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Seshie M, Obeng BM, Boamah VE, Bayor M, Bonney EY, Gbedema SY, Sagoe KWC. Resistance to protease inhibitors among persons living with HIV in Ghana: a case for viral load and drug resistance monitoring. Virol J 2024; 21:159. [PMID: 39033275 PMCID: PMC11265000 DOI: 10.1186/s12985-024-02354-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 03/30/2024] [Indexed: 07/23/2024] Open
Abstract
OBJECTIVE Routine viral load and drug resistance testing are well supported in most resource-rich settings and provide valuable benefits in the clinical care of PLWH in these communities. Undoubtedly, there exist financial and political constraints for the scale-up of viral load and drug resistance testing in Sub-Saharan Africa. To achieve the global UNAIDS 95/95/95 targets, there is the need to bridge this inequity in patient care and allow for a universal approach that leaves no community behind. METHODS Venous blood from 96 PLWH on second-line ART from Korle-Bu Teaching Hospital were collected and processed into plasma for CD4+ T- cell and viral load assessments. Ribonucleic acid (RNA) was extracted from stored plasma and the protease gene amplified, sequenced and analyzed for subtype and drug resistance mutations using the Stanford HIV drug resistance database. RESULTS Out of the 96 PLWH, 37 experienced virological failure with 8 patients' samples successfully sequenced. The predominant HIV-1 subtype identified was CRF02_AG (6/8, 75.0%) with 12.5% (1/8) each of CFR06_cpx infection and one case unable to subtype. The major PI resistance mutations identified were; M46I, I54V, V82A, I47V, I84V and L90M. CONCLUSIONS Persons living with HIV who had experienced virologic failure in this study harboured drug resistance mutations to PI, thus compromise the effectiveness of the drugs in the second line. Resistance testing is strongly recommended prior to switching to a new regimen. This will help to inform the choice of drug and to achieve optimum therapeutic outcome among PLWH in Ghana.
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Affiliation(s)
- Makafui Seshie
- Department of Medical Microbiology, School of Biomedical and Allied Health Sciences, University of Ghana, Accra, Ghana.
- Department of Pharmaceutics, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
| | - Billal Musah Obeng
- Department of Medical Microbiology, School of Biomedical and Allied Health Sciences, University of Ghana, Accra, Ghana.
- Immunovirology and Pathogenesis Program, Kirby Institute, University of New South Wales, Sydney, Australia.
| | - Vivian Etsiapa Boamah
- Department of Pharmaceutics, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Marcel Bayor
- Department of Pharmaceutics, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Evelyn Yayra Bonney
- Department of Virology, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Stephen Yao Gbedema
- Department of Pharmaceutics, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Kwamena William Coleman Sagoe
- Department of Medical Microbiology, School of Biomedical and Allied Health Sciences, University of Ghana, Accra, Ghana
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Monaco DC, Zapata L, Hunter E, Salomon H, Dilernia DA. Resistance profile of HIV-1 quasispecies in patients under treatment failure using single molecule, real-time sequencing. AIDS 2020; 34:2201-2210. [PMID: 33196493 DOI: 10.1097/qad.0000000000002697] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Short-read next-generation sequencing (NGS) has been implemented to study the resistance profile of HIV as it provides a higher sensitivity than Sanger sequencing. However, short-reads only generates a consensus view of the viral population rather than a reconstruction of the viral haplotypes. In this study, we evaluated the resistance profile of HIV quasispecies in patients undergoing treatment failure using SMRT sequencing. DESIGN Whole-pol RT-PCR was performed on viral RNA extracted from plasma samples of 38 HIV-positive individuals undergoing treatment failure, and sequenced in the RSII instrument. Error correction and viral haplotype phasing was performed with the Multilayer Directed Phasing and Sequencing (MDPSeq) algorithm. Presence of resistance mutations reported by the IAS-USA in 2017 was assessed using an in-house script. RESULTS The SMRT sequencing-based test detected 131/134 resistance mutations previously detected using a Sanger sequencing-based test. However, the SMRT test also identified seven additional mutations present at an estimated frequency lower than 30%. The intra-host phylogenetic analysis showed that seven samples harbored at least one resistance variant at 20--80% frequency. The haplotype-resolved sequencing revealed viral diversification and selection of new resistance during suboptimal treatment, an overall trend toward selection and accumulation of new resistance mutations, as well as the co-existence of resistant and susceptible variants. CONCLUSION Our results validate the SMRT sequencing-based test for detection of HIV drug resistance. In addition, this method unraveled the complex dynamic of HIV quasispecies during treatment failure, which might have several implications on clinical management.
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Affiliation(s)
| | - Lucas Zapata
- Institute of Biomedical Investigations in Retrovirus and AIDS (INBIRS), School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Eric Hunter
- Emory Vaccine Center, Emory University, Atlanta, Georgia, USA
- Department of Pathology, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Horacio Salomon
- Institute of Biomedical Investigations in Retrovirus and AIDS (INBIRS), School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Dario A Dilernia
- Emory Vaccine Center, Emory University, Atlanta, Georgia, USA
- Department of Pathology, School of Medicine, Emory University, Atlanta, Georgia, USA
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Osman FT, Yizengaw MA. Virological Failure and Associated Risk Factors among HIV/AIDS Pediatric Patients at the ART Clinic of Jimma university Medical Center, Southwest Ethiopia. Open AIDS J 2020. [DOI: 10.2174/1874613602014010061] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background:
Pediatric antiretroviral treatment failure is an under-recognized issue that receives inadequate attention in the field of pediatrics and within HIV treatment programs. Despite the reduction in morbidity and mortality, a considerable proportion of patients fail to achieve a sustained virologic response to therapy. Thus virological failure is an increasing concern globally.
Objective:
This study aimed to assess the virological failure and associated risk factors among HIV/AIDS pediatric patients at Antiretroviral Treatment (ART) follow up clinic of Jimma University Medical Center, southwest Ethiopia.
Methods:
An institution based cross-sectional study was conducted at the ART follow-up clinic of Jimma University Medical Center. A structured English version checklist was developed and used for data extraction from patients’ charts from April -May 2019. Then the data was coded and entered using epi data 4.2 and exported to statistical package for social science (SPSS version 22) for analysis. Descriptive analysis was conducted for categorical as well as continuous variables. Multivariable logistic regression was performed in a backward, step-wise manner until a best-fit model was found.
Results:
Of 140 HIV/AIDS pediatric patients enrolled in this study, 72(51.4%) were male and the mean age was 9.7±3.3 Years. ABC-3TC-NVP was the commonly used ART medication in this population, which was 37.1% followed by AZT-3TC-EFV(32.1%). The mean duration of antiretroviral treatment (ART) follow-up was 63.8±29.4 months. Among the study population, 11.0% of them had virological failure. Weight at ART initiation [OR=1.104, 95 CI% [1.013-1.203], p=0.024] and WHO clinical stage 3 [AOR=0.325, 95CI, 0.107-0.991,P=0.048] were the significant risk factors for the virological failure.
Conclusion:
A significant proportion of HIV/AIDS pediatric patients had virological failure. Weight at ART initiation and patients having WHO clinical stage 3 were risk factors associated with virological failure in this study. Governmental and non-governmental concerned bodies should invest their effort to devise strategies for the achievement of HIV/AIDS treatment targets.
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Bircher RE, Ntamatungiro AJ, Glass TR, Mnzava D, Nyuri A, Mapesi H, Paris DH, Battegay M, Klimkait T, Weisser M. High failure rates of protease inhibitor-based antiretroviral treatment in rural Tanzania - A prospective cohort study. PLoS One 2020; 15:e0227600. [PMID: 31929566 PMCID: PMC6957142 DOI: 10.1371/journal.pone.0227600] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 12/24/2019] [Indexed: 01/12/2023] Open
Abstract
Background Poor adherence to antiretroviral drugs and viral resistance are the main drivers of treatment failure in HIV-infected patients. In sub-Saharan Africa, avoidance of treatment failure on second-line protease inhibitor therapy is critical as treatment options are limited. Methods In the prospective observational study of the Kilombero & Ulanga Antiretroviral Cohort in rural Tanzania, we assessed virologic failure (viral load ≥1,000 copies/mL) and drug resistance mutations in bio-banked plasma samples 6–12 months after initiation of a protease inhibitor-based treatment regimen. Additionally, viral load was measured before start of protease inhibitor, a second time between 1–5 years after start, and at suspected treatment failure in patients with available bio-banked samples. We performed resistance testing if viral load was ≥1000 copies/ml. Risk factors for virologic failure were analyzed using logistic regression. Results In total, 252 patients were included; of those 56% were female and 21% children. Virologic failure occurred 6–12 months after the start of a protease inhibitor in 26/199 (13.1%) of adults and 7/53 of children (13.2%). The prevalence of virologic failure did not change over time. Nucleoside reverse transcriptase inhibitors drug resistance mutation testing performed at 6–12 months showed a positive signal in only 9/16 adults. No cases of resistance mutations for protease inhibitors were seen at this time. In samples taken between 1–5 years protease inhibitor resistance was demonstrated in 2/7 adults. In adult samples before protease inhibitor start, resistance to nucleoside reverse transcriptase inhibitors was detected in 30/41, and to non-nucleoside reverse-transcriptase inhibitors in 35/41 patients. In 15/16 pediatric samples, resistance to both drug classes but not for protease inhibitors was present. Conclusion Our study confirms high early failure rates in adults and children treated with protease inhibitors, even in the absence of protease inhibitors resistance mutations, suggesting an urgent need for adherence support in this setting.
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Affiliation(s)
- Rahel E. Bircher
- Ifakara Health Institute, Ifakara, Tanzania
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Molecular Virology, Department Biomedicine Petersplatz, University of Basel, Basel, Switzerland
| | | | - Tracy R. Glass
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | | | | | - Herry Mapesi
- Ifakara Health Institute, Ifakara, Tanzania
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- St. Francis Referral Hospital, Ifakara, Tanzania
| | - Daniel H. Paris
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Manuel Battegay
- University of Basel, Basel, Switzerland
- Departments of Medicine and Clinical Research, Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Thomas Klimkait
- Molecular Virology, Department Biomedicine Petersplatz, University of Basel, Basel, Switzerland
| | - Maja Weisser
- Ifakara Health Institute, Ifakara, Tanzania
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Departments of Medicine and Clinical Research, Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
- * E-mail:
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Stirrup OT, Sabin CA, Phillips AN, Williams I, Churchill D, Tostevin A, Hill T, Dunn DT. Associations between baseline characteristics, CD4 cell count response and virological failure on first-line efavirenz + tenofovir + emtricitabine for HIV. J Virus Erad 2019; 5:204-211. [PMID: 31754443 PMCID: PMC6844404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES The aim of this study was to investigate associations between baseline characteristics and CD4 cell count response on first-line antiretroviral therapy and risk of virological failure (VF) with or without drug resistance. METHODS We conducted an analysis of UK Collaborative HIV Cohort data linked to the UK HIV Drug Resistance Database. Inclusion criteria were viral sequence showing no resistance prior to initiation of first-line efavirenz + tenofovir disoproxil fumarate + emtricitabine and virological suppression within 6 months. Outcomes of VF (≥200 copies/mL) with or without drug resistance were assessed using a competing risks approach fitted jointly with a model for CD4 cell count recovery. Hazard ratios for each VF outcome were estimated for baseline CD4 cell count and viral load and characteristics of CD4 cell count response using latent variables on a standard normal scale. RESULTS A total of 3640 people were included with 338 VF events; corresponding viral sequences were available in 134 with ≥1 resistance mutation in 36. VF with resistance was associated with lower baseline CD4 (0.30, 0.09-0.62), lower CD4 recovery (0.04, 0.00-0.17) and higher CD4 variability (4.40, 1.22-12.68). A different pattern of associations was observed for VF without resistance, but the strength of these results was less consistent across sensitivity analyses. Cumulative incidence of VF with resistance was estimated to be <2% at 3 years for baseline CD4 ≥350 cells/μL. CONCLUSION Lower baseline CD4 cell count and suboptimal CD4 recovery are associated with VF with drug resistance. People with low CD4 cell count before ART or with suboptimal CD4 recovery on treatment should be a priority for regimens with high genetic barrier to resistance.
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Affiliation(s)
- Oliver T Stirrup
- Institute for Global Health, University College London, London, UK
| | - Caroline A Sabin
- Institute for Global Health, University College London, London, UK
| | | | - Ian Williams
- Institute for Global Health, University College London, London, UK
- Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, UK
| | | | - Anna Tostevin
- Institute for Global Health, University College London, London, UK
| | - Teresa Hill
- Institute for Global Health, University College London, London, UK
| | - David T Dunn
- Institute for Global Health, University College London, London, UK
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Saravanan S, Gomathi S, Delong A, Kausalya B, Sivamalar S, Poongulali S, Brooks K, Kumarasamy N, Balakrishnan P, Solomon SS, Cu-Uvin S, Kantor R. High discordance in blood and genital tract HIV-1 drug resistance in Indian women failing first-line therapy. J Antimicrob Chemother 2019; 73:2152-2161. [PMID: 29800305 DOI: 10.1093/jac/dky154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 03/30/2018] [Indexed: 11/12/2022] Open
Abstract
Objectives Examine HIV-1 plasma viral load (PVL) and genital tract (GT) viral load (GVL) and drug resistance in India. Methods At the YRG Centre for AIDS Research and Education, Chennai, we tested: PVL in women on first-line ART for ≥6 months; GVL when PVL >2000 copies/mL; and plasma, genital and proviral reverse transcriptase drug resistance when GVL >2000 copies/mL. Wilcoxon rank-sum and Fisher's exact tests were used to identify failure and resistance associations. Pearson correlations were calculated to evaluate PVL-GVL associations. Inter-compartmental resistance discordance was evaluated using generalized estimating equations. Results Of 200 women, 37% had detectable (>400 copies/mL) PVL and 31% had PVL >1000 copies/mL. Of women with detectable PVL, 74% had PVL >2000 copies/mL, of which 74% had detectable GVL. Higher PVL was associated with higher GVL. Paired plasma and genital sequences were available for 21 women; mean age of 34 years, median ART duration of 33 months, median CD4 count of 217 cells/mm3, median PVL of 5.4 log10 copies/mL and median GVL of 4.6 log10 copies/mL. Drug resistance was detected in 81%-91% of samples and 67%-76% of samples had dual-class resistance. Complete three-compartment concordance was seen in only 10% of women. GT-proviral discordance was significantly larger than plasma-proviral discordance. GT or proviral mutations discordant from plasma led to clinically relevant resistance in 24% and 30%, respectively. Conclusions We identified high resistance and high inter-compartmental resistance discordance in Indian women, which might lead to unrecognized resistance transmission and re-emergence compromising treatment outcomes, particularly relevant to countries like India, where sexual HIV transmission is predominant.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Sunil S Solomon
- YRG Centre for AIDS Research and Education, Chennai, India.,Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Stirrup OT, Sabin CA, Phillips AN, Williams I, Churchill D, Tostevin A, Hill T, Dunn DT, Asboe D, Pozniak A, Cane P, Chadwick D, Churchill D, Clark D, Collins S, Delpech V, Douthwaite S, Dunn D, Fearnhill E, Porter K, Tostevin A, Stirrup O, Fraser C, Geretti AM, Gunson R, Hale A, Hué S, Lazarus L, Leigh-Brown A, Mbisa T, Mackie N, Orkin C, Nastouli E, Pillay D, Phillips A, Sabin C, Smit E, Templeton K, Tilston P, Volz E, Williams I, Zhang H, Fairbrother K, Dawkins J, O’Shea S, Mullen J, Cox A, Tandy R, Fawcett T, Hopkins M, Booth C, Renwick L, Renwick L, Schmid ML, Payne B, Hubb J, Dustan S, Kirk S, Bradley-Stewart A, Hill T, Jose S, Thornton A, Huntington S, Glabay A, Shidfar S, Lynch J, Hand J, de Souza C, Perry N, Tilbury S, Youssef E, Gazzard B, Nelson M, Mabika T, Mandalia S, Anderson J, Munshi S, Post F, Adefisan A, Taylor C, Gleisner Z, Ibrahim F, Campbell L, Baillie K, Gilson R, Brima N, Ainsworth J, Schwenk A, Miller S, Wood C, Johnson M, Youle M, Lampe F, Smith C, Tsintas R, Chaloner C, Hutchinson S, Walsh J, Mackie N, Winston A, Weber J, Ramzan F, Carder M, Leen C, Wilson A, Morris S, Gompels M, Allan S, Palfreeman A, Lewszuk A, Kegg S, Faleye A, Ogunbiyi V, Mitchell S, Hay P, Kemble C, Martin F, Russell-Sharpe S, Gravely J, Allan S, Harte A, Tariq A, Spencer H, Jones R, Pritchard J, Cumming S, Atkinson C, Mital D, Edgell V, Allen J, Ustianowski A, Murphy C, Gunder I, Trevelion R, Babiker A. Associations between baseline characteristics, CD4 cell count response and virological failure on first-line efavirenz + tenofovir + emtricitabine for HIV. J Virus Erad 2019. [DOI: 10.1016/s2055-6640(20)30037-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Hsu WT, Pan SC, Hsieh SM. 10-year outcome of temporary structured treatment interruption (STI) among HIV-1-infected patients: An observational study in a single medical center. J Formos Med Assoc 2019; 119:455-461. [PMID: 31409497 DOI: 10.1016/j.jfma.2019.07.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/17/2019] [Accepted: 07/31/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Lifelong antiretroviral therapy (ART) is recommended for HIV-1 infected patients but may lead to intolerance or poor adherence. Structured treatment interruption (STI) is a strategy for drug holiday or to boost HIV-specific immunity. But the long-term outcome of STI was never reported in literature. METHODS This is a single-center observational study. We followed the HIV-infected patients who already had a stable viral suppression and voluntarily started temporary STI with a fixed 12-week interval after counseling, evaluation and education. HIV-1-specific T cell response was also measured in some patients. RESULTS Totally 34 HIV-infected patients received temporary STI since July, 2006. 18 patients completed 10-year follow-up. All patients received protease inhibitors (PI)-based ART before and during temporary STI. The patients received temporary STI with a period of 36-85 weeks. All of them reached viral suppression after 12 weeks of restarting continuous ART. No viral rebound or opportunistic disease was recorded during follow-up. No adverse event or comorbidity was attributed to STI. The plasma viral load (PVL) at the end of STI was significantly lower than baseline PVL in patients with a longer duration of STI (≤36 weeks vs. >36 weeks, P = 0.005). The T cell response study revealed that cyclically increased HIV-1-specific T cell response after starting STI in patients with baseline CD4+ count >350/μL. CONCLUSION Temporary STI may not lead to worse long-term outcome among highly selected patients. The policy may partially control viral replication through reminding the HIV-1 specific T cell immunity.
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Affiliation(s)
- Wei-Ting Hsu
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taiwan
| | - Sung-Ching Pan
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taiwan
| | - Szu-Min Hsieh
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taiwan.
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Thai national guidelines for antiretroviral therapy in HIV-1 infected adults and adolescents 2010. ASIAN BIOMED 2018. [DOI: 10.2478/abm-2010-0066] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abstract
In Thailand, more than 150,000 patients are currently treated with antiretroviral drugs under the support of the National AIDS Program (NAP). The appointed Adults and Adolescents Committee consisted of 28 members who are experts in HIV research, patient care or health care policy. Relevant published literature, guidelines, and the most recent relevant clinical trials presented internationally were reviewed. Several peer review and clinical studies conducted in Thailand were included in the review process. Special considerations for patients with co-infection of tuberculosis or hepatitis B were incorporated. Appropriate cut-off of CD4+ T-cell counts when to commence ART among Thai patients have been considered. It is now recommended to start ART at CD4+ T-cell count <350 cells/mm3. For treatment-naive patients, the preferred initial therapy is a nonnucleoside reverse transcriptase inhibitor (NNRTI)-based regimen containing lamivudine plus zidovudine or tenofovir. Stavudine will be phased out in a two-year plan at the national program level. Viral load and CD4+ T-cell counts should be monitored at least once and twice a year. To achieve long-term treatment success, enhancing adherence together with the proper management of antiretroviral-related toxicity is critical. In summary, the major changes from the Thai 2008 guidelines include commencing ART earlier. ART is recommended regardless of CD4+ T cell count if patients have an indication to treat their HBV co-infection. Preferred first regimen uses AZT or TDF, not d4T as the NRTI-backbone. Furthermore, efavirenz is now considered a preferred NNRTI, along with nevirapine.
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Negoescu DM, Zhang Z, Bucher HC, Bendavid E. Differentiated Human Immunodeficiency Virus RNA Monitoring in Resource-Limited Settings: An Economic Analysis. Clin Infect Dis 2018; 64:1724-1730. [PMID: 28329208 PMCID: PMC5447887 DOI: 10.1093/cid/cix177] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 02/25/2017] [Indexed: 12/17/2022] Open
Abstract
Background. Viral load (VL) monitoring for patients receiving antiretroviral therapy (ART) is recommended worldwide. However, the costs of frequent monitoring are a barrier to implementation in resource-limited settings. The extent to which personalized monitoring frequencies may be cost-effective is unknown. Methods. We created a simulation model parameterized using person-level longitudinal data to assess the benefits of flexible monitoring frequencies. Our data-driven model tracked human immunodeficiency virus (HIV)–infected individuals for 10 years following ART initiation. We optimized the interval between viral load tests as a function of patients’ age, gender, education, duration since ART initiation, adherence behavior, and the cost-effectiveness threshold. We compared the cost-effectiveness of the personalized monitoring strategies to fixed monitoring intervals every 1, 3, 6, 12, and 24 months. Results. Shorter fixed VL monitoring intervals yielded increasing benefits (6.034 to 6.221 discounted quality-adjusted life-years [QALYs] per patient with monitoring every 24 to 1 month over 10 years, respectively, standard error = 0.005 QALY), at increasing average costs: US$3445 (annual monitoring) to US$5393 (monthly monitoring) per patient, respectively (standard error = US$3.7). The adaptive policy optimized for low-income contexts achieved 6.142 average QALYs at a cost of US$3524, similar to the fixed 12-month policy (6.135 QALYs, US$3518). The adaptive policy optimized for middle-income resource settings yields 0.008 fewer QALYs per person, but saves US$204 compared to monitoring every 3 months. Conclusions. The benefits from implementing adaptive vs fixed VL monitoring policies increase with the availability of resources. In low- and middle-income countries, adaptive policies achieve similar outcomes to simpler, fixed-interval policies.
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Affiliation(s)
- Diana M Negoescu
- College of Science and Engineering, Industrial and System Engineering, University of Minnesota, Minneapolis
| | - Zhenhuan Zhang
- College of Science and Engineering, Industrial and System Engineering, University of Minnesota, Minneapolis
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel and University of Basel, Switzerland
| | - Eran Bendavid
- Department of Medicine, and.,Center for Health Policy/Center for Primary Care and Outcomes Research, Stanford University, California
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Izudi J, Alioni S, Kerukadho E, Ndungutse D. Virological failure reduced with HIV-serostatus disclosure, extra baseline weight and rising CD4 cells among HIV-positive adults in Northwestern Uganda. BMC Infect Dis 2016; 16:614. [PMID: 27793124 PMCID: PMC5084428 DOI: 10.1186/s12879-016-1952-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 10/25/2016] [Indexed: 11/22/2022] Open
Abstract
Background Little is known about the incidence of virological failure among Human Immunodeficiency virus (HIV) infected adults after Uganda transitioned from Zidovidine/Lamivudine/ Nevirapine (AZT/3TC/NVP) to Tenofovir/Lamivudine/Efavirenze (TDF/3 T/EFV) as a first-line anti-retroviral therapy (ART) in 2013. This was the first study in Uganda to investigate the incidence and predictors of virological failure among HIV-positive adults in Northwestern Uganda. Method A retrospective cohort of 383 HIV-positive adults at Arua Teaching and Regional Referral Hospital HIV Clinic with at least six months of ART duration and five consecutive good adherence levels was used. Socio-demographic and clinical variables were analyzed with STATA version 12 at 5 % significance level. The Chi-squared, Fisher’s exact and Student’s t-tests were used for bivariate analysis. Cox Proportional Hazard Regression analysis was used for univariable and multivariate analysis, Kaplan-Meier for comparison of survival probability and the log-rank for testing survivorship probability. Hazard ratios (HR), 95 % confidence intervals (CI) and probability values were stated. Results The average age of the cohort was 34.0 ± 11 years (Median: 32 years, Interquartile range (IQR): 25–31 years). 28 (7.3 %; 95 % Confidence Interval [CI]: 4.9-10.6) incident cases of virological failures and an incidence rate of 58 per 1000 person-years over risk time of 483 years was recorded. One-kilogram baseline body weight difference (41-kg and above) at ART initiation (Adjusted Hazard Ratio [aHR] = 0.86, 95 % CI:0.76-0.96, P = 0.008), one-CD4 cell increase (35 cells/ul and above) after ART initiation (aHR = 0.99, 95 % CI: 0.98-0.99, P < 0.001) and HIV-serostatus disclosure (aHR = 0.15, 95 % CI: 0.06-033, P < 0.001) reduced the hazard of virological failure. Conclusion Virological failure is common among HIV-positive adults in Northwestern Uganda. It reduced with extra baseline weight, rising CD4 cell counts and HIV-serostatus disclosure.
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Affiliation(s)
- Jonathan Izudi
- Institute of Public Health and Management, International Health Sciences University, P.O. Box 7782, Kampala, Uganda. .,Department of Anatomy, Uganda Society for Health Scientists, Makerere University College of Health Sciences, P.O. Box, 7072, Kampala, Uganda.
| | | | - Emmanuel Kerukadho
- Baylor College of Medicine Children's Foundation-Uganda, Box 72052, Kampala, Uganda
| | - David Ndungutse
- Bugema University, School of Graduate Studies, P.O Box 6529, Kampala, Uganda
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Superior virologic and treatment outcomes when viral load is measured at 3 months compared to 6 months on antiretroviral therapy. J Int AIDS Soc 2015; 18:20092. [PMID: 26403636 PMCID: PMC4582072 DOI: 10.7448/ias.18.1.20092] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 07/30/2015] [Accepted: 08/25/2015] [Indexed: 11/25/2022] Open
Abstract
Introduction Routine viral load (VL) monitoring is utilized to assess antiretroviral therapy (ART) adherence and virologic failure, and it is currently scaled-up in many resource-constrained settings. The first routine VL is recommended as late as six months after ART initiation for early detection of sub-optimal adherence. We aimed to assess the optimal timing of first VL measurement after initiation of ART. Methods This was a retrospective, cohort analysis of routine monitoring data of adults enrolled at three primary care clinics in Khayelitsha, Cape Town, between January 2002 and March 2009. Primary outcomes were virologic failure and switch to second-line ART comparing patients in whom first VL done was at three months (VL3M) and six months (VL6M) after ART initiation. Adjusted hazard ratios (aHR) were estimated using Cox proportional hazard models. Results In total, 6264 patients were included for the time to virologic failure and 6269 for the time to switch to second-line ART analysis. Patients in the VL3M group had a 22% risk reduction of virologic failure (aHR 0.78, 95% CI 0.64–0.95; p=0.016) and a 27% risk reduction of switch to second-line ART (aHR 0.73, 95% CI 0.58–0.92; p=0.008) when compared to patients in the VL6M group. For each additional month of delay of the first VL measurement (up to nine months), the risk of virologic failure increased by 9% (aHR 1.09, 95% CI 1.02–1.15; p=0.008) and switch to second-line ART by 13% (aHR 1.13, 95% CI 1.05–1.21; p<0.001). Conclusions A first VL at three months rather than six months with targeted adherence interventions for patients with high VL may improve long-term virologic suppression and reduce switches to costly second-line ART. ART programmes should consider the first VL measurement at three months after ART initiation.
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Ngarina M, Kilewo C, Karlsson K, Aboud S, Karlsson A, Marrone G, Leyna G, Ekström AM, Biberfeld G. Virologic and immunologic failure, drug resistance and mortality during the first 24 months postpartum among HIV-infected women initiated on antiretroviral therapy for life in the Mitra plus Study, Dar es Salaam, Tanzania. BMC Infect Dis 2015; 15:175. [PMID: 25886277 PMCID: PMC4392730 DOI: 10.1186/s12879-015-0914-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Accepted: 03/25/2015] [Indexed: 11/26/2022] Open
Abstract
Background In the Mitra plus study of prevention of mother-to-child transmission of HIV-1, which included 501 women in Dar es Salaam, Tanzania, triple antiretroviral therapy (ART) was given from late pregnancy throughout breastfeeding up to 6 months postnatally. Here we report findings in a sub-cohort of women with ≤200 CD4cells/μL at enrolment who were continued on ART for life and followed up during 24 months after delivery to determine virologic and immunologic responses, drug resistance and mortality. Methods Blood samples for viral load and CD4 counts testing were collected at enrolment and at 3, 6, 12 and 24 months postpartum. HIV drug resistance testing was performed at 12 months. Data analysis included descriptive statistics and multivariate analysis using Generalized Estimated Equations of 73 women with at least two postpartum assessments. The mortality analysis included 84 women who had delivered. Results The proportion of women with a viral load ≥400 copies/mL was 97% (71/73) at enrolment, 16% (11/67), 22% (15/69), 61% (36/59) and 86% (48/56) at 3, 6, 12 and 24 months postpartum, respectively. The proportion of women with immunologic failure was 12% (8/69), 25% (15/60) and 41% (24/58) at 6, 12 and 24 months, respectively. At 12 months, drug resistance was demonstrated in 34% (20/59), including 12 with dual-class resistance. Self-report on drug adherence was 95% (64/68), 85% (56/66), 74% (39/53) and 65% (30/46) at 3, 6, 12 and 24 months, respectively. The mortality rate was 5.9% (95% CI 2.5-13.7%) at 24 months. The probability of virologic and immunologic failure was significantly higher among women who reported non-perfect adherence to ART at month 24 postpartum. Conclusions Following an initial decline of viral load, virologic failure was common at 12 and 24 months postpartum among women initiated on ART for life during pregnancy because of low CD4 cell counts. A high proportion of viremic mothers also had resistance mutations. However, at 24 months follow-up, the mortality rate was still fairly low. Continuous adherence counseling and affordable means of monitoring of the virologic response are crucial for successful implementation of the WHO Option B+ guidelines to start all HIV-infected pregnant women on ART for life.
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Affiliation(s)
- Matilda Ngarina
- Department of Obstetrics and Gynecology, Muhimbili National Hospital, 65000, Dar es Salaam, Tanzania. .,Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden. .,Public Health Agency of Sweden, Stockholm, Sweden.
| | - Charles Kilewo
- Departments of Obstetrics and Gynecology, Muhimbili University of Health and Allied Sciences, 65001, Dar es Salaam, Tanzania.
| | | | - Said Aboud
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, 65001, Dar es Salaam, Tanzania.
| | - Annika Karlsson
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - Gaetano Marrone
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
| | - Germana Leyna
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
| | - Anna Mia Ekström
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden. .,Department of Infectious Diseases, Karolinska University Hospital, Huddinge, Stockholm, Sweden.
| | - Gunnel Biberfeld
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden. .,Public Health Agency of Sweden, Stockholm, Sweden.
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Masikini P, Mpondo BCT. HIV drug resistance mutations following poor adherence in HIV-infected patient: a case report. Clin Case Rep 2015; 3:353-6. [PMID: 26185627 PMCID: PMC4498841 DOI: 10.1002/ccr3.254] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Revised: 12/17/2014] [Accepted: 02/20/2015] [Indexed: 12/27/2022] Open
Abstract
Acquired HIV drug resistance following poor adherence is common. We report a case of HIV-infected patient with poor CD4 gain and self reported poor adherence. Investigations revealed high viral load and resistance to NRTIs and NNRTIs with sensitivity to boosted PIs. HIVDR mutations create treatment challenges in resource limited settings.
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Affiliation(s)
- Peter Masikini
- Department of Internal Medicine, Bugando Medical Centre Mwanza, Tanzania ; Department of Internal Medicine, Catholic University of Health and Allied Sciences Mwanza, Tanzania
| | - Bonaventura C T Mpondo
- Department of Internal Medicine, College of Health Sciences, The University of Dodoma Dodoma, Tanzania
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Sawe FK, Obiero E, Yegon P, Langat RC, Aoko A, Tarus J, Kiptoo I, Langat RK, Maswai J, Bii M, Khamadi S, Shikuku KP, Close N, Sinei S, Shaffer DN. Kericho CLinic-based ART Diagnostic Evaluation (CLADE): design, accrual, and baseline characteristics of a randomized controlled trial conducted in predominately rural, district-level, HIV clinics of Kenya. PLoS One 2015; 10:e0116299. [PMID: 25706652 PMCID: PMC4338154 DOI: 10.1371/journal.pone.0116299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 10/02/2014] [Indexed: 12/25/2022] Open
Abstract
Background Prospective clinical trial data regarding routine HIV-1 viral load (VL) monitoring of antiretroviral therapy (ART) in non-research clinics of Sub-Saharan Africa are needed for policy makers. Methods CLinic-based ART Diagnostic Evaluation (CLADE) is a randomized, controlled trial (RCT) evaluating feasibility, superiority, and cost-effectiveness of routine VL vs. standard of care (clinical and immunological) monitoring in adults initiating dual nucleoside reverse transcriptase inhibitor (NRTI)+non-NRTI ART. Participants were randomized (1:1) at 7 predominately rural, non-research, district-level clinics of western Kenya. Descriptive statistics present accrual patterns and baseline cohort characteristics. Results Over 15 months, 820 adults enrolled at 7 sites with 86–152 enrolled per site. Monthly site enrollment ranged from 2–92 participants. Full (100%) informed consent compliance was independently documented. Half (49.9%) had HIV diagnosed through voluntary counseling and testing. Study arms were similar: mostly females (57.6%) aged 37.6 (SD = 9.0) years with low CD4 (166 [SD = 106]) cells/m3). Notable proportions had WHO Stage III or IV disease (28.7%), BMI <18.5 kg/m2 (23.1%), and a history of tuberculosis (5.6%) or were receiving tuberculosis treatment (8.2%) at ART initiation. In the routine VL arm, 407/409 (99.5%) received baseline VL (234,577 SD = 151,055 copies/ml). All participants received lamivudine; 49.8% started zidovudine followed by 38.4% stavudine and 11.8% tenofovir; and, 64.4% received nevirapine as nNRTI (35.6% efavirenz). Conclusions A RCT can be enrolled successfully in rural, non-research, resource limited, district-level clinics in western Kenya. Many adults presenting for ART have advanced HIV/AIDS, emphasizing the importance of universal HIV testing and linkage-to-care campaigns. Trial Registration ClinicalTrials.gov NCT01791556
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Affiliation(s)
- Fredrick K. Sawe
- Kenya Medical Research Institute/Walter Reed Project, Kericho, Kenya
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, United States of America
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Rockville, MD, United States of America
- * E-mail:
| | - Eunice Obiero
- Kericho District Hospital, Kenya Ministry of Public Health and Sanitation, Kericho, Kenya
| | - Peter Yegon
- Kenya Medical Research Institute/Walter Reed Project, Kericho, Kenya
- HJF Medical Research International, Inc., Kericho, Kenya
| | - Rither C. Langat
- Kenya Medical Research Institute/Walter Reed Project, Kericho, Kenya
- HJF Medical Research International, Inc., Kericho, Kenya
| | - Appolonia Aoko
- Kenya Medical Research Institute/Walter Reed Project, Kericho, Kenya
- HJF Medical Research International, Inc., Kericho, Kenya
| | - Jemutai Tarus
- Kenya Medical Research Institute/Walter Reed Project, Kericho, Kenya
- HJF Medical Research International, Inc., Kericho, Kenya
| | - Ignatius Kiptoo
- Kenya Medical Research Institute/Walter Reed Project, Kericho, Kenya
| | - Raphael K. Langat
- Kenya Medical Research Institute/Walter Reed Project, Kericho, Kenya
- HJF Medical Research International, Inc., Kericho, Kenya
| | - Jonah Maswai
- Kenya Medical Research Institute/Walter Reed Project, Kericho, Kenya
- HJF Medical Research International, Inc., Kericho, Kenya
| | - Margaret Bii
- Kenya Medical Research Institute/Walter Reed Project, Kericho, Kenya
- HJF Medical Research International, Inc., Kericho, Kenya
| | - Samoel Khamadi
- Kenya Medical Research Institute/Walter Reed Project, Kericho, Kenya
- HJF Medical Research International, Inc., Kericho, Kenya
| | - Kibet P. Shikuku
- Kenya Medical Research Institute/Walter Reed Project, Kericho, Kenya
| | - Nicole Close
- EmpiriStat, Mt Airy, MD, United States of America
| | - Samuel Sinei
- Kenya Medical Research Institute/Walter Reed Project, Kericho, Kenya
- HJF Medical Research International, Inc., Kericho, Kenya
| | - Douglas N. Shaffer
- Kenya Medical Research Institute/Walter Reed Project, Kericho, Kenya
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, United States of America
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Emerging antiretroviral drug resistance in sub-Saharan Africa: novel affordable technologies are needed to provide resistance testing for individual and public health benefits. AIDS 2014; 28:2643-8. [PMID: 25493592 DOI: 10.1097/qad.0000000000000502] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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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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Hassan AS, Nabwera HM, Mwaringa SM, Obonyo CA, Sanders EJ, Rinke de Wit TF, Cane PA, Berkley JA. HIV-1 virologic failure and acquired drug resistance among first-line antiretroviral experienced adults at a rural HIV clinic in coastal Kenya: a cross-sectional study. AIDS Res Ther 2014; 11:9. [PMID: 24456757 PMCID: PMC3922732 DOI: 10.1186/1742-6405-11-9] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Accepted: 01/19/2014] [Indexed: 12/03/2022] Open
Abstract
Background An increasing number of people on antiretroviral therapy (ART) in sub-Saharan Africa has led to declines in HIV related morbidity and mortality. However, virologic failure (VF) and acquired drug resistance (ADR) may negatively affect these gains. This study describes the prevalence and correlates of HIV-1 VF and ADR among first-line ART experienced adults at a rural HIV clinic in Coastal Kenya. Methods HIV-infected adults on first-line ART for ≥6 months were cross-sectionally recruited between November 2008 and March 2011. The primary outcome was VF, defined as a one-off plasma viral load of ≥400 copies/ml. The secondary outcome was ADR, defined as the presence of resistance associated mutations. Logistic regression and Fishers exact test were used to describe correlates of VF and ADR respectively. Results Of the 232 eligible participants on ART over a median duration of 13.9 months, 57 (24.6% [95% CI: 19.2 – 30.6]) had VF. Fifty-five viraemic samples were successfully amplified and sequenced. Of these, 29 (52.7% [95% CI: 38.8 – 66.3]) had at least one ADR, with 25 samples having dual-class resistance mutations. The most prevalent ADR mutations were the M184V (n = 24), K103N/S (n = 14) and Y181C/Y/I/V (n = 8). Twenty-six of the 55 successfully amplified viraemic samples (47.3%) did not have any detectable resistance mutation. Younger age (15–34 vs. ≥35 years: adjusted odd ratios [95% CI], p-value: 0.3 [0.1–0.6], p = 0.002) and unsatisfactory adherence (<95% vs. ≥95%: 3.0 [1.5–6.5], p = 0.003) were strong correlates of VF. Younger age, unsatisfactory adherence and high viral load were also strong correlates of ADR. Conclusions High levels of VF and ADR were observed in younger patients and those with unsatisfactory adherence. Youth-friendly ART initiatives and strengthened adherence support should be prioritized in this Coastal Kenyan setting. To prevent unnecessary/premature switches, targeted HIV drug resistance testing for patients with confirmed VF should be considered.
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Keebler D, Revill P, Braithwaite S, Phillips A, Blaser N, Borquez A, Cambiano V, Ciaranello A, Estill J, Gray R, Hill A, Keiser O, Kessler J, Menzies NA, Nucifora KA, Vizcaya LS, Walker S, Welte A, Easterbrook P, Doherty M, Hirnschall G, Hallett TB. Cost-effectiveness of different strategies to monitor adults on antiretroviral treatment: a combined analysis of three mathematical models. LANCET GLOBAL HEALTH 2013; 2:e35-43. [PMID: 25104633 DOI: 10.1016/s2214-109x(13)70048-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND WHO's 2013 revisions to its Consolidated Guidelines on antiretroviral drugs recommend routine viral load monitoring, rather than clinical or immunological monitoring, as the preferred monitoring approach on the basis of clinical evidence. However, HIV programmes in resource-limited settings require guidance on the most cost-effective use of resources in view of other competing priorities such as expansion of antiretroviral therapy coverage. We assessed the cost-effectiveness of alternative patient monitoring strategies. METHODS We evaluated a range of monitoring strategies, including clinical, CD4 cell count, and viral load monitoring, alone and together, at different frequencies and with different criteria for switching to second-line therapies. We used three independently constructed and validated models simultaneously. We estimated costs on the basis of resource use projected in the models and associated unit costs; we quantified impact as disability-adjusted life years (DALYs) averted. We compared alternatives using incremental cost-effectiveness analysis. FINDINGS All models show that clinical monitoring delivers significant benefit compared with a hypothetical baseline scenario with no monitoring or switching. Regular CD4 cell count monitoring confers a benefit over clinical monitoring alone, at an incremental cost that makes it affordable in more settings than viral load monitoring, which is currently more expensive. Viral load monitoring without CD4 cell count every 6-12 months provides the greatest reductions in morbidity and mortality, but incurs a high cost per DALY averted, resulting in lost opportunities to generate health gains if implemented instead of increasing antiretroviral therapy coverage or expanding antiretroviral therapy eligibility. INTERPRETATION The priority for HIV programmes should be to expand antiretroviral therapy coverage, firstly at CD4 cell count lower than 350 cells per μL, and then at a CD4 cell count lower than 500 cells per μL, using lower-cost clinical or CD4 monitoring. At current costs, viral load monitoring should be considered only after high antiretroviral therapy coverage has been achieved. Point-of-care technologies and other factors reducing costs might make viral load monitoring more affordable in future. FUNDING Bill & Melinda Gates Foundation, WHO.
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Affiliation(s)
- Daniel Keebler
- South African Department of Science and Technology/National Research Foundation Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Paul Revill
- Centre for Health Economics, University of York, York, UK
| | | | - Andrew Phillips
- Research Department of Infection and Population Health, University College London, London, UK
| | - Nello Blaser
- Division of International and Environmental Health, Institute of Social and Preventive Medicine (ISPM) University of Bern, Bern, Switzerland
| | - Annick Borquez
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Valentina Cambiano
- Research Department of Infection and Population Health, University College London, London, UK
| | | | - Janne Estill
- Division of International and Environmental Health, Institute of Social and Preventive Medicine (ISPM) University of Bern, Bern, Switzerland
| | - Richard Gray
- The Kirby Institute, The University of New South Wales, Sydney, NSW, Australia
| | | | - Olivia Keiser
- Division of International and Environmental Health, Institute of Social and Preventive Medicine (ISPM) University of Bern, Bern, Switzerland
| | - Jason Kessler
- School of Medicine, New York University, New York, NY, USA
| | - Nicolas A Menzies
- Center for Health Decision Science, Harvard School of Public Health, Boston, MA, USA
| | | | - Luisa Salazar Vizcaya
- Division of International and Environmental Health, Institute of Social and Preventive Medicine (ISPM) University of Bern, Bern, Switzerland
| | - Simon Walker
- Centre for Health Economics, University of York, York, UK
| | - Alex Welte
- South African Department of Science and Technology/National Research Foundation Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | | | | | | | - Timothy B Hallett
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK.
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Marconi VC, Wu B, Hampton J, Ordóñez CE, Johnson BA, Singh D, John S, Gordon M, Hare A, Murphy R, Nachega J, Kuritzkes DR, del Rio C, Sunpath, and South Africa Resistanc H. Early warning indicators for first-line virologic failure independent of adherence measures in a South African urban clinic. AIDS Patient Care STDS 2013; 27:657-68. [PMID: 24320011 DOI: 10.1089/apc.2013.0263] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We sought to develop individual-level Early Warning Indicators (EWI) of virologic failure (VF) for clinicians to use during routine care complementing WHO population-level EWI. A case-control study was conducted at a Durban clinic. Patients after ≥ 5 months of first-line antiretroviral therapy (ART) were defined as cases if they had VF [HIV-1 viral load (VL)>1000 copies/mL] and controls (2:1) if they had VL ≤ 1000 copies/mL. Pharmacy refills and pill counts were used as adherence measures. Participants responded to a questionnaire including validated psychosocial and symptom scales. Data were also collected from the medical record. Multivariable logistic regression models of VF included factors associated with VF (p<0.05) in univariable analyses. We enrolled 158 cases and 300 controls. In the final multivariable model, male gender, not having an active religious faith, practicing unsafe sex, having a family member with HIV, not being pleased with the clinic experience, symptoms of depression, fatigue, or rash, low CD4 counts, family recommending HIV care, and using a TV/radio as ART reminders (compared to mobile phones) were associated with VF independent of adherence measures. In this setting, we identified several key individual-level EWI associated with VF including novel psychosocial factors independent of adherence measures.
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Affiliation(s)
- Vincent C. Marconi
- Department of Medicine/Infectious Disease, School of Medicine, Emory University, Atlanta, Georgia
- Rollins School of Public Health, Emory University, Atlanta, Georgia
- Atlanta Veterans Affairs Medical Center, Atlanta, Georgia
| | - Baohua Wu
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | | | - Brent A. Johnson
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | | | | | - Anna Hare
- Department of Medicine/Infectious Disease, School of Medicine, Emory University, Atlanta, Georgia
| | - Richard Murphy
- Albert Einstein College of Medicine and Medical Unit, Doctors Without Borders, New York, New York
| | - Jean Nachega
- Department of Epidemiology, Pittsburgh University Graduate School of Public Health, Pittsburgh, Pennsylvania
- Departments of Epidemiology and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Medicine and Centre for Infectious Diseases, Stellenbosch University, Faculty of Medicine & Health Sciences, Cape Town, South Africa
| | - Daniel R. Kuritzkes
- Section of Retroviral Therapeutics, Brigham and Women's Hospital, Boston, Massachusetts
| | - Carlos del Rio
- Department of Medicine/Infectious Disease, School of Medicine, Emory University, Atlanta, Georgia
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Henry Sunpath, and South Africa Resistanc
- McCord Hospital, Durban, South Africa
- Nelson Mandela School of Medicine, Durban, South Africa
- South Africa Resistance Cohort Study Team Group Authors included Helga Holst and Phacia Ngubane,4 and Rachel Kearns and Peng Wu.2
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Byrnes S, Fan A, Trueb J, Jareczek F, Mazzochette M, Sharon A, Sauer-Budge AF, Klapperich CM. A Portable, Pressure Driven, Room Temperature Nucleic Acid Extraction and Storage System for Point of Care Molecular Diagnostics. ANALYTICAL METHODS : ADVANCING METHODS AND APPLICATIONS 2013; 5:3177-3184. [PMID: 23914255 PMCID: PMC3727300 DOI: 10.1039/c3ay40162f] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Many new and exciting portable HIV viral load testing technologies are emerging for use in global medicine. While the potential to provide fast, isothermal, and quantitative molecular diagnostic information to clinicians in the field will soon be a reality, many of these technologies lack a robust front end for sample clean up and nucleic acid preparation. Such a technology would enable many different downstream molecular assays. Here, we present a portable system for centrifuge-free room temperature nucleic acid extraction from small volumes of whole blood (70 µL), using only thermally stable reagents compatible with storage and transport in low resource settings. Quantitative reverse transcriptase polymerase chain reaction (qRT-PCR) analysis of simulated samples demonstrate a lower limit of detection of 1000 copies/ml, with the ability to detect differences in viral load across four orders of magnitude. The system can also be used to store extracted RNA on detachable cartridges for up to one week at ambient temperature, and can be operated using only hand generated air pressure.
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Affiliation(s)
- Samantha Byrnes
- Department of Biomedical Engineering, Boston University, Boston, MA 02215
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Immuno-virologic outcomes and immuno-virologic discordance among adults alive and on anti-retroviral therapy at 12 months in Nigeria. BMC Infect Dis 2013; 13:113. [PMID: 23452915 PMCID: PMC3599241 DOI: 10.1186/1471-2334-13-113] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Accepted: 02/27/2013] [Indexed: 11/21/2022] Open
Abstract
Background Predictors of immuno-virologic outcomes and discordance and their associations with clinical, demographic, socio-economic and behavioral risk factors are not well described in Nigeria since HIV viral load testing is not routinely offered in public HIV treatment programs. Methods The HACART study was a multi-center observational clinic-based cohort study of 2585 adults who started HAART between April 2008 and February 2009. A total of 628 patients were randomly selected at 12 months for immuno-virologic analyses. Results Virologic suppression rate (<400 copies/ml) was 76.7%, immunologic recovery rate (CD4 change from baseline ≥50 cells/mm3) was 77.4% and immuno-virologic discordance rate was 33%. In multivariate logistic regression, virologic failure was associated with age <30 years (OR 1.79; 95% CI: 1.17-2.67, p=0.03), anemia (Hemoglobin < 10 g/dl) (OR 1.71; 95% CI: 1.22-2.61, p=0.03), poor adherence (OR 3.82; 95% CI: 2.17-5.97, p=0.001), and post-secondary education (OR 0.60; 95% CI: 0.30-0.86, p=0.02). Immunologic failure was associated with male gender (OR 1.46; 95% CI: 1.04-2.45, p=0.04), and age <30 years (OR 1.50; 95% CI: 1.11-2.39, p=0.03). Virologic failure with immunologic success (VL-/CD4+) was associated with anemia (OR 1.80; 95% CI: 1.13-2.88, p=0.03), poor adherence (OR 3.90; 95% CI: 1.92-8.24, p=0.001), and post-secondary education (OR 0.40; 95% CI: 0.22-0.68, p=0.005). Conclusions Although favorable immuno-virologic outcomes could be achieved in this large ART program, immuno-virologic discordance was observed in a third of the patients. Focusing on intensified treatment preparation and adherence, young patients, males, persons with low educational status and most importantly baseline anemia assessment and management may help address predictors of poor immuno-virologic outcomes, and improve overall HIV program impact. Viral load testing in addition to the CD4 testing should be considered to identify, characterize and address negative immuno-virologic outcomes and discordance.
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Mrudula ND, Suwarna UP, Khadse R, Minal P, Shubhangi DK. Statistical Analysis and Evaluation of CD4 Count after 6 Months on ART. Indian J Community Med 2013; 37:266-7. [PMID: 23293446 PMCID: PMC3531025 DOI: 10.4103/0970-0218.103480] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- N Dravid Mrudula
- Department of Microbiology, Incharge ART Centre SBHGMC, Dhule, Maharashtra, India E-mail:
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Walburn A, Swindells S, Fisher C, High R, Islam K. Missed visits and decline in CD4 cell count among HIV-infected patients: a mixed method study. Int J Infect Dis 2012; 16:e779-85. [DOI: 10.1016/j.ijid.2012.06.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Revised: 06/08/2012] [Accepted: 06/15/2012] [Indexed: 10/28/2022] Open
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Labhardt ND, Lejone T, Setoko M, Poka M, Ehmer J, Pfeiffer K, Kiuvu PZ, Lynen L. A clinical prediction score in addition to WHO criteria for anti-retroviral treatment failure in resource-limited settings--experience from Lesotho. PLoS One 2012; 7:e47937. [PMID: 23118910 PMCID: PMC3485299 DOI: 10.1371/journal.pone.0047937] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Accepted: 09/25/2012] [Indexed: 11/30/2022] Open
Abstract
Objective To assess the positive predictive value (PPV) of a clinical score for viral failure among patients fulfilling the WHO-criteria for anti-retroviral treatment (ART) failure in rural Lesotho. Methods Patients fulfilling clinical and/or immunological WHO failure-criteria were enrolled. The score includes the following predictors: Prior ART exposure (1 point), CD4-count below baseline (1), 25% and 50% drop from peak CD4-count (1 and 2), hemoglobin drop≥1 g/dL (1), CD4 count<100/µl after 12 months (1), new onset papular pruritic eruption (1), and adherence<95% (3). A nurse assessed the score the day blood was drawn for viral load (VL). Reported confidence intervals (CI) were calculated using Wilsons method. Results Among 1'131 patients on ART≥6 months, 134 (11.8%) had immunological and/or clinical failure, 104 (78%) had blood drawn (13 died, 10 lost to follow-up, 7 did not show up). From 92 (88%) a result could be obtained (2 samples hemolysed, 10 lost). Out of these 92 patients 47 (51%) had viral failure (≥5000 copies), 27 (29%) viral suppression (<40) and 18 (20%) intermediate viremia (40–4999). Overall, 20 (22%) had a score≥5. A score≥5 had a PPV of 100% to detect a VL>40 copies (95%CI: 84–100), and of 90% to detect a VL≥5000 copies (70–97). Within the score, adherence<95%, CD4-count<100/µl and papular pruritic eruption were the strongest single predictors. Among 47 patients failing, 8 (17%) died before or within 4 weeks after being switched. Overall mortality was 4 (20%) among those with score≥5 and 4 (5%) if score<5 (OR 4.3; 95%CI: 0.96–18.84, p = 0.057). Conclusion A score≥5 among patients fulfilling WHO-criteria had a PPV of 100% for a detectable VL and 90% for viral failure. In settings without regular access to VL-testing, this PPV may be considered high enough to switch this patient-group to second-line treatment without confirmatory VL-test.
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Affiliation(s)
| | - Thabo Lejone
- Seboche Hospital, Botha-Bothe, Lesotho
- * E-mail: (NDL); (TL)
| | | | | | | | | | | | - Lutgarde Lynen
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
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Sungkanuparph S, Win MM, Kiertiburanakul S, Phonrat B, Maek-a-nantawat W. HIV-1 drug resistance at virological failure versus immunological failure among patients failing first-line antiretroviral therapy in a resource-limited setting. Int J STD AIDS 2012; 23:316-8. [PMID: 22648883 DOI: 10.1258/ijsa.2011.011337] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Antiretroviral treatment failure has been defined by immunological failure (IF) in some resource-limited settings whereas defining by virological failure (VF) has been widely used in developed countries. There is limited comparison of the levels of HIV-1 drug resistance between using VF and IF for the diagnosis of treatment failure. A retrospective cohort study was conducted among HIV-1-infected patients failing first-line antiretroviral therapy (ART). Of 95 patients, median CD4 and HIV-1 RNA were 158 cells/mm(3) and 10,200 copies/mL, respectively. Patients in the IF group had higher HIV-1 RNA than those in VF group (23,820 versus 9510 copies/mL, P = 0.008). Nucleoside reverse transcriptase inhibitor (NRTI)-, non-NRTI- and protease inhibitor-resistance-associated mutations (RAMs) were observed in 57.9%, 94.7% and 5.3%, respectively. Q151M, a multidrug RAM, was more commonly observed in the IF group (14.8% versus 2.9%, P = 0.032). Using IF to diagnose treatment failure is associated with higher HIV-1 RNA levels and a higher rate of Q151M, which can limit the options for second-line ART.
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Affiliation(s)
- S Sungkanuparph
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand.
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HIV treatment and care in resource-constrained environments: challenges for the next decade. J Int AIDS Soc 2012; 15:17334. [PMID: 22944479 PMCID: PMC3494167 DOI: 10.7448/ias.15.2.17334] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Revised: 05/16/2012] [Accepted: 07/11/2012] [Indexed: 01/27/2023] Open
Abstract
Many successes have been achieved in HIV care in low- and middle-income countries (LMIC): increased number of HIV-infected individuals receiving antiretroviral treatment (ART), wide decentralization, reduction in morbidity and mortality and accessibility to cheapest drugs. However, these successes should not hide existing failures and difficulties. In this paper, we underline several key challenges. First, ensure long-term financing, increase available resources, in order to meet the increasing needs, and redistribute the overall budget in a concerted way amongst donors. Second, increase ART coverage and treat the many eligible patients who have not yet started ART. Competition amongst countries is expected to become a strong driving force in encouraging the least efficient to join better performing countries. Third, decrease early mortality on ART, by improving access to prevention, case-finding and treatment of tuberculosis and invasive bacterial diseases and by getting people to start ART much earlier. Fourth, move on from WHO 2006 to WHO 2010 guidelines. Raising the cut-off point for starting ART to 350 CD4/mm3 needs changing paradigm, adopting opt-out approach, facilitating pro-active testing, facilitating task shifting and increasing staff recruitments. Phasing out stavudine needs acting for a drastic reduction in the costs of other drugs. Scaling up routine viral load needs a mobilization for lower prices of reagents and equipments, as well as efforts in relation to point-of-care automation and to maintenance. The latter is a key step to boost the utilization of second-line regimens, which are currently dramatically under prescribed. Finally, other challenges are to reduce lost-to-follow-up rates; manage lifelong treatment and care for long-term morbidity, including drug toxicity, residual AIDS and HIV-non-AIDS morbidity and aging-related morbidity; and be able to face unforeseen events such as socio-political and military crisis. An old African proverb states that the growth of a deep-rooted tree cannot be stopped. Our tree is well rooted in existing field experience and is, therefore, expected to grow. In order for us to let it grow, long-term cost-effectiveness approach and life-saving evidence-based programming should replace short-term budgeting approach.
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Genotype assays and third-line ART in resource-limited settings: a simulation and cost-effectiveness analysis of a planned clinical trial. AIDS 2012; 26:1083-93. [PMID: 22343964 DOI: 10.1097/qad.0b013e32835221eb] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To project the clinical and economic outcomes of a genotype assay for selection of third-line antiretroviral therapy (ART) in resource-limited settings, as per the planned international A5288 trial (MULTI-OCTAVE). METHODS We used the Cost-effectiveness of Preventing AIDS Complications (CEPAC)-International Model to compare three strategies for patients who have failed second-line ART in South Africa: sustained second-line: no genotype assay, all patients remain on second-line ART; A5288: genotype to determine the resistance profile and assign an appropriate regimen; or population-based third-line: no genotype, all patients switch to a potent third-line regimen. Model inputs are from published data in South Africa. Resistance profiles, ART regimens, and efficacy data were those used for trial planning. RESULTS Projected life expectancy for sustained second-line, A5288, and population-based third-line are 61.1, 103.8, and 104.2 months. Compared to sustained second-line ($12 ,460), per person lifetime costs increase for the A5288 ($39, 250) and population-based ($44, 120) strategies. The incremental cost-effectiveness ratio of A5288, compared to sustained second-line, is $7500/year of life saved (YLS), and for population-based third-line, compared to A5288, is $154 ,500/YLS. In the A5288 strategy, very late presentation to care, coupled with lengthy delays to obtain the genotype, dramatically reduces 5-year survival, making the population-based third-line strategy more attractive. CONCLUSIONS We project that, whereas the public health approach to third-line therapy is unaffordable, genotype assays and third-line ART in resource-limited settings will increase survival and be cost-effective compared to the population-based approach, supporting the value of an efficacy study.
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Bélec L, Bonn JP. Challenges in implementing HIV laboratory monitoring in resource-constrained settings: how to do more with less. Future Microbiol 2012; 6:1251-60. [PMID: 22082287 DOI: 10.2217/fmb.11.121] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Laboratory monitoring for HIV disease in resource-limited settings has now become one of the key challenges for antiretroviral treatment (ART) access and success, as emphasized by the 2010 revised WHO guidelines for ART in resource-limited settings. Thus, the most common method for initiating ART, and monitoring treatment response in resource-constrained environments is the measurement of CD4 T-cell count. Affordable CD4 T-cell counting has gradually been made possible by using simple, compact and robust, low-cost, new-generation cytometers, operating as single-platform volumetric instruments. Several cost-effective point-of-care CD4 T-cell testing options are also already on the market, in order to improve access to CD4 T-cell monitoring, especially for rural patients, and to reduce loss-to-follow-up of patients. In addition, HIV RNA viral load measurement is becoming increasingly important, mainly for a systematic confirmation of first-line ART failure before switching to second-line treatment to avoid belated as well as premature therapeutic decisions and their potentially negative consequences. Viral load testing should now be considered as the standard of care for therapeutic failure in all resource-limited settings. However, the measurement of HIV viral load remains a centralized marker, carried out in a limited number of reference laboratories. Finally, the costs of second-line ART regimens, rather than the laboratory test costs themselves, currently constitute the primary determinant of the total cost in ART switching. Laboratory monitoring strategies may become more attractive as price negotiations render second-line ART regimens less expensive worldwide.
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Affiliation(s)
- Laurent Bélec
- Assistance Publique, Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Laboratoire de Virologie, Paris, France.
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Adekanmbi V, Uthman OA, Egbewale BE. Routine viral load monitoring versus standard care for reducing morbidity and mortality in adolescent and adult patients living with HIV on antiretroviral therapy (ART). Hippokratia 2012. [DOI: 10.1002/14651858.cd009588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Victor Adekanmbi
- University of Birmingham; Department of Public Health and Epidemiology; Birmingham UK B15 2TT
| | - Olalekan A Uthman
- Keele University; Primary Care Sciences; Keele Staffordshire UK ST5 5BG
| | - Bolaji E Egbewale
- Keele University; Primary Care Sciences; Keele Staffordshire UK ST5 5BG
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Beck M, Brockhuis S, van der Velde N, Breukers C, Greve J, Terstappen LWMM. On-chip sample preparation by controlled release of antibodies for simple CD4 counting. LAB ON A CHIP 2012; 12:167-173. [PMID: 22048158 DOI: 10.1039/c1lc20565j] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
We present a simple system for CD4 and CD8 counting for point-of-care HIV staging in low-resource settings. Automatic sample preparation is achieved through a dried reagent coating inside a thin (26 μm) counting chamber, allowing the delayed release of fluorochrome conjugated monoclonal antibodies after the filling of the chamber with whole blood by capillary flow. A custom-built image cytometer is used to capture fluorescence images representing more than 1 μl of blood. The thin layer of blood in combination with the large image area allows the use of whole blood from a finger prick without the need for dilution, lysis or cell enrichment. Automatic cell counting of CD4(+) and CD8(+) T-lymphocytes correlates well with results obtained by flow cytometry.
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Affiliation(s)
- Markus Beck
- Medical Cell Biophysics, MIRA Institute for Biomedical Technology and Technical Medicine, Faculty of Science and Technology, PO Box 217, 7500 AE Enschede, The Netherlands.
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Azzoni L, Foulkes AS, Liu Y, Li X, Johnson M, Smith C, Kamarulzaman AB, Montaner J, Mounzer K, Saag M, Cahn P, Cesar C, Krolewiecki A, Sanne I, Montaner LJ. Prioritizing CD4 count monitoring in response to ART in resource-constrained settings: a retrospective application of prediction-based classification. PLoS Med 2012; 9:e1001207. [PMID: 22529752 PMCID: PMC3328436 DOI: 10.1371/journal.pmed.1001207] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Accepted: 03/09/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Global programs of anti-HIV treatment depend on sustained laboratory capacity to assess treatment initiation thresholds and treatment response over time. Currently, there is no valid alternative to CD4 count testing for monitoring immunologic responses to treatment, but laboratory cost and capacity limit access to CD4 testing in resource-constrained settings. Thus, methods to prioritize patients for CD4 count testing could improve treatment monitoring by optimizing resource allocation. METHODS AND FINDINGS Using a prospective cohort of HIV-infected patients (n=1,956) monitored upon antiretroviral therapy initiation in seven clinical sites with distinct geographical and socio-economic settings, we retrospectively apply a novel prediction-based classification (PBC) modeling method. The model uses repeatedly measured biomarkers (white blood cell count and lymphocyte percent) to predict CD4(+) T cell outcome through first-stage modeling and subsequent classification based on clinically relevant thresholds (CD4(+) T cell count of 200 or 350 cells/µl). The algorithm correctly classified 90% (cross-validation estimate=91.5%, standard deviation [SD]=4.5%) of CD4 count measurements <200 cells/µl in the first year of follow-up; if laboratory testing is applied only to patients predicted to be below the 200-cells/µl threshold, we estimate a potential savings of 54.3% (SD=4.2%) in CD4 testing capacity. A capacity savings of 34% (SD=3.9%) is predicted using a CD4 threshold of 350 cells/µl. Similar results were obtained over the 3 y of follow-up available (n=619). Limitations include a need for future economic healthcare outcome analysis, a need for assessment of extensibility beyond the 3-y observation time, and the need to assign a false positive threshold. CONCLUSIONS Our results support the use of PBC modeling as a triage point at the laboratory, lessening the need for laboratory-based CD4(+) T cell count testing; implementation of this tool could help optimize the use of laboratory resources, directing CD4 testing towards higher-risk patients. However, further prospective studies and economic analyses are needed to demonstrate that the PBC model can be effectively applied in clinical settings. Please see later in the article for the Editors' Summary.
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Affiliation(s)
- Livio Azzoni
- Wistar Institute, Philadelphia, Pennsylvania, United States of America
| | - Andrea S. Foulkes
- University of Massachusetts, Amherst, Massachusetts, United States of America
| | - Yan Liu
- University of Massachusetts, Amherst, Massachusetts, United States of America
| | - Xiaohong Li
- BG Medicine, Waltham, Massachusetts, United States of America
| | | | | | | | - Julio Montaner
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Karam Mounzer
- Philadelphia FIGHT, Philadelphia, Pennsylvania, United States of America
| | - Michael Saag
- University of Alabama, Tuscaloosa, Alabama, United States of America
| | - Pedro Cahn
- Fundación Huésped, Buenos Aires, Argentina
| | | | | | - Ian Sanne
- University of the Witwatersrand, Johannesburg, South Africa
| | - Luis J. Montaner
- Wistar Institute, Philadelphia, Pennsylvania, United States of America
- * E-mail:
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Chandy S, Singh G, Heylen E, Gandhi M, Ekstrand ML. Treatment switching in South Indian patients on HAART: what are the predictors and consequences? AIDS Care 2011; 23:569-77. [PMID: 21293988 DOI: 10.1080/09540121.2010.525607] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Early identification and management of treatment failure on highly active antiretroviral therapy (HAART) is crucial in maintaining a sustained response to therapy in HIV infection. However, HIV viral load (VL) and resistance testing, and second-line HAART regimens, are unaffordable to many patients in India, leaving them with limited treatment options. Predictors and reasons for antiretroviral switching, therefore, are likely to differ in settings of varying resources. A one-year, observational study of patients receiving antiretroviral therapy was conducted in a private, non-profit hospital in Bangalore. This paper examines the predictors and consequences of antiretroviral treatment switching in this setting and explores reasons for switching in a subset of patients. Data on demographics, drug regimens, adherence, and physical and psychosocial outcomes were collected quarterly. Tests of VL and CD4 cell counts were performed every six months. One-third of the patients switched therapy during the study period. Baseline predictors of switching included lower CD4 cell counts and more physical symptoms. Contrary to studies in other settings, a high VL did not predict treatment switching, and only a minority of those experiencing drug failure were switched to second-line regimens. Both groups (switchers and non-switchers) improved significantly over time with respect to CD4 counts and psychological well-being, and showed a reduction in physical and depressive symptoms. Any differences between the groups were no longer significant at the end of the study, once we controlled for baseline levels. Clinical, policy, and research implications of these findings are discussed within the context of resource-limited settings.
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Affiliation(s)
- Sara Chandy
- Department of Medicine, St John's Medical College and Hospital, Bangalore, India
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Kanapathipillai R, McGuire M, Mogha R, Szumilin E, Heinzelmann A, Pujades-Rodríguez M. Benefit of viral load testing for confirmation of immunological failure in HIV patients treated in rural Malawi. Trop Med Int Health 2011; 16:1495-500. [PMID: 21883726 DOI: 10.1111/j.1365-3156.2011.02874.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Viral load testing is used in the HIV programme of Chiradzulu, Malawi, to confirm the diagnosis of immunological failure to prevent unnecessary switching to second-line therapy. Our objective was to quantify the benefit of this strategy for management of treatment failure in a large decentralized HIV programme in Africa. METHODS Retrospective analysis of monitoring data from adults treated with first-line antiretroviral regimens for >1 year and meeting the WHO immunological failure criteria in an HIV programme in rural Malawi. The positive predictive value of using immunological failure criteria to diagnose virological failure (viral load >5000 copies/ml) was estimated. RESULTS Of the 227 patients with immunological failure (185 confirmed with a repeat CD4 measurement), 155 (68.2%) had confirmatory viral load testing. Forty-four (28.4%) had viral load >5000 copies/ml and 57 (36.8%) >1000 copies/ml. Positive predictive value was 28.4% (95% CI 21.4-36.2%). Repeat CD4 count testing showed that 41% of patients initially diagnosed with immunological failure did no longer meet failure criteria. CONCLUSIONS Our results support the need for confirming all cases of immunological failure with viral load testing before switching to second-line ART to optimize the use of resources in developing countries.
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Davies MA, Boulle A, Eley B, Moultrie H, Technau K, Rabie H, van Cutsem G, Giddy J, Wood R, Egger M, Keiser O. Accuracy of immunological criteria for identifying virological failure in children on antiretroviral therapy - the IeDEA Southern Africa Collaboration. Trop Med Int Health 2011; 16:1367-71. [PMID: 21834797 DOI: 10.1111/j.1365-3156.2011.02854.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine the diagnostic accuracy of World Health Organization (WHO) 2010 and 2006 as well as United States Department of Health and Human Services (DHHS) 2008 definitions of immunological failure for identifying virological failure (VF) in children on antiretroviral therapy (ART). METHODS Analysis of data from children (<16 years at ART initiation) at South African ART sites at which CD4 count/per cent and HIV-RNA monitoring are performed 6-monthly. Incomplete virological suppression (IVS) was defined as failure to achieve ≥1 HIV-RNA ≤400 copies/ml between 6 and 15 months on ART and viral rebound (VR) as confirmed HIV-RNA ≥5000 copies/ml in a child on ART for ≥18 months who had achieved suppression during the first year on treatment. RESULTS Among 3115 children [median (interquartile range) age 48 (20-84) months at ART initiation] on treatment for ≥1 year, sensitivity of immunological criteria for IVS was 10%, 6% and 26% for WHO 2006, WHO 2010 and DHHS 2008 criteria, respectively. The corresponding positive predictive values (PPV) were 31%, 20% and 20%. Diagnostic accuracy for VR was determined in 2513 children with ≥18 months of follow-up and virological suppression during the first year on ART with sensitivity of 5% (WHO 2006/2010) and 27% (DHHS 2008). PPV results were 42% (WHO 2010), 43% (WHO 2006) and 20% (DHHS 2008). CONCLUSION Current immunological criteria are unable to correctly identify children failing ART virologically. Improved access to viral load testing is needed to reliably identify VF in children.
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Affiliation(s)
- Mary-Ann Davies
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
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van Zyl GU, Preiser W, Potschka S, Lundershausen AT, Haubrich R, Smith D. Pooling strategies to reduce the cost of HIV-1 RNA load monitoring in a resource-limited setting. Clin Infect Dis 2011; 52:264-70. [PMID: 21288854 DOI: 10.1093/cid/ciq084] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Quantitative human immunodeficiency virus (HIV) RNA load testing surpasses CD4 cell count and clinical monitoring in detecting antiretroviral therapy (ART) failure; however, its cost can be prohibitive. Recently, the use of pooling strategies with a clinically appropriate viral load threshold was shown to be accurate and efficient for monitoring when the prevalence of virologic failure is low. METHODS We used laboratory request form information to identify specimens with a low pretest probability of virologic failure. Patients aged ≥15 years who were receiving first-line ART had individual viral load results available were eligible. Blood plasma, dried blood spots, and dried plasma spots were evaluated. Two pooling strategies were compared: minipools of 5 samples and a 10 ×10 matrix platform (liquid plasma specimens only). A deconvolution algorithm was used to identify specimens(s) with detectable viral loads. RESULTS The virologic failure rate in the study sample was <10%. Specimens included were liquid plasma specimens tested in minipools(n = 400), of which 300 were available for testing by matrix, and specimens tested with minipools only: dried blood spots (n = 100) and dried plasma spots (n = 185). Pooling methods resulted in 30.5%-60% fewer HIV RNA tests required to screen the study sample. For plasma pooling, the matrix strategy had the better efficiency, but minipools of 5 dried blood spots had the best efficiency overall and were accurate at a >95% negative predictive value with minimal technical requirements. CONCLUSIONS In resource-constrained settings, a combination of preselection of patients with low pretest probability of virologic failure and pooled testing can reduce the cost of virologic monitoring without compromising accuracy.
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Affiliation(s)
- G U van Zyl
- Division of Medical Virology, Stellenbosch University, and National Health Laboratory Service, Tygerberg, South Africa.
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Early initiation of antiretroviral therapy and universal HIV testing in sub-Saharan Africa: has WHO offered a milestone for HIV prevention? J Public Health Policy 2011; 31:385-400. [PMID: 21119646 DOI: 10.1057/jphp.2010.29] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The majority of new HIV infections occur in sub-Saharan Africa and other developing countries with scarce financial resources and meagre health system infrastructure. Expansion of Antiretroviral Therapy (ART) may overwhelm health services capacity, result in suboptimal care, and divert attention from crucial preventive measures. A 2009 WHO guideline recommends earlier initiation of ART for adults and adolescents, treatment at CD4 counts of 350 cells/mm³ along with universal testing. For sub-Saharan Africa, WHO previously recommended a threshold of 200 cells/mm³. Despite vast potential benefits of early ART initiation at individual and community levels, it does not necessary follow that clinical experience in industrialised countries can be replicated in resource-limited settings with moderate to high HIV burdens. Adherence to the 2009 WHO guidelines is unlikely to be sustainable without guarantees of adequate national and donor support--something all developing countries need to consider before adoption of the new policy.
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El-Khatib Z, Katzenstein D, Marrone G, Laher F, Mohapi L, Petzold M, Morris L, Ekström AM. Adherence to drug-refill is a useful early warning indicator of virologic and immunologic failure among HIV patients on first-line ART in South Africa. PLoS One 2011; 6:e17518. [PMID: 21408071 PMCID: PMC3052314 DOI: 10.1371/journal.pone.0017518] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Accepted: 02/04/2011] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Affordable strategies to prevent treatment failure on first-line regimens among HIV patients are essential for the long-term success of antiretroviral therapy (ART) in sub-Saharan Africa. WHO recommends using routinely collected data such as adherence to drug-refill visits as early warning indicators. We examined the association between adherence to drug-refill visits and long-term virologic and immunologic failure among non-nucleoside reverse transcriptase inhibitor (NNRTI) recipients in South Africa. METHODS In 2008, 456 patients on NNRTI-based ART for a median of 44 months (range 12-99 months; 1,510 person-years) were enrolled in a retrospective cohort study in Soweto. Charts were reviewed for clinical characteristics before and during ART. Multivariable logistic regression and Kaplan-Meier survival analysis assessed associations with virologic (two repeated VL>50 copies/ml) and immunologic failure (as defined by WHO). RESULTS After a median of 15 months on ART, 19% (n = 88) and 19% (n = 87) had failed virologically and immunologically respectively. A cumulative adherence of <95% to drug-refill visits was significantly associated with both virologic and immunologic failure (p<0.01). In the final multivariable model, risk factors for virologic failure were incomplete adherence (OR 2.8, 95%CI 1.2-6.7), and previous exposure to single-dose nevirapine or any other antiretrovirals (adj. OR 2.1, 95%CI 1.2-3.9), adjusted for age and sex. In Kaplan-Meier analysis, the virologic failure rate by month 48 was 19% vs. 37% among adherent and non-adherent patients respectively (logrank p value = 0.02). CONCLUSION One in five failed virologically after a median of 15 months on ART. Adherence to drug-refill visits works as an early warning indicator for both virologic and immunologic failure.
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Affiliation(s)
- Ziad El-Khatib
- Division of Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden.
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Early virologic failure and the development of antiretroviral drug resistance mutations in HIV-infected Ugandan children. J Acquir Immune Defic Syndr 2011; 56:44-50. [PMID: 21099693 DOI: 10.1097/qai.0b013e3181fbcbf7] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Without virologic testing, HIV-infected African children starting antiretroviral (ARV) therapy are at risk for undetected virologic failure and the development of ARV resistance. We sought to determine the prevalence of early virologic failure (EVF), to characterize the evolution of ARV-resistance mutations and to predict the impact on second-line therapy. METHODS The prevalence of EVF (HIV RNA >400 copies/mL on sequential visits after 6 months of therapy) was identified among 120 HIV-infected Ugandan children starting ARV therapy. ARV mutations were identified by population sequencing of HIV-1 pol in sequential archived specimens. Composite discrete genotypic susceptibility scores were determined for second-line ARV regimens. RESULTS EVF occurred in 16 children (13%) and persisted throughout a median (interquartile ratio) 938 (760-1066) days of follow-up. M184V and nonnucleoside reverse transcriptase inhibitor-associated mutations emerged within 6 months of EVF; thymidine-analog-mutations arose after 12 months. Worse discrete genotypic susceptibility scores correlated with increasing duration of failure (Spearman R = -0.47; P = 0.001). Only 1 child met World Health Organization CD4 criteria for ARV failure at the time of EVF or during the follow-up period. CONCLUSIONS A significant portion of HIV-infected African children experience EVF that would be undetected using CD4/clinical monitoring and resulted in the accumulation of ARV mutations that could compromise second-line therapy options.
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Cost analysis of centralized viral load testing for antiretroviral therapy monitoring in Nicaragua, a low-HIV prevalence, low-resource setting. J Int AIDS Soc 2010; 13:43. [PMID: 21054866 PMCID: PMC2992476 DOI: 10.1186/1758-2652-13-43] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Accepted: 11/05/2010] [Indexed: 11/27/2022] Open
Abstract
Background HIV viral load testing as a component of antiretroviral therapy monitoring is costly. Understanding the full costs and the major sources of inefficiency associated with viral load testing is critical for optimizing the systems and technologies that support the testing process. The objective of our study was to estimate the costs associated with viral load testing performed for antiretroviral therapy monitoring to both patients and the public healthcare system in a low-HIV prevalence, low-resource country. Methods A detailed cost analysis was performed to understand the costs involved in each step of performing a viral load test in Nicaragua, from initial specimen collection to communication of the test results to each patient's healthcare provider. Data were compiled and cross referenced from multiple information sources: laboratory records, regional surveillance centre records, and scheduled interviews with the key healthcare providers responsible for HIV patient care in five regions of the country. Results The total average cost of performing a viral load test in Nicaragua varied by region, ranging from US$99.01 to US$124.58, the majority of which was at the laboratory level: $88.73 to $97.15 per specimen, depending on batch size. The average cost to clinics at which specimens were collected ranged from $3.31 to $20.92, depending on the region. The average cost per patient for transportation, food, lodging and lost income ranged from $3.70 to $14.93. Conclusions The quantitative viral load test remains the single most expensive component of the process. For the patient, the distance of his or her residence from the specimen collection site is a large determinant of cost. Importantly, the efficiency of results reporting has a large impact on the cost per result delivered to the clinician and utility of the result for patient monitoring. Detailed cost analysis can identify opportunities for removing barriers to effective antiretroviral therapy monitoring programmes in limited-resource countries with low HIV prevalence.
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Bhargava A, Booysen FLR. Healthcare infrastructure and emotional support are predictors of CD4 cell counts and quality of life indices of patients on antiretroviral treatment in Free State Province, South Africa. AIDS Care 2010; 22:1-9. [PMID: 20390475 DOI: 10.1080/09540120903012585] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
While many AIDS patients in sub-Saharan Africa are receiving antiretroviral treatment (ART) via public clinics, improvements in health status also depend on socioeconomic and psychological factors and quality of healthcare services. Inter-dependence between patients' clinical markers and quality of life indicators should be analyzed using comprehensive models. This longitudinal study compiled socioeconomic and clinical variables at six monthly intervals on patients receiving ART in South Africa; patients' ratings of quality of services and staff in "Assessment" and "Treatment" sites were assessed. Dynamic random effects models were estimated by maximum likelihood for CD4 cell counts and for quality of life indices (EQ-5D and Visual Analogue Scale), incorporating the inter-dependence between plasma HIV RNA levels and CD4 cell counts. The results showed that emotional support received by patients was a significant predictor (P<0.05) of CD4 cell counts and quality of life indices. Ratings of services and staff in Assessment and Treatment sites were significantly associated with CD4 cell counts and quality of life indices; CD4 cell count was a significant predictor of quality of life indices. The results indicated that it is important to compile socioeconomic and psychological variables for AIDS patients and monitor healthcare services for improving their health status and quality of life.
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Affiliation(s)
- Alok Bhargava
- Department of Economics, University of Houston, TX 77204-5019, USA.
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Bendavid E, Brandeau ML, Wood R, Owens DK. Comparative effectiveness of HIV testing and treatment in highly endemic regions. ARCHIVES OF INTERNAL MEDICINE 2010; 170:1347-54. [PMID: 20696960 PMCID: PMC2921232 DOI: 10.1001/archinternmed.2010.249] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Universal testing and treatment holds promise for reducing the burden of human immunodeficiency virus (HIV) in sub-Saharan Africa, but linkage from testing to treatment sites and retention in care are inadequate. METHODS We developed a simulation of the HIV epidemic and HIV disease progression in South Africa to compare the outcomes of the present HIV treatment campaign (status quo) with 4 HIV testing and treating strategies that increase access to antiretroviral therapy: (1) universal testing and treatment without changes in linkage to care and loss to follow-up; (2) universal testing and treatment with improved linkage to care; (3) universal testing and treatment with reduced loss to follow-up; and (4) comprehensive HIV care with universal testing and treatment, improved linkage to care, and reduced loss to follow-up. The main outcome measures were survival benefits, new HIV infections, and HIV prevalence. RESULTS Compared with the status quo strategy, universal testing and treatment (1) was associated with a mean (95% uncertainty bounds) life expectancy gain of 12.0 months (11.3-12.2 months), and 35.3% (32.7%-37.5%) fewer HIV infections over a 10-year time horizon. Improved linkage to care (2), prevention of loss to follow-up (3), and comprehensive HIV care (4) provided substantial additional benefits: life expectancy gains compared with the status quo strategy were 16.1, 18.6, and 22.2 months, and new infections were 55.5%, 51.4%, and 73.2% lower, respectively. In sensitivity analysis, comprehensive HIV care reduced new infections by 69.7% to 76.7% under a broad set of assumptions. CONCLUSIONS Universal testing and treatment with current levels of linkage to care and loss to follow-up could substantially reduce the HIV death toll and new HIV infections. However, increasing linkage to care and preventing loss to follow-up provides nearly twice the benefits of universal testing and treatment alone.
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Affiliation(s)
- Eran Bendavid
- Division of General Internal Medicine, Center for Health Policy, Department of Management Science and Engineering, Stanford University, 117 Encina Commons, Stanford, CA 94305-8526, USA.
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National Program Scale-Up and Patient Outcomes in a Pediatric Antiretroviral Treatment Program, Thailand, 2000-2007. J Acquir Immune Defic Syndr 2010; 54:423-9. [DOI: 10.1097/qai.0b013e3181dc5eb0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Chintu N, Giganti MJ, Putta NB, Sinkala M, Sadoki E, Stringer EM, Stringer JSA, Chi BH. Peripartum nevirapine exposure and subsequent clinical outcomes among HIV-infected women receiving antiretroviral therapy for at least 12 months. Trop Med Int Health 2010; 15:842-7. [PMID: 20487418 DOI: 10.1111/j.1365-3156.2010.02540.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Prior exposure to intrapartum/neonatal nevirapine (NVP) is associated with compromised virologic treatment outcomes once non-nucleoside reverse transcriptase inhibitor (NNRTI)-based antiretroviral therapy (ART) is initiated. We examined the longer-term clinical outcomes in a programmatic setting. METHODS We compared post-12 month mortality and clinical treatment failure (defined by WHO clinical and immunologic criteria) among women with and without prior NVP exposure in Lusaka, Zambia. RESULTS Between April 2004 and July 2006, 6740 women initiated an NNRTI-containing regimen. At 12 months, 5172 (78%) remained active and were included in this analysis. Of these, 596 (12%) reported prior NVP exposure, whose time from exposure to ART initiation was: <6 months for 11%, 6-12 months for 13%, >12 months for 37%, unknown for 39%. Overall, women with prior NVP exposure trended towards increased survival (adjusted hazard ratio [AHR]: 0.53; 95% confidence interval [CI]: 0.27-1.06, P = 0.07) and towards increased hazard of clinical treatment failure (AHR: 1.18; 95% CI: 0.95-1.47, P = 0.14), particularly those with exposure for <6 months (AHR: 1.52; 95% CI: 0.94-2.45, P = 0.09). CONCLUSIONS Prior NVP exposure appeared to increase risk for clinical treatment failure after 12 months of follow-up, but this finding did not reach statistical significance. With growing evidence linking recent NVP exposure to virologic failure, optimized monitoring algorithms should be considered for women with starting NNRTI-based ART. The association between prior NVP exposure and improved survival has not been previously shown and may be a result of residual confounding around health-seeking behaviours.
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Affiliation(s)
- Namwinga Chintu
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
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Early clinical and programmatic outcomes with tenofovir-based antiretroviral therapy in Zambia. J Acquir Immune Defic Syndr 2010; 54:63-70. [PMID: 20009765 DOI: 10.1097/qai.0b013e3181c6c65c] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In July 2007, amid some controversy over cost, Zambia was the first African country to introduce tenofovir (TDF) as a component of first-line antiretroviral therapy (ART) on a wide scale. METHODS We compared drug substitutions, mortality, and "programmatic failure" among adults starting TDF-, zidovudine (ZDV)-, and stavudine (d4T)-containing ART. Programmatic failure was defined as death, withdrawal, or loss to follow-up. RESULTS Between July 2007 and January 2009, 10,485 adults initiated ART (66% on TDF, 23% on ZDV, 11% on d4T), with a median follow-up time of 239 (interquartile range 98, 385) days. Those starting TDF were more likely to be male and more likely to have indicators of severe disease at baseline. In adjusted Cox proportional hazards models, ZDV- (adjusted hazard ratio [AHR] = 2.74, 95% confidence interval [CI] = 2.30-3.28) and d4T-based regimens (AHR = 1.92, 95% CI = 1.55-2.38) were associated with higher risk for drug substitution when compared with TDF-based regimens. Similar hazards were noted for overall mortality (ZDV: AHR = 0 .81, 95% CI = 0.62-1.06; d4T: AHR = 1.03, 95% CI = 0.74-1.43) and programmatic failure (ZDV: AHR = 0.99, 95% CI = 0.88-1.11; d4T: AHR = 1.11, 95% CI = 0.96-1.28) when compared with TDF. CONCLUSIONS TDF is associated with similar clinical and programmatic outcomes as ZDV and d4T but appears to be better tolerated. Although further evaluation is needed, these results are encouraging and support Zambia's policy decision.
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Abstract
PURPOSE OF REVIEW As antiretroviral therapy has been refined with the development of more potent agents and simpler regimens, fewer individuals experience treatment failure. This review will highlight recent trends in treatment failure and virologic resistance in the developed world and resource-limited settings. RECENT FINDINGS The goal of antiretroviral therapy in all individuals, regardless of prior treatment exposure or HIV drug resistance, is to achieve full suppression of viral replication with a viral load of less than 50 copies/ml. This goal has been made a reality by the development of newer agents and simpler, better tolerated regimens. Recent cohort studies have demonstrated improved virologic outcomes in the current antiretroviral era, with decreased rates of virologic failure and associated resistance. Improved tolerability has aided adherence, which remains a key determinant of treatment success. Cohorts in resource-limited settings report improved clinical and virologic outcomes as rollout of highly active antiretroviral therapy programs continues. SUMMARY There has been a reassuring decrease in the frequency of virological failure and drug resistance in the modern highly active antiretroviral therapy era. This observation provides an important incentive to strengthen support of antiretroviral therapy programs to optimize virological outcomes, particularly in resource-limited settings in which access to newer agents and laboratory monitoring may be needed to ensure sustainable success.
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Koethe JR, Westfall AO, Luhanga DK, Clark GM, Goldman JD, Mulenga PL, Cantrell RA, Chi BH, Zulu I, Saag MS, Stringer JSA. A cluster randomized trial of routine HIV-1 viral load monitoring in Zambia: study design, implementation, and baseline cohort characteristics. PLoS One 2010; 5:e9680. [PMID: 20300631 PMCID: PMC2837376 DOI: 10.1371/journal.pone.0009680] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2009] [Accepted: 02/23/2010] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The benefit of routine HIV-1 viral load (VL) monitoring of patients on antiretroviral therapy (ART) in resource-constrained settings is uncertain because of the high costs associated with the test and the limited treatment options. We designed a cluster randomized controlled trial to compare the use of routine VL testing at ART-initiation and at 3, 6, 12, and 18 months, versus our local standard of care (which uses immunological and clinical criteria to diagnose treatment failure, with discretionary VL testing when the two do not agree). METHODOLOGY Dedicated study personnel were integrated into public-sector ART clinics. We collected participant information in a dedicated research database. Twelve ART clinics in Lusaka, Zambia constituted the units of randomization. Study clinics were stratified into pairs according to matching criteria (historical mortality rate, size, and duration of operation) to limit the effect of clustering, and independently randomized to the intervention and control arms. The study was powered to detect a 36% reduction in mortality at 18 months. PRINCIPAL FINDINGS From December 2006 to May 2008, we completed enrollment of 1973 participants. Measured baseline characteristics did not differ significantly between the study arms. Enrollment was staggered by clinic pair and truncated at two matched sites. CONCLUSIONS A large clinical trial of routing VL monitoring was successfully implemented in a dynamic and rapidly growing national ART program. Close collaboration with local health authorities and adequate reserve staff were critical to success. Randomized controlled trials such as this will likely prove valuable in determining long-term outcomes in resource-constrained settings. TRIAL REGISTRATION Clinicaltrials.gov NCT00929604.
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Affiliation(s)
- John R. Koethe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- * E-mail:
| | | | - Dora K. Luhanga
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Gina M. Clark
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Jason D. Goldman
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | | | | | - Benjamin H. Chi
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, United States of America
| | - Isaac Zulu
- Department of Internal Medicine, University Teaching Hospital, Lusaka, Zambia
| | - Michael S. Saag
- Division of Infectious Diseases, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, United States of America
| | - Jeffrey S. A. Stringer
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, United States of America
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Barth RE, van der Loeff MFS, Schuurman R, Hoepelman AIM, Wensing AMJ. Virological follow-up of adult patients in antiretroviral treatment programmes in sub-Saharan Africa: a systematic review. THE LANCET. INFECTIOUS DISEASES 2010; 10:155-66. [DOI: 10.1016/s1473-3099(09)70328-7] [Citation(s) in RCA: 226] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Seven-year experience of a primary care antiretroviral treatment programme in Khayelitsha, South Africa. AIDS 2010; 24:563-72. [PMID: 20057311 DOI: 10.1097/qad.0b013e328333bfb7] [Citation(s) in RCA: 214] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We report on outcomes after 7 years of a community-based antiretroviral therapy (ART) programme in Khayelitsha, South Africa, with death registry linkages to correct for mortality under-ascertainment. DESIGN This is an observational cohort study. METHODS Since inception, patient-level clinical data have been prospectively captured on-site into an electronic patient information system. Patients with available civil identification numbers who were lost to follow-up were matched with the national death registry to ascertain their vital status. Corrected mortality estimates weighted these patients to represent all patients lost to follow-up. CD4 cell count outcomes were reported conditioned on continuous virological suppression. RESULTS Seven thousand, three hundred and twenty-three treatment-naive adults (68% women) started ART between 2001 and 2007, with annual enrolment increasing from 80 in 2001 to 2087 in 2006. Of 9.8% of patients lost to follow-up for at least 6 months, 32.8% had died. Corrected mortality was 20.9% at 5 years (95% confidence interval 17.9-24.3). Mortality fell over time as patients accessed care earlier (median CD4 cell count at enrolment increased from 43 cells/microl in 2001 to 131 cells/microl in 2006). Patients who remained virologically suppressed continued to gain CD4 cells at 5 years (median 22 cells/microl per 6 months). By 5 years, 14.0% of patients had failed virologically and 12.2% had been switched to second-line therapy. CONCLUSION At a time of considerable debate about future global funding of ART programmes in resource-poor settings, this study has demonstrated substantial and durable clinical benefits for those able to access ART throughout this period, in spite of increasing loss to follow-up.
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Harries AD, Zachariah R, van Oosterhout JJ, Reid SD, Hosseinipour MC, Arendt V, Chirwa Z, Jahn A, Schouten EJ, Kamoto K. Diagnosis and management of antiretroviral-therapy failure in resource-limited settings in sub-Saharan Africa: challenges and perspectives. THE LANCET. INFECTIOUS DISEASES 2010; 10:60-5. [DOI: 10.1016/s1473-3099(09)70321-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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