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Durability of switched therapy after failure of WHO-recommended antiretroviral therapy regimens in a resource-limited setting. AIDS 2022; 36:1791-1800. [PMID: 35876663 DOI: 10.1097/qad.0000000000003340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The study investigated the durability of switched therapy and factors associated with the viral rebound among patients on second-line antiretroviral therapy (ART) in Uganda. DESIGN A retrospective dynamic cohort of adults initiated on second-line ART after virological failure to first-line ART. METHODS Patients on second-line treatment for at least 6 months between 2007 and 2017 were included. Patients were followed, until they experienced a viral rebound (viral load ≥200 copies/ml). Cumulative probability of viral rebounds and factors associated with viral rebound were determined using Kaplan-Meier methods and Cox proportional hazard models. RESULTS One thousand, one hundred and one participants were enrolled of which 64% were women, the median age was 37 years [interquartile range (IQR) 31-43]. The preswitch median CD4 + cell count and viral load were 128 cells/μl (IQR 58-244) and 45 978 copies/ml (IQR 13 827-139 583), respectively. During the 4190.37 person-years, the incidence rate of viral rebound was 83.29 [95% confidence interval (CI) 74.99-92.49] per 1000 person-years. The probability of viral rebound at 5 and 10 years was 0.29 (95% CI 0.26-0.32) and 0.62 (95% CI 0.55-0.69), respectively. The median rebound-free survival was 8.7 years. Young adults (18-24 years) [adjusted hazard ratio (aHR) 2.49, 95% CI 1.32-4.67], preswitch viral load at least 100 000 copies/ml (aHR 1.53, 95% CI 1.22-1.92), and atazanavir/ritonavir (ATV/r)-based second-line (aHR 1.73, 95% CI 1.29-2.32) were associated with an increased risk of viral rebound. CONCLUSION Switched therapies are durable for 8 years after failure of recommended regimens. A high preswitch viral load, ATV/r-based regimens, and young adulthood are risk factors for viral rebound, which underscores the need for more durable regimens and differentiated care services.
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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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Reynolds Z, McCluskey SM, Moosa MYS, Gilbert RF, Pillay S, Aturinda I, Ard KL, Muyindike W, Musinguzi N, Masette G, Moodley P, Brijkumar J, Rautenberg T, George G, Johnson BA, Gandhi RT, Sunpath H, Marconi VC, Bwana MB, Siedner MJ. Who's slipping through the cracks? A comprehensive individual, clinical and health system characterization of people with virological failure on first-line HIV treatment in Uganda and South Africa. HIV Med 2021; 23:474-484. [PMID: 34755438 PMCID: PMC9010349 DOI: 10.1111/hiv.13203] [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: 04/23/2021] [Accepted: 10/18/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES HIV virological failure remains a major threat to programme success in sub-Saharan Africa. While HIV drug resistance (HIVDR) and inadequate adherence are the main drivers of virological failure, the individual, clinical and health system characteristics that lead to poor outcomes are not well understood. The objective of this paper is to identify those characteristics among people failing first-line antiretroviral therapy (ART). METHODS We enrolled a cohort of adults in HIV care experiencing virological failure on first-line ART at five sites and used standard statistical methods to characterize them with a focus on three domains: individual/demographic, clinical, and health system, and compared each by country of enrolment. RESULTS Of 840 participants, 51% were women, the median duration on ART was 3.2 years [interquartile range (IQR) 1.1, 6.4 years] and the median CD4 cell count prior to failure was 281 cells/µL (IQR 121, 457 cells/µL). More than half of participants [53%; 95% confidence interval (CI) 49-56%] stated that they had > 90% adherence and 75% (95% CI 72-77%) took their ART on time all or most of the time. Conversely, the vast majority (90%; 95% CI 86-92%) with a completed genotypic drug resistance test had any HIV drug resistance. This population had high health system use, reporting a median of 3 (IQR 2.6) health care visits and a median of 1 (IQR 1.1) hospitalization in the preceding 6 months. CONCLUSIONS Patients failing first-line ART in sub-Saharan Africa generally report high rates of adherence to ART, have extremely high rates of HIV drug resistance and utilize significant health care resources. Health systems interventions to promptly detect and manage treatment failure will be a prerequisite to establishing control of the HIV epidemic.
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Affiliation(s)
| | - Suzanne M McCluskey
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | | | | | - Isaac Aturinda
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Kevin L Ard
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | | | - Godfrey Masette
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Pravi Moodley
- University of KwaZulu-Natal, Durban, South Africa.,National Health Laboratory Service, KwaZulu-Natal, Durban, South Africa
| | | | | | - Gavin George
- University of KwaZulu-Natal, Durban, South Africa
| | - Brent A Johnson
- Department of Biostatistics and Computation Biology, University of Rochester, Rochester, NY, USA
| | - Rajesh T Gandhi
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | - Vincent C Marconi
- Emory University School of Medicine, Atlanta, GA, USA.,Department of Global Health, Emory University, Atlanta, GA, USA.,Emory Vaccine Center, Atlanta, GA, USA
| | | | - Mark J Siedner
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,University of KwaZulu-Natal, Durban, South Africa.,Mbarara University of Science and Technology, Mbarara, Uganda.,Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa
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Paredes R, Véliz F, Lucchetti A. Comparison of the Virological Response According to the Antiretroviral Regimens in Peruvian HIV Patients Who Presented the M184V Mutation in Two National Hospitals During the Years 2008 to 2019. AIDS Res Hum Retroviruses 2021; 37:196-203. [PMID: 33076683 DOI: 10.1089/aid.2020.0115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction: In patients with HIV in antiretroviral treatment (ART) and virological failure to the first-line regimen, establishing a therapeutic regimen after having identified the M184V mutation, which confers ART resistance, represents a dilemma. Objective: To compare the virological response of the therapeutic regimens prescribed to patients with HIV who presented the M184V mutation in two national hospitals in Lima, Peru, during the years 2008 to 2019, and to determine the risk factors associated with poor virological response. Methods: A retrospective cohort study was developed based on the information of the HIV program participants with the M184V mutation. Results: A total of 175 participants were eligible for the study. The male sex predominated (75.4%), the current median age was 41 years [interquartile range (IQR) 35.84-47.47], and the time on ART was 89 months (IQR 57.7-124.53). The median initial viral load (VL) was 4.5 log10 copies/mL (IQR 3.97-5.09) and the time between genotyping and the change of therapy was 2 months (IQR 0-3.56). The most used antiretroviral regimen was protease inhibitor plus two nucleoside reverse transcriptase inhibitors (55.4%). With the protease inhibitor plus integrase inhibitor (PI + INI) ART, 69% less risk of poor virological response was obtained [p = .019 (confidence interval 95% 0.117-0.825)]. Conclusions: In patients with HIV and the M184V mutation, the PI + INI ART has shown a greater decrease in control VL and, thus, a good virological response. The risk factors associated with a poor virological response were the delay between genotyping and change of therapy, high levels of initial VL, and poor adherence among the participants.
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Affiliation(s)
- Raisa Paredes
- Escuela de Medicina, Facultad de Ciencias de la Salud, Universidad Peruana de Ciencias Aplicadas, Lima, Peru
| | - Fritner Véliz
- Escuela de Medicina, Facultad de Ciencias de la Salud, Universidad Peruana de Ciencias Aplicadas, Lima, Peru
| | - Aldo Lucchetti
- Escuela de Medicina, Facultad de Ciencias de la Salud, Universidad Peruana de Ciencias Aplicadas, Lima, Peru
- Servicio de Infectología, Hospital Nacional Arzobispo Loayza, Lima, Peru
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Immunological Treatment Failure Among Adult Patients Receiving Highly Active Antiretroviral Therapy in East Africa: A Systematic Review and Meta-Analysis. Curr Ther Res Clin Exp 2021; 94:100621. [PMID: 34306262 PMCID: PMC8296083 DOI: 10.1016/j.curtheres.2020.100621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 12/05/2020] [Indexed: 11/22/2022] Open
Abstract
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.
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Monaco DC, Zapata L, Hunter E, Salomon H, Dilernia DA. Resistance profile of HIV-1 quasispecies in patients under treatment failure using single molecule, real-time sequencing. AIDS 2020; 34:2201-2210. [PMID: 33196493 DOI: 10.1097/qad.0000000000002697] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Short-read next-generation sequencing (NGS) has been implemented to study the resistance profile of HIV as it provides a higher sensitivity than Sanger sequencing. However, short-reads only generates a consensus view of the viral population rather than a reconstruction of the viral haplotypes. In this study, we evaluated the resistance profile of HIV quasispecies in patients undergoing treatment failure using SMRT sequencing. DESIGN Whole-pol RT-PCR was performed on viral RNA extracted from plasma samples of 38 HIV-positive individuals undergoing treatment failure, and sequenced in the RSII instrument. Error correction and viral haplotype phasing was performed with the Multilayer Directed Phasing and Sequencing (MDPSeq) algorithm. Presence of resistance mutations reported by the IAS-USA in 2017 was assessed using an in-house script. RESULTS The SMRT sequencing-based test detected 131/134 resistance mutations previously detected using a Sanger sequencing-based test. However, the SMRT test also identified seven additional mutations present at an estimated frequency lower than 30%. The intra-host phylogenetic analysis showed that seven samples harbored at least one resistance variant at 20--80% frequency. The haplotype-resolved sequencing revealed viral diversification and selection of new resistance during suboptimal treatment, an overall trend toward selection and accumulation of new resistance mutations, as well as the co-existence of resistant and susceptible variants. CONCLUSION Our results validate the SMRT sequencing-based test for detection of HIV drug resistance. In addition, this method unraveled the complex dynamic of HIV quasispecies during treatment failure, which might have several implications on clinical management.
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Affiliation(s)
| | - Lucas Zapata
- Institute of Biomedical Investigations in Retrovirus and AIDS (INBIRS), School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Eric Hunter
- Emory Vaccine Center, Emory University, Atlanta, Georgia, USA
- Department of Pathology, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Horacio Salomon
- Institute of Biomedical Investigations in Retrovirus and AIDS (INBIRS), School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Dario A Dilernia
- Emory Vaccine Center, Emory University, Atlanta, Georgia, USA
- Department of Pathology, School of Medicine, Emory University, Atlanta, Georgia, USA
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Bell-Gorrod H, Fox MP, Boulle A, Prozesky H, Wood R, Tanser F, Davies MA, Schomaker M. The Impact of Delayed Switch to Second-Line Antiretroviral Therapy on Mortality, Depending on Definition of Failure Time and CD4 Count at Failure. Am J Epidemiol 2020; 189:811-819. [PMID: 32219384 DOI: 10.1093/aje/kwaa049] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 03/23/2020] [Indexed: 11/13/2022] Open
Abstract
Little is known about the functional relationship of delaying second-line treatment initiation for human immunodeficiency virus-positive patients and mortality, given a patient's immune status. We included 7,255 patients starting antiretroviral therapy during 2004-2017, from 9 South African cohorts, with virological failure and complete baseline data. We estimated the impact of switch time on the hazard of death using inverse probability of treatment weighting of marginal structural models. The nonlinear relationship between month of switch and the 5-year survival probability, stratified by CD4 count at failure, was estimated with targeted maximum likelihood estimation. We adjusted for measured time-varying confounding by CD4 count, viral load, and visit frequency. Five-year mortality was estimated to be 10.5% (95% CI: 2.2, 18.8) for immediate switch and to be 26.6% (95% CI: 20.9, 32.3) for no switch (51.1% if CD4 count was <100 cells/mm3). The hazard of death was estimated to be 0.37 (95% CI: 0.30, 0.46) times lower if everyone had been switched immediately compared with never. The shorter the delay in switching, the lower the hazard of death-delaying 30-59 days reduced the hazard by 0.53 (95% CI: 0.43, 0.65) times and 60-119 days by 0.58 (95% CI: 0.49, 0.69) times, compared with no switch. Early treatment switch is particularly important for patients with low CD4 counts at failure.
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Fox MP, Brennan AT, Nattey C, MacLeod WB, Harlow A, Mlisana K, Maskew M, Carmona S, Bor J. Delays in repeat HIV viral load testing for those with elevated viral loads: a national perspective from South Africa. J Int AIDS Soc 2020; 23:e25542. [PMID: 32640101 PMCID: PMC7343337 DOI: 10.1002/jia2.25542] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 01/24/2020] [Accepted: 04/30/2020] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION In South Africa, HIV patients with an elevated viral load (VL) should receive repeat VL testing after adherence counselling. We set out to use a national HIV Cohort to describe time to repeat viral load testing across South Africa and identify predictors of time to repeat testing. METHODS We conducted a cohort study of prospectively collected laboratory data. HIV treatment guidelines have changed over time in South Africa, but call for repeat VL testing within six months if 400 to 1000 copies/mL and two to three months if >1000 copies/mL. We included patients with suppressed viral loads (indicating they are on ART) and a first elevated VL (>400 copies/mL) between April 2004 and December 2014. Follow-up began at first elevated VL and continued until repeat testing, loss to follow-up or December 2016. We calculated adjusted hazard ratios (aHR) using Cox proportional hazard models. RESULTS Of 371,648 patients with a VL > 400, 83.9% (311,790) had a repeat VL, in a median (IQR) of 7.0 (4.1 to 12.2) months. Of those with a first viral load 400 to 1000 copies/mL, 56.4% had a repeat VL within guideline recommended six months (defined as up to nine months), whereas among those >1000 copies/mL only 47.7% had a repeat viral load within guideline recommended two to three months (defined as up to six months). We found a small increase in repeat testing associated with higher VL value (aHR 1.11; 95% CI: 1.10 to 1.12 comparing >1000 vs 400 to 1000 copies/mL) and very low CD4 counts at first elevated VL (aHR 1.16; 95% CI: 1.13 to 1.19 comparing CD4 < 50 vs <500 cells/mm3 ). We also found strong variation in time to repeat VL testing by province. CONCLUSIONS Median time to repeat viral load testing for those with an elevated viral load was longer than guidelines recommend. Future work should identify whether delays are due to patient or provider factors.
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Affiliation(s)
- Matthew P Fox
- Department of EpidemiologyBoston University School of Public HealthBostonMAUSA
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Alana T Brennan
- Department of EpidemiologyBoston University School of Public HealthBostonMAUSA
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Cornelius Nattey
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - William B MacLeod
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Alyssa Harlow
- Department of EpidemiologyBoston University School of Public HealthBostonMAUSA
| | - Koleka Mlisana
- National Health Laboratory ServiceJohannesburgSouth Africa
| | - Mhairi Maskew
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Sergio Carmona
- National Health Laboratory ServiceJohannesburgSouth Africa
| | - Jacob Bor
- Department of EpidemiologyBoston University School of Public HealthBostonMAUSA
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
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Hermans LE, Carmona S, Nijhuis M, Tempelman HA, Richman DD, Moorhouse M, Grobbee DE, Venter WDF, Wensing AMJ. Virological suppression and clinical management in response to viremia in South African HIV treatment program: A multicenter cohort study. PLoS Med 2020; 17:e1003037. [PMID: 32097428 PMCID: PMC7041795 DOI: 10.1371/journal.pmed.1003037] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/24/2020] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Uptake of antiretroviral treatment (ART) is expanding rapidly in low- and middle-income countries (LMIC). Monitoring of virological suppression is recommended at 6 months of treatment and annually thereafter. In case of confirmed virological failure, a switch to second-line ART is indicated. There is a paucity of data on virological suppression and clinical management of patients experiencing viremia in clinical practice in LMIC. We report a large-scale multicenter assessment of virological suppression over time and management of viremia under programmatic conditions. METHODS AND FINDINGS Linked medical record and laboratory source data from adult patients on first-line ART at 52 South African centers between 1 January 2007 and 1 May 2018 were studied. Virological suppression, switch to second-line ART, death, and loss to follow-up were analyzed. Multistate models and Cox proportional hazard models were used to assess suppression over time and predictors of treatment outcomes. A total of 104,719 patients were included. Patients were predominantly female (67.6%). Median age was 35.7 years (interquartile range [IQR]: 29.9-43.0). In on-treatment analysis, suppression below 1,000 copies/mL was 89.0% at month 12 and 90.4% at month 72. Suppression below 50 copies/mL was 73.1% at month 12 and 77.5% at month 72. Intention-to-treat suppression was 75.0% and 64.3% below 1,000 and 50 copies/mL at month 72, respectively. Viremia occurred in 19.8% (20,766/104,719) of patients during a median follow-up of 152 (IQR: 61-265) weeks. Being male and below 35 years of age and having a CD4 count below 200 cells/μL prior to start of ART were risk factors for viremia. After detection of viremia, confirmatory testing took 29 weeks (IQR: 16-54). Viral resuppression to below 1,000 copies/mL without switch of ART occurred frequently (45.6%; 6,030/13,210) but was associated with renewed viral rebound and switch. Of patients with confirmed failure who remained in care, only 41.5% (1,872/4,510) were switched. The median time to switch was 68 weeks (IQR: 35-127), resulting in 12,325 person-years spent with a viral load above 1,000 copies/mL. Limitations of this study include potential missing data, which is in part addressed by the use of cross-matched laboratory source data, and the possibility of unmeasured confounding. CONCLUSIONS In this study, 90% virological suppression below the threshold of 1,000 copies/mL was observed in on-treatment analysis. However, this target was not met at the 50-copies/mL threshold or in intention-to-treat analysis. Clinical management in response to viremia was profoundly delayed, prolonging the duration of viremia and potential for transmission. Diagnostic tools to establish the cause of viremia are urgently needed to accelerate clinical decision-making.
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Affiliation(s)
- Lucas E. Hermans
- Virology, Department of Medical Microbiology, University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
- Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
- Ndlovu Research Consortium, Elandsdoorn, South Africa
| | - Sergio Carmona
- Department of Molecular Medicine and Haematology, University of the Witwatersrand, Johannesburg, South Africa
- National Health Laboratory Service (NHLS), Johannesburg, South Africa
| | - Monique Nijhuis
- Virology, Department of Medical Microbiology, University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
- Ndlovu Research Consortium, Elandsdoorn, South Africa
- University of the Witwatersrand, Johannesburg, South Africa
| | - Hugo A. Tempelman
- Ndlovu Research Consortium, Elandsdoorn, South Africa
- University of the Witwatersrand, Johannesburg, South Africa
| | - Douglas D. Richman
- Center for AIDS Research, University of California San Diego, United States of America
- VA San Diego Healthcare System, California, United States of America
| | - Michelle Moorhouse
- Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
| | - Diederick E. Grobbee
- Ndlovu Research Consortium, Elandsdoorn, South Africa
- Clinical Epidemiology, University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
- Julius Center for Health Sciences and Primary Care, Utrecht, the Netherlands
| | - Willem D. F. Venter
- Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
- Ndlovu Research Consortium, Elandsdoorn, South Africa
| | - Annemarie M. J. Wensing
- Virology, Department of Medical Microbiology, University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
- Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
- Ndlovu Research Consortium, Elandsdoorn, South Africa
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10
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Kaplan S, Nteso KS, Ford N, Boulle A, Meintjes G. Loss to follow-up from antiretroviral therapy clinics: A systematic review and meta-analysis of published studies in South Africa from 2011 to 2015. South Afr J HIV Med 2019; 20:984. [PMID: 31956435 PMCID: PMC6956684 DOI: 10.4102/sajhivmed.v20i1.984] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 08/20/2019] [Indexed: 11/05/2022] Open
Abstract
Background South Africa has the largest antiretroviral therapy (ART) programme in the world. To optimise programme outcomes, it is critical that patients are retained in care and that retention is accurately measured. Objectives To identify all studies published in South Africa from 2011 to 2015 that used loss to follow-up (LTFU) as an indicator or outcome to describe the variation in definitions and to estimate the proportion of patients lost to care across studies. Method All studies published between 01 January 2011 and October 2015 that included loss to follow-up or default from ART care in a South African cohort were included by use of a broad search strategy across multiple databases. To be included, the cohort had to include any patient ART data, including follow-up time, from 01 January 2010. Two authors, working independently, extracted data and assessed risk of bias from all manuscripts. Meta-analysis was performed for studies stratified by the same loss to follow-up definition. Results Forty-eight adult, 15 paediatric and 4 pregnant cohorts were included. Median cohort size was 3737; follow-up time ranged from 9 weeks to 5 years. Meta-analysis did not reveal an important difference in LTFU estimates in adult cohorts at 1 year between loss to follow-up defined as 3 months (11.0%, n = 4; 95% CI 10.7% – 11.2%) compared with 6 months (12.0%, n = 4; 95% CI 11.8% – 12.2%). Only two cohorts reported reliable LTFU estimates at 5 years: this was 25.1% (95% CI 24.8% – 25.4%). Conclusion South Africa should standardise a LTFU definition. This would aid in monitoring and evaluation of ART programmes, with the broader goal of improving patient outcomes.
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Affiliation(s)
- Samantha Kaplan
- Department of Internal Medicine, University of Washington, Seattle, United States
| | - Katleho S Nteso
- Medical Care Development International, Maseru, Lesotho, South Africa.,School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nathan Ford
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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11
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Essien-Baidoo S, Obiri-Yeboah D, Opoku YK, Ayamga E, Hodi Zie K, Attoh D, Obboh E, Hayfron Benjamin A, Afrifa J. ART Regimen and Other Sociodemographics Do Not Affect Cytokine Expression in HIV Patients in Ghana. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2019; 2019:2730370. [PMID: 31641392 PMCID: PMC6767853 DOI: 10.1155/2019/2730370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 08/21/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND HIV infection is marked by the production of cytokines by infected cells and cells of the immune system. Variations in the levels of cytokine in HIV-infected individuals significantly impact the role of the immune system with the possibility to affect the course of HIV disease by either exacerbating or suppressing HIV replication. AIM The study sought to investigate the effect of sociodemographic indices, clinical laboratory parameters, and ART regimen on Th1, Th2, and Th17 cytokines in HIV patients. MATERIALS AND METHODS A total of two hundred (200) HIV patients on either the first or second line of ART were recruited into the study. Sociodemographic indices were collected using researcher-administered questionnaires. Serum concentrations of two major immune-promoting cytokines, IL-12 and IFN-γ, and immune-suppressive cytokines, IL-10 and IL-17, were measured using enzyme-linked immunosorbent assay (ELISA). T-test and chi-square were used to compare mean scores, while correlation (Pearson's correlation) and linear regression analyses were also performed with the statistical significance set at p < 0.05. RESULTS The mean age of the participants was (45.54 ± 0.7846) years with a greater proportion (84.5%) between 31 and 60 years. The mean interferon-gamma (INF-γ), interleukin- (IL-) 10, interleukin-12, and interleukin-17 were estimated to be 349.9 ± 8.391 pg/ml, 19.32 ± 0.4593 pg/ml, 19.23 ± 0.3960 pg/ml, and 24.6 ± 0.6207 pg/ml, respectively. Although INF-γ and IL-17 levels were relatively higher in males compared to females, it was vice versa for IL-10 and IL-12. However, none of these was statistically significant. Again, no significant difference was observed among all the cytokines stratified by the duration of ART, stage of HIV, and smoking status. Most importantly, stratification by either first- or second-line ART regimens recorded no significant difference in cytokine levels. Age significantly correlated inversely with IFN-γ (r = -0.27, p ≤ 0.001), IL-10 (r = -0.24, p ≤ 0.001), and IL-12 (r = -0.18, p=0.01) while duration on ART significantly correlated inversely with IFN-γ (r = -0.16, p=0.02). CD4 counts at 6 months and 12 months on ART correlated inversely with IL-17 (r = -0.17, p=0.02) and plasma viral load at 1 year (r = -0.22, p ≤ 0.001), respectively. A positive correlation was observed between IFN-γ and IL-12 (r = -0.84, p ≤ 0.001) and IL-17 (r = -0.50, p ≤ 0.001). This positive trend was repeated between IL-10 and IL-12 (r = -0.92, p ≤ 0.001) and IL-17 (r = -0.61, p ≤ 0.001). CONCLUSION The levels of IFN-γ, IL-12, IL-17, and IL-10 are not significantly affected by sociodemographics and ART regimen. This observation shows that no significant difference was observed in cytokine levels stratified by ART regiments. This means that both regimens are effective in the suppression of disease progression.
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Affiliation(s)
- Samuel Essien-Baidoo
- Department of Medical Laboratory Science, School of Allied Health Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Dorcas Obiri-Yeboah
- Department of Microbiology and Immunology, School of Medical Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Yeboah Kwaku Opoku
- Biopharmaceutical Laboratory, College of Life Sciences, Northeast Agricultural University, Harbin, China
| | - Elvis Ayamga
- Department of Medical Laboratory Science, School of Allied Health Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Kevin Hodi Zie
- Department of Medical Laboratory Science, School of Allied Health Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Daniel Attoh
- Department of Medical Laboratory Science, School of Allied Health Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Evans Obboh
- Department of Microbiology and Immunology, School of Medical Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Anna Hayfron Benjamin
- Department of Maternal & Child Health, School of Nursing and Midwifery, University of Cape Coast, Cape Coast, Ghana
| | - Justice Afrifa
- Department of Medical Laboratory Science, School of Allied Health Sciences, University of Cape Coast, Cape Coast, Ghana
- Scientific Research Centre, Second Affiliated Hospital of Harbin Medical University, Harbin, China
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12
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Drug resistance and optimizing dolutegravir regimens for adolescents and young adults failing antiretroviral therapy. AIDS 2019; 33:1729-1737. [PMID: 31361272 DOI: 10.1097/qad.0000000000002284] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES The integrase strand inhibitor dolutegravir (DTG) combined with tenofovir and lamivudine (TLD) is a single tablet regimen recommended for 1st, 2nd and 3rd-line public health antiretroviral therapy (ART). We determined drug resistance mutations (DRMs) and evaluated the predictive efficacy of a TLD containing regimen for viremic adolescents and young adults in Harare, Zimbabwe. METHODS We sequenced plasma viral RNA from HIV-1-infected adolescents and young adults on 1st and 2nd-line ART with confirmed virologic failure (viral load >1000 copies/ml) and calculated total genotypic susceptibility scores to current 2nd, 3rd line and DTG regimens. RESULTS A total of 160 participants were genotyped; 112 (70%) on 1st line and 48 (30%) on 2nd line, median (interquartile range) age 18 (15-19) and duration of ART (interquartile range) was 6 (4-8) years. Major DRMs were present in 94 and 67% of 1st and 2nd-line failures, respectively (P < 0.001). Dual class resistance to nucleotide reverse transcriptase inhibitors and nonnucleotide reverse transcriptase inhibitors was detected in 96 (60%) of 1st-line failures; protease inhibitor DRMs were detected in a minority (10%) of 2nd-line failures. A total genotypic susceptibility score of 2 or less may risk protease inhibitor or DTG monotherapy in 11 and 42% of 1st-line failures switching to 2nd-line protease inhibitor and TLD respectively. CONCLUSION Among adolescents and young adults, current protease inhibitor-based 2nd-line therapies are poorly tolerated, more expensive and adherence is poor. In 1st-line failure, implementation of TLD for many adolescents and young adults on long-term ART may require additional active drug(s). Drug resistance surveillance and susceptibility scores may inform strategies for the implementation of TLD.
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Amico KR, Dunlap A, Dallas R, Lindsey J, Heckman B, Flynn P, Lee S, Horvath K, West Goolsby R, Hudgens M, Filipowicz T, Polier M, Hill E, Mueller Johnson M, Miller J, Neilan A, Ciaranello A, Gaur A. Triggered Escalating Real-Time Adherence Intervention to Promote Rapid HIV Viral Suppression Among Youth Living With HIV Failing Antiretroviral Therapy: Protocol for a Triggered Escalating Real-Time Adherence Intervention. JMIR Res Protoc 2019; 8:e11416. [PMID: 30882360 PMCID: PMC6441855 DOI: 10.2196/11416] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 11/05/2018] [Accepted: 01/23/2019] [Indexed: 01/19/2023] Open
Abstract
Background Youth living with HIV (YLWH) are confronted with many self-care challenges that can be experienced as overwhelming in the context of normal developmental processes that characterize adolescence and young adulthood. A sizable minority of YLWH have unsuppressed viral loads in the United States attributable to antiretroviral therapy (ART) nonadherence. Interventions to promote sustained viral suppression in YLWH are needed. Objective The aim of this study is to evaluate the efficacy of the Triggered Escalating Real-Time Adherence (TERA) intervention in comparison with standard of care (SOC) in YLWH (aged 13-24 years) failing ART on (1) primary outcome measures—HIV viral suppression (VLS), defined as both <200 copies/ml and <50 copies/ml at 12 weeks, and (2) secondary outcome measures—VLS rates and rates of ART adherence at 24, 36, and 48 weeks as well as patterns of adherence over time as measured by an electronic dose monitoring (EDM) device. Methods The TERA study is a phase 2, multisite clinical trial conducted with 120 YLWH failing ART (randomized 1:1 to TERA or SOC) at participating clinical sites within the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN). Participants are followed for a total of 48 weeks. For TERA arm participants, the first 12 weeks involve delivery of the intervention. For all participants, clinical outcomes are collected throughout follow-up, and adherence is assessed using EDM over the full 48 weeks. During the 12-week intervention period, TERA arm participants receive 3 remote coaching sessions delivered in clinic via videoconferencing timed to coincide with baseline and follow-up clinical visits, text message reminders when the EDM has not been opened at dose time (which escalate to 2-way theory-informed short message service coaching interactions in response to real-time nonadherence), and review of dosing graphs produced by EDM at follow-up visits. Results Launch dates for enrollment varied by site. Enrollment began in April 2018 and is expected to be completed by August 2019, with results presented by the second quarter of 2021. Conclusions Effective, generalizable, and scalable approaches to rapidly assist YLWH failing to achieve and sustain VLS may have a substantial impact on individual health and efforts to curb transmission. Coaching for a brief but intensive period from remote coaches and using communication channels common to youth may offer multiple unique advantages in promoting self-care. Trial Registration ClinicalTrials.gov NCT03292432; https://clinicaltrials.gov/ct2/show/NCT03292432 (Archived by WebCite at http://www.webcitation.org/768J8ijjp). International Registered Report Identifier (IRRID) DERR1-10.2196/11416
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Affiliation(s)
- K Rivet Amico
- School of Public Health, Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, MI, United States
| | - Amanda Dunlap
- School of Public Health, Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, MI, United States
| | - Ronald Dallas
- St. Jude Children's Research Hospital, Department of Infectious Diseases, Memphis, TN, United States
| | - Jane Lindsey
- Chan School of Public Health, Department of Biostatistics, Harvard University, Boston, MA, United States
| | - Barbara Heckman
- Frontier Science and Technology Research Foundation, Amherst, NY, United States
| | - Patricia Flynn
- St. Jude Children's Research Hospital, Department of Infectious Diseases, Memphis, TN, United States
| | - Sonia Lee
- National Institutes of Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
| | - Keith Horvath
- School of Public Health, Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, United States
| | - Rachel West Goolsby
- Gillings School of Public Health, Department of Biostatistics, Collaborative Studies Coordinating Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Michael Hudgens
- Gillings School of Public Health, Department of Biostatistics, Collaborative Studies Coordinating Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Teresa Filipowicz
- Gillings School of Public Health, Department of Biostatistics, Collaborative Studies Coordinating Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Melissa Polier
- Gillings School of Public Health, Department of Biostatistics, Collaborative Studies Coordinating Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Emily Hill
- School of Public Health, Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, MI, United States
| | - Megan Mueller Johnson
- School of Public Health, Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, MI, United States
| | - Jessica Miller
- School of Public Health, Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, MI, United States
| | - Anne Neilan
- Massachusetts General Hospital, Division of Infectious Diseases, Boston, MA, United States
| | - Andrea Ciaranello
- Massachusetts General Hospital, Division of Infectious Diseases, Boston, MA, United States
| | - Aditya Gaur
- St. Jude Children's Research Hospital, Department of Infectious Diseases, Memphis, TN, United States
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Sarfo FS, Castelnuovo B, Fanti I, Feldt T, Incardona F, Kaiser R, Lwanga I, Marrone G, Sonnerborg A, Tufa TB, Zazzi M, De Luca A. Longer-term effectiveness of protease-inhibitor-based second line antiretroviral therapy in four large sub-Saharan African clinics. J Infect 2019; 78:402-408. [PMID: 30849438 DOI: 10.1016/j.jinf.2019.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 02/26/2019] [Accepted: 03/03/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Data on the longer-term effectiveness of second line combination antiretroviral therapy (ART) in sub-Saharan Africa (SSA) are lacking. We sought to assess the probability and determinants of 2nd line ART failure in SSA. METHODS A retrospective, multi-center study of 2nd line ART initiated between 2005 and 2017 at four ART centers in Ethiopia, Ghana and Uganda. Main outcome measure was virologic failure (VF) defined as VL>1000 copies/ml after >6 months on 2nd line therapy. Predictors of VF and virologic re-suppression on 2nd line were evaluated using Cox Proportional Hazards and multivariable logistic regression models, respectively. RESULTS 2191 subjects started 2nd line therapy, 61.5% females. Switching from 1st line (56.4% NVP-based, 70.3% including thymidine-analogues) to 2nd line therapy occurred after mean of 4.1 years. 98.9% of patients started boosted PI with NRTI backbone (TDF+3TC/FTC 67.3%, AZT+3TC 18.5%, others 14.2%). There were 267 (12.0%) VF with a 5-year estimated probability of 15.0% (95% CI 13.2-16.9). Key determinants of VF were concomitant rifampicin use (aHR 2.50 [95% CI 1.54-4.05]) and clinical/immunological failure versus virologic failure as reason for switching therapy (aHR, 0.53 [0.33-0.86]). 138 of 267 (51.7%) subsequently achieved virologic re-suppression and predictors included HIV RNA levels at 2nd-line failure: +1 log higher aOR 0.59 [0.43-0.80], experiencing change within 2nd line ART before VF: aOR 0.17 [0.05-0.56], and more recent calendar year of 2nd line initiation: aOR 0.85 [0.75-0.94]. CONCLUSIONS The effectiveness of current 2nd line ART regimens in SSA is good but challenged by interactions with TB therapy.
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Affiliation(s)
- Fred S Sarfo
- Department of Medicine, Kwame Nkrumah University of Science and Technology, Private Mail Bag, Kumasi, Ghana.
| | | | | | - Torsten Feldt
- Clinic of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Dusseldorf, Germany
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15
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Haile GS, Berha AB. Predictors of treatment failure, time to switch and reasons for switching to second line antiretroviral therapy in HIV infected children receiving first line anti-retroviral therapy at a Tertiary Care Hospital in Ethiopia. BMC Pediatr 2019; 19:37. [PMID: 30696412 PMCID: PMC6352354 DOI: 10.1186/s12887-019-1402-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 01/14/2019] [Indexed: 11/10/2022] Open
Abstract
Background Treatment failure and delay in switching to second line regimen are major concerns in the treatment of HIV infected children in a resource limited setting. The aim of this study was to determine the prevalence and predictors of first line antiretroviral therapy (ART) regimen failure, reasons and time taken to switch to second line antiretroviral (ARV) medications after treatment failure among HIV-infected children. Methods A retrospective cohort study was conducted February 2003 to May 2018 in HIV-clinic at Tikur Anbessa Specialized Hospital (TASH), Ethiopia. All HIV infected children ≤15 years of age and who were taking first line ART for at least 6 months were included. Data abstraction format was used to collect the data from patients’ chart and registry. Binary and multivariable logistic regression statistics were used. Results Out of 318 enrolled HIV-infected children, the prevalence of treatment failure was found to be 22.6% (72/318), among these 37 (51.4%) had only immunologic failure, 6 (8.3%) had only virologic failure and 24 (33.3%) had both clinical and immunological failure. The mean time taken to modify combination antiretroviral therapy (cART) regimen was 12.67 (4.96) weeks after treatment failure was confirmed. WHO Stage 3 and 4 [Adjusted Odds Ratio (AOR), 3.64, 95% CI 1.76–7.56], not having both parents as primary caretakers [AOR, 2.72 95% CI, 1.05–7.06], negative serology of care takers [AOR, 2.69 95% CI, 1.03–7.03], and cART initiation at 11 month or younger were predicting factors of treatment failure. Of the 141 (47.9%) children who had regimen switching or substitution, treatment failure (44.4%) and replacement of stavudine (d4T) (30.8%) were major reasons. Only 6.6% patients had received PMTCT service. Conclusion One fifth of the patients had experienced treatment failure. Advanced WHO stage at baseline, not being taken care of by mother and father, negative sero-status caretakers, and younger age at initiation of cART were the predictors of treatment failure. PMTCT service uptake was very low. There was a significant time gap between detection of treatment failure and initiation of second line cART. Half of the patients encountered regimen switching or substitution of cART due to treatment failure and replacement of stavudine (d4T).
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Affiliation(s)
- Gelila Solomon Haile
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy , College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Alemseged Beyene Berha
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy , College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
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16
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HIV-1 second-line failure and drug resistance at high-level and low-level viremia in Western Kenya. AIDS 2018; 32:2485-2496. [PMID: 30134290 DOI: 10.1097/qad.0000000000001964] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Characterize failure and resistance above and below guidelines-recommended 1000 copies/ml virologic threshold, upon second-line failure. DESIGN Cross-sectional study. METHODS Kenyan adults on lopinavir/ritonavir-based second-line were enrolled at AMPATH (Academic Model Providing Access to Healthcare). Charts were reviewed for demographic/clinical characteristics and CD4/viral load were obtained. Participants with detectable viral load had a second visit and pol genotyping was attempted in both visits. Accumulated resistance was defined as mutations in the second, not the first visit. Low-level viremia (LLV) was detectable viral load less than 1000 copies/ml. Failure and resistance associations were evaluated using logistic and Poisson regression, Fisher Exact and t-tests. RESULTS Of 394 participants (median age 42, 60% women, median 1.9 years on second-line) 48% had detectable viral load; 21% had viral load more than 1000 copies/ml, associated with younger age, tuberculosis treatment, shorter time on second-line, lower CD4count/percentage, longer first-line treatment interruption and pregnancy. In 105 sequences from the first visit (35 with LLV), 79% had resistance (57% dual-class, 7% triple-class; 46% with intermediate-to-high-level resistance to ≥1 future drug option). LLV was associated with more overall and NRTI-associated mutations and with predicted resistance to more next-regimen drugs. In 48 second-visit sequences (after median 55 days; IQR 28-33), 40% accumulated resistance and LLV was associated with more mutation accumulation. CONCLUSION High resistance upon second-line failure exists at levels above and below guideline-recommended virologic-failure threshold, impacting future treatment options. Optimization of care should include increased viral load monitoring, resistance testing and third-line ART access, and consideration of lowering the virologic failure threshold, though this demands further investigation.
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17
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Hawkins C, Hertzmark E, Spiegelman D, Muya A, Ulenga N, Kim S, Khudyakov P, Christian B, Sando D, Aris E, Fawzi W. Switching to second-line ART in relation to mortality in a large Tanzanian HIV cohort. J Antimicrob Chemother 2018; 72:2060-2068. [PMID: 28387836 DOI: 10.1093/jac/dkx098] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 03/03/2017] [Indexed: 11/14/2022] Open
Abstract
Objectives In a large cohort of HIV-infected Tanzanians, we assessed: (i) rates of first-line treatment failure and switches to second-line ART; (ii) the effect of switching to second-line ART on death and loss to follow-up; and (iii) treatment outcomes on second-line ART by regimen. Methods HIV-1-infected adults (≥15 years) initiated on first-line ART between November 2004 and September 2012, and who remained on initial therapy for at least 24 weeks before switching, were studied. Survival analyses were conducted to examine the effect of second-line ART on mortality and loss to follow-up in: (i) the whole cohort; (ii) all patients eligible for second-line ART by immunological failure (IF) and/or virological failure (VF) criteria; and (iii) patients eligible by VF criteria. Results In total, 47 296 HIV-infected patients [mean age 37.5 (SD 9.5) years, CD4 175 (SD 158) cells/mm 3 , 71% female] were included in the analyses. Of these, 1760 (3.7%) patients switched to second-line ART (incidence rate = 1.7/100 person-years). Higher rates of mortality were observed in switchers versus non-switchers in all patients and patients with ART failure using IF/VF criteria. Switching only protected against mortality in patients with ART failure defined virologically and with the highest level of adherence [switching versus non-switching; >95% adherence; adjusted HR = 0.50 (95% CI = 0.26-0.93); P = 0.03]. Conclusions Switching patients to second-line ART may only be beneficial in a select group of patients who are virologically monitored and demonstrate good adherence. Our data emphasize the need for routine viral load monitoring and aggressive adherence interventions in HIV programmes in sub-Saharan Africa.
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Affiliation(s)
- Claudia Hawkins
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ellen Hertzmark
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Donna Spiegelman
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Aisa Muya
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Nzovu Ulenga
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Sehee Kim
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Polyna Khudyakov
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - David Sando
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Eric Aris
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Wafaie Fawzi
- Departments of Nutrition, Epidemiology and Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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18
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Evans D, Dahlberg S, Berhanu R, Sineke T, Govathson C, Jonker I, Lönnermark E, Fox MP. Social and behavioral factors associated with failing second-line ART - results from a cohort study at the Themba Lethu Clinic, Johannesburg, South Africa. AIDS Care 2018; 30:863-870. [PMID: 29463102 DOI: 10.1080/09540121.2017.1417527] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Poor adherence is a main challenge to successful second-line ART in South Africa. Studies have shown that patients can re-suppress their viral load following intensive adherence counselling. We identify factors associated with failure to re-suppress on second-line ART. The study was a retrospective cohort study which included HIV-positive adults who experienced an elevated viral load ≥400 copies/ml on second-line ART between January 2013-July 2014, had completed an adherence counselling questionnaire and had a repeat viral load result recorded within 6 months of intensive adherence counselling. Log-binomial regression was used to evaluate the association between patient characteristics and social, behavioral or occupational factors and failure to suppress viral load (≥400 copies/ml). A total of 128 patients were included in the analysis, and of these 39% (n = 50) failed to re-suppress their viral load. Compared to those who suppressed, far more patients who failed to suppress reported living with family (44.2% vs. 23.7%), missing a dose in the past week (53.3% vs. 30.0%), using traditional/herbal medications (63.2% vs. 34.3%) or had symptoms suggestive of depression (57.7% vs. 34.3%). These patient-related factors could be targeted for interventions to reduce the risk for treatment failure and prevent switching to expensive third-line ART.
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Affiliation(s)
- Denise Evans
- a Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg , South Africa
| | - Sara Dahlberg
- b Department of Infectious Diseases , Sahlgrenska Academy, University of Gothenburg , Göteborg , Sweden
| | - Rebecca Berhanu
- c Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg , South Africa
| | - Tembeka Sineke
- a Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg , South Africa
| | - Caroline Govathson
- a Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg , South Africa
| | - Ingrid Jonker
- c Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg , South Africa
| | - Elisabet Lönnermark
- b Department of Infectious Diseases , Sahlgrenska Academy, University of Gothenburg , Göteborg , Sweden
| | - Matthew P Fox
- d Center for Global Health & Development , Boston University , Boston , USA.,e Department of Epidemiology , Boston University School of Public Health , Boston , USA
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19
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Murphy RA, Court R, Maartens G, Sunpath H. Second-Line Antiretroviral Therapy in Sub-Saharan Africa: It Is Time to Mind the Gaps. AIDS Res Hum Retroviruses 2017; 33:1181-1184. [PMID: 28793781 PMCID: PMC5709698 DOI: 10.1089/aid.2017.0134] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The delay between first-line antiretroviral therapy (ART) failure and initiation of second-line ART in resource-limited settings can be prolonged. Increasing evidence links delayed antiretroviral switch with increased risk for opportunistic infection (OI) and death, particularly in patients with advanced HIV at the time of first-line failure. As access to viral load (VL) monitoring widens beyond a few countries, mechanisms are needed to optimize the use of routine virologic monitoring and assure that first-line regimen failure results in prompt second-line switch. For patients with advanced HIV or OI at the time of first-line failure, a targeted fast track to second-line ART should be considered, involving a switch to second-line ART during a single visit. To derive the maximum benefit from both the current expansion of VL monitoring and the falling costs of second-line ART, clinics and healthcare workers should be given the tools and training to detect and switch patients with regimen failure before HIV disease progression.
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Affiliation(s)
- Richard A. Murphy
- Division of Infectious Diseases, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Richard Court
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Henry Sunpath
- Division of Infectious Diseases, University of KwaZulu-Natal, Durban, South Africa
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20
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Makadzange AT, Boyd FK, Chimukangara B, Masimirembwa C, Katzenstein D, Ndhlovu CE. A Simple Phosphate-Buffered-Saline-Based Extraction Method Improves Specificity of HIV Viral Load Monitoring Using Dried Blood Spots. J Clin Microbiol 2017; 55:2172-2179. [PMID: 28468852 PMCID: PMC5483919 DOI: 10.1128/jcm.00176-17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 04/19/2017] [Indexed: 12/30/2022] Open
Abstract
Although Roche COBAS Ampliprep/COBAS TaqMan (CAP/CTM) systems are widely used in sub-Saharan Africa for early infant diagnosis of HIV from dried blood spots (DBS), viral load monitoring with this system is not practical due to nonspecific extraction of both cell-free and cell-associated viral nucleic acids. A simplified DBS extraction technique for cell-free virus elution using phosphate-buffered saline (PBS) may provide an alternative analyte for lower-cost quantitative HIV virus load (VL) testing to monitor antiretroviral therapy (ART). We evaluated the CAP/CTM v2.0 assay in 272 paired plasma and DBS specimens using the cell-free virus elution method and determined the level of agreement, sensitivity, and specificity at thresholds of target not detected (TND), target below the limit of quantification (BLQ) (<20 copies/ml in plasma or <400 copies/ml in DBS), and VL of <1,000 copies/ml, and VL of <5,000 copies/ml. Reported plasma VL ranged from TND, or <20, to 5,781,592 copies/ml, and DBS VL ranged from TND, or <400, to 467,600 copies/ml. At <1000 copies/ml, agreement between DBS and plasma was 96.7% (kappa coefficient, 0.93; P < 0.0001). The mean difference between DBS and plasma VL values was -1.06 log10 copies/ml (95% confidence interval [CI], -1.17, -0.97; P < 0.0001). At a treatment failure threshold of >1,000 copies/ml, the sensitivities, specificities, positive predictive values (PPV), and negative predictive values (NPV) were 92.7%, 100%, 100%, and 94.3%, respectively. PBS elution of DBS offers a sensitive and specific method for monitoring plasma viremia among adults and children on ART at the WHO-recommended threshold of >1,000 copies/ml on the Roche CAP/CTM system.
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Affiliation(s)
- A Tariro Makadzange
- Ragon Institute of MGH, MIT and Harvard, Cambridge, Massachussetts, USA
- Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - F Kathryn Boyd
- Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Benjamin Chimukangara
- Department of Virology, National Health Laboratory Service, University of KwaZulu-Natal, Durban, South Africa
| | | | - David Katzenstein
- Division of Infectious Diseases, Stanford University, Palo Alto, California, USA
| | - Chiratidzo E Ndhlovu
- Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
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21
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Rutstein SE, Compliment K, Nelson JAE, Kamwendo D, Mataya R, Miller WC, Hosseinipour MC. Differentiated Care Pathways for Antiretroviral Therapy Monitoring in Malawi: Expanding Viral Load Testing in Setting of Highly Prevalent Resistance. Open Forum Infect Dis 2017; 4:ofx125. [PMID: 30591918 PMCID: PMC6300304 DOI: 10.1093/ofid/ofx125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 06/14/2017] [Indexed: 11/15/2022] Open
Abstract
We quantified resistance to first-line antiretroviral therapy among previously unmonitored patients in Malawi with viremia (≥1000 copies/mL). Ninety-five percent (n = 57/61) harbored nucleoside/tide reverse transcriptase inhibitor/non-nucleoside reverse transcriptase inhibitor resistance; resistance was more common comparing >2 (97%) versus ≤2 years (87%) on therapy. Immediate switch for persons retained in care may improve monitoring efficiency and maximize clinical outcomes.
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Affiliation(s)
- Sarah E Rutstein
- Department of Health Policy and Management, University of North Carolina at Chapel Hill.,Division of Infectious Diseases, University of North Carolina at Chapel Hill
| | - Kara Compliment
- UNC Center for AIDS Research, University of North Carolina at Chapel Hill.,Department of Microbiology and Immunology, University of North Carolina at Chapel Hill
| | - Julie A E Nelson
- UNC Center for AIDS Research, University of North Carolina at Chapel Hill.,Department of Microbiology and Immunology, University of North Carolina at Chapel Hill
| | | | - Ronald Mataya
- School of Public Health, Loma Linda University, California
| | - William C Miller
- Division of Infectious Diseases, University of North Carolina at Chapel Hill.,Department of Epidemiology, University of North Carolina at Chapel Hill
| | - Mina C Hosseinipour
- Division of Infectious Diseases, University of North Carolina at Chapel Hill.,UNC Project, Lilongwe, Malawi
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22
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Collier D, Iwuji C, Derache A, de Oliveira T, Okesola N, Calmy A, Dabis F, Pillay D, Gupta RK. Virological Outcomes of Second-line Protease Inhibitor-Based Treatment for Human Immunodeficiency Virus Type 1 in a High-Prevalence Rural South African Setting: A Competing-Risks Prospective Cohort Analysis. Clin Infect Dis 2017; 64:1006-1016. [PMID: 28329393 PMCID: PMC5439490 DOI: 10.1093/cid/cix015] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 01/12/2017] [Indexed: 11/20/2022] Open
Abstract
Background Second-line antiretroviral therapy (ART) based on ritonavir-boosted protease inhibitors (bPIs) represents the only available option after first-line failure for the majority of individuals living with human immunodeficiency virus (HIV) worldwide. Maximizing their effectiveness is imperative. Methods This cohort study was nested within the French National Agency for AIDS and Viral Hepatitis Research (ANRS) 12249 Treatment as Prevention (TasP) cluster-randomized trial in rural KwaZulu-Natal, South Africa. We prospectively investigated risk factors for virological failure (VF) of bPI-based ART in the combined study arms. VF was defined by a plasma viral load >1000 copies/mL ≥6 months after initiating bPI-based ART. Cumulative incidence of VF was estimated and competing risk regression was used to derive the subdistribution hazard ratio (SHR) of the associations between VF and patient clinical and demographic factors, taking into account death and loss to follow-up. Results One hundred one participants contributed 178.7 person-years of follow-up. Sixty-five percent were female; the median age was 37.4 years. Second-line ART regimens were based on ritonavir-boosted lopinavir, combined with zidovudine or tenofovir plus lamivudine or emtricitabine. The incidence of VF on second-line ART was 12.9 per 100 person-years (n = 23), and prevalence of VF at censoring was 17.8%. Thirteen of these 23 (56.5%) virologic failures resuppressed after a median of 8.0 months (interquartile range, 2.8-16.8 months) in this setting where viral load monitoring was available. Tuberculosis treatment was associated with VF (SHR, 11.50 [95% confidence interval, 3.92-33.74]; P < .001). Conclusions Second-line VF was frequent in this setting. Resuppression occurred in more than half of failures, highlighting the value of viral load monitoring of second-line ART. Tuberculosis was associated with VF; therefore, novel approaches to optimize the effectiveness of PI-based ART in high-tuberculosis-burden settings are needed. Clinical Trials Registration NCT01509508.
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Affiliation(s)
- Dami Collier
- Department of Infection and Immunity, University College London, United Kingdom
| | - Collins Iwuji
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- Research Department of Infection and Population Health, University College London, United Kingdom
| | - Anne Derache
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- Sorbonne Universités, University Pierre and Marie Curie Université Paris 06, Inserm, Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP UMRS 1136), Paris, France
| | - Tulio de Oliveira
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- University of KwaZulu-Natal, Durban, South Africa
| | | | - Alexandra Calmy
- Geneva University Hospital, HIV Unit, Department of Internal Medicine, Switzerland
| | - Francois Dabis
- INSERM U1219-Centre Inserm Bordeaux Population Health, Université de Bordeaux, France
- Université de Bordeaux, ISPED, Centre INSERM U1219-Bordeaux Population Health, France
| | - Deenan Pillay
- Department of Infection and Immunity, University College London, United Kingdom
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | - Ravindra K Gupta
- Department of Infection and Immunity, University College London, United Kingdom
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
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23
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Rohr JK, Ive P, Horsburgh CR, Berhanu R, Shearer K, Maskew M, Long L, Sanne I, Bassett J, Ebrahim O, Fox MP. Marginal Structural Models to Assess Delays in Second-Line HIV Treatment Initiation in South Africa. PLoS One 2016; 11:e0161469. [PMID: 27548695 PMCID: PMC4993510 DOI: 10.1371/journal.pone.0161469] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Accepted: 08/06/2016] [Indexed: 12/11/2022] Open
Abstract
Background South African HIV treatment guidelines call for patients who fail first-line antiretroviral therapy (ART) to be switched to second-line ART, yet logistical issues, clinician decisions and patient preferences make delay in switching to second-line likely. We explore the impact of delaying second-line ART after first-line treatment failure on rates of death and virologic failure. Methods We include patients with documented virologic failure on first-line ART from an observational cohort of 9 South African clinics. We explored predictors of delayed second-line switch and used marginal structural models to analyze rates of death following first-line failure by categorical time to switch to second-line. Cox proportional hazards models were used to examine virologic failure on second-line ART among patients who switched to second-line. Results 5895 patients failed first-line ART, and 63% switched to second-line. Among patients who switched, median time to switch was 3.4 months (IQR: 1.1–8.7 months). Longer time to switch was associated with higher CD4 counts, lower viral loads and more missed visits prior to first-line failure. Worse outcomes were associated with delay in second-line switch among patients with a peak CD4 count on first-line treatment ≤100 cells/mm3. Among these patients, marginal structural models showed increased risk of death (adjusted HR for switch in 6–12 months vs. 0–1.5 months = 1.47 (95% CI: 0.94–2.29), and Cox models showed increased rates of second-line virologic failure despite the presence of survivor bias (adjusted HR for switch in 3–6 months vs. 0–1.5 months = 2.13 (95% CI: 1.01–4.47)). Conclusions Even small delays in switch to second-line ART were associated with increased death and second-line failure among patients with low CD4 counts on first-line. There is opportunity for healthcare providers to switch patients to second-line more quickly.
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Affiliation(s)
- Julia K. Rohr
- Center for Global Health & Development, Boston University, Boston, United States of America
- * E-mail:
| | - Prudence Ive
- Clinical HIV Research Unit, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - C. Robert Horsburgh
- Center for Global Health & Development, Boston University, Boston, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, United States of America
| | - Rebecca Berhanu
- Clinical HIV Research Unit, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kate Shearer
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mhairi Maskew
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence Long
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ian Sanne
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Right to Care, Johannesburg, South Africa
| | - Jean Bassett
- Witkoppen Health and Welfare Centre, Johannesburg, South Africa
| | - Osman Ebrahim
- Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa
| | - Matthew P. Fox
- Center for Global Health & Development, Boston University, Boston, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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24
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Labhardt ND, Bader J, Lejone TI, Ringera I, Hobbins MA, Fritz C, Ehmer J, Cerutti B, Puga D, Klimkait T. Should viral load thresholds be lowered?: Revisiting the WHO definition for virologic failure in patients on antiretroviral therapy in resource-limited settings. Medicine (Baltimore) 2016; 95:e3985. [PMID: 27428189 PMCID: PMC4956783 DOI: 10.1097/md.0000000000003985] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The World Health Organization (WHO) guidelines on antiretroviral therapy (ART) define treatment failure as 2 consecutive viral loads (VLs) ≥1000 copies/mL. There is, however, little evidence supporting 1000 copies as an optimal threshold to define treatment failure. Objective of this study was to assess the correlation of the WHO definition with the presence of drug-resistance mutations in patients who present with 2 consecutive unsuppressed VL in a resource-limited setting.In 10 nurse-led clinics in rural Lesotho children and adults on first-line ART for ≥6 months received a first routine VL. Those with plasma VL ≥80 copies/mL were enrolled in a prospective study, receiving enhanced adherence counseling (EAC) and a follow-up VL after 3 months. After a second unsuppressed VL genotypic resistance testing was performed. Viruses with major mutations against ≥2 drugs of the current regimen were classified as "resistant".A total of 1563 adults and 191 children received a first routine VL. Of the 138 adults and 53 children with unsuppressed VL (≥80 copies/mL), 165 (116 adults; 49 children) had a follow-up VL after EAC; 108 (74 adults; 34 children) remained unsuppressed and resistance testing was successful. Ninety of them fulfilled the WHO definition of treatment failure (both VL ≥1000 copies/mL); for another 18 both VL were unsuppressed but with <1000 copies/mL. The positive predictive value (PPV) for the WHO failure definition was 81.1% (73/90) for the presence of resistant virus. Among the 18 with VL levels between 80 and 1000 copies/mL, thereby classified as "non-failures", 17 (94.4%) harbored resistant viruses. Lowering the VL threshold from 1000 copies/mL to 80 copies/mL at both determinations had no negative influence on the PPV (83.3%; 90/108).The current WHO-definition misclassifies patients who harbor resistant virus at VL below 1000 c/mL as "nonfailing." Lowering the threshold to VL ≥80 copies/mL identifies a significantly higher number of patients with treatment-resistant virus and should be considered.
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Affiliation(s)
- Niklaus D Labhardt
- Medical Services and Diagnostic, Clinical Research Unit, Swiss Tropical and Public Health Institute University of Basel Molecular Virology, Department Biomedicine-Petersplatz, University of Basel, Basel, Switzerland SolidarMed, Swiss Organization for Health in Africa, Maseru, Lesotho SolidarMed, Swiss Organization for Health in Africa, Luzern, Switzerland Faculty of Medicine, University of Geneva, Geneva, Switzerland
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25
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Ramadhani HO, Bartlett JA, Thielman NM, Pence BW, Kimani SM, Maro VP, Mwako MS, Masaki LJ, Mmbando CE, Minja MG, Lirhunde ES, Miller WC. The Effect of Switching to Second-Line Antiretroviral Therapy on the Risk of Opportunistic Infections Among Patients Infected With Human Immunodeficiency Virus in Northern Tanzania. Open Forum Infect Dis 2016; 3:ofw018. [PMID: 26949717 PMCID: PMC4776054 DOI: 10.1093/ofid/ofw018] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 01/07/2016] [Indexed: 11/13/2022] Open
Abstract
Background. Due to the unintended potential misclassifications of the World Health Organization (WHO) immunological failure criteria in predicting virological failure, limited availability of treatment options, poor laboratory infrastructure, and healthcare providers' confidence in making switches, physicians delay switching patients to second-line antiretroviral therapy (ART). Evaluating whether timely switching and delayed switching are associated with the risk of opportunistic infections (OI) among patients with unrecognized treatment failure is critical to improve patient outcomes. Methods. A retrospective review of 637 adolescents and adults meeting WHO immunological failure criteria was conducted. Timely and delayed switching to second-line ART were defined when switching happened at <3 and ≥3 months, respectively, after failure diagnosis was made. Cox proportional hazard marginal structural models were used to assess the effect of switching to second-line ART on the risk of developing OI. Results. Of 637 patients meeting WHO immunological failure criteria, 396 (62.2%) switched to second-line ART. Of those switched, 230 (58.1%) were delayed. Switching to second-line ART reduced the risk of OI (adjusted hazards ratio [AHR], 0.4; 95% CI, .2-.6). Compared with patients who received timely switch after failure diagnosis was made, those who delayed switching were more likely to develop OI (AHR, 2.2; 95% CI, 1.1-4.3). Conclusion. Delayed switching to second-line ART after failure diagnosis may increase the risk of OI. Serial immunological assessment for switching patients to second-line ART is critical to improve their outcomes.
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Affiliation(s)
- Habib O Ramadhani
- Kilimanjaro Christian Medical Centre, Moshi; Tanzania; Department of Epidemiology, University of North Carolina, Chapel Hill
| | - John A Bartlett
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, and; Duke Global Health Institute, Durham, North Carolina
| | - Nathan M Thielman
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, and; Duke Global Health Institute, Durham, North Carolina
| | - Brian W Pence
- Department of Epidemiology , University of North Carolina , Chapel Hill
| | | | | | | | | | | | - Mary G Minja
- Kibosho Designated District Hospital , Moshi , Tanzania
| | | | - William C Miller
- Department of Epidemiology , University of North Carolina , Chapel Hill
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Wilhelmson S, Reepalu A, Balcha TT, Jarso G, Björkman P. Retention in care among HIV-positive patients initiating second-line antiretroviral therapy: a retrospective study from an Ethiopian public hospital clinic. Glob Health Action 2016; 9:29943. [PMID: 26765104 PMCID: PMC4712321 DOI: 10.3402/gha.v9.29943] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Revised: 12/05/2015] [Accepted: 12/07/2015] [Indexed: 01/15/2023] Open
Abstract
Background Access to second-line antiretroviral therapy (ART) for HIV-positive patients remains limited in sub-Saharan Africa. Furthermore, outcomes of second-line ART may be compromised by mortality and loss to follow-up (LTFU). Objective To determine retention in care among patients receiving second-line ART in a public hospital in Ethiopia, and to investigate factors associated with LTFU among adults and adolescents. Design HIV-positive persons with documented change of first-line ART to a second-line regimen were retrospectively identified from hospital registers, and data were collected at the time of treatment change and subsequent clinic visits. Baseline variables for adults and adolescents were analyzed using multivariate Cox proportional hazards models comparing subjects remaining in care and those LTFU (defined as a missed appointment of ≥90 days). Results A total of 383 persons had started second-line ART (330 adults/adolescents; 53 children) and were followed for a median of 22.2 months (the total follow-up time was 906 person years). At the end of study follow-up, 80.5% of patients remained in care (adults and adolescents 79.8%; children 85.7%). In multivariate analysis, LTFU among adults and adolescents was associated with a baseline CD4 cell count <100 cells/mm3 and a first-line regimen failure that was not confirmed by HIV RNA testing. Conclusions Although retention in care during second-line ART in this cohort was satisfactory, and similar to that reported from first-line ART programs in Ethiopia, our findings suggest the benefit of earlier recognition of patients with first-line ART failure and confirmation of suspected treatment failure by viral load testing.
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Affiliation(s)
- Sten Wilhelmson
- Section for Infectious Diseases, Institution of Clinical Sciences, Lund University, Malmö, Sweden
| | - Anton Reepalu
- Section for Infectious Diseases, Institution of Clinical Sciences, Lund University, Malmö, Sweden
| | - Taye Tolera Balcha
- Section for Infectious Diseases, Institution of Clinical Sciences, Lund University, Malmö, Sweden.,Ministry of Health of Ethiopia, Addis Abeba, Ethiopia
| | | | - Per Björkman
- Section for Infectious Diseases, Institution of Clinical Sciences, Lund University, Malmö, Sweden;
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27
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Thao VP, Quang VM, Day JN, Chinh NT, Shikuma CM, Farrar J, Van Vinh Chau N, Thwaites GE, Dunstan SJ, Le T. High prevalence of PI resistance in patients failing second-line ART in Vietnam. J Antimicrob Chemother 2015; 71:762-74. [PMID: 26661398 PMCID: PMC4743698 DOI: 10.1093/jac/dkv385] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 10/16/2015] [Indexed: 01/11/2023] Open
Abstract
Background There are limited data from resource-limited settings on antiretroviral resistance mutations that develop in patients failing second-line PI ART. Methods We performed a cross-sectional virological assessment of adults on second-line ART for ≥6 months between November 2006 and December 2011, followed by a prospective follow-up over 2 years of patients with virological failure (VF) at the Hospital for Tropical Diseases, Vietnam. VF was defined as HIV RNA concentrations ≥1000 copies/mL. Resistance mutations were identified by population sequencing of the pol gene and interpreted using the 2014 IAS-USA mutation list and the Stanford algorithm. Logistic regression modelling was performed to identify predictors of VF. Results Two hundred and thirty-one patients were enrolled in the study. The median age was 32 years; 81.0% were male, 95.7% were on a lopinavir/ritonavir-containing regimen and 22 (9.5%) patients had VF. Of the patients with VF, 14 (64%) carried at least one major protease mutation [median: 2 (IQR: 1–3)]; 13 (59%) had multiple protease mutations conferring intermediate- to high-level resistance to lopinavir/ritonavir. Mutations conferring cross-resistance to etravirine, rilpivirine, tipranavir and darunavir were identified in 55%, 55%, 45% and 27% of patients, respectively. Higher viral load, adherence <95% and previous indinavir use were independent predictors of VF. The 2 year outcomes of the patients maintained on lopinavir/ritonavir included: death, 7 (35%); worsening virological/immunological control, 6 (30%); and virological re-suppression, 5 (25%). Two patients were switched to raltegravir and darunavir/ritonavir with good HIV control. Conclusions High-prevalence PI resistance was associated with previous indinavir exposure. Darunavir plus an integrase inhibitor and lamivudine might be a promising third-line regimen in Vietnam.
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Affiliation(s)
- Vu Phuong Thao
- Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Vo Minh Quang
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Jeremy N Day
- Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Cecilia M Shikuma
- Hawaii Center for AIDS, University of Hawaii at Manoa, Honolulu, HI, USA
| | - Jeremy Farrar
- Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Guy E Thwaites
- Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sarah J Dunstan
- The Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
| | - Thuy Le
- Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK Hawaii Center for AIDS, University of Hawaii at Manoa, Honolulu, HI, USA
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28
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Thao VP, Quang VM, Wolbers M, Anh ND, Shikuma C, Farrar J, Dunstan S, Chau NVV, Day J, Thwaites G, Le T. Second-Line HIV Therapy Outcomes and Determinants of Mortality at the Largest HIV Referral Center in Southern Vietnam. Medicine (Baltimore) 2015; 94:e1715. [PMID: 26512561 PMCID: PMC4985375 DOI: 10.1097/md.0000000000001715] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
The growing numbers of HIV-infected patients requiring second-line antiretroviral therapy (ART) in Vietnam make essential the evaluation of treatment efficacy to guide treatment strategies.We evaluated all patients aged ≥15 years who initiated second-line ART after documented failure of first-line therapy at the Hospital for Tropical Diseases in Ho Chi Minh City. The primary outcome was time from second-line ART initiation to death, or to a new or reoccurrence of a WHO-defined immunological or clinical failure event, whichever occurred first. Risks of treatment failure and death were evaluated using Cox proportional hazards modeling.Data from 326 of 373 patients initiating second-line ART between November 2006 and August 2011 were included in this analysis. The median age was 32 years (IQR: 28-36). Eighty one percent were men. The median CD4 count was 44 cells/μL (IQR: 16-84). During a median follow-up of 29 months (IQR: 15-44), 60 (18.4%) patients experienced treatment failure, including 12 immunological failures, 4 WHO stage IV AIDS events, and 44 deaths (13.5%). Sixty percent of deaths occurred during the first 6-12 months. The Kaplan-Meier estimates of treatment failure after 1, 2, 3, and 4 years were 13.1% (95% CI: 9.2-16.8), 18.6% (95% CI: 14.0-23.1), 20.4% (95% CI: 15.4-25.1), and 22.8% (95% CI: 17.2-28.1), respectively. Older age, history of injection drug use, lower CD4 count, medication adherence <95%, and previous protease inhibitor use independently predicted treatment failure.While treatment efficacy was similar to that reported from other resource-limited settings, mortality was higher. Early deaths may be averted by prioritizing second-line therapy for those with lower CD4 counts and by improving treatment adherence support.
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Affiliation(s)
- Vu Phuong Thao
- From the Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit (VPT, MW, NDA, JF, JD, GT, TLE); Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam (VMQ, NVVC); Hawaii Centre for AIDS, University of Hawaii at Manoa, Honolulu, Hawaii (CS, TLE); and Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Australia (SD)
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Vanobberghen FM, Kilama B, Wringe A, Ramadhani A, Zaba B, Mmbando D, Todd J. Immunological failure of first-line and switch to second-line antiretroviral therapy among HIV-infected persons in Tanzania: analysis of routinely collected national data. Trop Med Int Health 2015; 20:880-92. [PMID: 25779383 PMCID: PMC4672690 DOI: 10.1111/tmi.12507] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Rates of first-line treatment failure and switches to second-line therapy are key indicators for national HIV programmes. We assessed immunological treatment failure defined by WHO criteria in the Tanzanian national HIV programme. METHODS We included adults initiating first-line therapy in 2004-2011 with a pre-treatment CD4 count, and ≥6-months of follow-up. We assessed subhazard ratios (SHR) for immunological treatment failure, and subsequent switch to second-line therapy, using competing risks methods to account for deaths. RESULTS Of 121 308 adults, 7% experienced immunological treatment failure, and 2% died without observed immunological treatment failure, over a median 1.7 years. The 6-year cumulative probability of immunological treatment failure was 19.0% (95% CI 18.5, 19.7) and of death, 5.1% (4.8, 5.4). Immunological treatment failure predictors included earlier year of treatment initiation (P < 0.001), initiation in lower level facilities (SHR = 2.23 [2.03, 2.45] for dispensaries vs. hospitals), being male (1.27 [1.19, 1.33]) and initiation at low or high CD4 counts (for example, 1.78 [1.65, 1.92] and 5.33 [4.65, 6.10] for <50 and ≥500 vs. 200-349 cells/mm(3) , respectively). Of 7382 participants in the time-to-switch analysis, 6% switched and 5% died before switching. Four years after immunological treatment failure, the cumulative probability of switching was 7.3% (6.6, 8.0) and of death, 6.8% (6.0, 7.6). Those who immunologically failed in dispensaries, health centres and government facilities were least likely to switch. CONCLUSIONS Immunological treatment failure rates and unmet need for second-line therapy are high in Tanzania; virological monitoring, at least for persons with immunological treatment failure, is required to minimise unnecessary switches to second-line therapy. Lower level government health facilities need more support to reduce treatment failure rates and improve second-line therapy uptake to sustain the benefits of increased coverage.
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Affiliation(s)
- Fiona M Vanobberghen
- London School of Hygiene & Tropical Medicine, London, UK.,Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
| | - Bonita Kilama
- National AIDS Control Program, Dar es Salaam, Tanzania
| | - Alison Wringe
- London School of Hygiene & Tropical Medicine, London, UK
| | | | - Basia Zaba
- London School of Hygiene & Tropical Medicine, London, UK
| | - Donan Mmbando
- Ministry of Health and Social Welfare, Dar es Salaam, Tanzania
| | - Jim Todd
- London School of Hygiene & Tropical Medicine, London, UK.,Kilimanjaro Christian Medical University College, Moshi, Tanzania
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Petersen ML, Tran L, Geng EH, Reynolds SJ, Kambugu A, Wood R, Bangsberg DR, Yiannoutsos CT, Deeks SG, Martin JN. Delayed switch of antiretroviral therapy after virologic failure associated with elevated mortality among HIV-infected adults in Africa. AIDS 2014; 28:2097-107. [PMID: 24977440 DOI: 10.1097/qad.0000000000000349] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Routine monitoring of plasma HIV RNA among HIV-infected patients on antiretroviral therapy (ART) is unavailable in many resource-limited settings. Alternative monitoring approaches correlate poorly with virologic failure and can substantially delay switch to second-line therapy. We evaluated the impact of delayed switch on mortality among patients with virologic failure in Africa. DESIGN A cohort. METHODS We examined patients with confirmed virologic failure on first-line nonnucleoside reverse transcriptase inhibitor (NNRTI)-based regimens from four cohorts with serial HIV RNA monitoring in Uganda and South Africa. Marginal structural models aimed to estimate the effect of delayed switch on mortality in a hypothetical trial in which switch time was randomly assigned. Inverse probability weights adjusted for measured confounders including time-updated CD4+ T-cell count and HIV RNA. Results: Among 823 patients with confirmed virologic failure, the cumulative incidence of switch 180 days after failure was 30% [95% confidence interval (CI) 27-33]. The majority of patients (74%) had not failed immunologically as defined by WHO criteria by the time of virologic failure. Adjusted mortality was higher for individuals who remained on first-line therapy than for those who had switched [odds ratio (OR) 2.1, 95% CI 1.1-4.2]. Among those without immunologic failure, the relative harm of failure to switch was similar (OR 2.4; 95% CI 0.99-5.8) to that of the entire cohort, although of borderline statistical significance. CONCLUSION Among HIV-infected patients with confirmed virologic failure on first-line ART, remaining on first-line therapy led to an increase in mortality relative to switching. Our results suggest that detection and response to confirmed virologic failure could decrease mortality.
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Ramadhani HO, Bartlett JA, Thielman NM, Pence BW, Kimani SM, Maro VP, Mwako MS, Masaki LJ, Mmbando CE, Minja MG, Lirhunde ES, Miller WC. Association of first-line and second-line antiretroviral therapy adherence. Open Forum Infect Dis 2014; 1:ofu079. [PMID: 25734147 PMCID: PMC4281791 DOI: 10.1093/ofid/ofu079] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 08/03/2014] [Indexed: 11/15/2022] Open
Abstract
Adherence to first-line ART is an important predictor of adherence to second-line ART. Improving adherence prior to switch is critical to improve patient outcomes. Background Adherence to first-line antiretroviral therapy (ART) may be an important indicator of adherence to second-line ART. Evaluating this relationship may be critical to identify patients at high risk for second-line failure, thereby exhausting their treatment options, and to intervene and improve patient outcomes. Methods Adolescents and adults (n = 436) receiving second-line ART were administered standardized questionnaires that captured demographic characteristics and assessed adherence. Optimal and suboptimal cumulative adherence were defined as percentage adherence of ≥90% and <90%, respectively. Bivariable and multivariable binomial regression models were used to assess the prevalence of suboptimal adherence percentage by preswitch adherence status. Results A total of 134 of 436 (30.7%) participants reported suboptimal adherence to second-line ART. Among 322 participants who had suboptimal adherence to first-line ART, 117 (36.3%) had suboptimal adherence to second-line ART compared with 17 of 114 (14.9%) who had optimal adherence to first-line ART. Participants who had suboptimal adherence to first-line ART were more likely to have suboptimal adherence to second-line ART (adjusted prevalence ratio, 2.4; 95% confidence interval, 1.5–3.9). Conclusions Adherence to first-line ART is an important predictor of adherence to second-line ART. Targeted interventions should be evaluated in patients with suboptimal adherence before switching into second-line therapy to improve their outcomes.
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Affiliation(s)
- Habib O Ramadhani
- Kilimanjaro Christian Medical Centre , Moshi , Tanzania ; Department of Epidemiology , University of North Carolina , Chapel Hill
| | - John A Bartlett
- Division of Infectious Diseases and International Health, Department of Medicine , Duke University Medical Center ; Duke Global Health Institute , Durham, North Carolina
| | - Nathan M Thielman
- Division of Infectious Diseases and International Health, Department of Medicine , Duke University Medical Center ; Duke Global Health Institute , Durham, North Carolina
| | - Brian W Pence
- Department of Epidemiology , University of North Carolina , Chapel Hill
| | | | | | | | | | | | - Mary G Minja
- Kibosho Designated District Hospital , Moshi , Tanzania
| | | | - William C Miller
- Department of Epidemiology , University of North Carolina , Chapel Hill
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Newman H, Breunig L, van Zyl G, Stich A, Preiser W. A qualitative PCR minipool strategy to screen for virologic failure and antiretroviral drug resistance in South African patients on first-line antiretroviral therapy. J Clin Virol 2014; 60:387-91. [DOI: 10.1016/j.jcv.2014.05.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 05/15/2014] [Accepted: 05/20/2014] [Indexed: 01/11/2023]
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Madec Y, Leroy S, Rey-Cuille MA, Huber F, Calmy A. Persistent difficulties in switching to second-line ART in sub-saharan Africa--a systematic review and meta-analysis. PLoS One 2013; 8:e82724. [PMID: 24376570 PMCID: PMC3871158 DOI: 10.1371/journal.pone.0082724] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Accepted: 10/27/2013] [Indexed: 11/23/2022] Open
Abstract
Objectives Switching to second-line antiretroviral therapy (ART) largely depends on careful clinical assessment and access to biological measurements. We performed a systematic review and meta-analysis to estimate the incidence of switching to second-line ART in sub-Saharan Africa and its main programmatic determinants. Methods We searched 2 databases for studies reporting the incidence rate of switching to second-line ART in adults living in sub-Saharan Africa. Data on the incidence rate of switching were pooled, and random-effect models were used to evaluate the effect of factors measured at the programme level on this incidence rate. Results Nine studies (157,340 patients) in 21 countries were included in the meta-analysis. All studies considered patients under first-line ART and conditions to initiate ART were similar across studies. Overall, 3,736 (2.4%) patients switched to second-line ART. Incidence rate of switch was in mean 2.65 per 100 person-years (PY) (95% confidence interval: 2.01–3.30); it ranged from 0.42 to 4.88 per 100 PY and from 0 to 4.80 per 100 PY in programmes with and without viral load monitoring, respectively. No factors measured at the programme level were associated with the incidence rate of switching to second-line ART. Conclusion The low incidence rate of switching to second-line ART suggests that the monitoring of patients under ART is challenging and that access to second-line ART is ineffective; efforts should be made to increase access to second-line ART to those in need by providing monitoring tools, education and training, as well as a more convenient regimen.
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Affiliation(s)
- Yoann Madec
- Institut Pasteur, Emerging Diseases Epidemiology Unit, Paris, France
- * E-mail:
| | - Sandrine Leroy
- Institut Pasteur, Emerging Diseases Epidemiology Unit, Paris, France
| | | | | | - Alexandra Calmy
- Geneva University Hospital, HIV Unit, Department of Internal Medicine, Geneva, Switzerland
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Rawizza HE, Chaplin B, Meloni ST, Darin KM, Olaitan O, Scarsi KK, Onwuamah CK, Audu RA, Chebu PR, Imade GE, Okonkwo P, Kanki PJ. Accumulation of protease mutations among patients failing second-line antiretroviral therapy and response to salvage therapy in Nigeria. PLoS One 2013; 8:e73582. [PMID: 24069209 PMCID: PMC3775797 DOI: 10.1371/journal.pone.0073582] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 07/19/2013] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND To date, antiretroviral therapy (ART) guidelines and programs in resource-limited settings (RLS) have focused on 1(st)- and 2(nd)-line (2 L) therapy. As programs approach a decade of implementation, policy regarding access to 3(rd)-line (3 L) ART is needed. We aimed to examine the impact of maintaining patients on failing 2 L ART on the accumulation of protease (PR) mutations. METHODS AND FINDINGS From 2004-2011, the Harvard/APIN PEPFAR Program provided ART to >100,000 people in Nigeria. Genotypic resistance testing was performed on a subset of patients experiencing 2 L failure, defined as 2 consecutive viral loads (VL)>1000 copies/mL after ≥6 months on 2 L. Of 6714 patients who received protease inhibitor (PI)-based ART, 673 (10.0%) met virologic failure criteria. Genotypes were performed on 61 samples. Patients on non-suppressive 2 L therapy for <12 months prior to genotyping had a median of 2 (IQR: 0-5) International AIDS Society (IAS) PR mutations compared with 5 (IQR: 0-6) among patients failing for >24 months. Patients developed a median of 0.6 (IQR: 0-1.4) IAS PR mutations per 6 months on failing 2 L therapy. In 38% of failing patients no PR mutations were present. For patients failing >24 months, high- or intermediate-level resistance to lopinavir and atazanavir was present in 63%, with 5% to darunavir. CONCLUSIONS This is the first report assessing the impact of duration of non-suppressive 2 L therapy on the accumulation of PR resistance in a RLS. This information provides insight into the resistance cost of failing to switch non-suppressive 2 L regimens and highlights the issue of 3 L access.
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Affiliation(s)
- Holly E. Rawizza
- Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Beth Chaplin
- Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Seema T. Meloni
- Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Kristin M. Darin
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | | | - Kimberly K. Scarsi
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | | | | | | | | | | | - Phyllis J. Kanki
- Harvard School of Public Health, Boston, Massachusetts, United States of America
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High-levels of acquired drug resistance in adult patients failing first-line antiretroviral therapy in a rural HIV treatment programme in KwaZulu-Natal, South Africa. PLoS One 2013; 8:e72152. [PMID: 23991055 PMCID: PMC3749184 DOI: 10.1371/journal.pone.0072152] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 07/05/2013] [Indexed: 11/19/2022] Open
Abstract
Objective To determine the frequency and patterns of acquired antiretroviral drug resistance in a rural primary health care programme in South Africa. Design Cross-sectional study nested within HIV treatment programme. Methods Adult (≥18 years) HIV-infected individuals initially treated with a first-line stavudine- or zidovudine-based antiretroviral therapy (ART) regimen and with evidence of virological failure (one viral load >1000 copies/ml) were enrolled from 17 rural primary health care clinics. Genotypic resistance testing was performed using the in-house SATuRN/Life Technologies system. Sequences were analysed and genotypic susceptibility scores (GSS) for standard second-line regimens were calculated using the Stanford HIVDB 6.0.5 algorithms. Results A total of 222 adults were successfully genotyped for HIV drug resistance between December 2010 and March 2012. The most common regimens at time of genotype were stavudine, lamivudine and efavirenz (51%); and stavudine, lamivudine and nevirapine (24%). Median duration of ART was 42 months (interquartile range (IQR) 32–53) and median duration of antiretroviral failure was 27 months (IQR 17–40). One hundred and ninety one (86%) had at least one drug resistance mutation. For 34 individuals (15%), the GSS for the standard second-line regimen was <2, suggesting a significantly compromised regimen. In univariate analysis, individuals with a prior nucleoside reverse-transcriptase inhibitor (NRTI) substitution were more likely to have a GSS <2 than those on the same NRTIs throughout (odds ratio (OR) 5.70, 95% confidence interval (CI) 2.60–12.49). Conclusions There are high levels of drug resistance in adults with failure of first-line antiretroviral therapy in this rural primary health care programme. Standard second-line regimens could potentially have had reduced efficacy in about one in seven adults involved.
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Onyedum CC, Iroezindu MO, Chukwuka CJ, Anyaene CE, Obi FI, Young EE. Profile of HIV-infected patients receiving second-line antiretroviral therapy in a resource-limited setting in Nigeria. Trans R Soc Trop Med Hyg 2013; 107:608-14. [PMID: 23959002 DOI: 10.1093/trstmh/trt071] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Second-line antiretroviral therapy (ART) accounts for less than 5% of total ART in resource-limited settings. We described the baseline characteristics, reasons for switch and treatment outcomes of Nigerian patients receiving second-line ART. METHODS In this retrospective cohort study we recorded the baseline characteristics of HIV-infected adults whose treatment regimen was switched from a non-nucleoside reverse transcriptase inhibitor, a first-line agent, to a protease inhibitor-based second-line regimen. The duration of follow-up was 12 months. RESULTS Of 4229 patients who started first-line therapy, 186 (4.4%) were switched to second-line therapy after a mean duration of 16.6 ± 7.6 months. Their mean age was 41.8 ± 9.6 years and 59.1% were women. The median (range) viral load and CD4 cell counts at switch were 4.7 (4.1-6.3) log10 copies/ml and 71 (6-610) cells/µl, respectively. The predominant reason for switch was virological failure (79.0%). Only 55.4% and 36.6% of patients had CD4 cell count and viral load at 12 months. About 82%, 79% and 82% of patients with available data achieved virological suppression at 3 months, 6 months and 12 months respectively (p = 0.81). The proportion of patients who achieved ≥50% rise in CD4 cell count increased from 55.8% at 3 months to 78.6% at 12 months (p = 0.0002). CONCLUSION The rate of switch to second-line therapy was low but there were good treatment outcomes among patients with available data. Attrition rate was high. Regular viral load monitoring, improved availability/affordability of second-line regimens and retention in care should become priorities in resource-limited settings.
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Affiliation(s)
- Cajetan C Onyedum
- Department of Medicine, College of Medicine, University of Nigeria Teaching Hospital (UNTH), Enugu, Nigeria
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Schoffelen AF, Wensing AMJ, Tempelman HA, Geelen SPM, Hoepelman AIM, Barth RE. Sustained virological response on second-line antiretroviral therapy following virological failure in HIV-infected patients in rural South Africa. PLoS One 2013; 8:e58526. [PMID: 23505529 PMCID: PMC3594302 DOI: 10.1371/journal.pone.0058526] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Accepted: 02/05/2013] [Indexed: 11/18/2022] Open
Abstract
Objective This study aims to describe the virological, immunological and clinical efficacy of protease inhibitor (PI)-based second-line antiretroviral therapy (ART) in rural South Africa. Methods An observational cohort study was performed on 210 patients (including 39 children) who initiated PI-based second-line therapy at least 12 months prior to data collection. Biannual clinical, immunological and virological monitoring was performed. Primary endpoints were adequate virological response (plasma HIV-1 RNA<400 copies/ml), full virological suppression (plasma HIV-1 RNA<50 copies/ml) and treatment failure (virological failure (plasma HIV-1 RNA>1000 after initial virological response) or on-going viremia (plasma HIV-1 RNA never<400 copies/ml for more than six months)). Data were analyzed by an on-treatment (OT) and intention-to-treat (ITT) approach. Analyses were primarily performed on the group of patients who switched following first-line virological failure. Results Median duration of follow-up after switch to second-line treatment was 20 months [IQR 11–35]. 191 patients had switched to second-line ART due to first-line virological failure. 139/191 of them (72.8%, ITT) were in care and on treatment at the end of follow-up and 11/191 (5.8%, ITT) had died. After twelve months, an adequate virological response was seen in 92/128 patients (71.9%, OT), of which 78/128 (60.9%, OT) experienced full virological suppression. Virological response remained stable after 24 months. Virological efficacy was similar amongst adult and pediatric patients. As in first-line ART, we observed a lack of correlation between virological failure and WHO-defined immunological failure. Conclusions Good virological outcomes following first-line failure can be achieved with PI-based, second-line antiretroviral therapy in both adult and pediatric patients in rural South Africa. Retention rates were high and virological outcomes were sustainable during the two-year follow-up period, although persisting low-level viremia occurred in a subset of patients. The observed viro-immunological dissociation emphasizes the need for virological monitoring.
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Affiliation(s)
- Annelot F Schoffelen
- Department of Internal Medicine and Infectious Diseases, University Medical Centre Utrecht, Utrecht, The Netherlands.
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Labhardt ND, Lejone T, Setoko M, Poka M, Ehmer J, Pfeiffer K, Kiuvu PZ, Lynen L. A clinical prediction score in addition to WHO criteria for anti-retroviral treatment failure in resource-limited settings--experience from Lesotho. PLoS One 2012; 7:e47937. [PMID: 23118910 PMCID: PMC3485299 DOI: 10.1371/journal.pone.0047937] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Accepted: 09/25/2012] [Indexed: 11/30/2022] Open
Abstract
Objective To assess the positive predictive value (PPV) of a clinical score for viral failure among patients fulfilling the WHO-criteria for anti-retroviral treatment (ART) failure in rural Lesotho. Methods Patients fulfilling clinical and/or immunological WHO failure-criteria were enrolled. The score includes the following predictors: Prior ART exposure (1 point), CD4-count below baseline (1), 25% and 50% drop from peak CD4-count (1 and 2), hemoglobin drop≥1 g/dL (1), CD4 count<100/µl after 12 months (1), new onset papular pruritic eruption (1), and adherence<95% (3). A nurse assessed the score the day blood was drawn for viral load (VL). Reported confidence intervals (CI) were calculated using Wilsons method. Results Among 1'131 patients on ART≥6 months, 134 (11.8%) had immunological and/or clinical failure, 104 (78%) had blood drawn (13 died, 10 lost to follow-up, 7 did not show up). From 92 (88%) a result could be obtained (2 samples hemolysed, 10 lost). Out of these 92 patients 47 (51%) had viral failure (≥5000 copies), 27 (29%) viral suppression (<40) and 18 (20%) intermediate viremia (40–4999). Overall, 20 (22%) had a score≥5. A score≥5 had a PPV of 100% to detect a VL>40 copies (95%CI: 84–100), and of 90% to detect a VL≥5000 copies (70–97). Within the score, adherence<95%, CD4-count<100/µl and papular pruritic eruption were the strongest single predictors. Among 47 patients failing, 8 (17%) died before or within 4 weeks after being switched. Overall mortality was 4 (20%) among those with score≥5 and 4 (5%) if score<5 (OR 4.3; 95%CI: 0.96–18.84, p = 0.057). Conclusion A score≥5 among patients fulfilling WHO-criteria had a PPV of 100% for a detectable VL and 90% for viral failure. In settings without regular access to VL-testing, this PPV may be considered high enough to switch this patient-group to second-line treatment without confirmatory VL-test.
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Affiliation(s)
| | - Thabo Lejone
- Seboche Hospital, Botha-Bothe, Lesotho
- * E-mail: (NDL); (TL)
| | | | | | | | | | | | - Lutgarde Lynen
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
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Gilliam BL, Patel D, Talwani R, Temesgen Z. HIV in Africa: Challenges and Directions for the Next Decade. Curr Infect Dis Rep 2012; 14:91-101. [PMID: 22143960 DOI: 10.1007/s11908-011-0230-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Africa carries a disproportionate burden of the global HIV endemic, accounting for two thirds of the global 33.3 million people living with HIV. While tremendous advances have been made in addressing the HIV epidemic in Africa, considerable challenges remain. Testing for HIV increased by 86% from 2007 to 2009 but more than 75% of people 15-49 years remain unaware of their HIV status. CD4 count at diagnosis tends to be low and linkage to care and treatment is suboptimal. The scale-up of antiretroviral therapy is ongoing but is hampered by the lack of diagnostic capability to monitor response to therapy and a substantial healthcare workforce shortage. Prevention strategies such as male circumcision, pre-exposure prophylaxis, and antiretroviral therapy for prevention have generated great excitement but cost and healthcare infrastructure deficiencies may limit their widespread applicability. Operational research to validate and inform treatment decisions, health care policies, and prevention strategies is sorely needed.
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Affiliation(s)
- Bruce L Gilliam
- Institute of Human Virology, University of Maryland School of Medicine, 725 West Lombard Street, Baltimore, MD, 21201, USA,
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Genotype assays and third-line ART in resource-limited settings: a simulation and cost-effectiveness analysis of a planned clinical trial. AIDS 2012; 26:1083-93. [PMID: 22343964 DOI: 10.1097/qad.0b013e32835221eb] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To project the clinical and economic outcomes of a genotype assay for selection of third-line antiretroviral therapy (ART) in resource-limited settings, as per the planned international A5288 trial (MULTI-OCTAVE). METHODS We used the Cost-effectiveness of Preventing AIDS Complications (CEPAC)-International Model to compare three strategies for patients who have failed second-line ART in South Africa: sustained second-line: no genotype assay, all patients remain on second-line ART; A5288: genotype to determine the resistance profile and assign an appropriate regimen; or population-based third-line: no genotype, all patients switch to a potent third-line regimen. Model inputs are from published data in South Africa. Resistance profiles, ART regimens, and efficacy data were those used for trial planning. RESULTS Projected life expectancy for sustained second-line, A5288, and population-based third-line are 61.1, 103.8, and 104.2 months. Compared to sustained second-line ($12 ,460), per person lifetime costs increase for the A5288 ($39, 250) and population-based ($44, 120) strategies. The incremental cost-effectiveness ratio of A5288, compared to sustained second-line, is $7500/year of life saved (YLS), and for population-based third-line, compared to A5288, is $154 ,500/YLS. In the A5288 strategy, very late presentation to care, coupled with lengthy delays to obtain the genotype, dramatically reduces 5-year survival, making the population-based third-line strategy more attractive. CONCLUSIONS We project that, whereas the public health approach to third-line therapy is unaffordable, genotype assays and third-line ART in resource-limited settings will increase survival and be cost-effective compared to the population-based approach, supporting the value of an efficacy study.
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Second-line antiretroviral therapy in a workplace and community-based treatment programme in South Africa: determinants of virological outcome. PLoS One 2012; 7:e36997. [PMID: 22666338 PMCID: PMC3362581 DOI: 10.1371/journal.pone.0036997] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Accepted: 04/11/2012] [Indexed: 01/11/2023] Open
Abstract
Background: As antiretroviral treatment (ART) programmes in resource-limited settings mature, more patients are experiencing virological failure. Without resistance testing, deciding who should switch to second-line ART can be difficult. The consequences for second-line outcomes are unclear. In a workplace- and community-based multi-site programme, with 6-monthly virological monitoring, we describe outcomes and predictors of viral suppression on second-line, protease inhibitor-based ART. Methods: We used prospectively collected clinic data from patients commencing first-line ART between 1/1/03 and 31/12/08 to construct a study cohort of patients switched to second-line ART in the presence of a viral load (VL) ≥400 copies/ml. Predictors of VL<400 copies/ml within 15 months of switch were assessed using modified Poisson regression to estimate risk ratios. Results: 205 workplace patients (91.7% male; median age 43 yrs) and 212 community patients (38.7% male; median age 36 yrs) switched regimens. At switch compared to community patients, workplace patients had a longer duration of viraemia, higher VL, lower CD4 count, and higher reported non-adherence on first-line ART. Non-adherence was the reported reason for switching in a higher proportion of workplace patients. Following switch, 48.3% (workplace) and 72.0% (community) achieved VL<400, with non-adherence (17.9% vs. 1.4%) and virological rebound (35.6% vs. 13.2% with available measures) reported more commonly in the workplace programme. In adjusted analysis of the workplace programme, lower switch VL and younger age were associated with VL<400. In the community programme, shorter duration of viraemia, higher CD4 count and transfers into programme on ART were associated with VL<400. Conclusion: High levels of viral suppression on second-line ART can be, but are not always, achieved in multi-site treatment programmes with both individual- and programme-level factors influencing outcomes. Strategies to support both healthcare workers and patients during this switch period need to be evaluated; sub-optimal adherence, particularly in the workplace programme must be addressed.
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Treatment outcomes of patients on second-line antiretroviral therapy in resource-limited settings: a systematic review and meta-analysis. AIDS 2012; 26:929-38. [PMID: 22313953 DOI: 10.1097/qad.0b013e328351f5b2] [Citation(s) in RCA: 136] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND A growing proportion of patients on antiretroviral therapy in resource-limited settings have switched to second-line regimens. We carried out a systematic review in order to summarize reported rates and reasons for virological failure among people on second-line therapy in resource-limited settings. METHODS Two reviewers independently searched four databases and three conference websites. Full text articles were screened and data extracted using a standardized data extraction form. RESULTS We retrieved 5812 citations, of which 19 studies reporting second-line failure rates in 2035 patients across low-income and middle-income countries were eligible for inclusion. The cumulative pooled proportion of adult patients failing virologically was 21.8, 23.1, 26.7 and 38.0% at 6, 12, 24 and 36 months, respectively. Most studies did not report adequate information to allow discrimination between drug resistance and poor adherence as reasons for virological failure, but for those that did poor adherence appeared to be the main driver of virological failure. Mortality on second-line was low across all time points. CONCLUSION Rates of virological failure on second-line therapy are high in resource-limited settings and associated with duration of exposure to previous drug regimens and poor adherence. The main concern appears to be poor adherence, rather than drug resistance, from the limited number of studies accessing both factors. Access to treatment options beyond second-line remains limited and, therefore, a cause for a concern for those patients in whom drug resistance is the identified cause of virological failure.
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Levison JH, Orrell C, Gallien S, Kuritzkes DR, Fu N, Losina E, Freedberg KA, Wood R. Virologic failure of protease inhibitor-based second-line antiretroviral therapy without resistance in a large HIV treatment program in South Africa. PLoS One 2012; 7:e32144. [PMID: 22427821 PMCID: PMC3302781 DOI: 10.1371/journal.pone.0032144] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Accepted: 01/20/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND We investigated the prevalence of wild-type virus (no major drug resistance) and drug resistance mutations at second-line antiretroviral treatment (ART) failure in a large HIV treatment program in South Africa. METHODOLOGY/ PRINCIPAL FINDINGS HIV-infected patients ≥ 15 years of age who had failed protease inhibitor (PI)-based second-line ART (2 consecutive HIV RNA tests >1000 copies/ml on lopinavir/ritonavir, didanosine, and zidovudine) were identified retrospectively. Patients with virologic failure were continued on second-line ART. Genotypic testing for drug resistance was performed on frozen plasma samples obtained closest to and after the date of laboratory confirmed second-line ART failure. Of 322 HIV-infected patients on second-line ART, 43 were adults with confirmed virologic failure, and 33 had available plasma for viral sequencing. HIV-1 RNA subtype C predominated (n = 32, 97%). Mean duration on ART (SD) prior to initiation of second-line ART was 23 (17) months, and time from second-line ART initiation to failure was 10 (9) months. Plasma samples were obtained 7(9) months from confirmed failure. At second-line failure, 22 patients (67%) had wild-type virus. There was no major resistance to PIs found. Eleven of 33 patients had a second plasma sample taken 8 (5.5) months after the first. Median HIV-1 RNA and the genotypic resistance profile were unchanged. CONCLUSIONS/ SIGNIFICANCE Most patients who failed second-line ART had wild-type virus. We did not observe evolution of resistance despite continuation of PI-based ART after failure. Interventions that successfully improve adherence could allow patients to continue to benefit from second-line ART therapy even after initial failure.
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Affiliation(s)
- Julie H Levison
- Division of General Medicine Massachusetts General Hospital, Boston, Massachusetts, United States of America.
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