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Vaz P, Buck WC, Bhatt N, Bila D, Auld A, Houston J, Cossa L, Alfredo C, Jobarteh K, Sabatier J, Macassa E, Sousa A, DeVos J, Jani I, Yang C. Compromise of Second-Line Antiretroviral Therapy Due to High Rates of Human Immunodeficiency Virus Drug Resistance in Mozambican Treatment-Experienced Children With Virologic Failure. J Pediatric Infect Dis Soc 2020; 9:6-13. [PMID: 30364958 DOI: 10.1093/jpids/piy102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 09/25/2018] [Indexed: 11/12/2022]
Abstract
BACKGROUND Virologic failure (VF) is highly prevalent in sub-Saharan African children on antiretroviral therapy (ART) and is often associated with human immunodeficiency virus drug resistance (DR). Most children still lack access to routine viral load (VL) monitoring for early identification of treatment failure, with implications for the efficacy of second-line ART. METHODS Children aged 1 to 14 years on ART for ≥12 months at 6 public facilities in Maputo, Mozambique were consecutively enrolled after informed consent. Chart review and caregiver interviews were conducted. VL testing was performed, and specimens with ≥1000 copies/mL were genotyped. RESULTS Of the 715 children included, the mean age was 103 months, 85.8% had no immunosuppression, 73.1% were taking stavudine/lamivudine/nevirapine, and 20.1% had a history prevention of mother-to-child transmission exposure. The mean time on ART was 60.0 months. VF was present in 259 patients (36.3%); 248 (95.8%) specimens were genotyped, and DR mutations were found in 238 (96.0%). Severe immunosuppression and nutritional decline were associated with DR. M184V and Y181C were the most common mutations. In the 238 patients with DR, standard second-line ART would have 0, 1, 2, and 3 effective antiretrovirals in 1 (0.4%), 74 (31.1%), 150 (63.0%), and 13 (5.5%) patients, respectively. CONCLUSION This cohort had high rates of VF and DR with frequent compromise of second-line ART. There is urgent need to scale-up VL monitoring and heat-stable protease inhibitor formulations or integrase inhibitorsfor a more a durable first-line regimen that can feasibly be implemented in developing settings.
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Affiliation(s)
- Paula Vaz
- Fundação Ariel Glaser, Maputo, Mozambique
| | - W Chris Buck
- University of California Los Angeles, David Geffen School of Medicine
| | | | - Dulce Bila
- Fundação Ariel Glaser, Maputo, Mozambique.,Instituto Nacional de Saúde, Maputo, Mozambique
| | - Andrew Auld
- Division of Global HIV and TB, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - James Houston
- Division of Global HIV and TB, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Loide Cossa
- Instituto Nacional de Saúde, Maputo, Mozambique
| | - Charity Alfredo
- Centers for Disease Control and Prevention, Maputo, Mozambique
| | - Kebba Jobarteh
- Centers for Disease Control and Prevention, Maputo, Mozambique
| | - Jennifer Sabatier
- Division of Global HIV and TB, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Amina Sousa
- Instituto Nacional de Saúde, Maputo, Mozambique
| | - Josh DeVos
- Division of Global HIV and TB, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ilesh Jani
- Instituto Nacional de Saúde, Maputo, Mozambique
| | - Chunfu Yang
- Division of Global HIV and TB, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
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Newman LP, Pagkas-Bather J, Njoroge A, Wamalwa D, Nduati R, Overbaugh J, Farquhar C. Virological failure in children living with HIV on antiretroviral therapy: correlates and predictive value of clinical measurements and CD4 cell count. Int J STD AIDS 2019; 30:1207-1213. [PMID: 31558136 DOI: 10.1177/0956462419871422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Clinical correlates and CD4 cell count are used to predict HIV virological failure among children living with HIV in resource-limited settings, but there are limited data on their prediction of treatment failure compared to viral measurement. Using HIV viral load as a gold standard, sensitivity and specificity of longitudinal CD4 responses and clinical changes were defined in children living with HIV on antiretroviral therapy (ART) for ≥6 months in Kenya. Prevalence and correlates of virological failure were determined using log-binomial regression with robust standard error. Among 223 children who were followed for 12 months, median age in years at HIV diagnosis, ART initiation, and study enrollment were 3.3, 3.6, and 7.5, respectively. Older children at HIV diagnosis and ART initiation were less likely to experience virological failure. Immunological and clinical failure had low sensitivity (0 and 2%, respectively) to identify virological failure. Among those with virological failure, there was no indication from immunological markers and only two (2%) indicated with clinical markers. Clinical and immunological monitoring of HIV were insensitive and poor predictors of virological failure, emphasizing the importance of routine virological monitoring to inform ART treatment decisions for children living with HIV.
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Affiliation(s)
- Laura P Newman
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | - Anne Njoroge
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Dalton Wamalwa
- Department of Paediatrics, University of Nairobi, Nairobi, Kenya
| | - Ruth Nduati
- Department of Paediatrics, University of Nairobi, Nairobi, Kenya
| | - Julie Overbaugh
- Divisions of Public Health Sciences and Human Biology, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Carey Farquhar
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA
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3
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Moolasart V, Chottanapund S, Ausavapipit J, Likanonsakul S, Uttayamakul S, Changsom D, Lerdsamran H, Puthavathana P. The Effect of Detectable HIV Viral Load among HIV-Infected Children during Antiretroviral Treatment: A Cross-Sectional Study. CHILDREN-BASEL 2018; 5:children5010006. [PMID: 29301267 PMCID: PMC5789288 DOI: 10.3390/children5010006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 12/20/2017] [Accepted: 12/27/2017] [Indexed: 11/24/2022]
Abstract
The RNA viral load of human immunodeficiency virus (HIV) is initially used to determine the status of the HIV infection. The goal of therapy following treatment failure is to achieve and maintain virologic suppression. A detectable viral load may relate to the progression of HIV infection. A cross-sectional survey was conducted from January 2013 to December 2014 at the Bamrasnaradura Infectious Diseases Institute, Thailand. The aim was to determine the prevalence of detectable HIV viral load (dVL) and analyze the factors associated with post-dVL conditions that occur independently of a switch to a new antiretroviral agent. The prevalence of dVL was 27% (27 of 101). The mean ages of dVL and non-dVL children were 12.0 and 12.3 years, respectively. Age, sex, body mass index for age z-scores, previous tuberculosis disease history and parental tuberculosis history of both groups were not significantly different (p > 0.05). The prevalence of poor adherence (<95%), influenza-like illness (ILI) and opportunistic infections were higher in dVL than non-dVL children (p < 0.05). The mean nadir CD4 cell count during the study was lower in dVL than non-dVL children (646 compared to 867, respectively; p < 0.05). Other factors were not significant (all p > 0.05). In multivariable analysis, dVL was significantly associated with ILI (odds ratio (OR) = 9.6, 95% confidence interval (CI) = 1.3–69.4), adherence (OR = 0.195, 95% CI = 0.047–0.811) and nadir CD4 during the study (OR = 1.102, 95% CI = 1.100–1.305). The prevalence of dVL was 27% with this dVL among HIV-infected children found to be associated with ILI, poor adherence and lower nadir CD4 during the study.
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Affiliation(s)
- Visal Moolasart
- Bamrasnaradura Infectious Diseases Institute, Ministry of Public Health, 11000 Nonthaburi, Thailand.
| | - Suthat Chottanapund
- Bamrasnaradura Infectious Diseases Institute, Ministry of Public Health, 11000 Nonthaburi, Thailand.
| | - Jarurnsook Ausavapipit
- Bamrasnaradura Infectious Diseases Institute, Ministry of Public Health, 11000 Nonthaburi, Thailand.
| | - Sirirat Likanonsakul
- Bamrasnaradura Infectious Diseases Institute, Ministry of Public Health, 11000 Nonthaburi, Thailand.
| | - Sumonmal Uttayamakul
- Bamrasnaradura Infectious Diseases Institute, Ministry of Public Health, 11000 Nonthaburi, Thailand.
| | - Don Changsom
- Department of Microbiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 10700 Bangkok, Thailand.
| | - Hatairat Lerdsamran
- Department of Microbiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 10700 Bangkok, Thailand.
| | - Pilaipan Puthavathana
- Department of Microbiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 10700 Bangkok, Thailand.
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Karade SK, Kulkarni SS, Ghate MV, Patil AA, Londhe R, Salvi SP, Kadam DB, Joshi RK, Rewari BB, Gangakhedkar RR. Antiretroviral resistance following immunological monitoring in a resource-limited setting of western India: A cross-sectional study. PLoS One 2017; 12:e0181889. [PMID: 28763465 PMCID: PMC5538665 DOI: 10.1371/journal.pone.0181889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 07/07/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The free antiretroviral therapy (ART) program in India still relies on the clinico-immunological monitoring for diagnosis of treatment failure. As the nucleoside reverse transcriptase inhibitor (NRTI) backbone is shared in first- and second-line regimens, accumulation of drug resistant mutations (DRMs) can compromise the efficacy of NRTI. This study was undertaken to describe the pattern of HIV DRMs following immunological monitoring and investigate its impact on the cycling of NRTI between first- and second-line ART. METHODS AND FINDINGS This cross-sectional study was performed at a state-sponsored ART clinic of Pune city in western India between January and June 2016. Consecutive adults receiving first-line ART with immunological failure (IF) were recruited for plasma viral load (PVL) estimation. Randomly selected 80 participants with PVL >1000 copies/mL underwent HIV drug resistance genotyping. Of these, 75 plasma sample were successfully genotyped. The median CD4 count and duration of ART at the time of failure were 98 (IQR: 61.60-153.50) cells/μL and 4.62 (IQR: 3.17-6.15) years, respectively. The prevalence of NRTI, non-NRTI, and major protease inhibitor resistance mutations were 89.30%, 96%, and 1.33%, respectively. Following first-line failure, sequences from 56.67% of individuals indicated low- to high-level resistance to all available NRTI. The proportion of sequences with ≥2 thymidine analogue mutations (TAMs) and ≥3 TAMs were 62.12% and 39.39%, respectively. An average of 1.98 TAMs per sequence were observed following IF as compared to 0.37 TAMs per sequence following targeted PVL monitoring at 12 months of ART from a prior study; this difference was significant (p<0.001). CONCLUSION The option of cycling of NRTI analogues between first- and second-line regimens would no longer be effective if individuals are followed-up by immunological monitoring due to accumulation of mutations. Introduction of routine PVL monitoring is a priority for the long-term sustainability of free ART program in India.
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Affiliation(s)
- Santosh K. Karade
- HIV Drug Resistance Laboratory, National AIDS Research Institute (ICMR), Pune, India
- Department of Microbiology, Armed Forces Medical College, Pune, India
| | - Smita S. Kulkarni
- Department of Virology, National AIDS Research Institute (ICMR), Pune, India
| | - Manisha V. Ghate
- Department of Clinical Sciences, National AIDS Research Institute (ICMR), Pune, India
| | - Ajit A. Patil
- HIV Drug Resistance Laboratory, National AIDS Research Institute (ICMR), Pune, India
| | - Rajkumar Londhe
- Department of Virology, National AIDS Research Institute (ICMR), Pune, India
| | - Sonali P. Salvi
- Department of Medicine, BJ Medical College and Sasoon General Hospital, Pune, India
| | - Dileep B. Kadam
- Department of Medicine, BJ Medical College and Sasoon General Hospital, Pune, India
| | - Rajneesh K. Joshi
- Department of Epidemiology and Biostatistics, National AIDS Research Institute (ICMR), Pune, India
- Department of Community Medicine, Armed Forces Medical college, Pune, India
| | - Bharat B. Rewari
- Department of AIDS Control, National AIDS Control Organization, New Delhi, India
| | - Raman R. Gangakhedkar
- Department of Clinical Sciences, National AIDS Research Institute (ICMR), Pune, India
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5
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Gunda DW, Kidenya BR, Mshana SE, Kilonzo SB, Mpondo BCT. Accuracy of WHO immunological criteria in identifying virological failure among HIV-infected adults on First line antiretroviral therapy in Mwanza, North-western Tanzania. BMC Res Notes 2017; 10:45. [PMID: 28095920 PMCID: PMC5240422 DOI: 10.1186/s13104-016-2334-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 12/10/2016] [Indexed: 11/10/2022] Open
Abstract
Background Optimal HIV treatment monitoring remains a big challenge in resource limited settings. Guidelines recommend the use of clinical and immunological criteria in resource limited settings due to unavailability of viral load monitoring; however their utility is questionable. This study aimed at assessing the accuracy of immunological criteria in detecting treatment failure among HIV infected Tanzanian adults receiving first line ART. Methods A clinic based cross sectional study was conducted between February and July 2011 at Bugando Medical centre (BMC) HIV care and treatment clinic (CTC) involving HIV infected patients aged 18 years and above, receiving first line ART; followed up for at least 1 year. Viral load was tested for every enrolled patient. Standard WHO criteria were used to define immunological failure. Virological failure was defined as one viral load measurement of >5000 copies/ml and was used as a gold standard. A 2 × 2 table was used to assess the accuracy of immunological criteria in detecting treatment failure. Results A total of 274 HIV-infected adults were enrolled into the study. Out of these, 65.7% were females, the median age was 39 years (IQR 33–45), the median BMI 21.9 kg/m2 (IQR 19.7–24.0). Out of the 274 study participants 156 (56.9%) had immunological failure. Only 60 of the study participants (21.9%) had viral load >5000. Only 42 patients (70%) were found to have both immunological failure and virological failure. The sensitivity of immunological criteria in detecting treatment failure was 70%, specificity 46.7%, positive predictive and negative predictive values of 26.9 and 84.7% respectively. Conclusion WHO immunological criteria have low sensitivity and positive predictive value for detecting treatment failure. Relying on CD4 counts for treatment monitoring would therefore lead to misclassifications of treatment failure that could result into unnecessary or delayed switch to second line ART. Access to viral load monitoring is important to avoid these misclassifications.
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Affiliation(s)
- Daniel W Gunda
- Department of Medicine, Weill Bugando School of Medicine, Mwanza, Tanzania
| | - Benson R Kidenya
- Department of Biochemistry and Molecular Biology, Weill Bugando School of Medicine, Mwanza, Tanzania
| | - Stephen E Mshana
- Department of Microbiology/Immunology, Weill Bugando School of Medicine, Mwanza, Tanzania
| | - Semvua B Kilonzo
- Department of Medicine, Weill Bugando School of Medicine, Mwanza, Tanzania
| | - Bonaventura C T Mpondo
- Department of Medicine, College of Health Sciences, The University of Dodoma, P.O Box 395, Dodoma, Tanzania.
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6
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Hoffmann CJ, Maritz J, van Zyl GU. CD4 count-based failure criteria combined with viral load monitoring may trigger worse switch decisions than viral load monitoring alone. Trop Med Int Health 2015; 21:219-23. [PMID: 26584666 DOI: 10.1111/tmi.12639] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE CD4 count decline often triggers antiretroviral regimen switches in resource-limited settings, even when viral load testing is available. We therefore compared CD4 failure and CD4 trends in patients with viraemia with or without antiretroviral resistance. METHODS Retrospective cohort study investigating the association of HIV drug resistance with CD4 failure or CD4 trends in patients on first-line antiretroviral regimens during viraemia. Patients with viraemia (HIV RNA >1000 copies/ml) from two HIV treatment programmes in South Africa (n = 350) were included. We investigated the association of M184V and NNRTI resistance with WHO immunological failure criteria and CD4 count trends, using chi-square tests and linear mixed models. RESULTS Fewer patients with the M184V mutation reached immunologic failure criteria than those without: 51 of 151(34%) vs. 90 of 199 (45%) (P = 0.03). Similarly, 79 of 220 (36%) patients, who had major NNRTI resistance, had immunological failure, whereas 62 of 130 (48%) without (chi-square P = 0.03) did. The CD4 count decline among patients with the M184V mutation was 2.5 cells/mm(3) /year, whereas in those without M184V it was 14 cells/mm(3) /year (P = 0.1), but the difference in CD4 count decline with and without NNRTI resistance was marginal. CONCLUSION Our data suggest that CD4 count monitoring may lead to inappropriate delayed therapy switches for patients with HIV drug resistance. Conversely, patients with viraemia but no drug resistance are more likely to have a CD4 count decline and thus may be more likely to be switched to a second-line regimen.
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Affiliation(s)
- Christopher J Hoffmann
- Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Aurum Institute, Johannesburg, South Africa
| | - Jean Maritz
- National Health Laboratory Service, Tygerberg, Cape Town, South Africa.,Division of Medical Virology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Gert U van Zyl
- National Health Laboratory Service, Tygerberg, Cape Town, South Africa.,Division of Medical Virology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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7
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Chakravarty J, Sundar S, Chourasia A, Singh PN, Kurle S, Tripathy SP, Chaturbhuj DN, Rai M, Agarwal AK, Mishra RN, Paranjape RS. Outcome of patients on second line antiretroviral therapy under programmatic condition in India. BMC Infect Dis 2015; 15:517. [PMID: 26572102 PMCID: PMC4647630 DOI: 10.1186/s12879-015-1270-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 11/06/2015] [Indexed: 11/10/2022] Open
Abstract
Background The National AIDS Control Organization of India has been providing free second line antiretroviral therapy (ART) since 2008. This observational study reports the survival and virologic suppression of patients on second-line ART under programmatic condition and type of mutations acquired by those failing therapy. Methods 170 patients initiated on second-line therapy between 2008 and 2012 were followed up till 2013. Viral Load (VL) was repeated at 6 months for all patients and at 12 months for those with VL >400 copies/ml at 6 months. Adequate virological response was defined as plasma HIV-1 VL <400 copies/ml and virological failure was defined as VL >1000 copies/ml. Genotyping was done in 16 patients with virological failure. Results Out of 170 patients, 110 (64.7 %) were alive and on therapy and 35 (20.5 %) expired. In the first year the occurrence of death was 13.7 /100 person years while between1 and 5 year it was 3.88 /100 person years. In the first year, duration of immunological failure >12 months, weight <45 kg, WHO clinical stage 3 and 4 and WHO criteria CD4 count less than pretherapy baseline [hazard ratio HR 4.2. 15.8, 11.9 & 4.1 respectively] and beyond first year poor first and second line adherence and first line CD4 count < 200/μL [HR 5.2,15.8, 3.3 respectively] had high risk of death. 119/152 (78.2 %) had adequate virological response and 27/152 (17.7 %) had virological failure. High viral load at baseline and poor second line adherence (Odds Ratio 3.4 & 2.8 respectively) had increased risk of virological failure. Among those genotyped, 50 % had major Protease Inhibitor mutation (M46I commonest) however 87.5 % were still susceptible to darunavir. Conclusions Second line therapy has shown high early mortality but good virological suppression under programmatic conditions.
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Affiliation(s)
- Jaya Chakravarty
- Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, 221005, India.
| | - Shyam Sundar
- Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, 221005, India.
| | - Ankita Chourasia
- Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, 221005, India.
| | - Pallav Narayan Singh
- Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, 221005, India.
| | - Swarali Kurle
- Indian Council of Medical Research, National AIDS Research Institute, Bhosari, Pune, India.
| | - Srikanth P Tripathy
- Indian Council of Medical Research, National JALMA Institute of Leprosy and Other Mycobacterial Diseases, Agra, India.
| | - Devidas N Chaturbhuj
- Indian Council of Medical Research, National AIDS Research Institute, Bhosari, Pune, India.
| | - Madhukar Rai
- Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, 221005, India.
| | - Amit Kumar Agarwal
- Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, 221005, India.
| | - Rabindra Nath Mishra
- Department of Community Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India.
| | - Ramesh S Paranjape
- Indian Council of Medical Research, National AIDS Research Institute, Bhosari, Pune, India.
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Maddali MV, Dowdy DW, Gupta A, Shah M. Economic and epidemiological impact of early antiretroviral therapy initiation in India. J Int AIDS Soc 2015; 18:20217. [PMID: 26434780 PMCID: PMC4592848 DOI: 10.7448/ias.18.1.20217] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 07/31/2015] [Accepted: 08/25/2015] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Recent WHO guidance advocates for early antiretroviral therapy (ART) initiation at higher CD4 counts to improve survival and reduce HIV transmission. We sought to quantify how the cost-effectiveness and epidemiological impact of early ART strategies in India are affected by attrition throughout the HIV care continuum. METHODS We constructed a dynamic compartmental model replicating HIV transmission, disease progression and health system engagement among Indian adults. Our model of the Indian HIV epidemic compared implementation of early ART initiation (i.e. initiation above CD4 ≥350 cells/mm(3)) with delayed initiation at CD4 ≤350 cells/mm(3); primary outcomes were incident cases, deaths, quality-adjusted-life-years (QALYs) and costs over 20 years. We assessed how costs and effects of early ART initiation were impacted by suboptimal engagement at each stage in the HIV care continuum. RESULTS Assuming "idealistic" engagement in HIV care, early ART initiation is highly cost-effective ($442/QALY-gained) compared to delayed initiation at CD4 ≤350 cells/mm(3) and could reduce new HIV infections to <15,000 per year within 20 years. However, when accounting for realistic gaps in care, early ART initiation loses nearly half of potential epidemiological benefits and is less cost-effective ($530/QALY-gained). We project 1,285,000 new HIV infections and 973,000 AIDS-related deaths with deferred ART initiation with current levels of care-engagement in India. Early ART initiation in this continuum resulted in 1,050,000 new HIV infections and 883,000 AIDS-related deaths, or 18% and 9% reductions (respectively), compared to current guidelines. Strengthening HIV screening increases benefits of earlier treatment modestly (1,001,000 new infections; 22% reduction), while improving retention in care has a larger modulatory impact (676,000 new infections; 47% reduction). CONCLUSIONS Early ART initiation is highly cost-effective in India but only has modest epidemiological benefits at current levels of care-engagement. Improved retention in care is needed to realize the full potential of earlier treatment.
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Affiliation(s)
- Manoj V Maddali
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - David W Dowdy
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Amita Gupta
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Maunank Shah
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA;
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9
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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: 22] [Impact Index Per Article: 2.2] [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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10
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Salazar-Vizcaya L, Keiser O, Technau K, Davies MA, Haas AD, Blaser N, Cox V, Eley B, Rabie H, Moultrie H, Giddy J, Wood R, Egger M, Estill J. Viral load versus CD4⁺ monitoring and 5-year outcomes of antiretroviral therapy in HIV-positive children in Southern Africa: a cohort-based modelling study. AIDS 2014; 28:2451-60. [PMID: 25392857 DOI: 10.1097/qad.0000000000000446] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVES Many paediatric antiretroviral therapy (ART) programmes in Southern Africa rely on CD4⁺ to monitor ART. We assessed the benefit of replacing CD4⁺ by viral load monitoring. DESIGN A mathematical modelling study. METHODS A simulation model of HIV progression over 5 years in children on ART, parameterized by data from seven South African cohorts. We simulated treatment programmes with 6-monthly CD4⁺ or 6- or 12-monthly viral load monitoring. We compared mortality, second-line ART use, immunological failure and time spent on failing ART. In further analyses, we varied the rate of virological failure, and assumed that the rate is higher with CD4⁺ than with viral load monitoring. RESULTS About 7% of children were predicted to die within 5 years, independent of the monitoring strategy. Compared with CD4⁺ monitoring, 12-monthly viral load monitoring reduced the 5-year risk of immunological failure from 1.6 to 1.0% and the mean time spent on failing ART from 6.6 to 3.6 months; 1% of children with CD4⁺ compared with 12% with viral load monitoring switched to second-line ART. Differences became larger when assuming higher rates of virological failure. When assuming higher virological failure rates with CD4⁺ than with viral load monitoring, up to 4.2% of children with CD4⁺ compared with 1.5% with viral load monitoring experienced immunological failure; the mean time spent on failing ART was 27.3 months with CD4⁺ monitoring and 6.0 months with viral load monitoring. Conclusion: Viral load monitoring did not affect 5-year mortality, but reduced time on failing ART, improved immunological response and increased switching to second-line ART.
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