Factors associated with first-line antiretroviral treatment failure in adult HIV-positive patients: a case-control study from Ethiopia

Predictors of Clinical Outcomes among People with HIV and Tuberculosis Symptoms after Rapid Treatment Initiation in Haiti

Introduction

Few studies have evaluated baseline predictors of clinical outcomes among people with HIV starting antiretroviral therapy (ART) in the modern era of rapid ART initiation.

Methods

We conducted a secondary analysis of a randomized controlled trial of two rapid treatment initiation strategies for people with treatment-naïve HIV and tuberculosis symptoms at an urban clinic in Haiti. We used logistic regression models to assess associations between baseline characteristics and (1) retention in care at 48 weeks, (2) HIV viral load suppression at 48 weeks (among participants who underwent viral load testing), and (3) all-cause mortality.

Results

500 participants were enrolled in the study 11/2017-1/2020. Eighty-eight (18%) participants were diagnosed with tuberculosis, and ART was started in 494 (99%). After adjustment, less than secondary education (adjusted odds ratio [AOR] 0.21, 95% CI 0.10-0.46), dolutegravir initiation (AOR 2.57, 95% CI 1.22-5.43), age (AOR 1.42 per 10-year increase, 95% CI 1.01-1.99), and tuberculosis diagnosis (AOR 3.92, 95% CI 1.36-11.28) were significantly associated with retention. Age (AOR 1.36, 95% CI 1.05-1.75), dolutegravir initiation (AOR 1.75, 95% CI 1.07-2.85), and tuberculosis diagnosis (AOR 0.50, 95% CI 0.28-0.89) were associated with viral suppression. Higher CD4 cell count at enrollment (unadjusted odds ratio [OR] 0.69, 95% CI 0.55-0.87) and anemia (OR 4.86, 95% CI 1.71-13.81) were associated with mortality.

Conclusions

We identified sociodemographic, treatment-related, clinical, and laboratory-based predictors of clinical outcomes. These characteristics may serve as markers of sub-populations that could benefit from additional interventions to support treatment success after rapid treatment initiation.

Highly active antiretroviral therapy discontinuation time is associated with therapeutic failure among human immunodeficiency virus (HIV)-infected immigrant adults: A cohort study from a Peruvian referral hospital during the Venezuelan exodus

OBJECTIVE

To evaluate the association between Highly Active Antiretroviral Therapy (HAART) discontinuation time and therapeutic failure (TF) in Venezuelan immigrants with HIV that restart HAART.

METHODS

We carried out a retrospective cohort study in a large hospital in Peru. We included Venezuelan immigrants who restarted HAART and were followed over at least 6 months. The primary outcome was TF. Secondary outcomes were immunologic (IF), virologic (VF) and clinical (CF) failures. The exposure variable was HAART discontinuation, categorised as no discontinuation, less than 6 months, and 6 months or more. We applied generalised linear models Poisson family with robust standard errors to calculate crude (cRR) and adjusted (aRR) relative risks by statistical and epidemiological criteria.

RESULTS

We included 294 patients, 97.2% were males, and the median age was 32 years. Out of all the patients, 32.7% discontinued HAART for less than 6 months, 15.0% discontinued for more than 6 months and the remaining 52.3% did not discontinue. The cumulative incidence of TF was 27.9%, 24.5% in VF, 6.0% in IF and 6.0% in CF. Compared with non-discontinued HAART patients, the discontinuation for less than 6 months (aRR = 1.98 [95% CI: 1.27-3.09]) and from 6 months to more (aRR = 3.17 [95% CI: 2.02-4.95]) increased the risk of TF. Likewise, treatment discontinuation of up to 6 months (aRR = 2.32 [95% CI: 1.40-3.84]) and from 6 months to more (aRR = 3.93 [95% CI: 2.39-6.45]) increased the risk of VF.

CONCLUSIONS

HAART discontinuation increases the probability of TF and VF in Venezuelan immigrants.

Antiretroviral treatment failure and associated factors among people living with HIV on therapy in Homa Bay, Kenya: A retrospective study

Despite large numbers of patients accessing antiretroviral treatment (ART) in Kenya, few studies have explored factors associated with virologic failure in Western Kenya, specifically. We undertook a study in Homa Bay County, Kenya to assess the extent of virologic treatment failure and factors associated with it. This was an observational retrospective study conducted from September 2020 to January 2021. Data were abstracted from the records of patients who had been on ART for at least six months at the time of data collection after systematic sampling stratified by age group at ART initiation (0-14 and 15+ years), using probability proportion to the numbers of patients attending the facility. Confirmed viral treatment failure was defined as viral load ≥1000 copies/ml based on two consecutive viral load measurements after at least three months of enhanced adherence counseling. Data were analyzed using descriptive statistics and Cox regression modeling. Of the 2,007 patients sampled, 160 (8.0%) had confirmed virologic treatment failure. Significantly higher virologic treatment failure rates were identified among male patients 78/830 (9.4%) and children 115/782 (14.7%). Factors associated with virologic treatment failure (VTF), were age 0-14 years, adjusted hazard ratio (AHR) 4.42, (95% Confidence Interval [CI], 3.12, 6.32), experience of treatment side effects AHD: 2.43, (95% CI, 1.76, 3.37), attending level 2/3 health facility, AHR: 1.87, (95% CI: 1.29, 2,72), and history of opportunistic infections (OIs), AHR: 1.81, (95% CI, 1.76, 3.37). Children, attendees of level 2/3 health facilities, patients with a history of OIs, and those experiencing treatment side-effects are at risk of VTF. Increased focus on children and adolescents on screening for drug resistance, administration of and adherence to medication, and on effective information and education on side-effects is critical. Additionally, there is need for increased training and support for health care workers at primary level care facilities.

Effect of tenofovir containing ART on renal function in patients with moderate/severe reduced creatinine clearance at baseline: A retrospective study at two referral hospitals in Namibia

Prescription of tenofovir disoproxil fumarate (TDF) for patients with baseline creatinine clearances (CrCl) <60 mL/min is said to increase risk of further decline in CrCl. Study objectives were to assess incidence of improvement and predictors thereof; to assess incidence of decline and transition to lower stages of CrCl; and comparison of declines between patients with a baseline CrCl < 60mL/min (group-I) and ≥ 60 mL/min (group-II). The study was retrospective, included patients 16 yrs or older who received TDF-containing ART. Improvement and decline were defined as ≥ 25% increase or decrease in CrCl, respectively. Binary logistic regression was performed to identify predictors of improvement. Groups I and II had 2862 and 7526 patients, respectively. In group-I, improvement in CrCl was observed in 40.1% (n = 1146), and was associated with stage IV of CrCl (adjusted Odds Ratio [aOR]=13.4 [95% CI: 6.7 - 26.9, P < .001]); male gender (aHR = 1.8 [95% CI: 1.5 - 2.2, P < .001]); and a poor HIV-status (aHR = 1.2 [95% CI: 1.0 - 1.4], P = .033). In group-I and group-II, respectively, decline occurred in 2.3% and 13.0%, (P < .001); transition to lower stages occurred in 1.0% and 25.2% (P < .001); and migration to stage IV CrCl occurred in 1.0% and 0.5% (P < .001). Improvement was more likely than decline in group-I patients. Although, group-I patients were more likely to experience new onset severe reduced CrCl than group-II patients, the proportions were extremely low. TDF should not be withheld from HIV-positive patients with a baseline CrCl < 60 mL/min.

Determinants of therapy failure among adults on first-line antiretroviral therapy in Asmara, Eritrea: a multicenter retrospective matched case-control study

BACKGROUND

Information on treatment failure (TF) in People living with HIV in a data-poor setting is necessary to counter the epidemic of TF with first-line combined antiretroviral therapies (cART) in sub-Saharan Africa (SSA). In this study, we examined the risk factors associated with TF in Asmara, Eritrea from 2001 to 2020.

METHODS

A multicenter, retrospective 1:2 matched (by age and gender) case-control study was conducted in four major hospitals in Asmara, Eritrea on adults aged ≥ 18 years who were on treatment for at least 6 months. Cases were patients who fulfills at least one of the WHO therapy failure criterion during the study period. Controls were randomly selected patients on first-line treatment and plasma viral load < 1000 copies/ml in their latest follow-up measurement. Multivariable logistic regression analysis was conducted to identify risk factors for TF. All P-values were 2-sided and the level of significance was set at P < 0.05 for all analyses.

RESULTS

Of the 1068 participants (356 cases; 712 controls), 585 (54.7%) were females. The median age at treatment initiation was 46 years [interquartile range (IQR): 39-51]. Median time to combined antiretroviral therapy (cART) failure was 37 months (IQR = 24-47). In the multivariate analysis, factors associated with increased likelihood of TF included initial nucleoside reverse transcriptase inhibitors (NRTI) backbone (Zidovudine + Lamivudine (AZT + 3TC): adjusted odds ratio (aOR) = 2.70, 95% Confidence interval (CI): 1.65-4.41, P-value < 0.001), (Abacavir + lamivudine (ABC + 3TC): aOR = 4.73, 95%CI: 1.18-18.92, P-value = 0.028], and (Stavudine + Lamivudine (D4T + 3TC): aOR = 5.00; 95% CI: 3.03-8.20, P-value < 0.001) in comparison to Emtricitabine and Tenofovir diproxil fumarate (FTC + TDF). Additional associations included prior exposure to cART (aOR = 2.28, 95%CI: 1.35-3.86; P- value = 0.002), record of sub-optimal drug adherence (aOR = 3.08, 95%CI: 2.22-4.28; P < 0.001), ambulatory/bedridden at presentation (aOR = 1.61, 95%CI: 1.12-4.28; P-value = 0.010), presence of comorbidities (aOR = 2.37; 95%CI: 1.36-4.10, P-value = 0.002), duration of cART (< 5 years: aOR: 5.90; 95% CI: 3.95-8.73, P-value < 0.001), and use of SMX-TMP prophylaxis (aOR = 2.00, 95%CI, 1.44-2.78, P-value < 0.001).

CONCLUSION

Our findings underscore the importance of optimizing cART adherence, diversification of cART regimens, and interventions directed at enhancing early HIV diagnosis, prompt initiations of treatment, and improved patient-focused monitoring of treatment response.

Prediction-driven pooled testing methods: Application to HIV treatment monitoring in Rakai, Uganda

Chronic medical conditions often necessitate regular testing for proper treatment. Regular testing of all afflicted individuals may not be feasible due to limited resources, as is true with HIV monitoring in resource-limited settings. Pooled testing methods have been developed in order to allow regular testing for all while reducing resource burden. However, the most commonly used methods do not make use of covariate information predictive of treatment failure, which could improve performance. We propose and evaluate four prediction-driven pooled testing methods that incorporate covariate information to improve pooled testing performance. We then compare these methods in the HIV treatment management setting to current methods with respect to testing efficiency, sensitivity, and number of testing rounds using simulated data and data collected in Rakai, Uganda. Results show that the prediction-driven methods increase efficiency by up to 20% compared with current methods while maintaining equivalent sensitivity and reducing number of testing rounds by up to 70%. When predictions were incorrect, the performance of prediction-based matrix methods remained robust. The best performing method using our motivating data from Rakai was a prediction-driven hybrid method, maintaining sensitivity over 96% and efficiency over 75% in likely scenarios. If these methods perform similarly in the field, they may contribute to improving mortality and reducing transmission in resource-limited settings. Although we evaluate our proposed pooling methods in the HIV treatment setting, they can be applied to any setting that necessitates testing of a quantitative biomarker for a threshold-based decision.

Determinants of first-line antiretroviral treatment failure among adult HIV patients at Nekemte Specialized Hospital, Western Ethiopia: Unmatched case-control study

OBJECTIVE

In Ethiopia, only a few studies were conducted to determine factors contributing to antiretroviral treatment failure, in general, and there are no published data in the study area, in particular. Thus, the aim of the study was to assess the determinants of first-line treatment failure among adult HIV patients on antiretroviral treatment at Nekemte Specialized Hospital, western Ethiopia.

METHODS

The hospital-based 1:2 unmatched case-control study was conducted in Nekemte Specialized Hospital from 1 August to 30 September, 2019, on 252 HIV-positive patients receiving antiretroviral treatment (86 cases and 166 controls). Cases were selected from patients who were switched to second-line antiretroviral treatment regimen after first-line antiretroviral treatment failure. Controls were from those who are on the first-line antiretroviral regimens for at least 6 months. Data were collected by two trained clinical nurses. Record review and an interviewer-administered questionnaire were used to collect data. Data were entered into Epi-Data, version 7.2.2, and then exported to SPSS, version 25, for analysis. The association between treatment failure and each covariate was assessed by bivariate analysis to identify candidate variables at p value < 0.25. All candidate variables were entered into multivariate analysis done in stepwise backward likelihood ratio to declare statistical significance association at p value < 0.05, 95% confidence interval.

RESULTS

Data from a total of 252 (86 cases and 166 controls) patients were extracted at a response rate of 98.4%. Statistically higher odds of first-line treatment failure were observed among those who started treatment at an advanced stage (Baseline World Health Organization stage 3 o r4 (adjusted odds ratio = 3.12, 95% confidence interval: 1.55-6.26), lower Baseline CD4 count < 100 cells (adjusted odds ratio = 3.06, 95 % confidence interval: 1.45-6.50), lack of participation in a support group (adjusted odds ratio = 4.03, 95% confidence interval: 1.98-8.21), history of antiretroviral treatment discontinuation for greater than 1 month (adjusted odds ratio = 2.36, 95% confidence interval: 1.17-4.78) and poor adherence to antiretroviral treatment (adjusted odds ratio = 3.09, 95% confidence interval: 1.54-6.19).

CONCLUSION

Antiretroviral treatment initiation at an advanced stage, lower CD4 count, no participation in a support group, and poor adherence were determinants of treatment first-line antiretroviral treatment failure. Therefore, health care providers and program developers should give special attention to; early diagnosis and start of treatment, encouraging patients to participate in a support group, trace patients early, and attentively follow patients to improve their adherence to antiretroviral treatment.

First line antiretroviral treatment failure and associated factors among people living with HIV in northwest Ethiopia

BACKGROUND

Anti-retroviral treatment enhances the immune status and reduces unwanted outcomes. However, development of treatment failure and drug resistance raises concern over lifelong treatments to chronic diseases such as HIV/AIDS.

OBJECTIVES

This study determined proportion of treatment failure (TF) and identified factors associated with TF among people living with human immunodeficiency virus (HIV) in Bahir Dar, Northwest Ethiopia.

METHODS

Facility based cross sectional study was carried out from November, 2017 to April, 2018. Sociodemographic and clinical data were collected using structured questioner. Blood sample was collected and analyzed for viral load, complete blood count (CBC), liver and kidney function test and CD4 count. A patient is declared as treatment failure when viral load value is higher than 1000 RNA copies/ml in two consecutive viral load analyses within three months interval. Data were entered and analyzed using SPSS version 23. To identify factors associated with TF, logistic regressions model was employed.

RESULTS

A total of 430 people who had six months and above antiretroviral treatment (ART) follow up were enrolled in the study. Of these, 57.9% were females & the mean age was 38 years. The mean month of ART follow up was 83 months. In the first viral load analysis, 106 (24.7%) of the cohort were virologically failed. These failed people were followed for 3 months with intensive adherence support; then second viral load analysis showed a viralogical failure among 65 people of the second cohort. Thus, the overall viralogical failure or TF was 15.1%. The re-suppression rates were 41(38.7%). Male gender, people with history of drug discontinuation, poor adherence, irregular time of drug intake, multiple sexual practice showed significant association with TF. Moreover, base line and current CD4 counts of <200 cells/ml also demonstrated significant association with TF.

CONCLUSION

Significant proportion of treatment failure was reported in the present study. Moreover, behavioral factors such as drug discontinuation, poor adherence, multiple sexual partner were associated with treatment failure. Hence, to avoid TF, regular patient counseling and monitoring should be in place. To identify the predictors for treatment failure, further follow-up study is desirable.

COVID-19 and nutritional deficiency: a review of existing knowledge

COVID-19 has resulted in an ongoing global pandemic, which spread largely among people who have had close contact with the infected person. The immunopathology of the SARS-CoV-2 virus includes the production of an excess amount of pro-inflammatory cytokines "a cytokine-storm". The respiratory system (main), cardiovascular system and the gastrointestinal tract are the most affected body systems during viral infection. It has been found that most of the patients who require admission to hospital are elderly or have chronic underlying diseases. Higher cases of malnutrition and co-morbidities like diabetes mellitus and cardiovascular diseases are reported in elderly patients due to which, the immune system weakens and hence, the response to the virus is diminished in magnitude. A deficiency of micronutrients results in impaired immune responses leading to improper secretion of cytokines, alterations in secretory antibody response and antibody affinity which increases susceptibility to viral infection. The deficiency of various micronutrients in COVID-19 patient can be treated by appropriate nutritional supplements, prescribed after evaluating the patients' nutritional status. Here we aim to highlight the role of a few particular nutrients namely Vitamin D, Vitamin C, Omega-3 fatty acids, Zinc and Magnesium along with the synergistic roles they play in enhancing immunity and thus, maintaining homeostasis.

Immunological Treatment Failure Among Adult Patients Receiving Highly Active Antiretroviral Therapy in East Africa: A Systematic Review and Meta-Analysis

Background

Minimizing antiretroviral treatment failure is crucial for improving patient health and for maintaining long-term access to care in low-income settings such as eastern Africa. To develop interventions to support adherence, policymakers must understand the extent and scope of treatment failure in their programs. However, estimates of treatment failure in eastern Africa have been variable and inconclusive.

Objective

This systematic review and meta-analysis sought to determine the pooled prevalence of immunological failure among adults receiving antiretroviral therapy in eastern Africa.

Methods

We performed a systematic search of the PubMed, Google Scholar, Excerpta Medica Database, and the World Health Organization's Hinari portal (which includes the Scopus, African Index Medicus, and African Journals Online databases) databases. Unpublished studies were also accessed from conference websites and university repositories. We used Stata version 14 for data analysis. The Cochrane Q test and I ² test statistic were used to test for heterogeneity across the studies. Due to high levels of heterogeneity, a random effects model was used to estimate the pooled prevalence of immunological failure. Begg and Egger tests of the intercept in the random effects model were used to check for publication bias.

Results

After removing duplicates, 25 articles remained for assessment and screening. After quality screening, 15 articles were deemed eligible and incorporated into the final analysis. The average pooled estimate of immunological treatment failure prevalence was found to be 21.89% (95% CI, 15.14-28.64). In the subgroup analysis conducted by geographic region, the pooled prevalence of immunological treatment failure in Ethiopia was 15.2% (95% CI, 12.27-18.13) while in Tanzania it was 53.93% (95% CI, 48.14-59.73). Neither the results of Egger test or Begg tests suggested publication bias; however, on visual examination, the funnel plot appeared asymmetric. The large heterogeneity across the studies could be explained by study country.

Conclusion

Immunological treatment failure among patients receiving antiretroviral therapy in eastern Africa was high, and greater than previously reported. The relatively low rates of treatment failure found in Ethiopia suggest that its health extension program should be studied as a model for improving adherence in the region. (Curr Ther Res Clin Exp. 2021; 82:XXX-XXX) © 2021 Elsevier HS Journals, Inc.

Effect of AIDS-defining events at initiation of antiretroviral therapy on long-term mortality of HIV/AIDS patients in Southwestern China: a retrospective cohort study

Objective

To evaluate the impact of AIDS-defining events (ADE) on long-term mortality of HIV positive individuals on antiretroviral therapy (ART), a retrospective HIV/AIDS treatment cohort study performed in Southwestern China.

Methods

The retrospective cohort was conducted among 6757 HIV/AIDS patients on ART (2NRTIs + 1NNRTI, 2NRTIs + 1PI and Single or two drugs) recruited in Guigang city, Guangxi, China, from January 2004 to December 2018. Participants were divided into ADE and non-ADE groups, and were followed-up every six months to observe treatment outcomes. Comparison of mortality between groups was performed using the log-rank test and Kaplan–Meier analysis. Cox proportional hazard regression was used to explore the risk factors of mortality. 1:1 propensity score matching (PSM) was used to balance confounding factors and adjust the mortality risk.

Results

Of 6757 participants with 29,096.06 person-years of follow-up, 16.86% (1139/6757) belonged to ADE group while the others (83.14%) belonged to the non-ADE group. The most common cause of death by ADE was disseminated mycosis (31.65%), followed by recurrent severe bacterial pneumonia (28.48%), herpes zoster (17.72%), and extra-pulmonary tuberculosis (8.86%). The mortality of the ADE group was significantly higher than that of the non-ADE group [3.45/100 person-years (95% CI 2.92–3.97) vs. 2.34/100 person-years (95% CI 2.15–2.52), P<0.001]. The death risk of the ADE group was also higher than that of the non- ADE group [adjusted hazard ratio (aHR) = 1.291, 95% CI 1.061–1.571, P = 0.011], which was confirmed by PSM analysis (aHR = 1.581, 95% CI 1.192–2.099, P = 0.002). Cox analysis indicated that ADE, older age, male gender, previous non-use of cotrimoxazole, advanced WHO clinical stage, and low baseline CD4⁺ cell count were the risk factors for death.

Conclusions

Even on ART, the mortality risk of HIV positive individuals with ADE was higher than those without ADE. Active testing, earlier diagnosis, and timely therapy with ART may reduce the death risk of ADE.

Early nutritional supplementation in non-critically ill patients hospitalized for the 2019 novel coronavirus disease (COVID-19): Rationale and feasibility of a shared pragmatic protocol

OBJECTIVES

Beginning in December 2019, the 2019 novel coronavirus disease (COVID-19) has caused a pneumonia epidemic that began in Wuhan, China, and is rapidly spreading throughout the whole world. Italy is the hardest hit country after China. Considering the deleterious consequences of malnutrition, which certainly can affect patients with COVID-19, the aim of this article is to present a pragmatic protocol for early nutritional supplementation of non-critically ill patients hospitalized for COVID-19 disease. It is based on the observation that most patients present at admission with severe inflammation and anorexia leading to a drastic reduction of food intake, and that a substantial percentage develops respiratory failure requiring non-invasive ventilation or even continuous positive airway pressure.

METHODS

High-calorie dense diets in a variety of different consistencies with highly digestible foods and snacks are available for all patients. Oral supplementation of whey proteins as well as intravenous infusion of multivitamin, multimineral trace elements solutions are implemented at admission. In the presence of 25-hydroxyvitamin D deficit, cholecalciferol is promptly supplied. If nutritional risk is detected, two to three bottles of protein-calorie oral nutritional supplements (ONS) are provided. If <2 bottles/d of ONS are consumed for 2 consecutive days and/or respiratory conditions are worsening, supplemental/total parenteral nutrition is prescribed.

CONCLUSION

We are aware that our straight approach may be debatable. However, to cope with the current emergency crisis, its aim is to promptly and pragmatically implement nutritional care in patients with COVID-19, which might be overlooked despite being potentially beneficial to clinical outcomes and effective in preventing the consequences of malnutrition in this patient population.

The effect of tuberculosis on immune reconstitution among HIV patients on highly active antiretroviral therapy in Adigrat general hospital, eastern Tigrai, Ethiopia; 2019: a retrospective follow up study

Background

Ethiopia initiated antiretroviral therapy early in 2005. Managing and detecting antiretroviral treatment response is important to monitor the effectiveness of medication and possible drug switching for low immune reconstitution. There is less recovery of CD4+ T cells among human immunodeficiency virus patients infected with tuberculosis. Hence, we aimed to assess the effect of tuberculosis and other determinant factors of immunological response among human immunodeficiency virus patients on highly active antiretroviral therapy. A retrospective follow up study was conducted from October to July 2019. A total of 393 participants were enrolled. An interviewer based questionnaire was used for data collection. Patient charts were used to extract clinical data and follow up results of the CD4+ T cell. Current CD4+ T cell counts of patients were performed. STATA 13 software was used to analyze the data. A p-value ≤0.05 was considered a statistically significant association.

Results

The mean age of study participants was 39.2 years (SD: + 12.2 years) with 8.32 mean years of follow up. The overall prevalence of immune reconstitution failure was 24.7% (97/393). Highest failure rate occurred within the first year of follow up time, 15.7 per 100 Person-year. Failure of CD4+ T cells reconstitution was higher among tuberculosis coinfected patients (48.8%) than mono-infected patients (13.7%). Living in an urban residence, baseline CD4+ T cell count ≤250 cells/mm³, poor treatment adherence and tuberculosis infection were significantly associated with the immunological failure.

Conclusions

There was a high rate of CD4+ T cells reconstitution failure among our study participants. Tuberculosis infection increased the rate of failure. Factors like low CD4+ T cell baseline count, poor adherence and urban residence were associated with the immunological failure. There should be strict monitoring of CD4+ T cell counts among individuals with tuberculosis coinfection.