with 170 [28.1%] placebo-treated patients). Patients experiencing virologic failure had more baseline antiretroviral resistance and lower activity of the background regimen relative to those not experiencing failure. Emergence of NNRTI resistance-associated mutations was observed in 55 of 93 patients. The most frequently emerging RT mutations were V179F, V179I, and Y181C, with positions K101 and E138 also showing frequent changes. Mutations usually emerged in a background of multiple other NNRTI mutations and were, in most cases, associated with a decrease in phenotypic sensitivity to etravirine at endpoint. Further analysis is needed to clarify the role of mutations at position 138 as determinants of etravirine resistance.
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Enhanced Susceptibility of Human Immunodeficiency Virus Type 1 to Tipranavir in Treatment-Experienced Patients. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2010. [DOI: 10.1097/ipc.0b013e3181f0c036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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36
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Oyomopito R, Lee MP, Phanuphak P, Lim PL, Ditangco R, Zhou J, Sirisanthana T, Chen YMA, Pujari S, Kumarasamy N, Sungkanuparph S, Lee CKC, Kamarulzaman A, Oka S, Zhang FJ, Mean CV, Merati T, Tau G, Smith J, Li PCK. Measures of site resourcing predict virologic suppression, immunologic response and HIV disease progression following highly active antiretroviral therapy (HAART) in the TREAT Asia HIV Observational Database (TAHOD). HIV Med 2010; 11:519-29. [PMID: 20345881 PMCID: PMC2914850 DOI: 10.1111/j.1468-1293.2010.00822.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Surrogate markers of HIV disease progression are HIV RNA in plasma viral load (VL) and CD4 cell count (immune function). Despite improved international access to antiretrovirals, surrogate marker diagnostics are not routinely available in resource-limited settings. Therefore, the objective was to assess effects of economic and diagnostic resourcing on patient treatment outcomes. METHODS Analyses were based on 2333 patients initiating highly active antiretroviral therapy (HAART) from 2000 onwards. Sites were categorized by World Bank country income criteria (high/low) and annual frequency of VL (> or = 3, 1-2 or <1) or CD4 (> or = 3 or <3) testing. Endpoints were time to AIDS/death and change in CD4 cell count and VL suppression (<400 HIV-1 RNA copies/mL) at 12 months. Demographics, Centers for Disease Control and Prevention (CDC) classification, baseline VL/CD4 cell counts, hepatitis B/C coinfections and HAART regimen were covariates. Time to AIDS/death was analysed by proportional hazards models. CD4 and VL endpoints were analysed using linear and logistic regression, respectively. RESULTS Increased disease progression was associated with site-reported VL testing less than once per year [hazard ratio (HR)=1.4; P=0.032], severely symptomatic HIV infection (HR=1.4; P=0.003) and hepatitis C virus coinfection (HR=1.8; P=0.011). A total of 1120 patients (48.2%) had change in CD4 cell count data. Smaller increases were associated with older age (P<0.001) and 'Other' HIV source exposures, including injecting drug use and blood products (P=0.043). A total of 785 patients (33.7%) contributed to the VL suppression analyses. Patients from sites with VL testing less than once per year [odds ratio (OR)=0.30; P<0.001] and reporting 'Other' HIV exposures experienced reduced suppression (OR=0.28; P<0.001). CONCLUSION Low measures of site resourcing were associated with less favourable patient outcomes, including a 35% increase in disease progression in patients from sites with VL testing less than once per year.
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Affiliation(s)
- R Oyomopito
- National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, Australia.
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Trøseid M, Johannessen A. [The battle against HIV can be won, but there is not enough money!]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2010; 130:1599-600. [PMID: 20805855 DOI: 10.4045/tidsskr.10.0705] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Affiliation(s)
- Marius Trøseid
- Infeksjonsmedisinsk avdeling, Oslo universitetssykehus, Ullevål, 0407 Oslo, Norway.
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Palombi L, Marazzi MC, Guidotti G, Germano P, Buonomo E, Scarcella P, Doro Altan A, Zimba IDVM, San Lio MM, De Luca A. Incidence and predictors of death, retention, and switch to second-line regimens in antiretroviral- treated patients in sub-Saharan African Sites with comprehensive monitoring availability. Clin Infect Dis 2010; 48:115-122. [PMID: 20380075 DOI: 10.1086/593312] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Antiretroviral treatment programs in sub-Saharan Africa have high rates of early mortality and loss to follow-up. Switching to second-line regimens is often delayed because of limited access to laboratory monitoring. METHODS Retrospective analysis was performed of a cohort of adults who initiated a standard first-line antiretroviral treatment at 5 public sector sites in 3 African countries. Monitoring included routine CD4 cell counts, human immunodeficiency virus RNA measures, and records of whether appointments were kept. Incidence and predictors of death, loss to follow-up, and switch to second-line regimens were analyzed by time-to-event approaches. RESULTS A total of 3749 patients were analyzed; at baseline, 37.1% were classified as having World Health Organization disease stage 3 or 4, and the median CD4 cell count was 192 cells/mL. First-line regimens were nevirapine based in 96.5% of patients; 17.7% of patients attended <95% of their drug pickup appointments. During 4545 person-years of follow-up, mortality was 8.6 deaths per 100 person-years and was predicted by lower baseline CD4 cell count, lower hemoglobin level, and lower body mass index (calculated as weight in kilograms divided by the square of height in meters); more-advanced clinical stage of infection; male sex; and more missed drug pickup appointments. Dropouts (which accrued at a rate of 2.1 dropouts per 100 person-years) were predicted by a lower body mass index, more missed visits and missed drug pickup appointments, and later calendar year. Incidence of switches to second-line regimens was 4.9 per 100 person-years; increased hazards were observed with lower CD4 cell count and earlier calendar year at baseline. In patients who switched, virological failure was predicted by combined clinical and CD4 criteria with 74% sensitivity and 30% specificity. CONCLUSIONS In an antiretroviral treatment program employing comprehensive monitoring, the probability of switching to second-line therapy was limited. Regular pickup of medication was a predictor of survival and was also strongly predictive of patient retention.
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Affiliation(s)
- Leonardo Palombi
- Department of Public Health, University Tor Vergata, Catholic University, Rome, Italy
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Etravirine limits the emergence of darunavir and other protease inhibitor resistance-associated mutations in the DUET trials. AIDS 2010; 24:921-4. [PMID: 20160633 DOI: 10.1097/qad.0b013e328336ac2a] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Etravirine is a recently approved nonnucleoside reverse transcriptase inhibitor. The ability of etravirine to limit the emergence of resistance to protease inhibitors, and specifically to darunavir, was investigated in the subset of treatment-experienced patients with virologic rebound in the phase III DUET trials. Of those experiencing rebound, fewer etravirine-treated than placebo-treated patients developed mutations associated with resistance to protease inhibitors in general and to darunavir in particular, and more patients in the etravirine than the placebo-group maintained baseline darunavir susceptibility at endpoint.
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Hearps AC, Greengrass V, Hoy J, Crowe SM. An HIV-1 integrase genotype assay for the detection of drug resistance mutations. Sex Health 2010; 6:305-9. [PMID: 19917199 DOI: 10.1071/sh09041] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2009] [Accepted: 08/11/2009] [Indexed: 11/23/2022]
Abstract
BACKGROUND The integrase inhibitors (e.g. Raltegravir) are a new class of antiretroviral drugs that have recently become available for the treatment of patients with multi-drug resistant HIV-1 within Australia. The emergence of mutations that confer resistance to the integrase inhibitors has been observed in vivo; however, no commercial genotyping assay is currently available to screen for resistance to these drugs. METHODS The HIV-1 integrase gene was amplified from plasma-derived HIV-1 viral RNA via reverse transcription-polymerase chain reaction and genotype determined via population DNA sequencing. Drug resistance mutations and polymorphisms were detected using the Stanford University online HIV database. Assay sensitivity and reproducibility were determined using clinical and laboratory-derived samples. RESULTS Our in-house assay was capable of genotyping the integrase gene from all samples tested (n = 30) of HIV-1 subtypes B, C, D, F, CFR01_AE and CRF02_AG and can amplify the integrase region from plasma samples containing as few as 50 HIV RNA copies/mL. The assay is highly reproducible (average nucleotide concordance = 99.6%, n = 4) and is capable of detecting resistance-associated mutations. CONCLUSIONS This assay is suitable for routine drug resistance screening of plasma samples from HIV-infected patients receiving integrase inhibitor antiretroviral drugs and also serves as a useful research tool.
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Affiliation(s)
- Anna C Hearps
- Clinical Research Laboratory, Centre for Virology, Burnet Institute for Medical Research and Public Health, Melbourne, Vic. 3004, Australia.
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Abstract
PURPOSE OF REVIEW This review examines situations in which information from cohort studies has proved to be useful for the development of treatment guidelines. RECENT FINDINGS Although there are several reasons why randomized controlled trials (RCTs) are felt to provide the most robust evidence for treatment guidelines, they may suffer from insufficient duration of follow-up, inadequate power to consider differences in important adverse events and highly selected patient populations. Furthermore, as most RCTs are performed for licensing purposes, strategic treatment decisions often lack supportive evidence from RCTs. Although data from cohort studies may be used to complement information from RCTs, cohort studies themselves are susceptible to several biases (most notably confounding) which may limit their findings. However, in the HIV field, information from such studies has been influential in guiding decisions relating to when to start highly active antiretroviral therapy, what drugs to use in the initial highly active antiretroviral therapy regimen and when to switch highly active antiretroviral therapy should virological failure occur. SUMMARY Given the biases that may be present, caution should be exercised when interpreting findings from cohort studies, particularly if comparisons are made of treatment strategies that involve some element of patient or clinician choice.
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Prasitsuebsai W, Bowen AC, Pang J, Hesp C, Kariminia A, Sohn AH. Pediatric HIV clinical care resources and management practices in Asia: a regional survey of the TREAT Asia pediatric network. AIDS Patient Care STDS 2010; 24:127-31. [PMID: 20059355 DOI: 10.1089/apc.2009.0224] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Characterizing intraregional differences in current pediatric HIV care and treatment in Asia can guide the development of clinical practice guidelines and improve the understanding of local resource availability. The Therapeutics Research, Education, and AIDS Training in Asia (TREAT Asia) Pediatric Program is a collaboration of clinics and referral hospitals studying pediatric HIV outcomes in the region. A Web-based survey to characterize clinical management practices and monitoring resources was developed and distributed to 20 sites in January 2008. Seventeen (85%) sites from 6 countries responded through April 2008; 14 (82%) were hospital-based and 16 (94%) were public facilities. Of 4050 HIV-infected children under care, 3606 (89%) were on antiretroviral treatment; 80% were on their first mono-, dual-, or triple-drug regimen and 74% were on nevirapine- or efavirenz-based regimens. Fifteen (88%) sites had consistent access to polymerase chain reaction (PCR) testing for infant diagnosis. All sites had access to CD4 testing, with 13 (76%) routinely monitoring patients every 3-6 months; 7 (41%) sites monitored viral load at 6- to 12-month intervals. Although there is some variation in clinical practices, high levels of treatment and monitoring resources were available at these sites. The availability of PCR for early infant diagnosis positions them to implement recent WHO recommendations to treat HIV-infected children younger than 1 year of age. This information will be used to develop future research and programs to support children with HIV in Asia.
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Affiliation(s)
| | - Asha C. Bowen
- Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Joselyn Pang
- TREAT Asia, amfAR–The Foundation for AIDS Research, Bangkok, Thailand
| | - Cees Hesp
- PharmAccess, Amsterdam, The Netherlands
| | - Azar Kariminia
- National Centre in HIV Epidemiology and Clinical Research, Sydney, New South Wales, Australia
| | - Annette H. Sohn
- TREAT Asia, amfAR–The Foundation for AIDS Research, Bangkok, Thailand
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Ma Y, Zhao D, Yu L, Bulterys M, Robinson ML, Zhao Y, Dou Z, Chiliade P, Wei X, Zhang F. Predictors of virologic failure in HIV-1-infected adults receiving first-line antiretroviral therapy in 8 provinces in China. Clin Infect Dis 2010; 50:264-71. [PMID: 20017637 PMCID: PMC2805417 DOI: 10.1086/649215] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Despite poor primary health care systems, free antiretroviral therapy (ART) has been available in China for >5 years. Virologic outcomes in Chinese patients receiving ART have not been described on a national level. METHODS A multistage cluster design was used in 8 provinces to randomly select patients who had been receiving first-line ART for at least 6 months, who were stratified into 3 treatment-duration groups. Viral load testing and patient interviews were conducted, and data were linked with national treatment database information. Collected data were analyzed for association with viral suppression by means of multivariate modeling. Adequate viral suppression was defined as a viral load of <400 copies/mL. RESULTS Of 5256 patients receiving ART, 3894 met the eligibility criteria, among whom 1153 were analyzed. Overall, 72% demonstrated viral suppression, and 82%, 73%, and 67% of the participants receiving ART for 6-11, 12-23, and > or = 24 months, respectively, experienced viral suppression (P < .001). In a multivariate model, treatment given at locations other than county-level hospitals was less likely to achieve viral suppression, with greater odds for inadequate virologic response found at village clinics (odds ratio [OR], 5.4; 95% confidence interval [CI], 2.9-10.1), township health centers (OR, 3.1; 95% CI, 1.7-5.6), and public health clinics (OR, 3.1; 95% CI, 1.7-5.6). Patients receiving didanosine-based regimens were more likely to experience an inadequate virologic response than were those receiving lamivudine-based regimens (OR, 3.9; 95% CI, 2.7-5.7). CONCLUSIONS China's national ART program is largely successful at suppressing viral load. Care received outside of hospitals and regimens containing didanosine were associated with less favorable virologic outcomes.
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Affiliation(s)
- Ye Ma
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Decai Zhao
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Lan Yu
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Marc Bulterys
- Global AIDS Program, Centers for Disease Control and Prevention, U.S. Embassy, Beijing, China
| | - Matthew L. Robinson
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
- School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Yan Zhao
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Zhihui Dou
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | | | - Xiaoyu Wei
- Global AIDS Program, Centers for Disease Control and Prevention, U.S. Embassy, Beijing, China
| | - Fujie Zhang
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
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Boyd MA, Hill AM. Clinical management of treatment-experienced, HIV/AIDS patients in the combination antiretroviral therapy era. PHARMACOECONOMICS 2010; 28 Suppl 1:17-34. [PMID: 21182341 DOI: 10.2165/11587420-000000000-00000] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Despite the success of combination antiretroviral therapy (ART) in improving clinical outcomes, treatment failure remains a significant challenge, particularly for highly treatment-experienced patients. This review evaluates current issues in the management of HIV-infected, treatment-experienced patients. It may provide guidance in selecting active, tolerable drug combinations that promote a reasonable quality of life, full adherence and a durable treatment response. Current treatment guidelines and clinical trial data were reviewed to identify reasons for treatment failure and to summarize therapy options for treatment-experienced and highly treatment-experienced patients. Current treatment options include nucleoside reverse transcriptase inhibitors (NRTIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs), protease inhibitors (PIs), and inhibitors of viral fusion, entry and integration. The use of NRTIs may be limited by resistance and short- and long-term toxicities. Resistance has restricted the NNRTI class with cross-resistance preventing their sequential use. Etravirine, a next-generation NNRTI, however, demonstrates effective virological suppression in patients with baseline NNRTI resistance. Boosted PIs are key components of ART for treatment-experienced patients. The newer boosted PIs tipranavir and darunavir have demonstrated impressive activity in patients with resistance to NRTIs, NNRTIs and PIs, as well as in less treatment-experienced patients for darunavir. The fusion inhibitor enfuvirtide has demonstrated efficacy in heavily treatment-experienced patients, although injection-site reactions can be problematical. The recently approved integrase inhibitor raltegravir has also shown impressive potency and tolerability in highly treatment-experienced patients. Finally, the entry inhibitor maraviroc has also been approved recently, although its use is somewhat limited by the need for HIV tropism testing. The availability of potent next-generation PIs, NNRTIs, integrase and entry-inhibitors may offer improved therapy for treatment-experienced patients, including those with multiresistant virus. These new drugs may reduce HIV immunological and clinical progression and in doing so may also reduce treatment costs.
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Affiliation(s)
- Mark A Boyd
- National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, New South Wales 2010, Australia
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Pujari S, Srasuebkul P, Sungkanuparph S, Lim PL, Kumarasamy N, Chuah J, Kumar RN, Chen YMA, Oka S, Choi JY, Lee MP, Phanuphak P, Kamarulzaman A, Lee C, Fujie Z, Ditangco R, Saphonn V, Sirisanthana T, Merati TP, Smith J, Law MG. Patient Characteristics and Treatment Outcome Associated with Protease Inhibitor (PI) use in the Asia-Pacific Region. ACTA ACUST UNITED AC 2009; 1:28-35. [PMID: 20505782 DOI: 10.4172/jaa.1000004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVES: Regimens containing protease inhibitors (PI) are less commonly used in developing countries due to high cost and less availability. We evaluated characteristics of patients initiating PI-based therapy according to previous antiretroviral (ARV) exposure; factors associated with initiating a PI-containing regimen using newer versus older PIs, and proportion of patients with detectable viral loads (VL) after initiating a PI-based regimen. METHODS: This analysis includes all patients who have initiated a PI-based regimen. ARV exposure was categorised: naïve (no previous ARV), 1st, 2nd, >/= 3rd switches; a switch was defined as starting or stopping any drug in a regimen. Newer PIs were defined as those approved by the US FDA after 1 January 2000. Detectable VL at 12 months was defined as VL >/= 400 copies/mL. Characteristics at PI initiation were evaluated. Logistic regression was used to determine factors associated with initiating a newer PI and detectable VL at 12 months after PI initiation. RESULTS: 1106 patients initiated PI-based therapy; of these, 618 (56%) were naïve patients. Overall, 22% (176) of patients had detectable VL at 12 months following the PI initiation. Being from a high income country (vs. mid/low income, OR = 1.80, p = 0.034) were more likely to be associated with detectable VL. CONCLUSION: The use of PIs in this cohort is dictated by accessibility and affordability issues particularly for the newer PIs. Short-term virological outcomes following PI-therapy in our cohort were good, and were associated with CD4 count at time of initiation.
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Lorenzen T, Walther I, Stoehr A, Salzberger B, Plettenberg A. Effective treatment of patients in a deep salvage situation with "non-active HAART": experiences with the expert advice system RADATA. Infection 2009; 37:528-33. [PMID: 19826762 DOI: 10.1007/s15010-009-9022-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2009] [Accepted: 06/22/2009] [Indexed: 11/28/2022]
Abstract
BACKGROUND Clinical studies suggest expert recommendations as a possibility to optimize highly active antiretroviral therapy (HAART) in patients with multi-drug resistant virus strains. An online system (RADATA) has been developed to provide expert advice for the drug therapy of HIV-infected patients. OBJECTIVE To evaluate the efficacy of expert-advice-guided HAART switches in patients with triple-class failure. METHODS Virological and immunological outcome of patients having undergone at least three prior ART regimens, including nucleoside inhibitor (NRTI), nonnucleoside reverse transcriptase inhibitor (NNRTI), and protease inhibitor (PI) use, were analyzed. Changes in HIV-RNA and CD4-cell count were evaluated every 3 months. RESULTS 183 patients with a median baseline viral load of 3.90 log copies/ml (1.88-6.54 log) and a CD4-cell count of 298 c/ll (5-910 c/ll) were eligible for analysis. The patients had a median of seven prior ART regimens and a treatment duration of 83 months. A median of three (range 0-8) NRTI-, two (0-7) thymidine-associated (TA), one (0-4) NNRTI-, and three (0-13) PI-associated resistance mutations were present at baseline. Despite available resistance analyses and expert recommendations, 66% (n = 119) of the patients started a new ART regimen without any active drugs according to the resistance analysis. The HIV-RNA declined by a median of 0.61 log and 0.92 log after 12 and 24 months, respectively, while the CD4-cell count rose by a median of +9 c/microl and +25 c/microl during this period. No significant differences related to number of prior regimens or number of active substances used could be found. CONCLUSION Despite extensive pre-treatment and multiple resistances against prescribed HAART, our patients demonstrated a decline in viral load and a stable CD4-cell count over the observation period. We conclude that the activity of antiretroviral regimens is not exclusively explained by the current algorithms used for estimating antiretroviral drug activity.
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Affiliation(s)
- T Lorenzen
- Ifi-Institute for Interdisciplinary Medicine, Hospital St. George, Hamburg, Germany
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Paredes R, Clotet B. Clinical management of HIV-1 resistance. Antiviral Res 2009; 85:245-65. [PMID: 19808056 DOI: 10.1016/j.antiviral.2009.09.015] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2009] [Revised: 09/28/2009] [Accepted: 09/30/2009] [Indexed: 11/18/2022]
Abstract
Antiretroviral drug resistance is a fundamental survival strategy for the virus that stems from its vast capacity to generate diversity. With the recent availability of new ARV drugs and classes, it is now possible to prescribe fully active ART to most HIV-infected subjects and achieve viral suppression even in those with multidrug-resistant HIV. It is uncertain, however, if this scenario will endure. Given that ART must be given for life, and new compounds other than second-generation integrase inhibitors may not reach the clinic soon, all efforts must be done to avoid the development of resistance to the new agents. Here, we discuss relevant aspects for the clinical management of antiretroviral drug resistance, leaving detailed explanations of mechanisms and mutation patterns to other articles in this issue. This article forms part of a special issue of Antiviral Research marking the 25th anniversary of antiretroviral drug discovery and development, vol. 85, issue 1, 2010.
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Affiliation(s)
- Roger Paredes
- Institut de Recerca de SIDA - irsiCaixa & Fundació Lluita contra SIDA, Servei de Medicina Interna, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Catalonia, Spain.
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An algorithm to optimize viral load testing in HIV-positive patients with suspected first-line antiretroviral therapy failure in Cambodia. J Acquir Immune Defic Syndr 2009; 52:40-8. [PMID: 19550349 DOI: 10.1097/qai.0b013e3181af6705] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To develop an algorithm for optimal use of viral load testing in patients with suspected first-line antiretroviral treatment (ART) failure. METHODS Data from a cohort of patients on first-line ART in Cambodia were analyzed in a cross-sectional way to detect markers for treatment failure. Markers with an adjusted likelihood ratio <0.67 or >1.5 were retained to calculate a predictor score. The accuracy of a 2-step algorithm based on this score followed by targeted viral load testing was compared with World Health Organization criteria for suspected treatment failure. RESULTS One thousand eight hundred three viral load measurements of 764 patients were available for analysis. Prior ART exposure, CD4 count below baseline, 25% and 50% drop from peak CD4 count, hemoglobin drop of > or =1 g/dL, CD4 count <100 cells per microliter after 12 months of treatment, new onset of papular pruritic eruption, and visual analog scale <95% were included in the predictor score. A score >or=2 had the best combination of sensitivity and specificity and required confirmatory viral load testing for only 9% of patients. World Health Organization criteria had a similar sensitivity but a lower specificity and required viral load testing for 24.9% of patients. CONCLUSION An algorithm combining a predictor score with targeted viral load testing in patients with an intermediate probability of failure optimizes the use of scarce resources.
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Johannessen A, Naman E, Kivuyo SL, Kasubi MJ, Holberg-Petersen M, Matee MI, Gundersen SG, Bruun JN. Virological efficacy and emergence of drug resistance in adults on antiretroviral treatment in rural Tanzania. BMC Infect Dis 2009; 9:108. [PMID: 19583845 PMCID: PMC2713244 DOI: 10.1186/1471-2334-9-108] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2008] [Accepted: 07/07/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Virological response to antiretroviral treatment (ART) in rural Africa is poorly described. We examined virological efficacy and emergence of drug resistance in adults receiving first-line ART for up to 4 years in rural Tanzania. METHODS Haydom Lutheran Hospital has provided ART to HIV-infected patients since October 2003. A combination of stavudine or zidovudine with lamivudine and either nevirapine or efavirenz is the standard first-line regimen. Nested in a longitudinal cohort study of patients consecutively starting ART, we carried out a cross-sectional virological efficacy survey between November 2007 and June 2008. HIV viral load was measured in all adults who had completed at least 6 months first-line ART, and genotypic resistance was determined in patients with viral load >1000 copies/mL. RESULTS Virological response was measured in 212 patients, of whom 158 (74.5%) were women, and median age was 35 years (interquartile range [IQR] 29-43). Median follow-up time was 22.3 months (IQR 14.0-29.9). Virological suppression, defined as <400 copies/mL, was observed in 187 patients (88.2%). Overall, prevalence of > or =1 clinically significant resistance mutation was 3.9, 8.4, 16.7 and 12.5% in patients receiving ART for 1, 2, 3 and 4 years, respectively. Among those successfully genotyped, the most frequent mutations were M184I/V (64%), conferring resistance to lamivudine, and K103N (27%), Y181C (27%) and G190A (27%), conferring resistance to non-nucleoside reverse transcriptase inhibitors (NNRTIs), whereas 23% had thymidine analogue mutations (TAMs), associated with cross-resistance to all nucleoside reverse transcriptase inhibitors (NRTIs). Dual-class resistance, i.e. resistance to both NRTIs and NNRTIs, was found in 64%. CONCLUSION Virological suppression rates were good up to 4 years after initiating ART in a rural Tanzanian hospital. However, drug resistance increased with time, and dual-class resistance was common, raising concerns about exhaustion of future antiretroviral drug options. This study might provide a useful forecast of drug resistance and demand for second-line antiretroviral drugs in rural Africa in the coming years.
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Affiliation(s)
- Asgeir Johannessen
- Ulleval Department of Infectious Diseases, Oslo University Hospital, Oslo, Norway
- HIV Care and Treatment Centre, Haydom Lutheran Hospital, Mbulu, Tanzania
| | - Ezra Naman
- HIV Care and Treatment Centre, Haydom Lutheran Hospital, Mbulu, Tanzania
| | - Sokoine L Kivuyo
- National Institute for Medical Research, Haydom Research Station, Mbulu, Tanzania
| | - Mabula J Kasubi
- Department of Microbiology and Immunology, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | | | - Mecky I Matee
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Svein G Gundersen
- Research Unit, Sorlandet Hospital HF, Kristiansand, Norway
- Centre for Development Studies, University of Agder, Kristiansand, Norway
| | - Johan N Bruun
- Ulleval Department of Infectious Diseases, Oslo University Hospital, Oslo, Norway
- Department of Infectious Diseases, University Hospital of North Norway, Tromso, Norway
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Increased mutations in Env and Pol suggest greater HIV-1 replication in sputum-derived viruses compared with blood-derived viruses. AIDS 2009; 23:923-8. [PMID: 19349849 DOI: 10.1097/qad.0b013e328329f964] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Low-level HIV-1 replication may occur during antiretroviral therapy (ART) that suppresses plasma HIV-1 RNA to less than 50 copies/ml (suppressive ART). Antiretroviral drugs appear less effective in macrophages and monocytes compared with lymphocytes, both in vitro and as implied in vivo by greater viral evolution observed during suppressive ART. Our objective was to examine sputum, which is rich in macrophages, for evidence of increased HIV-1 replication compared with that in the blood during suppressive ART. DESIGN A cross-sectional study during suppressive ART was performed, and HIV-1 DNA sequences derived from induced sputa and peripheral blood mononuclear cells were compared. METHODS Multiple sequences encoding HIV-1 reverse transcriptase, protease, and envelope were generated using single-genome sequencing. Reverse transcriptase and protease sequences were analyzed for genotypic drug resistance. The evolutionary distances of env sequences from the inferred most recent common ancestor of infection were calculated, and CXCR4 usage was predicted. RESULTS Nine hundred seventy bidirectional sequences from 11 individuals were analyzed. HIV-1 env and pol derived from sputa had greater frequency of drug-resistance mutations (P = 0.05), evolutionary divergence (P = 0.004), and tendency for CXCR4 usage (P = 0.1) compared with viruses derived from peripheral blood mononuclear cells. CONCLUSION The greater frequency of HIV-1 drug-resistance mutations and divergence of HIV-1 env in sputa-derived viruses compared with peripheral blood mononuclear cell-derived viruses suggests greater HIV-1 replication in the respiratory tract compared with the blood. Characterization of viral evolution over time and by cell-type could identify cells that provide a sanctuary for low-level viral replication in the respiratory tract during suppressive ART.
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