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Zhao Y, Voget J, Singini I, Omar Z, Mudaly V, Boulle A, Maartens G, Meintjes G. Virologic outcomes with tenofovir-lamivudine-dolutegravir in adults failing PI-based second-line ART. South Afr J HIV Med 2024; 25:1567. [PMID: 38725705 PMCID: PMC11079356 DOI: 10.4102/sajhivmed.v25i1.1567] [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: 01/23/2024] [Accepted: 03/06/2024] [Indexed: 05/12/2024] Open
Abstract
Background In South African antiretroviral guidelines, selected patients failing second-line protease inhibitor (PI)-based therapy qualify for genotypic resistance testing - those with PI resistance receive darunavir-based third-line regimens; those without PI resistance continue current regimen with adherence support. The Western Cape province, from September 2020, implemented a strategy of tenofovir-lamivudine-dolutegravir (TLD) for patients, provided there was no tenofovir resistance, irrespective of PI resistance. Objectives To evaluate virologic outcomes with TLD among adults failing second-line PI regimens with no tenofovir resistance. Method An observational cohort study comparing outcomes in patients switched to TLD with those continuing the same PI or switched to darunavir-based regimens. Follow-up was until virologic suppression (HIV-1 RNA < 400 copies/mL), or at the point of censoring. Results One hundred and thirty-three patients switched to TLD, 101 to darunavir-based regimens, and 121 continued with the same PI. By 12 months, among patients with PI resistance, 42/47 (89%) in the TLD group had HIV-1 RNA < 400 copies/mL compared to 91/99 (92%) in the darunavir group (hazard ratio, 1.11; 95% confidence interval, 0.77-1.60). In patients without PI resistance, 66/86 (77%) in the TLD group had HIV-1 RNA < 400 copies/mL compared to 42/120 (35%) in those continuing with the same PI (hazard ratio, 4.03; 95% confidence interval, 2.71-5.98). Two patients receiving TLD developed virologic failure with high-level dolutegravir resistance. Conclusion Amongst patients failing second-line PI with no PI resistance, switching to TLD was associated with higher virologic suppression, likely due to improved adherence. Virologic outcomes were similar in patients with PI resistance switched to darunavir-based regimens or TLD.
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Affiliation(s)
- Ying Zhao
- Department of Medicine, Faculty of Health Science, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Jacqueline Voget
- Western Cape Government Department of Health and Wellness, Cape Town, South Africa
| | - Isaac Singini
- Biostatistics Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Zaayid Omar
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Vanessa Mudaly
- Western Cape Government Department of Health and Wellness, Cape Town, South Africa
| | - Andrew Boulle
- Provincial Health Data Centre, Western Cape Department of Health and CIDER, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Department of Medicine, Faculty of Health Science, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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Steegen K, van Zyl GU, Claassen M, Khan A, Pillay M, Govender S, Bester PA, van Straaten JM, Kana V, Cutler E, Kalimashe MN, Lebelo RL, Moloi MBH, Hans L. Advancing HIV Drug Resistance Technologies and Strategies: Insights from South Africa's Experience and Future Directions for Resource-Limited Settings. Diagnostics (Basel) 2023; 13:2209. [PMID: 37443603 DOI: 10.3390/diagnostics13132209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/23/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
Monitoring of HIV drug resistance (HIVDR) remains critical for ensuring countries attain and sustain the global goals for ending HIV as a public health threat by 2030. On an individual patient level, drug resistance results assist in ensuring unnecessary treatment switches are avoided and subsequent regimens are tailored on a case-by-case basis, should resistance be detected. Although there is a disparity in access to HIVDR testing in high-income countries compared to low- and middle-income countries (LMICS), more LMICs have now included HIVDR testing for individual patient management in some groups of patients. In this review, we describe different strategies for surveillance as well as where HIVDR testing can be implemented for individual patient management. In addition, we briefly review available technologies for HIVDR testing in LMICs, including Sanger sequencing, next-generation sequencing, and some point-of-care options. Finally, we describe how South Africa has implemented HIVDR testing in the public sector.
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Affiliation(s)
- Kim Steegen
- Department of Molecular Medicine and Haematology, National Health Laboratory Service, Charlotte Maxeke Johannesburg Hospital, Johannesburg 2193, South Africa
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2000, South Africa
- Wits Diagnostic Innovation Hub, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2000, South Africa
| | - Gert U van Zyl
- Division of Medical Virology, Stellenbosh University, Stellenbosh 7602, South Africa
- Division of Medical Virology, Stellenbosh National Health Laboratory Service, Tygerberg Hospital, Tygerberg 7505, South Africa
| | - Mathilda Claassen
- Division of Medical Virology, Stellenbosh University, Stellenbosh 7602, South Africa
- Division of Medical Virology, Stellenbosh National Health Laboratory Service, Tygerberg Hospital, Tygerberg 7505, South Africa
| | - Aabida Khan
- Department of Virology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban 4041, South Africa
- Department of Virology, National Health Laboratory Service, Inkosi Albert Luthuli Central Hospital, Durban 4058, South Africa
| | - Melendhran Pillay
- Department of Virology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban 4041, South Africa
- Department of Virology, National Health Laboratory Service, Inkosi Albert Luthuli Central Hospital, Durban 4058, South Africa
| | - Subitha Govender
- Department of Virology, National Health Laboratory Service, Inkosi Albert Luthuli Central Hospital, Durban 4058, South Africa
| | - Phillip A Bester
- Department of Medical Microbiology and Virology, University of the Free State, Bloemfontein 9300, South Africa
- Department of Medical Microbiology and Virology, National Health Laboratory Service, Universitas Academic Hospital, Bloemfontein 9301, South Africa
| | - Johanna M van Straaten
- Department of Medical Microbiology and Virology, National Health Laboratory Service, Universitas Academic Hospital, Bloemfontein 9301, South Africa
| | - Vibha Kana
- Centre for HIV and STIs, National Institute for Communicable Diseases, Johannesburg 2192, South Africa
| | - Ewaldé Cutler
- Centre for HIV and STIs, National Institute for Communicable Diseases, Johannesburg 2192, South Africa
| | - Monalisa N Kalimashe
- Centre for HIV and STIs, National Institute for Communicable Diseases, Johannesburg 2192, South Africa
| | - Ramokone L Lebelo
- Department of Virological Pathology, Sefako Makgatho Health Sciences University, Pretoria 0204, South Africa
- Department of Virological Pathology, National Health Laboratory Service, Sefako Makgatho Health Sciences University, Pretoria 0204, South Africa
| | - Mokopi B H Moloi
- Department of Virological Pathology, Sefako Makgatho Health Sciences University, Pretoria 0204, South Africa
- Department of Virological Pathology, National Health Laboratory Service, Sefako Makgatho Health Sciences University, Pretoria 0204, South Africa
| | - Lucia Hans
- Department of Molecular Medicine and Haematology, National Health Laboratory Service, Charlotte Maxeke Johannesburg Hospital, Johannesburg 2193, South Africa
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2000, South Africa
- Wits Diagnostic Innovation Hub, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2000, South Africa
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3
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Avihingsanon A, Hughes MD, Salata R, Godfrey C, McCarthy C, Mugyenyi P, Hogg E, Gross R, Cardoso SW, Bukuru A, Makanga M, Badal‐aesen S, Mave V, Ndege BW, Fontain SN, Samaneka W, Secours R, Van Schalkwyk M, Mngqibisa R, Mohapi L, Valencia J, Sugandhavesa P, Montalban E, Munyanga C, Chagomerana M, Santos BR, Kumarasamy N, Kanyama C, Schooley RT, Mellors JW, Wallis CL, Collier AC, Grinsztejn B. Third‐line antiretroviral therapy, including raltegravir (RAL), darunavir (DRV/r) and/or etravirine (ETR), is well tolerated and achieves durable virologic suppression over 144 weeks in resource‐limited settings: ACTG A5288 strategy trial. J Int AIDS Soc 2022; 25:e25905. [PMID: 36039892 PMCID: PMC9332128 DOI: 10.1002/jia2.25905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 03/23/2022] [Indexed: 11/22/2022] Open
Abstract
Introduction ACTG A5288 was a strategy trial conducted in diverse populations from multiple continents of people living with HIV (PLWH) failing second‐line protease inhibitor (PI)‐based antiretroviral therapy (ART) from 10 low‐ and middle‐income countries (LMICs). Participants resistant to lopinavir (LPV) and/or multiple nucleotide reverse transcriptase inhibitors started on third‐line regimens that included raltegravir (RAL), darunavir/ritonavir (DRV/r) and/or etravirine (ETR) according to their resistance profiles. At 48 weeks, 87% of these participants achieved HIV‐1 RNA ≤200 copies/ml. We report here long‐term outcomes over 144 weeks. Methods Study participants were enrolled from 2013 to 2015, prior to the availability of dolutegravir in LMICs. “Extended Follow‐up” of the study started after the last participant enrolled had reached 48 weeks and included participants still on antiretroviral (ARV) regimens containing RAL, DRV/r and/or ETR at that time. RAL, DRV/r and ETR were provided for an additional 96 weeks (giving total follow‐up of ≥144 weeks), with HIV‐1 RNA measured at 48 and 96 weeks and CD4 count at 96 weeks after entry into Extended Follow‐up. Proportion of participants with HIV‐1 RNA ≤200 copies/ml was estimated every 24 weeks, using imputation if necessary to handle the different measurement schedule in Extended Follow‐up; mean CD4 count changes were estimated using loess regression. Results and Discussion Of 257 participants (38% females), at study entry, median CD4 count was 179 cells/mm3, and HIV‐1 RNA was 4.6 log10 copies/ml. Median follow‐up was 168 weeks (IQR: 156–204); 15 (6%) participants were lost to follow‐up and 9 (4%) died. 27/246 (11%), 26/246 (11%) and 13/92 (14%) of participants who started RAL, DRV/r and ETR, respectively, discontinued these drugs; only three due to adverse events. 87%, 86%, 83% and 80% of the participants had HIV‐1 RNA ≤200 copies/ml at weeks 48, 96, 144 and 168 (95% CI at week 168: 74–85%), respectively. Mean increase from study entry in CD4 count at week 168 was 265 cells/mm3 (95% CI 247–283). Conclusions Third‐line regimens comprising of RAL, DRV/r and/or ETR were very well tolerated and had high rates of durable virologic suppression among PLWH in LMICs who were failing on second‐line PI‐based ART prior to the availability of dolutegravir.
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Affiliation(s)
- Anchalee Avihingsanon
- HIV‐NAT, Thai Red Cross AIDS Research Centre and Centre of Excellence in Tuberculosis Faculty of Medicine Chulalongkorn University Bangkok Thailand
| | - Michael D. Hughes
- Center for Biostatistics in AIDS Research in the Department of Biostatistics Harvard T H Chan School of Public Health Boston Massachusetts USA
| | | | - Catherine Godfrey
- Division of AIDS National Institutes of Allergy and Infectious Disease National Institutes of Health Bethesda Maryland USA
| | - Caitlyn McCarthy
- Center for Biostatistics in AIDS Research in the Department of Biostatistics Harvard T H Chan School of Public Health Boston Massachusetts USA
| | | | - Evelyn Hogg
- Social & Scientific Systems Inc. a DLH Holdings Company Silver Spring Maryland USA
| | - Robert Gross
- Center for Clinical Epidemiology and Biostatistics University of Pennsylvania Philadelphia Pennsylvania USA
| | - Sandra W. Cardoso
- Instituto Nacional de Infectologia Evandro Chagas Fundacao Oswaldo Cruz Rio de Janeiro Brazil
| | | | - Mumbi Makanga
- Kenya Medical Research Institute/Center of Disease Control Kisumu Kenya
| | - Sharlaa Badal‐aesen
- Clinical HIV Research Unit Helen Joseph Hospital University of Witwatersrand Johannesburg South Africa
| | - Vidya Mave
- BJ Medical College Clinical Research Site Pune India
| | | | | | - Wadzanai Samaneka
- University of Zimbabwe Clinical Trials Research Centre Harare Zimbabwe
| | - Rode Secours
- Les Centres GHESKIO Clinical Research Site Port‐au‐Prince Haiti
| | - Marije Van Schalkwyk
- Family Centre for Research with Ubuntu (FAMCRU) Stellenbosch University Cape Town South Africa
| | - Rosie Mngqibisa
- Durban International Clinical Research Site, King Edward Hospital, Enhancing Care Foundation Durban South Africa
| | - Lerato Mohapi
- Soweto AIDS Clinical Trials Group Clinical Research Site, Perinatal HIV Research Unit University of the Witwatersrand Johannesburg South Africa
| | | | | | | | - Cornelius Munyanga
- University of North Carolina Project, Kamazu Central Hospital Lilongwe Malawi
| | | | | | | | - Cecilia Kanyama
- University of North Carolina Project, Kamazu Central Hospital Lilongwe Malawi
| | - Robert T. Schooley
- Division of Infectious Diseases University of California San Diego California USA
| | - John W. Mellors
- Division of Infectious Diseases Department of Medicine University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - Carole L. Wallis
- BARC‐South Africa and Lancet Laboratories Johannesburg South Africa
| | - Ann C. Collier
- University of Washington School of Medicine University of Washington Seattle Washington USA
| | - Beatriz Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas Fundacao Oswaldo Cruz Rio de Janeiro Brazil
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4
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Chimukangara B, Lessells RJ, Sartorius B, Gounder L, Manyana S, Pillay M, Singh L, Giandhari J, Govender K, Samuel R, Msomi N, Naidoo K, de Oliveira T, Moodley P, Parboosing R. HIV-1 drug resistance in adults and adolescents on protease inhibitor-based antiretroviral treatment in KwaZulu-Natal Province, South Africa. J Glob Antimicrob Resist 2021; 29:468-475. [PMID: 34785393 DOI: 10.1016/j.jgar.2021.10.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/19/2021] [Accepted: 10/26/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND In low- and middle-income countries, increasing levels of HIV drug resistance (HIVDR) on second-line protease inhibitor (PI)-based regimens are a cause for concern, given limited drug options for third-line antiretroviral therapy (ART). OBJECTIVES We conducted a retrospective analysis of routine HIV-1 genotyping laboratory data from KwaZulu-Natal, in South Africa, to describe the frequency and patterns of HIVDR mutations and their consequent impact on standardized third-line regimens. METHODS This was a cross-sectional analysis of all HIV-1 genotypic resistance tests conducted by the National Health Laboratory Service in KwaZulu-Natal, South Africa (Jan 2015 - Dec 2016), for adults and adolescents (age ≥10 years) on second-line PI-based ART with virological failure. We assigned a third-line regimen to each record, based on a national treatment algorithm and calculated the genotypic susceptibility score (GSS) for that regimen. RESULTS Of 348 samples analyzed, 287 (83%) had at least one drug resistance mutation (DRM) and 114 (33%) had at least one major PI DRM. Major PI resistance was associated with longer duration on second-line ART (aOR per 6-months, 1.11, 95% CI 1.04-1.19) and older age (aOR 1.03, 95% CI 1.01-1.05). Of 112 patients requiring third-line ART, 12 (11%) had a GSS of <2 for the algorithm-assigned third-line regimen. CONCLUSIONS One in three people failing second-line ART had significant PI DRMs. A subgroup of these individuals had extensive HIVDR, where the predicted activity of third-line ART was suboptimal, highlighting the need for continuous evaluation of outcomes on third-line regimens and close monitoring for emergent HIV-1 integrase-inhibitor resistance.
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Affiliation(s)
- Benjamin Chimukangara
- Department of Virology, University of KwaZulu-Natal/National Health Laboratory Service, Durban, South Africa; Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa; Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD, USA.
| | - Richard J Lessells
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa; KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Benn Sartorius
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Lilishia Gounder
- Department of Virology, University of KwaZulu-Natal/National Health Laboratory Service, Durban, South Africa
| | - Sontaga Manyana
- Department of Virology, University of KwaZulu-Natal/National Health Laboratory Service, Durban, South Africa
| | - Melendhran Pillay
- Department of Virology, University of KwaZulu-Natal/National Health Laboratory Service, Durban, South Africa
| | - Lavanya Singh
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Jennifer Giandhari
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Kerusha Govender
- Department of Virology, University of KwaZulu-Natal/National Health Laboratory Service, Durban, South Africa
| | - Reshmi Samuel
- Department of Virology, University of KwaZulu-Natal/National Health Laboratory Service, Durban, South Africa
| | - Nokukhanya Msomi
- Department of Virology, University of KwaZulu-Natal/National Health Laboratory Service, Durban, South Africa
| | - Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa; South African Medical Research Council (SAMRC), CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Tulio de Oliveira
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa; KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa; Department of Global Health, University of Washington, Seattle, United States
| | - Pravi Moodley
- Department of Virology, University of KwaZulu-Natal/National Health Laboratory Service, Durban, South Africa
| | - Raveen Parboosing
- Department of Virology, University of KwaZulu-Natal/National Health Laboratory Service, Durban, South Africa
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5
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Datir R, Kemp S, El Bouzidi K, Mlchocova P, Goldstein R, Breuer J, Towers GJ, Jolly C, Quiñones-Mateu ME, Dakum PS, Ndembi N, Gupta RK. In Vivo Emergence of a Novel Protease Inhibitor Resistance Signature in HIV-1 Matrix. mBio 2020; 11:e02036-20. [PMID: 33144375 PMCID: PMC7642677 DOI: 10.1128/mbio.02036-20] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 09/21/2020] [Indexed: 12/16/2022] Open
Abstract
Protease inhibitors (PIs) are the second- and last-line therapy for the majority of HIV-infected patients worldwide. Only around 20% of individuals who fail PI regimens develop major resistance mutations in protease. We sought to explore the role of mutations in gag-pro genotypic and phenotypic changes in viruses from six Nigerian patients who failed PI-based regimens without known drug resistance-associated protease mutations in order to identify novel determinants of PI resistance. Target enrichment and next-generation sequencing (NGS) with the Illumina MiSeq system were followed by haplotype reconstruction. Full-length Gag-protease gene regions were amplified from baseline (pre-PI) and virologic failure (VF) samples, sequenced, and used to construct gag-pro-pseudotyped viruses. Phylogenetic analysis was performed using maximum-likelihood methods. Susceptibility to lopinavir (LPV) and darunavir (DRV) was measured using a single-cycle replication assay. Western blotting was used to analyze Gag cleavage. In one of six participants (subtype CRF02_AG), we found 4-fold-lower LPV susceptibility in viral clones during failure of second-line treatment. A combination of four mutations (S126del, H127del, T122A, and G123E) in the p17 matrix of baseline virus generated a similar 4-fold decrease in susceptibility to LPV but not darunavir. These four amino acid changes were also able to confer LPV resistance to a subtype B Gag-protease backbone. Western blotting demonstrated significant Gag cleavage differences between sensitive and resistant isolates in the presence of drug. Resistant viruses had around 2-fold-lower infectivity than sensitive clones in the absence of drug. NGS combined with haplotype reconstruction revealed that resistant, less fit clones emerged from a minority population at baseline and thereafter persisted alongside sensitive fitter viruses. We used a multipronged genotypic and phenotypic approach to document emergence and temporal dynamics of a novel protease inhibitor resistance signature in HIV-1 matrix, revealing the interplay between Gag-associated resistance and fitness.
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Affiliation(s)
| | - Steven Kemp
- University College London, London, United Kingdom
| | | | - Petra Mlchocova
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | | | - Judy Breuer
- University College London, London, United Kingdom
| | | | - Clare Jolly
- University College London, London, United Kingdom
| | | | - Patrick S Dakum
- Institute for Human Virology, Abuja, Nigeria
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Nicaise Ndembi
- Institute for Human Virology, Abuja, Nigeria
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ravindra K Gupta
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
- Africa Health Research Institute, Durban, South Africa
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6
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Nel J, Dlamini S, Meintjes G, Burton R, Black JM, Davies NECG, Hefer E, Maartens G, Mangena PM, Mathe MT, Moosa MY, Mulaudzi MB, Moorhouse M, Nash J, Nkonyane TC, Preiser W, Rassool MS, Stead D, van der Plas H, van Vuuren C, Venter WDF, Woods JF. Southern African HIV Clinicians Society guidelines for antiretroviral therapy in adults: 2020 update. South Afr J HIV Med 2020; 21:1115. [PMID: 33101723 PMCID: PMC7564911 DOI: 10.4102/sajhivmed.v21i1.1115] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 06/21/2020] [Indexed: 12/13/2022] Open
Affiliation(s)
- Jeremy Nel
- Helen Joseph Hospital, Department of Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Sipho Dlamini
- Department of Infectious Diseases, Faculty of Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Department of Medicine, Division of Infectious Diseases and HIV Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Rosie Burton
- Southern African Medical Unit, Médecins Sans Frontières (MSF), Cape Town, South Africa
| | - John M Black
- Department of Medicine, Division of Infectious Diseases, Livingstone Tertiary Hospital, Port Elizabeth, South Africa
| | | | - Eric Hefer
- Private Practice Medical Adviser, Johannesburg, South Africa
| | - Gary Maartens
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Phetho M Mangena
- Department of Internal Medicine, School of Medicine, Pietersburg Hospital, Polokwane, South Africa.,Department of Medicine, School of Medicine, University of Limpopo, Turfloop, South Africa
| | | | - Mahomed-Yunus Moosa
- Department of Infectious Diseases, Division of Internal Medicine, University of KwaZulu-Natal, Durban, South Africa
| | | | - Michelle Moorhouse
- Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jennifer Nash
- Specialist Family Physician, Amathole District Clinical Specialist Team, East London, South Africa
| | - Thandeka C Nkonyane
- Department of Infectious Diseases, Faculty of Medicine, Sefako Makgatho Health Sciences University, Pretoria, South Africa.,Department of Medicine, Dr George Mokhari Hospital, Pretoria, South Africa
| | - Wolfgang Preiser
- Department of Medical Virology, National Health Laboratory Service, Tygerberg, South Africa.,Department of Pathology, Faculty of Medicine and Health, Stellenbosch University, Cape Town, South Africa
| | - Mohammed S Rassool
- Clinical HIV Research Unit, Wits Health Consortium, Johannesburg, South Africa
| | - David Stead
- Department of Medicine, Faculty of Infectious Diseases, Frere and Cecilia Makiwane Hospitals, East London, South Africa.,Department of Medicine, Faculty of Health Sciences, Walter Sisulu University, Mthatha, South Africa
| | - Helen van der Plas
- Department of Infectious Diseases, Faculty of Medicine, University of Cape Town, Cape Town, South Africa
| | - Cloete van Vuuren
- Department of Internal Medicine, Military Hospital, Bloemfontein, South Africa.,Department of Internal Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
| | - Willem D F Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Joana F Woods
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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7
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Transition to third-line ART in resource-limited settings. Lancet HIV 2019; 6:e725-e727. [PMID: 31601545 DOI: 10.1016/s2352-3018(19)30324-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 08/01/2019] [Indexed: 11/20/2022]
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8
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Grinsztejn B, Hughes MD, Ritz J, Salata R, Mugyenyi P, Hogg E, Wieclaw L, Gross R, Godfrey C, Cardoso SW, Bukuru A, Makanga M, Faesen S, Mave V, Wangari Ndege B, Nerette Fontain S, Samaneka W, Secours R, van Schalkwyk M, Mngqibisa R, Mohapi L, Valencia J, Sugandhavesa P, Montalban E, Avihingsanon A, Santos BR, Kumarasamy N, Kanyama C, Schooley RT, Mellors JW, Wallis CL, Collier AC. Third-line antiretroviral therapy in low-income and middle-income countries (ACTG A5288): a prospective strategy study. Lancet HIV 2019; 6:e588-e600. [PMID: 31371262 PMCID: PMC6857629 DOI: 10.1016/s2352-3018(19)30146-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 03/22/2019] [Accepted: 04/26/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Antiretroviral therapy (ART) management is challenging for individuals in resource-limited settings presenting for third-line treatment because of complex resistance patterns, partly due to reduced access to viral load monitoring. We aimed to evaluate use of newer antiretroviral drugs and contemporary management approaches, including population-based sequencing, to select appropriate antiretrovirals, plasma viral load monitoring, and interventions to improve adherence in individuals presenting with second-line viral failure. METHODS A5288 was a phase 4, third-line ART strategy study done at 19 urban sites in ten countries that enrolled adult participants with confirmed plasma HIV-1 RNA (viral load) of 1000 copies per mL or more after more than 24 weeks of protease inhibitor-based second-line ART. The primary objective was to use antiretrovirals (raltegravir, etravirine, and ritonavir-boosted darunavir) and diagnostic monitoring technologies, including viral load, genotyping, and adherence support to achieve viral load suppression (defined as ≤200 copies per mL) in 65% or more of participants. ART history and real-time drug resistance genotypes were used to assign participants to one of four cohorts: cohort A (no lopinavir resistance) stayed on second-line ART and cohorts B (B1, best available nucleoside reverse transcriptase inhibitors [NRTIs] plus ritonavir-boosted darunavir plus raltegravir; B2, ritonavir-boosted darunavir plus raltegravir plus etravirine; B3, ritonavir-boosted darunavir, raltegravir, and either tenofovir plus emtricitabine or tenofovir plus lamivudine), C (ritonavir-boosted darunavir plus raltegravir plus tenofovir-emtricitabine or tenofovir plus lamivudine), and D (best available NRTIs plus ritonavir-boosted darunavir plus raltegravir) were defined by increasing levels of resistance and received appropriate regimens, including new antiretrovirals. Participants in Cohort B without detectable hepatitis B surface antigen were assigned by blocked randomisation to cohorts B1 and B2, and those with detectable hepatitis B surface antigen were assigned to cohort B3. The trial is registered with ClinicalTrials.gov, number NCT01641367. FINDINGS From Jan 10, 2013, to Sept 10, 2015, 545 participants were enrolled. 287 (53%) were assigned to cohort A, 74 (14%) to B1, 72 (13%) to B2, eight (1%) to B3, 70 (13%) to C, and 34 (6%) to D. Overall, 349 (64%, 95% CI 60-68) participants achieved viral suppression at week 48, with proportions varying from 125 (44%) of 287 in cohort A to 65 (88%) of 74 in cohort B1, 63 (88%) of 72 in B2, eight (100%) of eight in B3, 63 (90%) of 70 in C, and 25 (74%) of 34 in D. Participants in cohort A remained on their second-line protease inhibitor, and had the most participants with grade 3 or higher adverse events (147 [51%]). INTERPRETATION Targeted real-time genotyping to select third-line ART can appropriately allocate more costly antiretrovirals to those with greater levels of HIV drug resistance. FUNDING National Institutes of Health.
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Affiliation(s)
- Beatriz Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil.
| | | | - Justin Ritz
- Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Robert Salata
- Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | | | - Evelyn Hogg
- Social & Scientific Systems, Inc, Silver Spring, MD, USA
| | - Linda Wieclaw
- Frontier Science & Technology Research Foundation, Amherst, NY, USA
| | - Robert Gross
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - Catherine Godfrey
- Division of AIDS, National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Sandra W Cardoso
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | | | - Mumbi Makanga
- Kenya Medical Research Institute, Kisumu, Kenya; Center of Disease Control, Kisumu, Kenya
| | - Sharlaa Faesen
- Wits HIV Clinical Research Site, Johannesburg, South Africa
| | - Vidya Mave
- BJ Medical College Clinical Research Site, Pune, India
| | | | | | - Wadzanai Samaneka
- University of Zimbabwe College of Health Sciences Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Rode Secours
- Les Centres GHESKIO Clinical Research Site, Port-au-Prince, Haiti
| | - Marije van Schalkwyk
- Family Clinical Research Unit Clinical Research Site, Stellenbosch University, Cape Town, South Africa
| | - Rosie Mngqibisa
- Durban Adult HIV Clinical Research Site, Enhancing Care Foundation, Durban, South Africa
| | - Lerato Mohapi
- Soweto AIDS Clinical Trials Group Clinical Research Site, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | | | - Anchalee Avihingsanon
- Thai Red Cross AIDS Research Center Treatment Clinical Research Site, Bangkok, Thailand
| | - Breno R Santos
- Serviço de Infectologia, Hospital Nossa Senhora da Conceicao, Grupo Hospitalar Conceição, Porto Alegre, Brazil
| | | | - Cecilia Kanyama
- University of North Carolina Project, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Robert T Schooley
- Division of Infectious Disease, University of California, San Diego, CA, USA
| | - John W Mellors
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Carole L Wallis
- Bio Analytical Research Corporation South Africa, Lancet Laboratories, Johannesburg, South Africa
| | - Ann C Collier
- University of Washington School of Medicine, University of Washington, Seattle, WA, USA
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Edessa D, Sisay M, Asefa F. Second-line HIV treatment failure in sub-Saharan Africa: A systematic review and meta-analysis. PLoS One 2019; 14:e0220159. [PMID: 31356613 PMCID: PMC6663009 DOI: 10.1371/journal.pone.0220159] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Increased second-line antiretroviral therapy (ART) failure rate narrows future options for HIV/AIDS treatment. It has critical implications in resource-limited settings; including sub-Saharan Africa (SSA) where the burden of HIV-infection is immense. Hence, pooled estimate for second-line HIV treatment failure is relevant to suggest valid recommendations that optimize ART outcomes in SSA. METHODS We retrieved literature systematically from PUBMED/MEDLINE, EMBASE, CINAHL, Google Scholar, and AJOL. The retrieved studies were screened and assessed for eligibility. We also assessed the eligible studies for their methodological quality using the Joanna Briggs Institute's appraisal checklist. The pooled estimates for second-line HIV treatment failure and its associated factors were determined using STATA, version 15.0 and MEDCALC, version 18.11.3, respectively. We assessed publication bias using Comprehensive Meta-analysis software, version 3. Detailed study protocol for this review/meta-analysis is registered and found on PROSPERO (ID: CRD42018118959). RESULTS A total of 33 studies with the overall 18,550 participants and 19,988.45 person-years (PYs) of follow-up were included in the review. The pooled second-line HIV treatment failure rate was 15.0 per 100 PYs (95% CI: 13.0-18.0). It was slightly higher at 12-18 months of follow-up (19.0/100 PYs; 95% CI: 15.0-22.0), in children (19.0/100 PYs; 95% CI: 14.0-23.0) and in southern SSA (18.0/100 PYs; 95% CI: 14.0-23.0). Baseline values (high viral load (OR: 5.67; 95% CI: 13.40-9.45); advanced clinical stage (OR: 3.27; 95% CI: 2.07-5.19); and low CD4 counts (OR: 2.80; 95% CI: 1.83-4.29)) and suboptimal adherence to therapy (OR: 1.92; 95% CI: 1.28-2.86) were the factors associated with increased failure rates. CONCLUSION Second-line HIV treatment failure has become highly prevalent in SSA with alarming rates during the 12-18 month period of treatment start; in children; and southern SSA. Therefore, the second-line HIV treatment approach in SSA should critically consider excellent adherence to therapy, aggressive viral load suppression, and rapid immune recovery.
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Affiliation(s)
- Dumessa Edessa
- Department of Clinical Pharmacy, School of Pharmacy, College of Health and Medical Sciences, Haramaya University, Harar, Oromia, Ethiopia
- * E-mail:
| | - Mekonnen Sisay
- Department of Pharmacology and Toxicology, School of Pharmacy, College of Health and Medical Sciences, Haramaya University, Harar, Oromia, Ethiopia
| | - Fekede Asefa
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Oromia, Ethiopia
- Center for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, NSW, Australia
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