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Maseke I, Joachim A, Kamori D, Abade A, Moremi N, Majigo M. Prevalence of human immunodeficiency virus drug resistance and factors associated with high viral load among adolescents on antiretroviral therapy in Dar Es Salaam, Tanzania. HIV Res Clin Pract 2024; 25:2400827. [PMID: 39244659 DOI: 10.1080/25787489.2024.2400827] [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: 05/22/2024] [Revised: 08/28/2024] [Accepted: 08/30/2024] [Indexed: 09/10/2024]
Abstract
BACKGROUND Resistance to antiretrovirals against human immunodeficiency virus (HIV) poses a threat to zero transmission of HIV by 2030. Few studies have been conducted on HIV drug resistance (HIVDR) mutations targeting adolescents. We determined the prevalence, pattern of HIVDR mutations, and factors associated with unsuppressed HIV viral load among adolescents on antiretroviral therapy (ART). METHODS From March to June 2020, we conducted a cross-sectional study at the Infectious Disease Clinic in Dar es Salaam, Tanzania. HIV-1 viral load was tested using m2000rt Real-Time HIV-1 assay. A sample with a viral load equal or more than 1,000 copies/ml was tested for HIVDR mutations. We determined the factors associated with unsuppressed viral load using logistic regression. A p-value less than 0.05 was considered significant. RESULTS We enrolled 131 participants with a median age (interquartile range) of 15 (13-18) years. Of all, 24(18.3%) had a viral load above 1000 copies/ml. HIVDR mutations were found in 19/24(68.4%). Mutation to protease inhibitors, nucleotide reverse transcriptase inhibitors, and non-nucleoside reverse transcriptase inhibitors were 1(5.2%), 9(47.4%), and 11(57.9%), respectively. Non-antiretroviral therapy and orphanages were independently associated with unsuppressed viral load. CONCLUSION The prevalence of HIVDR and unsuppressed HIV viral load among adolescents are relatively high. The use of non-antiretroviral therapy and orphanage influenced the persistence of high viral load. Strategies for surveillance of HIVDR early warning signs should be devised among adolescents.
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Affiliation(s)
- Irene Maseke
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Agricola Joachim
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Doreen Kamori
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Ahmed Abade
- Tanzania Field Epidemiology and Laboratory Training Program, Dar es Salaam, Tanzania
| | | | - Mtebe Majigo
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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Kitenge MK, Fatti G, Eshun-Wilson I, Aluko O, Nyasulu P. Prevalence and trends of advanced HIV disease among antiretroviral therapy-naïve and antiretroviral therapy-experienced patients in South Africa between 2010-2021: a systematic review and meta-analysis. BMC Infect Dis 2023; 23:549. [PMID: 37608300 PMCID: PMC10464046 DOI: 10.1186/s12879-023-08521-4] [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: 02/08/2023] [Accepted: 08/08/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Despite the significant progress made in South Africa in getting millions of individuals living with HIV into care, many patients still present or re-enter care with Advanced HIV Disease (AHD). We aimed to estimate the prevalence of AHD among ART-naive and ART-experienced patients in South Africa using studies published between January 2010 and May 2022. METHODS We searched for relevant data on PubMed, CINAHL, Scopus and other sources, with a geographical filters limited to South Africa, up to May 31, 2022. Two reviewers conducted all screening, eligibility assessment, data extraction, and critical appraisal. We synthesized the data using the inverse-variance heterogeneity model and Freeman-Tukey transformation. We assessed heterogeneity using the I2 statistic and publication bias using the Egger and Begg's test. RESULTS We identified 2,496 records, of which 53 met the eligibility criteria, involving 11,545,460 individuals. The pooled prevalence of AHD among ART-naive and ART-experienced patients was 43.45% (95% CI 40.1-46.8%, n = 53 studies) and 58.6% (95% CI 55.7 to 61.5%, n = 2) respectively. The time trend analysis showed a decline of 2% in the prevalence of AHD among ART-naive patients per year. However, given the high heterogeneity between studies, the pooled prevalence should be interpreted with caution. CONCLUSION Despite HIV's evolution to a chronic disease, our findings show that the burden of AHD remains high among both ART-naive and ART-experienced patients in South Africa. This emphasizes the importance of regular measurement of CD4 cell count as an essential component of HIV care. In addition, providing innovative adherence support and interventions to retain ART patients in effective care is a crucial priority for those on ART.
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Affiliation(s)
- Marcel K Kitenge
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
- Tuberculosis and HIV investigative Network (THINK), Durban, Kwazulu-Natal, South Africa.
| | - Geoffrey Fatti
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Kheth'Impilo AIDS Free Living, Cape Town, South Africa
| | - Ingrid Eshun-Wilson
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Infectious Diseases, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Omololu Aluko
- Faculty of Health Sciences, School of Medical Sciences, Department of Biostatistics, University of the Free State, Bloemfontein, South Africa
| | - Peter Nyasulu
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Machila N, Libonda L, Habineza P, Velu RM, Kamboyi HK, Ndhlovu J, Wamunyima I, Sinadambwe MM, Mudenda S, Zyambo C, Bumbangi FN. Prevalence and predictors of virological failure in pediatric patients on HAART in sub-Saharan Africa: a systematic review and meta-analysis. Pan Afr Med J 2023; 45:98. [PMID: 37692980 PMCID: PMC10491719 DOI: 10.11604/pamj.2023.45.98.37017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 06/08/2023] [Indexed: 09/12/2023] Open
Abstract
Antiretroviral treatment failure has emerged as a challenge in the management of pediatric human immunodeficiency virus (HIV) patients, especially in resource-limited countries despite accessibility to Highly Active Antiretroviral Therapy (HAART). A systematic review and meta-analysis was conducted to synthesize virological failure (VF) prevalence and ascertain its predictors in children in sub-Saharan Africa. An electronic database search strategy was conducted from January to September 2021 on PubMed, EMBASE, SCOPUS, HINARI, and CINAHL. Further, manual searching was conducted on non-indexed journals. Utilizing the JASP© version 0.17.2 (2023) statistical software, a meta-analysis of pooled prevalence of VF was estimated using the standardized mean differences. Further, selection models were used to assess the risk of bias and heterogeneity. The pooled odds ratios were estimated for the respective studies reporting on predictors of VF. The overall pooled estimate of the prevalence of VF in sub-Saharan Africa among the sampled population was 29% (95% CI: 27.0-32.0; p<0.001). Predictors of VF were drug resistance (OR: 1.68; 95% CI: 0.88-2.49; p < 0.001), poor adherence (OR: 5.35; 95% CI: 5.26-5.45; p < 0.001), nevirapine (NVP)-based regimen (OR: 5.11; 95% CI: 4.66-5.56; p < 0.001), non-usage of cotrimoxazole prophylaxis (OR: 4.30; 95% CI: 4.13-4.47; p < 0.001), higher viral load at the initiation of antiretroviral therapy (ART) (OR: 244.32; 95% CI: 244.2-244.47; p <0.001), exposure to the prevention of mother to child transmission (PMTCT) (OR: 8.02; 95%CI: 7.58-8.46; p < 0.001), increased age/older age (OR: 3.37; 95% CI: 2.70-4.04; p < 0.001), advanced World Health Organization (WHO) stage (OR: 6.57; 95% CI: 6.17-6.98; p < 0.001), not having both parents as primary caregivers (OR: 3.01; 95% CI: 2.50-3.53; p < 0.001), and tuberclosis (TB) treatment (OR: 4.22; 95% CI: 3.68-4.76; p <0.001). The mean VF prevalence documented is at variance with studies in other developing countries outside the sub-Saharan region. The high prevalence of HIV cases contrasting with the limited expertise in the management of pediatric ART patients could explain this variance.
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Affiliation(s)
- Nchimunya Machila
- Department of Disease Control and Prevention, School of Medicine, Eden University, Lusaka, Zambia
| | - Liyali Libonda
- Department of Disease Control and Prevention, School of Medicine, Eden University, Lusaka, Zambia
| | - Paul Habineza
- Department of Disease Control and Prevention, School of Medicine, Eden University, Lusaka, Zambia
| | | | - Harvey Kakoma Kamboyi
- Department of Disease Control and Prevention, School of Medicine, Eden University, Lusaka, Zambia
- Division of Infection and Immunity, International Institute for Zoonosis Control, Hokkaido University, Hokkaido, Japan
| | - Jacob Ndhlovu
- Department of Disease Control and Prevention, School of Medicine, Eden University, Lusaka, Zambia
| | - Inonge Wamunyima
- Department of Disease Control and Prevention, School of Medicine, Eden University, Lusaka, Zambia
| | | | - Steward Mudenda
- Department of Pharmacy, School of Medicine, University of Zambia, Lusaka, Zambia
| | - Cosmas Zyambo
- Department of Community and Family Health, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Flavien Nsoni Bumbangi
- Department of Disease Control and Prevention, School of Medicine, Eden University, Lusaka, Zambia
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Hunt GM, Yousif M, Levin L, Ledwaba J, Steegen K, Kufa T, Zwane H, Kalimashe M, Kana V, Aynalem G, Perlman J, Ayalew K, Kindra G, Diallo K, Carmona S, Sherman G, Raizes EJ. Resistance is common in paediatric patients failing ART in South Africa. J Antimicrob Chemother 2023; 78:1160-1167. [PMID: 37017009 PMCID: PMC10616358 DOI: 10.1093/jac/dkac443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 12/05/2022] [Indexed: 04/06/2023] Open
Abstract
BACKGROUND Minimal data exist on HIV drug resistance patterns and prevalence among paediatric patients failing ART in resource-limited settings. We assessed levels of HIV drug resistance in children with virological failure. METHODS This cross-sectional study, performed from March 2017 to March 2019 in South Africa, enrolled HIV-positive children aged ≤19 years, receiving ART through public health facilities with recent evidence suggestive of virological failure (at least one viral load ≥1000 copies/mL), across 45 randomly selected high-volume clinics from all nine provinces. Resistance genotyping was performed using next-generation sequencing technologies. Descriptive analysis taking into account survey design was used to determine outcomes. RESULTS Among 899 participants enrolled, the adjusted proportion of HIV drug resistance among children with virological failure was 87.5% (95% CI 83.0%-90.9%). Resistance to NNRTIs was detected in 77.4% (95% CI 72.5%-81.7%) of participants, and resistance to NRTIs in 69.5% (95% CI 62.9%-75.4%) of participants. Overall, resistance to PIs was detected in 7.7% (95% CI 4.4%-13.0%) of children. CONCLUSIONS HIV drug resistance was highly prevalent in paediatric patients failing ART in South Africa, with 9 in 10 patients harbouring resistance to NNRTIs and/or NRTIs. PI-based regimens are predicted to be highly efficacious in achieving virological suppression amongst patients failing NNRTI-based regimens. Scaling up resistance testing amongst patients would facilitate access to second- and third-line regimens in South Africa.
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Affiliation(s)
- Gillian M. Hunt
- Centre for HIV and STIs, National Institute for Communicable Diseases, Private Bag X4, Sandringham, Johannesburg 2131, South Africa
- Department of Virology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mukhlid Yousif
- Centre for HIV and STIs, National Institute for Communicable Diseases, Private Bag X4, Sandringham, Johannesburg 2131, South Africa
- Department of Virology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Leon Levin
- Right to Care, Johannesburg, South Africa
| | - Johanna Ledwaba
- Centre for HIV and STIs, National Institute for Communicable Diseases, Private Bag X4, Sandringham, Johannesburg 2131, South Africa
| | - Kim Steegen
- National Health Laboratory Services, Johannesburg, South Africa
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Tendesayi Kufa
- Centre for HIV and STIs, National Institute for Communicable Diseases, Private Bag X4, Sandringham, Johannesburg 2131, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Hloniphile Zwane
- Centre for HIV and STIs, National Institute for Communicable Diseases, Private Bag X4, Sandringham, Johannesburg 2131, South Africa
| | - Monalisa Kalimashe
- Centre for HIV and STIs, National Institute for Communicable Diseases, Private Bag X4, Sandringham, Johannesburg 2131, South Africa
| | - Vibha Kana
- Centre for HIV and STIs, National Institute for Communicable Diseases, Private Bag X4, Sandringham, Johannesburg 2131, South Africa
| | - Getahun Aynalem
- Division of Global HIV and Tuberculosis, Center for Global Health, Centers for Disease Control and Prevention, Pretoria, South Africa
| | - Jaclyn Perlman
- Division of Global HIV and Tuberculosis, Center for Global Health, Centers for Disease Control and Prevention, Pretoria, South Africa
| | - Kassahun Ayalew
- Division of Global HIV and Tuberculosis, Center for Global Health, Centers for Disease Control and Prevention, Pretoria, South Africa
| | - Gurpreet Kindra
- Division of Global HIV and Tuberculosis, Center for Global Health, Centers for Disease Control and Prevention, Pretoria, South Africa
| | - Karidia Diallo
- Division of Global HIV and Tuberculosis, Center for Global Health, Centers for Disease Control and Prevention, Pretoria, South Africa
| | - Sergio Carmona
- National Health Laboratory Services, Johannesburg, South Africa
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Gayle Sherman
- Centre for HIV and STIs, National Institute for Communicable Diseases, Private Bag X4, Sandringham, Johannesburg 2131, South Africa
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Elliot J. Raizes
- Division of Global HIV and Tuberculosis, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Mengistu ST, Ghebremeskel GG, Achila OO, Abrehe MB, Tewelde SF, Idris MM, Tikue TG, Mesfin AB. Prevalence and factors associated with pediatric HIV therapy failure in a tertiary hospital in Asmara, Eritrea: A 15-year retrospective cohort study. PLoS One 2023; 18:e0282642. [PMID: 36893200 PMCID: PMC9997912 DOI: 10.1371/journal.pone.0282642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 02/20/2023] [Indexed: 03/10/2023] Open
Abstract
INTRODUCTION Treatment failure (TF) in HIV infected children is a major concern in resource-constrained settings in Sub-Saharan Africa (SSA). This study investigated the prevalence, incidence, and factors associated with first-line cART failure using the virologic (plasma viral load), immunologic and clinical criteria among HIV-infected children. METHODS A retrospective cohort study of children (<18 years of age on treatment for a period of > 6 months) enrolled in the pediatric HIV/AIDs treatment program at Orotta National Pediatric Referral Hospital from January 2005 to December 2020 was conducted. Data were summarized using percentages, medians (± interquartile range (IQR)), or mean ± standard deviation (SD). Where appropriate, Pearson Chi-Squire (χ2) tests or Fishers exacts test, Kaplan-Meier (KM) estimates, and unadjusted and adjusted Cox-proportional hazard regression models were employed. RESULTS Out of 724 children with at least 24 weeks' follow-up 279 experienced therapy failure (TF) making prevalence of 38.5% (95% CI 35-42.2) over a median follow-up of 72 months (IQR, 49-112 months), with a crude incidence of failure of 6.5 events per 100- person-years (95% CI 5.8-7.3). In the adjusted Cox proportional hazards model, independent factors of TF were suboptimal adherence (Adjusted Hazard Ratio (aHR) = 2.9, 95% CI 2.2-3.9, p < 0.001), cART backbone other than Zidovudine and Lamivudine (aHR = 1.6, 95% CI 1.1-2.2, p = 0.01), severe immunosuppression (aHR = 1.5, 95% CI 1-2.4, p = 0.04), wasting or weight for height z-score < -2 (aHR = 1.5, 95% CI 1.1-2.1, p = 0.02), late cART initiation calendar years (aHR = 1.15, 95% CI 1.1-1.3, p < 0.001), and older age at cART initiation (aHR = 1.01, 95% CI 1-1.02, p < 0.001). CONCLUSIONS Seven in one hundred children on first-line cART are likely to develop TF every year. To address this problem, access to viral load tests, adherence support, integration nutritional care into the clinic, and research on factors associated with suboptimal adherence should be prioritized.
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Affiliation(s)
- Samuel Tekle Mengistu
- Nakfa Hospital, Ministry of Health Northern Red Sea Branch, Nakfa, Eritrea
- Orotta School of Medicine, Orotta College of Medicine and Health Sciences, Asmara, Eritrea
- * E-mail:
| | - Ghirmay Ghebrekidan Ghebremeskel
- Nakfa Hospital, Ministry of Health Northern Red Sea Branch, Nakfa, Eritrea
- Orotta School of Medicine, Orotta College of Medicine and Health Sciences, Asmara, Eritrea
| | - Oliver Okoth Achila
- Department of Allied Health Sciences, Orotta College of Medicine and Health Sciences, Asmara, Eritrea
| | - Miriam Berhane Abrehe
- Department of Pediatrics and Child Health, Orotta National Referral and Teaching Hospital, Asmara, Eritrea
| | - Samuel Fisseha Tewelde
- Department of Pediatrics and Child Health, Orotta National Referral and Teaching Hospital, Asmara, Eritrea
| | - Mahmud Mohammed Idris
- Orotta School of Medicine, Orotta College of Medicine and Health Sciences, Asmara, Eritrea
- Department of Pediatrics and Child Health, Orotta National Referral and Teaching Hospital, Asmara, Eritrea
| | - Tsegereda Gebrehiwot Tikue
- Orotta School of Medicine, Orotta College of Medicine and Health Sciences, Asmara, Eritrea
- Department of Pediatrics and Child Health, Orotta National Referral and Teaching Hospital, Asmara, Eritrea
| | - Araia Berhane Mesfin
- National Communicable Disease Control Division, Ministry of Health, Asmara, Eritrea
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Yan L, Yu F, Liang J, Cheng Y, Li H, Zhao Q, Chen J, Chen M, Guo J, Zhao H, Zhang F. Drug resistance profiles and influencing factors among HIV-infected children and adolescents receiving long-term ART: a multicentre observational study in China. J Antimicrob Chemother 2022; 77:727-734. [PMID: 35195695 DOI: 10.1093/jac/dkab430] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 10/21/2021] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES To analyse the characteristics and determinants of drug resistance mutations (DRMs) in HIV-infected children and adolescents on long-term ART in China. METHODS An observational cohort study was conducted in five centres. All participants younger than 15 years at ART initiation were screened, and those identified as having virological failure (VF) with viral load (VL) ≥ 400 copies/mL were included for genotypic resistance testing. Logistic regression analysis was performed and the accumulation of major mutations was analysed in a subgroup of resistant individuals with complete VL results since HIV diagnosis. RESULTS Among 562 eligible participants, protease and RT regions were successfully amplified for 93 who failed treatment with a median of 10.0 years ART. Sixty-eight (73.1%) harboured ≥1 major mutations. NRTI, NNRTI and dual-class resistance accounted for 48.4%, 63.4% and 38.7%, respectively. Only 3.2% were resistant to PIs. Age at ART initiation [adjusted OR (aOR) = 0.813, 95% CI 0.690-0.957], subtype B (aOR = 4.378, 95% CI 1.414-13.560) and an initial NNRTI-based regimen (aOR = 3.331, 95% CI 1.180-9.402) were independently associated with DRMs. Among 40 resistant participants with additional VL data, 55.0% had continued VF on a suboptimal regimen and the estimated duration of VF was positively correlated with the total number of major mutations (r = 0.504, P = 0.001). CONCLUSIONS The development of DRMs was common in children and adolescents receiving long-term treatment, and continued VF was prevalent in those with resistance. Timely genotypic testing and new child-friendly formulations are therefore urgently required.
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Affiliation(s)
- Liting Yan
- Capital Medical University Affiliated Beijing Ditan Hospital, Beijing, China.,Clinical and Research Center for Infectious Diseases, Beijing Ditan Hospital, Beijing, China
| | - Fengting Yu
- Capital Medical University Affiliated Beijing Ditan Hospital, Beijing, China.,Clinical and Research Center for Infectious Diseases, Beijing Ditan Hospital, Beijing, China
| | - Jiangming Liang
- Guangxi Zhuang Autonomous Region Center for Disease Control and Prevention, Nanning, China
| | - Yuewu Cheng
- Shangcai Center for Disease Control and Prevention of Henan Province, Shangcai, China
| | - Huiqin Li
- AIDS Care Center, Yunnan Provincial Hospital of Infectious Disease, Kunming, China
| | - Qingxia Zhao
- The Sixth People's Hospital of Zhengzhou, Zhengzhou, China
| | - Jinfeng Chen
- Center for Infectious Diseases, Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Meiling Chen
- Capital Medical University Affiliated Beijing Ditan Hospital, Beijing, China.,Clinical and Research Center for Infectious Diseases, Beijing Ditan Hospital, Beijing, China
| | - Jing Guo
- Capital Medical University Affiliated Beijing Ditan Hospital, Beijing, China.,Clinical and Research Center for Infectious Diseases, Beijing Ditan Hospital, Beijing, China
| | - Hongxin Zhao
- Capital Medical University Affiliated Beijing Ditan Hospital, Beijing, China.,Clinical and Research Center for Infectious Diseases, Beijing Ditan Hospital, Beijing, China
| | - Fujie Zhang
- Capital Medical University Affiliated Beijing Ditan Hospital, Beijing, China.,Clinical and Research Center for Infectious Diseases, Beijing Ditan Hospital, Beijing, China
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Chimukangara B, Lessells RJ, Sartorius B, Gounder L, Manyana S, Pillay M, Singh L, Giandhari J, Govender K, Samuel R, Msomi N, Naidoo K, de Oliveira T, Moodley P, Parboosing R. HIV-1 drug resistance in adults and adolescents on protease inhibitor-based antiretroviral treatment in KwaZulu-Natal Province, South Africa. J Glob Antimicrob Resist 2021; 29:468-475. [PMID: 34785393 DOI: 10.1016/j.jgar.2021.10.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/19/2021] [Accepted: 10/26/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND In low- and middle-income countries, increasing levels of HIV drug resistance (HIVDR) on second-line protease inhibitor (PI)-based regimens are a cause for concern, given limited drug options for third-line antiretroviral therapy (ART). OBJECTIVES We conducted a retrospective analysis of routine HIV-1 genotyping laboratory data from KwaZulu-Natal, in South Africa, to describe the frequency and patterns of HIVDR mutations and their consequent impact on standardized third-line regimens. METHODS This was a cross-sectional analysis of all HIV-1 genotypic resistance tests conducted by the National Health Laboratory Service in KwaZulu-Natal, South Africa (Jan 2015 - Dec 2016), for adults and adolescents (age ≥10 years) on second-line PI-based ART with virological failure. We assigned a third-line regimen to each record, based on a national treatment algorithm and calculated the genotypic susceptibility score (GSS) for that regimen. RESULTS Of 348 samples analyzed, 287 (83%) had at least one drug resistance mutation (DRM) and 114 (33%) had at least one major PI DRM. Major PI resistance was associated with longer duration on second-line ART (aOR per 6-months, 1.11, 95% CI 1.04-1.19) and older age (aOR 1.03, 95% CI 1.01-1.05). Of 112 patients requiring third-line ART, 12 (11%) had a GSS of <2 for the algorithm-assigned third-line regimen. CONCLUSIONS One in three people failing second-line ART had significant PI DRMs. A subgroup of these individuals had extensive HIVDR, where the predicted activity of third-line ART was suboptimal, highlighting the need for continuous evaluation of outcomes on third-line regimens and close monitoring for emergent HIV-1 integrase-inhibitor resistance.
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Affiliation(s)
- Benjamin Chimukangara
- Department of Virology, University of KwaZulu-Natal/National Health Laboratory Service, Durban, South Africa; Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa; Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD, USA.
| | - Richard J Lessells
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa; KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Benn Sartorius
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Lilishia Gounder
- Department of Virology, University of KwaZulu-Natal/National Health Laboratory Service, Durban, South Africa
| | - Sontaga Manyana
- Department of Virology, University of KwaZulu-Natal/National Health Laboratory Service, Durban, South Africa
| | - Melendhran Pillay
- Department of Virology, University of KwaZulu-Natal/National Health Laboratory Service, Durban, South Africa
| | - Lavanya Singh
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Jennifer Giandhari
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Kerusha Govender
- Department of Virology, University of KwaZulu-Natal/National Health Laboratory Service, Durban, South Africa
| | - Reshmi Samuel
- Department of Virology, University of KwaZulu-Natal/National Health Laboratory Service, Durban, South Africa
| | - Nokukhanya Msomi
- Department of Virology, University of KwaZulu-Natal/National Health Laboratory Service, Durban, South Africa
| | - Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa; South African Medical Research Council (SAMRC), CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Tulio de Oliveira
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa; KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa; Department of Global Health, University of Washington, Seattle, United States
| | - Pravi Moodley
- Department of Virology, University of KwaZulu-Natal/National Health Laboratory Service, Durban, South Africa
| | - Raveen Parboosing
- Department of Virology, University of KwaZulu-Natal/National Health Laboratory Service, Durban, South Africa
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8
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Hackett S, Teasdale CA, Pals S, Muttiti A, Mogashoa M, Chang J, Zeh C, Ramos A, Rivadeneira ED, DeVos J, Sleeman K, Abrams EJ. Drug Resistance Mutations Among South African Children Living With HIV on WHO-recommended ART Regimens. Clin Infect Dis 2021; 73:e2217-e2225. [PMID: 32735012 DOI: 10.1093/cid/ciaa1068] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Children living with human immunodeficiency virus (HIV) (CLHIV) receiving antiretroviral therapy (ART) in resource-limited settings are susceptible to high rates of acquired HIV drug resistance (HIVDR), but few studies include children initiating age-appropriate World Health Organization (WHO)-recommended first-line regimens. We report data from a cohort of ART-naive South African children who initiated first-line ART. METHODS ART-eligible CLHIV aged 0-12 years were enrolled from 2012 to 2014 at 5 public South African facilities and were followed for up to 24 months. Enrolled CLHIV received standard-of-care WHO-recommended first-line ART. At the final study visit, a dried blood spot sample was obtained for viral load and genotypic resistance testing. RESULTS Among 72 successfully genotyped CLHIV, 49 (68.1%) received ABC/3TC/LPV/r, and 23 (31.9%) received ABC/3TC/EFV. All but 2 children on ABC/3TC/LPV/r were <3 years, and all CLHIV on ABC/3TC/EFV were ≥3 years. Overall, 80.6% (58/72) had at least one drug resistance mutation (DRM). DRMs to nonnucleoside reverse transcriptase inhibitors (NNRTIs) and nucleoside reverse transcriptase inhibitors (NRTIs) were found among 65% and 51% of all CLHIV, respectively, with no statistical difference by ART regimen. More CLHIV on ABC/3TC/EFV, 47.8% (11/23), were found to have 0 or only 1 effective antiretroviral drug remaining in their current regimen compared to 8.2% (4/49) on ABC/3TC/LPV/r. CONCLUSIONS High levels of NNRTI and NRTI DRMs among CLHIV receiving ABC/3TC/LPV/r suggests a lasting impact of failed mother-to-child transmission interventions on DRMs. However, drug susceptibility analysis reveals that CLHIV with detectable viremia on ABC/3TC/LPV/r are more likely to have maintained at least 2 effective agents on their current HIV regimen than those on ABC/3TC/EFV.
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Affiliation(s)
- Stephanie Hackett
- US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Chloe A Teasdale
- Department of Epidemiology and Biostatistics, CUNY Graduate School of Public Health & Health Policy, New York, USA.,ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Sherri Pals
- US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Anthony Muttiti
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Mary Mogashoa
- US Centers for Disease Control and Prevention, Pretoria, South Africa
| | - Joy Chang
- US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Clement Zeh
- US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Artur Ramos
- US Centers for Disease Control and Prevention, Maputo, Mozambique
| | | | - Joshua DeVos
- US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Katrina Sleeman
- US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Elaine J Abrams
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA.,Department of Pediatrics, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
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9
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Brice J, Sylla M, Desire N, Sayon S, Telly F, Bocar-Fofana D, Murphy R, Peytavin G, Diallo S, Nastouli E, Calvez V, Marcelin AG, Maiga AI, Lambert-Niclot S. Characterization of drug resistance and the defective HIV reservoir in virally suppressed vertically infected children in Mali. J Antimicrob Chemother 2021; 75:1272-1279. [PMID: 32073629 DOI: 10.1093/jac/dkaa002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 12/20/2019] [Accepted: 12/26/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In the perspective of ART-free HIV remission, vertically infected children treated with suppressive ART from early infancy represent an optimal population model to better understand the genetic complexity of the reservoir. OBJECTIVES To evaluate the proportion of defective viral population and the genotypic resistance patterns in cell-associated HIV DNA. METHODS In a cohort including 93 ART-treated vertically HIV-infected (VHIV) children in Mali with plasma HIV-1 RNA ≤50 copies/mL for at least 6 months, we studied total HIV DNA, percentage of defective genomes and resistance by reverse transcriptase and protease bulk sequencing from whole blood in dried blood spots. RESULTS Children had a median age of 9.9 years at the time of inclusion (IQR = 7.6-13.4) and 3.3 years (IQR = 2-7) at ART initiation; median ART duration was 5.5 years (IQR = 3.7-7.3). The median level of total HIV DNA was 470 copies/106 cells with one patient presenting undetectable HIV DNA (<66 copies/106 cells). We observed the presence of at least one stop codon in viruses from 34 patients (37%). The presence of stop codons was not correlated with the level of HIV DNA or duration of ART. We showed a high prevalence of HIV-1 resistance in DNA with 26% of children harbouring virus resistant to at least one NRTI and 40% to at least one NNRTI. CONCLUSIONS While these VHIV children were successfully treated for a long time, they showed high prevalence of resistance in HIV DNA and a moderate defective HIV reservoir.
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Affiliation(s)
- Josephine Brice
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (iPLESP), AP-HP, Pitié Salpêtrière Hospital, Department of Virology, F-75013 Paris, France
| | - Mariam Sylla
- Department of Pediatrics, University Hospital Gabriel Toure, Bamako, Mali
| | - Nathalie Desire
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (iPLESP), AP-HP, Pitié Salpêtrière Hospital, Department of Virology, F-75013 Paris, France
| | - Sophie Sayon
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (iPLESP), AP-HP, Pitié Salpêtrière Hospital, Department of Virology, F-75013 Paris, France
| | - Fatoumata Telly
- Unité d'Epidémiologie Moléculaire de la Résistance du VIH aux ARV, SEREFO, FMOS, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Djeneba Bocar-Fofana
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (iPLESP), AP-HP, Saint Antoine Hospital, Department of Virology, F-75012 Paris, France
| | - Robert Murphy
- Division of Infectious Diseases, Feinberg School of Medicine, Northwestern University, 645 N. Michigan Avenue, Suite 900, Chicago, IL 60611, USA
| | - Gilles Peytavin
- AP-HP, Department of Pharmacology, Bichat-Claude Bernard Hospital, F-75018 Paris, France
| | - Souleymane Diallo
- Unité d'Epidémiologie Moléculaire de la Résistance du VIH aux ARV, SEREFO, FMOS, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Eleni Nastouli
- Department of Population, Policy and Practice, University College London GOS Institute of Child Health, London, UK
| | - Vincent Calvez
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (iPLESP), AP-HP, Pitié Salpêtrière Hospital, Department of Virology, F-75013 Paris, France
| | - Anne-Geneviève Marcelin
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (iPLESP), AP-HP, Pitié Salpêtrière Hospital, Department of Virology, F-75013 Paris, France
| | - Almoustapha Issiaka Maiga
- Unité d'Epidémiologie Moléculaire de la Résistance du VIH aux ARV, SEREFO, FMOS, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali.,Clinical and Microbiology Laboratory, University Hospital Gabriel Toure, Bamako, Mali
| | - Sidonie Lambert-Niclot
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (iPLESP), AP-HP, Saint Antoine Hospital, Department of Virology, F-75012 Paris, France
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10
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Musana H, Ssensamba JT, Nakafeero M, Mugerwa H, Kiweewa FM, Serwadda D, Ssali F. Predictors of failure on second-line antiretroviral therapy with protease inhibitor mutations in Uganda. AIDS Res Ther 2021; 18:17. [PMID: 33882938 PMCID: PMC8059285 DOI: 10.1186/s12981-021-00338-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 04/08/2021] [Indexed: 11/10/2022] Open
Abstract
Introduction Failure on second-line antiretroviral therapy (ART) with protease inhibitor (PI) mutations (VF-M) is on the rise. However, there is a paucity of information on the factors associated with this observation in low-income countries. Knowledge of underlying factors is critical if we are to minimize the number of PLHIV switched to costly third-line ART. Our study investigated the factors associated with VF-M. Methods We conducted a matched case–control analysis of patients' records kept at the Joint Clinical Research Center, starting from January 2008 to May 2018. We matched records of patients who failed the second-line ART with major PI mutations (cases) with records of patients who were virologically suppressed (controls) by a ratio of 1:3. Data analysis was conducted using STATA Version 14. Categorical variables were compared with the outcomes failure on second-line ART with PI mutations using the Chi-square and Fisher's exact tests where appropriate. Conditional logistic regression for paired data was used to assess the association between the outcome and exposure variables, employing the backward model building procedure. Results Of the 340 reviewed patients' records, 53% were women, and 6.2% had previous tuberculosis treatment. Males (aOR = 2.58, [CI 1.42–4.69]), and patients concurrently on tuberculosis treatment while on second-line ART (aOR = 5.65, [CI 1.76–18.09]) had higher odds of VF-M. ART initiation between 2001 and 2015 had lower odds of VF-M relative to initiation before the year 2001. Conclusion Males and patients concomitantly on tuberculosis treatment while on second-line ART are at a higher risk of VF-M. HIV/AIDS response programs should give special attention to this group of people if we are to minimize the need for expensive third-line ART. We recommend more extensive, explorative studies to ascertain underlying factors.
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11
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Subronto YW, Kusmayanti NA, Abdalla AS, Sattwika PD. Nevirapine and tuberculosis predict first-line treatment failure in HIV patients in Indonesia: Case-control study. Ann Med Surg (Lond) 2020; 60:56-60. [PMID: 33133585 PMCID: PMC7584999 DOI: 10.1016/j.amsu.2020.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/24/2020] [Accepted: 10/07/2020] [Indexed: 11/02/2022] Open
Abstract
Introduction Indonesia antiretroviral therapy guideline suggests the use of Non-Nucleoside Reverse Transcriptase Inhibitor (NNRTI)-based regiments as first line of HIV treatment and Protease Inhibitor to replace NNRTI when treatment failure occurred. This case-control study was aimed to study factors predicting first-line ART treatment failure among HIV positive patients aged >15 years, non-pregnant, and registered in our institution, Indonesia. Methods Diagnosis of HIV treatment failure was made according to the standard WHO criteria. Demographic and outcome variables were recorded. The association between variables were analyzed by Chi-square test with odds ratios (OR) and 95% confidence intervals (95% CI), followed by multivariate analysis using logistic regression test. Results Twenty-six index cases and 26 age- and sex-matched control cases were included in the study with a mean age of 32.27 ± 8.7 years and 32.88 ± 8.15 years, respectively. Median time for switching to second-line (Lopinavir/ritonavir, LPV/r) was 46.32 ± 30.21 months. Patients presented with tuberculosis and treated by nevirapine as the first-line treatment were 26.6-folds (95% CI: 2.41-293.81, p = 0.007) and 6.7-folds (95% CI: 1.56-28.45, p = 0.011) higher risk for treatment failure, respectively. Conclusions The presence of tuberculosis and the use of nevirapine in first-line treatment were strong predictors for first-line ARV treatment failure, suggesting for closer clinical monitoring for patients with those conditions. A further and larger prospective cohort study is needed to confirm the findings in this study.
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Affiliation(s)
- Yanri Wijayanti Subronto
- Division of Tropical Medicine and Infectious Diseases, Department of Internal Medicine, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada/Dr. Sardjito General Hospital, Yogyakarta, 55281, Indonesia.,Center for Tropical Medicine, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, 55281, Indonesia
| | - Nur Aini Kusmayanti
- Center for Tropical Medicine, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, 55281, Indonesia
| | - Albarisa Shobry Abdalla
- Department of Internal Medicine, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, 55281, Indonesia
| | - Prenaly Dwisthi Sattwika
- Department of Internal Medicine, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, 55281, Indonesia
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12
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Obasa AE, Mikasi SG, Brado D, Cloete R, Singh K, Neogi U, Jacobs GB. Drug Resistance Mutations Against Protease, Reverse Transcriptase and Integrase Inhibitors in People Living With HIV-1 Receiving Boosted Protease Inhibitors in South Africa. Front Microbiol 2020; 11:438. [PMID: 32265875 PMCID: PMC7099763 DOI: 10.3389/fmicb.2020.00438] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 03/02/2020] [Indexed: 12/17/2022] Open
Abstract
The South African national combination antiretroviral therapy (cART) roll-out program started in 2006, with over 4.4 million people accessing treatment since it was first introduced. HIV-1 drug resistance can hamper the success of cART. This study determined the patterns of HIV-1 drug-resistance associated mutations (RAMs) in People Living with HIV-1 (PLHIV-1). Receiving first (for children below 3 years of age) and second-line (for adults) cART regimens in South Africa. During 2017 and 2018, 110 patients plasma samples were selected, 96 samples including those of 17 children and infants were successfully analyzed. All patients were receiving a boosted protease inhibitor (bPI) as part of their cART regimen. The viral sequences were analyzed for RAMs through genotypic resistance testing. We performed genotypic resistance testing (GRT) for Protease inhibitors (PIs), Reverse transcriptase inhibitors (RTIs) and Integrase strand transfer inhibitors (InSTIs). Viral sequences were subtyped using REGAv3 and COMET. Based on the PR/RT sequences, HIV-1 subtypes were classified as 95 (99%) HIV-1 subtype C (HIV-1C) while one sample as 02_AG. Integrase sequencing was successful for 89 sequences, and all the sequences were classified as HIV-1C (99%, 88/89) except one sequence classified CRF02_AG, as observed in PR/RT. Of the 96 PR/RT sequences analyzed, M184V/I (52/96; 54%) had the most frequent RAM nucleoside reverse transcriptase inhibitor (NRTI). The most frequent non-nucleoside reverse transcriptase inhibitor (NNRTI) RAM was K103N/S (40/96, 42%). Protease inhibitor (PI) RAMs M46I and V82A were present in 12 (13%) of the sequences analyzed. Among the InSTI major RAM two (2.2%) sequences have Y143R and T97A mutations while one sample had T66I. The accessory RAM E157Q was identified in two (2.2%). The data indicates that the majority of the patients failed on bPIs didn't have any mutation; therefore adherence could be major issue in these groups of individuals. We propose continued viral load monitoring for better management of infected PLHIV.
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Affiliation(s)
- Adetayo Emmanuel Obasa
- Division of Medical Virology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institute, Stockholm University, Stockholm, Sweden
| | - Sello Given Mikasi
- Division of Medical Virology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Dominik Brado
- Division of Virology, Institute for Virology and Immunobiology, Faculty of Medicine, University of Würzburg, Würzburg, Germany
| | - Ruben Cloete
- South African Medical Research Council Bioinformatics Unit, South African National Bioinformatics Institute, University of the Western Cape, Bellville, South Africa
| | - Kamlendra Singh
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institute, Stockholm University, Stockholm, Sweden
- Department of Molecular Microbiology and Immunology, University of Missouri, Columbia, MO, United States
- Christopher S. Bond Life Sciences Center, University of Missouri, Columbia, MO, United States
| | - Ujjwal Neogi
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institute, Stockholm University, Stockholm, Sweden
| | - Graeme Brendon Jacobs
- Division of Medical Virology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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13
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Anderson K, Muloiwa R, Davies MA. Long-term outcomes in perinatally HIV-infected adolescents and young adults on antiretroviral therapy: a review of South African and global literature. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2020; 19:1-12. [PMID: 32122278 DOI: 10.2989/16085906.2019.1676802] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Paediatric antiretroviral programmes have been implemented globally for more than a decade, yet information on long-term treatment outcomes in perinatally HIV-infected adolescents is limited. Published literature on long-term treatment outcomes was reviewed, including virologic, immunologic and growth outcomes, as well as drug resistance and factors associated with drug resistance. Outcomes were compared between high-income countries and low- and middle-income countries (LMIC), with additional focus on South Africa, the country with the biggest HIV epidemic in the world and the largest treatment programme. Treatment outcomes varied but viral suppression results globally were generally concerning. No studies from LMIC have reported on outcomes after >10 years follow-up, demonstrating that further studies are needed.
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Affiliation(s)
- Kim Anderson
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Rudzani Muloiwa
- Department of Paediatrics, Groote Schuur Hospital, Cape Town, South Africa
| | - Mary-Ann Davies
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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14
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Ekong E, Ndembi N, Okonkwo P, Dakum P, Idoko J, Banigbe B, Okuma J, Agaba P, Blattner W, Adebamowo C, Charurat M. Epidemiologic and viral predictors of antiretroviral drug resistance among persons living with HIV in a large treatment program in Nigeria. AIDS Res Ther 2020; 17:7. [PMID: 32066473 PMCID: PMC7027291 DOI: 10.1186/s12981-020-0261-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 01/23/2020] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Expanded access to combination antiretroviral therapy (cART) throughout sub-Saharan Africa over the last decade has remarkably improved the prognosis of persons living with HIV (PLWH). However, some PLWH experience virologic rebound after a period of viral suppression, usually followed by selection of drug resistant virus. Determining factors associated with drug resistance can inform patient management and healthcare policies, particularly in resource-limited settings where drug resistance testing is not routine. METHODS A case-control study was conducted using data captured from an electronic medical record in a large treatment program in Nigeria. Cases PLWH receiving cART who developed acquired drug resistance (ADR) and controls were those without ADR between 2004 and 2011. Each case was matched to up to 2 controls by sex, age, and education. Logistic regression was used estimate odds ratios (ORs) and 95% confidence intervals (CIs) for factors associated with ADR. RESULTS We evaluated 159 cases with ADR and 299 controls without ADR. In a multivariate model, factors associated with ADR included older age (OR = 2.35 [age 30-40 years 95% CI 1.29, 4.27], age 41 + years OR = 2.31 [95% CI 1.11, 4.84], compared to age 17-30), higher education level (secondary OR 2.14 [95% CI 1.1.11-4.13]), compared to primary and tertiary), non-adherence to care (OR = 2.48 [95% CI 1.50-4.00]), longer treatment duration (OR = 1.80 [95% CI 1.37-2.35]), lower CD4 count((OR = 0.95 [95% CI 0.95-0.97]) and higher viral load (OR = 1.97 [95% CI 1.44-2.54]). CONCLUSIONS Understanding these predictors may guide programs in developing interventions to identify patients at risk of developing ADR and implementing prevention strategies.
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Affiliation(s)
- Ernest Ekong
- Department of Prevention, Care and Treatment, Institute of Human Virology-Nigeria (IHVN), Federal Capital Territory, Plot 252, Herbert Macaulay Way, Central Business District, Abuja, Nigeria.
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Nicaise Ndembi
- Department of Prevention, Care and Treatment, Institute of Human Virology-Nigeria (IHVN), Federal Capital Territory, Plot 252, Herbert Macaulay Way, Central Business District, Abuja, Nigeria.
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA.
| | | | - Patrick Dakum
- Department of Prevention, Care and Treatment, Institute of Human Virology-Nigeria (IHVN), Federal Capital Territory, Plot 252, Herbert Macaulay Way, Central Business District, Abuja, Nigeria
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - John Idoko
- Jos University Teaching Hospital, Jos, Nigeria
| | | | - James Okuma
- Department of Prevention, Care and Treatment, Institute of Human Virology-Nigeria (IHVN), Federal Capital Territory, Plot 252, Herbert Macaulay Way, Central Business District, Abuja, Nigeria
| | | | - William Blattner
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Clement Adebamowo
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Manhattan Charurat
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
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15
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Wilson JW, Nilsen DM, Marks SM. Multidrug-Resistant Tuberculosis in Patients with Human Immunodeficiency Virus. Management Considerations within High-resourced Settings. Ann Am Thorac Soc 2020; 17:16-23. [PMID: 31365831 PMCID: PMC6938532 DOI: 10.1513/annalsats.201902-185cme] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 07/30/2019] [Indexed: 12/15/2022] Open
Abstract
The management of multidrug-resistant tuberculosis (MDR TB) is notably complex among patients with human immunodeficiency virus (HIV). TB treatment recommendations typically include very little information specific to HIV and MDR TB, which often is derived from clinical trials conducted in low-resource settings. Mortality rates among patients with HIV and MDR TB remain high. We reviewed the published literature and recommendations to synthesize possible patient management approaches demonstrated to improve treatment outcomes in high-resourced countries for patients with MDR TB and HIV. Approaches to diagnostic testing, impact and timing of antiretroviral therapy on mortality, anti-MDR TB and antiretroviral drug interactions, and the potential role for short-course MDR TB therapy are examined. The combination of antiretroviral therapy with expanded TB drug therapy, along with the management of immune reconstitution inflammatory syndrome, other potential HIV-associated opportunistic diseases, and drug toxicities, necessitate an integrated multidisciplinary patient care approach using public health case management and provider expertise in drug-resistant TB and HIV management.
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Affiliation(s)
- John W. Wilson
- Division of Infectious Diseases, Mayo Clinic, 200 First Street, SW, Rochester MN 55905, Tel (507) 255-0596, Fax (507255-7767
| | - Diana M. Nilsen
- Bureau of TB Control, New York City Department of Health & Mental Hygiene, Gotham Center, CN#72B, 42-09 28th Street, Queens, NY 11101-4132
| | - Suzanne M. Marks
- Data Management, Statistics, and Evaluation Branch, Division of Tuberculosis Elimination, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Mailstop MS12-4, 1600 Clifton Road, NE, Atlanta, GA 30333
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16
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Indriati DW, Kotaki T, Khairunisa SQ, Witaningrum AM, Matondang MQY, Ueda S, Nasronudin, Purnama A, Kurniawan D, Kameoka M. Appearance of Drug Resistance Mutations Among the Dominant HIV-1 Subtype, CRF01_AE in Maumere, Indonesia. Curr HIV Res 2019; 16:158-166. [PMID: 29732988 DOI: 10.2174/1570162x16666180502114344] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 04/17/2018] [Accepted: 04/24/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND AND OBJECTIVES Human Immunodeficiency Virus (HIV) is still a major health issue in Indonesia. In recent years, the appearance of drug resistance-associated mutations has reduced the effectiveness of Antiretroviral Therapy (ART). We conducted genotypic studies, including the detection of drug resistance-associated mutations (from first-line regimen drugs), on HIV-1 genes derived from infected individuals in Maumere, West Nusa Tenggara. Maumere, a transit city in West Nusa Tenggara, which has a high HIV-1 transmission rate. METHOD We collected 60 peripheral blood samples from 53 ART-experienced and 7 ART-naive individuals at TC Hillers Hospital, Maumere between 2014 and 2015. The amplification and a sequencing analysis of pol genes encoding protease (the PR gene) and reverse transcriptase (the RT gene) as well as the viral env and gag genes were performed. HIV-1 subtyping and the detection of drug resistance-associated mutations were then conducted. RESULTS Among 60 samples, 46 PR, 31 RT, 30 env, and 20 gag genes were successfully sequenced. The dominant HIV-1 subtype circulating in Maumere was CRF01_AE. Subtype B and recombinant viruses containing gene fragments of CRF01_AE, subtypes A, B, C, and/or G were also identified as minor populations. The major drug resistance-associated mutations, M184V, K103N, Y188L, and M230I, were found in the RT genes. However, no major drug resistance-associated mutations were detected in the PR genes. CONCLUSION CRF01_AE was the major HIV-1 subtype prevalent in Maumere. The appearance of drug resistance-associated mutations found in the present study supports the necessity of monitoring the effectiveness of ART in Maumere.
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Affiliation(s)
- Dwi Wahyu Indriati
- Indonesia-Japan Collaborative Research Center for Emerging and Re-emerging Infectious Disease, Institute of Tropical Disease, Universitas Airlangga, Surabaya, Indonesia.,Department of Health, Faculty of Vocational Studies, Universitas Airlangga, Surabaya, Indonesia
| | - Tomohiro Kotaki
- Indonesia-Japan Collaborative Research Center for Emerging and Re-emerging Infectious Disease, Institute of Tropical Disease, Universitas Airlangga, Surabaya, Indonesia.,Department of International Health, Kobe University Graduate School of Health Sciences, Hyogo, Japan
| | - Siti Qamariyah Khairunisa
- Indonesia-Japan Collaborative Research Center for Emerging and Re-emerging Infectious Disease, Institute of Tropical Disease, Universitas Airlangga, Surabaya, Indonesia
| | - Adiana Mutamsari Witaningrum
- Indonesia-Japan Collaborative Research Center for Emerging and Re-emerging Infectious Disease, Institute of Tropical Disease, Universitas Airlangga, Surabaya, Indonesia
| | - Muhammad Qushai Yunifiar Matondang
- Indonesia-Japan Collaborative Research Center for Emerging and Re-emerging Infectious Disease, Institute of Tropical Disease, Universitas Airlangga, Surabaya, Indonesia
| | - Shuhei Ueda
- Indonesia-Japan Collaborative Research Center for Emerging and Re-emerging Infectious Disease, Institute of Tropical Disease, Universitas Airlangga, Surabaya, Indonesia.,Department of International Health, Kobe University Graduate School of Health Sciences, Hyogo, Japan
| | - Nasronudin
- Indonesia-Japan Collaborative Research Center for Emerging and Re-emerging Infectious Disease, Institute of Tropical Disease, Universitas Airlangga, Surabaya, Indonesia.,Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | | | | | - Masanori Kameoka
- Department of International Health, Kobe University Graduate School of Health Sciences, Hyogo, Japan.,Center for Infectious Diseases, Kobe University, Graduate School of Medicine, Hyogo, Japan
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Abstract
PURPOSE OF REVIEW To provide an update on the patterns of HIV drug resistance in children, including pretreatment drug resistance (PDR) and acquired drug resistance (ADR), focusing on children in low- and middle-income countries (LMICs) for whom empiric first-line (FL) and second-line (SL) antiretroviral regimens are usually recommended. RECENT FINDINGS High levels of PDR, particularly to non-nucleoside reverse transcriptase inhibitors (NNRTIs), and poor treatment outcomes on NNRTI-based FL antiretroviral therapy (ART) have been widely reported among infants and young children. There is a paucity of recent data on the use of protease inhibitor (PI)-based FL and SL regimens in children, but studies have reported poor tolerability, adherence problems and the development of PI resistance. Limited access to virological monitoring and HIV drug resistance testing contributes to delays in identifying treatment failure due to ADR and delays in switching to SL regimens in children. Implementation of FL ART regimens that have a higher barrier to developing resistance and are safe and well tolerated is required in order to attain global treatment targets. Although PI-based regimens may be effective as FL or SL treatment in children, lack of appropriate formulations leading to poor tolerability, drug-drug interactions, and cost considerations have negatively impacted their use among children in LMICs. There is hope that dolutegravir-based regimens recommended for children by the World Health Organization will be widely implemented once child-friendly formulations are available, and dosing and safety studies currently underway are completed, and that this will significantly improve treatment outcomes.
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Affiliation(s)
- J Nuttall
- Paediatric Infectious Diseases Unit, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Rondebosch, Cape Town, 7700, South Africa.
| | - V Pillay
- Paediatric Infectious Diseases Unit, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Rondebosch, Cape Town, 7700, South Africa
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The Treatment Cascade in Children With Unsuppressed Viral Load-A Reality Check in Rural Lesotho, Southern Africa. J Acquir Immune Defic Syndr 2019; 77:250-256. [PMID: 29189416 DOI: 10.1097/qai.0000000000001597] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND As per the guidelines of the World Health Organization, HIV-infected children who do not achieve viral suppression while under antiretroviral therapy (ART) receive enhanced adherence counseling (EAC) with follow-up viral load (VL). A persisting unsuppressed VL after EAC triggers switch to a second-line regimen. We describe the care cascade of children with unsuppressed VL while taking ART. METHODS Children, aged <16 years, on first-line ART for ≥6 months with unsuppressed VL (≥80 copies/mL) at first measurement were enrolled. As per guidelines, children/caregivers received EAC and a follow-up VL after 3 months, whereas those with persisting viremia despite good adherence were eligible for switching to second-line. Eighteen months after the first unsuppressed VL, outcomes were assessed. RESULTS Of 191 children receiving a first-time VL in May/June 2014, 53 (28%) had unsuppressed viremia. The care cascade of these 53 children was as follows: 49 (92%) received EAC and a follow-up VL in October 2014 (1 died, 3 lost to follow-up). 36/49 (73%) stayed unsuppressed, but only 24 were switched to second-line. At 18-months follow-up, 10 (19%) were retained in care with suppressed VL, 26 were retained with ongoing viremia (49%), 2 (4%) had died, and 15 (28%) had no VL documentation. CONCLUSIONS Only 1 of 5 children with unsuppressed initial VL under ART was retained in care and virally suppressed at 18 months of follow-up. ART programs must increase the focus onto the extremely vulnerable care cascade in children with unsuppressed VL.
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Chimbetete C, Katzenstein D, Shamu T, Spoerri A, Estill J, Egger M, Keiser O. HIV-1 Drug Resistance and Third-Line Therapy Outcomes in Patients Failing Second-Line Therapy in Zimbabwe. Open Forum Infect Dis 2018; 5:ofy005. [PMID: 29435471 PMCID: PMC5801603 DOI: 10.1093/ofid/ofy005] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 01/23/2018] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES To analyze the patterns and risk factors of HIV drug resistance mutations among patients failing second-line treatment and to describe early treatment responses to recommended third-line antiretroviral therapy (ART) in a national referral HIV clinic in Zimbabwe. METHODS Patients on boosted protease inhibitor (PI) regimens for more than 6 months with treatment failure confirmed by 2 viral load (VL) tests >1000 copies/mL were genotyped, and susceptibility to available antiretroviral drugs was estimated by the Stanford HIVdb program. Risk factors for major PI resistance were assessed by logistic regression. Third-line treatment was provided as Darunavir/r, Raltegravir, or Dolutegravir and Zidovudine, Abacavir Lamivudine, or Tenofovir. RESULTS Genotypes were performed on 86 patients who had good adherence to treatment. The median duration of first- and second-line ART was 3.8 years (interquartile range [IQR], 2.3-5.1) and 2.6 years (IQR, 1.6-4.9), respectively. The median HIV viral load and CD4 cell count were 65 210 copies/mL (IQR, 8728-208 920 copies/mL) and 201 cells/mm3 (IQR, 49-333 cells/mm3). Major PI resistance-associated mutations (RAMs) were demonstrated in 44 (51%) non-nucleoside reverse transcriptase inhibitor RAMs in 72 patients (83%) and nucleoside reverse transcriptase inhibitors RAMs in 62 patients (72%). PI resistance was associated with age >24 years (P = .003) and CD4 cell count <200 cells/mm3 (P = .007). In multivariable analysis, only age >24 years was significantly associated (adjusted odds ratio, 4.75; 95% confidence interval, 1.69-13.38; P = .003) with major PI mutations. Third-line DRV/r- and InSTI-based therapy achieved virologic suppression in 29/36 patients (81%) after 6 months. CONCLUSIONS The prevelance of PI mutations was high. Adolescents and young adults had a lower risk of acquiring major PI resistance mutations, possibly due to poor adherence to ART. Third-line treatment with a regimen of Darunavir/r, Raltegravir/Dolutegravir, and optimized nucleoside reverse transcriptase inhibitors was effective.
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Affiliation(s)
- Cleophas Chimbetete
- Institute of Global Health, University of Geneva, Geneva, Switzerl
- Newlands Clinic, Harare, Zimbabwe
| | | | | | - Adrian Spoerri
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerl
| | - Janne Estill
- Institute of Global Health, University of Geneva, Geneva, Switzerl
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerl
- Institute of Mathematical Statistics and Actuarial Science, University of Bern, Bern, Switzerl
| | - Matthias Egger
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerl
| | - Olivia Keiser
- Institute of Global Health, University of Geneva, Geneva, Switzerl
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerl
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Siberry GK, Amzel A, Ramos A, Rivadeneira ED. Impact of Human Immunodeficiency Virus Drug Resistance on Treatment of Human Immunodeficiency Virus Infection in Children in Low- and Middle-Income Countries. J Infect Dis 2017; 216:S838-S842. [PMID: 29045697 DOI: 10.1093/infdis/jix407] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Children living with human immunodeficiency virus (HIV) in low- and middle-income countries (LMICs) experience higher rates of virologic failure than adults. Human immunodeficiency virus drug resistance (HIVDR) plays a major role in pediatric HIV treatment failure because nonsuppressive maternal antiretroviral therapy (ART) during pregnancy and breastfeeding as well as infant antiretroviral prophylaxis lead to high rates of pretreatment drug resistance to regimens most commonly used in children living with HIV. Lack of availability of durable, potent drugs in child-friendly formulations in LMICs and adherence difficulties contribute to acquired drug resistance during treatment. Optimizing drugs available for treating children living with HIV in LMICs, providing robust adherence support, and ensuring virologic monitoring for children receiving ART are essential for reducing HIVDR and improving treatment outcomes for children living with HIV in LMICs.
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Affiliation(s)
- George K Siberry
- Office of the US Global AIDS Coordinator, US Department of State
| | - Anouk Amzel
- Prevention Care and Treatment Division, Office of HIV/AIDS, Global Health Bureau, US Agency for International Development
| | | | - Emilia D Rivadeneira
- Maternal and Child Health Branch, Division of Global HIV/TB, Center for Global Health, Centers for Disease Control and Prevention
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Viral load monitoring and antiretroviral treatment outcomes in a pediatric HIV cohort in Ghana. BMC Infect Dis 2016; 16:58. [PMID: 26843068 PMCID: PMC4738803 DOI: 10.1186/s12879-016-1402-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 01/28/2016] [Indexed: 11/21/2022] Open
Abstract
Background HIV-infected children in sub-Saharan Africa may be at a high risk of staying on a failing first-line regimen and developing drug-resistance HIV variants due to lack of routine viral load monitoring. We investigated whether cumulative viral load, measured as viremia copy-years (VCY) could predict morbidity in a setting where viral load is not routinely monitored. Methods This was a single-center prospective observational longitudinal study of HIV-infected children initiating antiretroviral therapy (ART) at the Pediatric HIV/AIDS Care program at Korle-Bu Teaching Hospital in Accra, Ghana. The main outcome was morbidity measured as frequency of hospitalizations, opportunistic infections, and outpatient sick visits. The main explanatory variable was viral load measured as VCY. Results The study included 140 children who initiated ART between September 2009 and May 2013 and had at least 2 viral load measurements. There were 184 hospitalizations, with pneumonia being the most common cause (22.8 %). A total of 102 opportunistic infections was documented, with tuberculosis being the most common opportunistic infection (68 %). A total of 823 outpatient sick visits was documented, with upper respiratory infections (14.2 %) being the most common cause. Forty-four percent of our study participants had >4 log10 VCY. Children in this sub-cohort had a higher frequency of sick visits compared with those with <4 log10 VCY (p = 0.03). Only 6.5 % of children with >4 log10 VCY had been identified as treatment failure using WHO clinical and immunological treatment failure criteria. Conclusions High level of cumulative viral load may translate to virological failure and subsequent increased all-cause morbidity. Our finding of potential utility of VCY in pediatrics warrants further investigations. VCY may be a good alternate to routine viral load measurement as its determination may be less frequent and could be personalized to save cost.
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Sequencing paediatric antiretroviral therapy in the context of a public health approach. J Int AIDS Soc 2015; 18:20265. [PMID: 26639116 PMCID: PMC4670836 DOI: 10.7448/ias.18.7.20265] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 07/03/2015] [Accepted: 09/02/2015] [Indexed: 01/20/2023] Open
Abstract
Introduction As access to prevention of mother-to-child transmission (PMTCT) efforts has increased, the total number of children being born with HIV has significantly decreased. However, those children who do become infected after PMTCT failure are at particular risk of HIV drug resistance, selected by exposure to maternal or paediatric antiretroviral drugs used before, during or after birth. As a consequence, the response to antiretroviral therapy (ART) in these children may be compromised, particularly when non-nucleoside reverse transcriptase inhibitors (NNRTIs) are used as part of the first-line regimen. We review evidence guiding choices of first- and second-line ART. Discussion Children generally respond relatively well to ART. Clinical trials show the superiority of protease inhibitor (PI)- over NNRTI-based treatment in young children, but observational reports of NNRTI-containing regimens are usually favourable as well. This is reassuring as national guidelines often still recommend the use of NNRTI-based treatment for PMTCT-unexposed young children, due to the higher costs of PIs. After failure of NNRTI-based, first-line treatment, the rate of acquired drug resistance is high, but HIV may well be suppressed by PIs in second-line ART. By contrast, there are currently no adequate alternatives in resource-limited settings (RLS) for children failing either first- or second-line, PI-containing regimens. Conclusions Affordable salvage treatment options for children in RLS are urgently needed.
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