Impact of Human Immunodeficiency Virus Drug Resistance on Treatment of Human Immunodeficiency Virus Infection in Children in Low- and Middle-Income Countries

Disparities in access to Dolutegravir in West African children, adolescents and young adults aged 0-24 years living with HIV. A IeDEA Pediatric West African cohort analysis

Introduction

We describe the 24-month incidence of Dolutegravir (DTG)-containing antiretroviral treatment (ART) initiation since its introduction in 2019 in the pediatric West African IeDEA cohorts.

Methods

We included all patients aged 0-24 years on ART, from nine clinics in Côte d'Ivoire (n=4), Ghana, Nigeria, Mali, Benin, and Burkina Faso. Baseline varied by clinic and was defined as date of first DTG prescription; patients were followed-up until database closure/death/loss to follow-up (LTFU, no visit ≥ 7 months), whichever came first. We computed the cumulative incidence function for DTG initiation; associated factors were explored in a shared frailty model, accounting for clinic heterogeneity.

Results

Since 2019, 3,350 patients were included; 49% were female;79% had been on ART ≥ 12 months. Median baseline age was 12.9 years (IQR: 9-17). Median follow-up was 14 months (IQR: 7-22). The overall cumulative incidence of DTG initiation reached 35.5% (95% CI: 33.7-37.2) and 56.4% (95% CI: 54.4-58.4) at 12 and 24 months, respectively. In univariate analyses, those aged <5 years and females were overall less likely to switch. Adjusted on ART line and available viral load (VL) at baseline, females >10 years were less likely to initiate DTG compared to males of the same age (aHR among 10-14 years: 0.62, 95% CI: 0.54-0.72; among ≥15 years: 0.43, 95% CI: 0.36-0.50), as were those with detectable VL (> 50 copies/mL) compared to those in viral suppression (aHR: 0.86, 95% CI: 0.77-0.97) and those on PIs compared to those on NNRTIs (aHR after 12 months of roll-out: 0.75, 95% CI: 0.65-0.86). Conclusion: Access to paediatric DTG was incomplete and unequitable in West African settings: children <5years, females ≥ 10 years and those with detectable viral load were least likely to access DTG. Maintained monitoring and support of treatment practices is required to better ensure universal and equal access.

Key messages

What is already known on this topic?: Dolutegravir (DTG)-based ART regimens are recommended as the preferred first-line ART regimens recommended by the World Health Organisation in all people living with HIV since 2018, with a note of caution for pregnant women, then confirmed in all children with approved DTG dosing and adolescents since 2019.Deployment of universal DTG access in adults in West Africa has faced challenges such as infrastructure challenges, and healthcare system disparities, and was hindered by initial perinatal safety concerns affecting greatly women of childbearing age.Specific data on access to DTG in children, adolescents and young adults in West Africa is limited.What this study adds ?: This study describes the dynamic of the DTG roll-out over the first 24 months and its correlates since 2019 in a large West African multicentric cohort of children, adolescents and youth.We observed a rapid scale-up of DTG among children, adolescents and young adults living with HIV in West Africa, despite the COVID-19 pandemic.However, DTG access after 24 months was incomplete and unequitable, with adolescent girls and young women being less likely to initiate DTG compared to males, as were those with a detectable viral load (> 50 copies/mL) compared to those in success.Younger children < 5 years were also less likely to initiate DTG, explained by the later approval of paediatric formulations and their low availability.How this study might affect research, practice or policy?: Maintained monitoring, training and updating guidance for healthcare workers is essential to ensure universal access to DTG, especially for females, for whom inequity begins age 10 years.Efforts to improve access to universal DTG in West Africa require multifaceted interventions including healthcare infrastructure improvement and facilitation of paediatric antiretroviral forecasting and planification.

Emergence of HIV-1 drug resistance mutations among children and adolescents undergoing prolonged antiretroviral therapy in Guangxi

OBJECTIVE

Antiretroviral therapy (ART) has been implemented in Guangxi for a long time, and there are no reports of HIV drug resistance mutation (DRM) among children and adolescents experiencing virologic failure after ART. This study aimed to analyse HIV DRM prevalence, patterns, and influencing factors among children and adolescents experiencing virologic failure after ART in Guangxi.

METHODS

We collected samples from a total of 491 HIV-infected individuals under 18 years old experiencing virologic failure after ART from 14 cities in Guangxi. Sequencing and DRM analysis were performed based on pol region. Multivariate logistic regression was employed to analysis the influencing factors of DRM.

RESULTS

Among these patients, 396 cases were successfully sequenced. Of all, 52.53% exhibited HIV DRM, including NNRTI (48.48%), NRTI (34.85%) and PI (1.01%). NRTI and NNRTI dual-class resistance was prevalent (30.3%). M184V/I and K103N mutations were the common mutations in NRTI and NNRTI, respectively. Male sex (aOR = 2.1, 95% CI: 1.26-3.50), CRF01_AE subtype (OR = 2.50, 95% CI: 1.02-5.88), the primary regimen 3TC+AZT+NVP (OR = 10.00, 95% CI: 5.00-25.00), low pretreatment CD4+ T lymphocytes (<200 cells/mm³) (OR = 1.85, 95% CI: 1.00-3.45), and high viral load (>1000 copies/mL) (OR = 4.90, 95% CI: 1.03-23.39) showed higher risk of DRM.

CONCLUSION

HIV DRM is pervasive among children and adolescents experiencing virologic failure in Guangxi. Timely HIV DRM monitoring is crucial to mitigate major mutation accumulation and inform effective treatment strategies.

Drug resistance profiles and influencing factors among HIV-infected children and adolescents receiving long-term ART: a multicentre observational study in China

OBJECTIVES

To analyse the characteristics and determinants of drug resistance mutations (DRMs) in HIV-infected children and adolescents on long-term ART in China.

METHODS

An observational cohort study was conducted in five centres. All participants younger than 15 years at ART initiation were screened, and those identified as having virological failure (VF) with viral load (VL) ≥ 400 copies/mL were included for genotypic resistance testing. Logistic regression analysis was performed and the accumulation of major mutations was analysed in a subgroup of resistant individuals with complete VL results since HIV diagnosis.

RESULTS

Among 562 eligible participants, protease and RT regions were successfully amplified for 93 who failed treatment with a median of 10.0 years ART. Sixty-eight (73.1%) harboured ≥1 major mutations. NRTI, NNRTI and dual-class resistance accounted for 48.4%, 63.4% and 38.7%, respectively. Only 3.2% were resistant to PIs. Age at ART initiation [adjusted OR (aOR) = 0.813, 95% CI 0.690-0.957], subtype B (aOR = 4.378, 95% CI 1.414-13.560) and an initial NNRTI-based regimen (aOR = 3.331, 95% CI 1.180-9.402) were independently associated with DRMs. Among 40 resistant participants with additional VL data, 55.0% had continued VF on a suboptimal regimen and the estimated duration of VF was positively correlated with the total number of major mutations (r = 0.504, P = 0.001).

CONCLUSIONS

The development of DRMs was common in children and adolescents receiving long-term treatment, and continued VF was prevalent in those with resistance. Timely genotypic testing and new child-friendly formulations are therefore urgently required.

HIV Drug Resistance in Children and Adolescents: Always a Challenge?

Purpose of Review

With the expanded roll-out of antiretrovirals for treatment and prevention of HIV during the last decade, the emergence of HIV drug resistance (HIVDR) has become a growing challenge. This review provides an overview of the epidemiology and trajectory of HIVDR globally with an emphasis on pediatric and adolescent populations.

Recent Findings

HIVDR is associated with suboptimal virologic suppression and treatment failure, leading to an increased risk of HIV transmission to uninfected people and increased morbidity and mortality among people living with HIV. High rates of HIVDR to non-nucleoside reverse transcriptase inhibitors globally are expected to decline with the introduction of the integrase strand transfer inhibitors and long-acting combination regimens, while challenge remains for HIVDR to other classes of antiretroviral drugs.

Summary

We highlight several solutions including increased HIV viral load monitoring, expanded HIVDR surveillance, and adopting antiretroviral regimens with a high-resistance barrier to decrease HIVDR. Implementation studies and programmatic changes are needed to determine the best approach to prevent and combat the development of HIVDR.

Community-Based Interventions to Reach 95-95-95 for Children and Adolescents: An Exploratory Programmatic Review From Lesotho

BACKGROUND

Viral suppression is the desired outcome for children and adolescents with HIV. In this article, data from districts supporting community interventions (implementation districts) were reviewed and compared with data from districts without community interventions (nonimplementation districts) to explore a potential correlation between community interventions and clinical outcomes.

SETTING

The study was based on data collected from facilities in 6 districts in Lesotho.

METHODS

Twelve-month retention, viral load coverage, and viral suppression data from patients with ART between ages 5 and 24 from facilities in both district types were collected retrospectively.

RESULTS

Implementation districts showed retention rates of 75%, with 5365 patients (47% of all patients on ART) having documented viral load results and 4641 (87%) being virally suppressed. Retention comparison demonstrated significantly higher rates in implementation districts (73%) as compared to (63%) in nonimplementation districts (P = 0.023). Viral load coverage and suppression comparison found that implementation district hospitals reported 632 (37% of total on ART) patients with a documented viral load, with 539 (85%) virally suppressed, whereas nonimplementation district hospitals reported 220 (31%) patients with viral load results, of whom 181 (82%) were suppressed.

CONCLUSIONS

Overall, retention rates in the implementation districts were reasonable and were significantly better than the rates in the nonimplementation districts.

Getting Treatment and Care Services Right for Children and Adolescents to Reach High Viral Suppression

In August 2014, PEPFAR and the Children's Investment Fund Foundation launched the Accelerating Children's HIV/AIDS Treatment (ACT) initiative with the aim of doubling the number of children on antiretroviral treatment in 9 African countries. Increasing rates of pretreatment drug resistance and use of suboptimal treatment regimens and formulations result in poor adherence and high rates of viral failure. Supporting adherence and ensuring appropriate treatment monitoring are needed to maximize duration of first-line treatment and enable timely sequencing to subsequent lines of antiretroviral treatment. Although timely antiretroviral treatment is the core of clinical care for infants, children and adolescents living with HIV, ensuring a broader package of biomedical and non-biomedical interventions is also required to address highly prevalent comorbidities among children living with HIV. Providing such a comprehensive package has been challenging for health care workers who lack the necessary skills and confidence to care for pediatric populations. Efforts to simplify clinical management and specific training and mentorship are needed to address these challenges. In this article, we review the progress made during the ACT initiative and the persistent challenges in achieving and maintaining virological suppression across the age spectrum. We identify innovations needed to build on the success of the ACT initiative. Despite the challenges, achieving high levels of virological suppression in children and adolescents is possible. The complexity of pediatric HIV treatment can be offset as antiretroviral regimens become more effective, tolerable, and easier to prescribe and administer. Meanwhile, basic programmatic elements to address comorbidities as well as support health care workers remain critical. In this article we review the progress made through the ACT initiative, as well as identify innovations needed to address persistent challenges to viral suppression across the age spectrum.

Prevalence of drug resistance in children recently diagnosed with HIV-1 infection in France (2006-17): impact on susceptibility to first-line strategies

Objectives

To describe the prevalence of transmitted drug resistance (TDR) among 84 children newly diagnosed with HIV in France in 2006-17.

Methods

HIV-1 resistance-associated mutations (RAMs) were characterized using both the 2009 Stanford list of mutations and the 2017 French National Agency for AIDS Research (ANRS) algorithm. A genotypic susceptibility score (GSS) was estimated for each first-line recommended ART combination.

Results

Patients were mainly infected through mother-to-child transmission (MTCT) (73/84; 86.9%), but only 18 children (24.7% of vertically infected patients) were previously exposed to antiretroviral prophylaxis from MTCT. Non-B variants were identified in 90.5% (76/84) of patients. The frequency of TDR was 8.3% (7/84) using the 2009 Stanford list and 16.7% (14/84) using both the Stanford list and the 2017 ANRS algorithm. The prevalence of PI-, NRTI-, efavirenz/nevirapine-, etravirine/rilpivirine- and doravirine-associated RAMs was 0%, 3.6%, 6.0%, 11.9% and 2.4%, respectively. Single-, dual- and triple-class resistance was present in 15.5%, 1.2% and 0% of cases, respectively. Additionally, 3/60 (5%) strains had integrase inhibitor (INI)-related RAMs (an isolated E157Q mutation, which could mostly affect the susceptibility to raltegravir/elvitegravir rather than that to dolutegravir). Among the 18 children exposed to MTCT prophylaxis, RAMs were identified in only 1 case (5.6%). The proportion of fully active combinations (GSS = 3) was ≥97.6%, ≥94.1%, ≥92.9% and ≥89.3% for PI-, INI-, efavirenz/nevirapine- and rilpivirine-based regimens, respectively.

Conclusions

The proportion of NRTI- and NNRTI-related TDR in children is lower in France than in low- and middle-income countries. However, we suggest favouring PI- or dolutegravir- over NNRTI-based combinations to treat newly diagnosed HIV-infected children, even in the absence of previous exposure to antiretroviral prophylaxis of MTCT.

Outcomes of protease inhibitor-based antiretroviral therapy amongst children and associated-factors in Yaoundé, Cameroon

Background

There are limited data on protease inhibitor (PI)-based antiretroviral therapy (ART) amongst children in resource-limited settings, for informing on optimal paediatric regimens.

Objective

To evaluate therapeutic response to PI-based ART amongst HIV-infected Cameroonian children.

Methods

A retrospective study was conducted amongst children aged 2–18 years receiving a PI-based ART at the Essos Hospital Centre (EHC), Yaounde, Cameroon. Primary end points were therapeutic success on PI-based ART, defined as clinical success (WHO I/II clinical stage), immunological success (CD4 ≥ 500/mm³) and viral suppression (viral load [VL]<1000 copies/ml). Factors associated with therapeutic success were assessed in uni- and multivariate analysis using SPSS software v.2.0; with p<0.05 considered statistically significant.

Results

A total of 71 eligible children on PI-based ART were enrolled (42 on initial and 29 on substituted regimens), with a median age of 8 [IQR: 5–12] years and mean duration on ART of 7 years. Following therapeutic responses, all (100%) experienced clinical success, 95.2% experienced immunological success (91.7% on initial and 97.2% on substituted PI/r-based regimens) and 74.7% viral suppression. In univariate analysis, viral suppression was associated with: younger age (p<0.0001), living with parents as opposed to guardians (p = 0.049), and the educational level (p<0.0001). In multivariate analysis, only the age ranges of 10–14 years (OR: 0.22 [0.07–0.73]) and 15–18 years (OR: 0.08 [0.02–0.57]), were determinants of poor viral suppression.

Conclusion

Among these Cameroonian children, PI-based ART confers favourable clinical and immunological outcomes. The poor rate of viral suppression was mainly attributed to adolescence (10–18 years).

Implementation of a point mutation assay for HIV drug resistance testing in Kenya

OBJECTIVES

An increasing prevalence of HIV pretreatment drug resistance (PDR) has been observed in Africa, which could decrease the effectiveness of antiretroviral therapy (ART) programs. We describe our experiences, the costs and challenges of implementing an oligonucleotide ligation assay (OLA) for management of PDR in Nairobi, Kenya.

DESIGN

An observational report of the implementation of OLA in a Kenyan laboratory for a randomized clinical trial evaluating whether onsite use of OLA in individuals initiating ART would decrease rates of virologic failure.

METHODS

Compared detection of mutations and proportion of mutants in participants' viral quasispecies by OLA in Kenya vs. Seattle. Reviewed records of laboratory workflow and performance of OLA. Calculated the costs of laboratory set-up and of performing the OLA based on equipment purchase receipts and supplies and labor utilization, respectively.

RESULTS

OLA was performed on 492 trial participants. Weekly batch-testing of median of seven (range: 2-13) specimens provided test results to Kenyan clinicians within 10-14 days of sample collection at a cost of US$ 42 per person tested. Cost of laboratory setup was US$ 32 594. Challenges included an unreliable local supply chain for reagents and the need for an experienced molecular biologist to supervise OLA performance.

CONCLUSION

OLA was successfully implemented in a Kenyan research laboratory. Cost was twice that projected because of fewer than predicted specimens per batch because of slow enrollment. OLA is a potential simple, low-cost method for PDR testing in resource-limited settings (RLS). Ongoing work to develop a simplified kit could improve future implementation of OLA in RLS.