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Yuan L, Chen K, Cai Y, Zhou Z, Yang J, Jiqu W, Zhu Q, Zhang H, Niu S, Sun H. Analysis of ART effects and drug resistance in adult HIV/AIDS patients in Meigu County, Liangshan Prefecture, China. BMC Infect Dis 2024; 24:155. [PMID: 38302941 PMCID: PMC10832074 DOI: 10.1186/s12879-024-09048-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 01/23/2024] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND OBJECTIVE This study aimed to understand the basic situation of adults with human immunodeficiency virus (HIV) receiving antiretroviral therapy (ART) in Meigu County, Liangshan Yi Autonomous Prefecture. The information of patients who had been on ART for more than 6 months, the effect of ART, the possible reasons for ART failure, knowledge of drug resistance among patients with ART failure and the possible reasons for the emergence of drug resistance were analyzed. METHODS A total of 2753 people living with HIV (PLWH) were collected for HIV-1 RNA virus nucleic acid testing. Plasma specimens with HIV-1 RNA ≥ 1000 copies/mL were sent to the laboratory for nucleic acid extraction, PCR, electrophoresis and sequencing, and the sequencing results were submitted to the HIV drug resistance database of Stanford University for subtyping to determine the drug resistance mutation sites and drug sensitivity levels. RESULTS A total of 2753 patients were enrolled in this study. Antiviral therapy failed in 288 patients and was successfully amplified in 245, of which 111 had resistance genes. The resistance rate to failure of viral suppression was 45.3% (111/245). The highest rates of resistance to NNRTIs were found for efavirenz (EFV) and nevirapine (NVP) (42.9%), and the highest rates of resistance to NRTIs were found for 3TC and emtricitabine (FTC) (15.9%). The most common NNRTI resistance mutation site was K103N (20.8%), followed by V179D (9.4%) and V106M (7.8%); the most common NRTI resistance mutation site was M184V/I/MV (14.3%), followed by K65R (6.9%); three PI-associated resistance mutation sites were identified. The subtype of the resistant strain was CRF07-BC in almost all patients (98.9%). CONCLUSIONS Compared with the previous low ART efficacy in the county, this study showed that the overall virological failure (VF) resistance rate in the county is still low, dominated by resistance to EFV, NVP, 3TC, FTC, and didanosine (DDI). Due to economic constraints, the core regimen is still 3TC + TDF, but before initiating ART, testing for HIV-1 subtypes and resistance should be conducted to avoid resistance that can lead to VF, especially for patients with high risk factors for resistance as shown by epidemiologic investigations.
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Affiliation(s)
- Li Yuan
- Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Kaiyou Chen
- Meigu County People's Hospital, Meigu, Liangshan Prefecture, Sichuan, China
| | - Yuanfang Cai
- Meigu County People's Hospital, Meigu, Liangshan Prefecture, Sichuan, China
| | - Zhonghui Zhou
- Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Ju Yang
- Meigu County People's Hospital, Meigu, Liangshan Prefecture, Sichuan, China
| | - Wuti Jiqu
- Meigu County People's Hospital, Meigu, Liangshan Prefecture, Sichuan, China
| | - Qirong Zhu
- Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Hong Zhang
- Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Shaowei Niu
- Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Hui Sun
- Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China.
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Jennings L, Kellermann T, Spinelli M, Nkantsu Z, Cogill D, van Schalkwyk M, Decloedt E, van Zyl G, Orrell C, Gandhi M. Drug Resistance, Rather than Low Tenofovir Levels in Blood or Urine, Is Associated with Tenofovir, Emtricitabine, and Efavirenz Failure in Resource-Limited Settings. AIDS Res Hum Retroviruses 2022; 38:455-462. [PMID: 34779228 PMCID: PMC9225825 DOI: 10.1089/aid.2021.0135] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
The high cost of viral load (VL) testing limits its use for antiretroviral therapy (ART) adherence support. A low-cost lateral flow urine tenofovir (TFV) rapid assay predicts pre-exposure prophylaxis breakthroughs, but has not yet been investigated in HIV treatment. We therefore evaluated its utility in a pilot cross-sectional study of TFV-containing ART recipients at an increased risk of virologic failure (VF). Participants who had a treatment interruption ≥30 days or had ≥1 episode of viremia (VL ≥400 copies/mL) in the previous year were recruited from a public health setting in Cape Town, South Africa. Self-reported adherence data were collected, the urine TFV assay performed, and concurrent TFV-diphosphate analyzed in dried blood spots. VL testing was done concurrently and, if viremic, genotypic HIV drug resistance testing was performed. Of 48 participants, 18 (37.5%) had VL (>400 copies/mL) at the time of the study, including 16 of 39 receiving efavirenz (EFV), 2 of 6 receiving protease inhibitors, and 0 of 3 receiving dolutegravir. Resistance testing succeeded in 17/18, of which 14 had significant mutations compromising ≥2 agents of the current EFV-based regimen. Of these 14, all had detected urine TFV. Urine TFV was undetectable in two out of three without regimen-relevant resistance; p = .02. In participants on EFV-based regimens returning to care, VF was largely due to viral resistance, where detectable urine TFV had 100% sensitivity (14/14 participants) in predicting resistance. Conversely, when undetectable, the urine-based assay could be used to preclude participants with poor adherence from undergoing costly HIV drug resistance testing.
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Affiliation(s)
- Lauren Jennings
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, South Africa
| | - Tracy Kellermann
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Matthew Spinelli
- Division of HIV, Infectious Diseases, and Global Medicine at UCSF/San Francisco General Hospital, San Francisco, California, USA
| | - Zukiswa Nkantsu
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, South Africa
| | - Dolphina Cogill
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, South Africa
| | - Marije van Schalkwyk
- Division of Infectious Diseases, Department of Medicine, Stellenbosch University, Cape Town, South Africa
| | - Eric Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Gert van Zyl
- Division of Medical Virology, Stellenbosch University, Faculty of Medicine and Health Sciences, Cape Town, South Africa
- National Health Laboratory Service, Tygerberg Business Unit, Cape Town, South Africa
| | - Catherine Orrell
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, South Africa
| | - Monica Gandhi
- Division of HIV, Infectious Diseases, and Global Medicine at UCSF/San Francisco General Hospital, San Francisco, California, USA
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Zhou C, Zhang W, Lu R, Ouyang L, Xing H, Shao Y, Wu G, Ruan Y. Higher Risk of Mortality and Virologic Failure in HIV-Infected Patients With High Viral Load at Antiretroviral Therapy Initiation: An Observational Cohort Study in Chongqing, China. Front Public Health 2022; 10:800839. [PMID: 35186841 PMCID: PMC8851314 DOI: 10.3389/fpubh.2022.800839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 01/05/2022] [Indexed: 12/15/2022] Open
Abstract
Background Viral load (VL) is a strong predictor of human immunodeficiency virus (HIV) disease progression. The aim of this study was to evaluate the effect of high baseline VL on antiretroviral therapy (ART) outcomes among HIV-infected patients. Methods This retrospective study observed HIV-infected patients who had baseline VL test at ART initiation between 2015 and 2019 in Chongqing, China. Cox proportional hazards regression and logistic regression models were used to evaluate the effects of baseline VL on Acquired immunodeficiency syndrome (AIDS)-related mortality and virologic failure, respectively. Results The cohort included 7,176 HIV-infected patients, of whom 38.7% had a baseline VL ≥ 100,000 copies/mL. Of the patients who died during follow-up, 58.9% had a baseline VL ≥ 100,000 copies/mL. Compared with a baseline VL < 10,000 copies/mL, ART initiation at VL ≥ 100,000 copies/mL was significantly associated with the AIDS-related death (adjusted hazard ratio, AHR = 1.4) and virologic failure (adjusted odds ratio, AOR = 2.4). Compared with patients with a baseline VL < 10,000 copies/mL, patients on the recommended first-line regimen with a VL ≥ 100,000 copies/mL at ART initiaition had higher mortality rate (5.1 vs. 1.7 per 100 person-years), but there was no significant difference in the mortality accoding to the initial VL level among patients on second-line ART (2.8 vs. 2.7 per 100 person-years). ART initiation ≤ 30 days after HIV diagnosis was associated with a lower risk of AIDS-related death (AHR = 0.6). Conclusions ART initiation with VL ≥ 100,000 copies/mL was associated with a significantly greater risk of mortality and virologic failure. Optimizing the ART regimen and initiating ART early may help to reduce mortality effectively among patients with a high baseline VL. VL testing for all HIV patients is recommended at HIV diagnosis or on ART initiation.
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Affiliation(s)
- Chao Zhou
- Chongqing Municipal Center for Disease Control and Prevention, Chongqing, China
| | - Wei Zhang
- Chongqing Municipal Center for Disease Control and Prevention, Chongqing, China
| | - Rongrong Lu
- Chongqing Municipal Center for Disease Control and Prevention, Chongqing, China
| | - Lin Ouyang
- Chongqing Municipal Center for Disease Control and Prevention, Chongqing, China
| | - Hui Xing
- State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Beijing, China
| | - Yiming Shao
- State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Beijing, China
| | - Guohui Wu
- Chongqing Municipal Center for Disease Control and Prevention, Chongqing, China
- *Correspondence: Guohui Wu
| | - Yuhua Ruan
- State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Beijing, China
- Yuhua Ruan
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Lailulo Y, Kitenge M, Jaffer S, Aluko O, Nyasulu PS. Factors associated with antiretroviral treatment failure among people living with HIV on antiretroviral therapy in resource-poor settings: a systematic review and metaanalysis. Syst Rev 2020; 9:292. [PMID: 33308294 PMCID: PMC7733304 DOI: 10.1186/s13643-020-01524-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 11/08/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Despite the increase in the number of people accessing antiretroviral therapy (ART), there is limited data regarding treatment failure and its related factors among HIV-positive individuals enrolled in HIV care in resource-poor settings. This review aimed to identify factors associated with antiretroviral treatment failure among individuals living with HIV on ART in resource-poor settings. METHODS We conducted a comprehensive search on MEDLINE (PubMed), Excerpta Medica Database (EMBASE), Cochrane Central Register of Controlled Trials (CENTRAL), World Health Organization's (WHO's) library database, and Latin American and Caribbean Health Sciences Literature (LILACS). We included observational studies (cohort, case-control, and cross-sectional studies) where adolescents and adults living with HIV were on antiretroviral treatment regardless of the ART regimen. The primary outcomes of interest were immunological, virological, and clinical failure. Some of the secondary outcomes were mm3 opportunistic infections, WHO clinical stage, and socio-demographic factors. We screened titles, abstracts, and the full texts of relevant articles in duplicate. Disagreements were resolved by consensus. We analyzed the data by doing a meta-analysis to pool the results for each outcome of interest. RESULTS Antiretroviral failure was nearly 6 times higher among patients who had poor adherence to treatment as compared to patients with a good treatment adherence (OR = 5.90, 95% CI 3.50, 9.94, moderate strength of evidence). The likelihood of the treatment failure was almost 5 times higher among patients with CD4 < 200 cells/mm3 compared to those with CD4 ≥ 200 CD4 cells/mm3 (OR = 4.82, 95% CI 2.44, 9.52, low strength of evidence). This result shows that poor adherence and CD4 count below < 200 cells/mm3 are significantly associated with treatment failure among HIV-positive patients on ART in a resource-limited setting. CONCLUSION This review highlights that low CD4 counts and poor adherence to ART were associated to ART treatment failure. There is a need for healthcare workers and HIV program implementers to focus on patients who have these characteristics in order to prevent ART treatment failure. SYSTEMATIC REVIEW REGISTRATION The systematic review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO), registration number: 2019 CRD42019136538.
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Affiliation(s)
- Yishak Lailulo
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Marcel Kitenge
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Médecins Sans Frontières (MSF), Eshowe, KwaZulu Natal South Africa
| | - Shahista Jaffer
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Omololu Aluko
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Peter Suwirakwenda Nyasulu
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Epidemiology & Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Basson AE, Charalambous S, Hoffmann CJ, Morris L. HIV-1 re-suppression on a first-line regimen despite the presence of phenotypic drug resistance. PLoS One 2020; 15:e0234937. [PMID: 32555643 PMCID: PMC7302689 DOI: 10.1371/journal.pone.0234937] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 06/04/2020] [Indexed: 11/26/2022] Open
Abstract
We have previously reported on HIV-1 infected patients who fail anti-retroviral therapy but manage to re-suppress without a regimen change despite harbouring major drug resistance mutations. Here we explore phenotypic drug resistance in such patients in order to better understand this phenomenon. Patients (n = 71) failing a non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimen, but who subsequently re-suppressed on the same regimen, were assessed for HIV-1 genotypic drug resistance through Sanger sequencing. A subset (n = 23) of these samples, as well as genotypically matched samples from patients who did not re-suppress (n = 19), were further assessed for phenotypic drug resistance in an in vitro single cycle assay. Half of the patients (n = 36/71, 51%) harboured genotypic drug resistance, with M184V (n = 18/36, 50%) and K103N (n = 16/36, 44%) being the most prevalent mutations. No significant difference in the median time to re-suppression (31–39 weeks) were observed for either group (p = 0.41). However, re-suppressors with mutant virus rebounded significantly earlier than those with wild-type virus (16 vs. 33 weeks; p = 0.014). Similar phenotypic drug resistance profiles were observed between patients who re-suppressed and patients who failed to re-suppress. While most remained susceptible to stavudine (d4T) and zidovudine (AZT), both groups showed a reduced susceptibility to 3TC and NNRTIs. HIV- 1 infected patients on an NNRTI-based regimen can achieve viral re-suppression on the same regimen despite harbouring viruses with genotypic and phenotypic drug resistance. However, re-suppression was less durable in those with resistance, reinforcing the importance of appropriate regimen choices, ongoing viral load monitoring and adherence counselling.
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Affiliation(s)
- Adriaan E. Basson
- Centre for HIV and STIs, National Institute for Communicable Diseases of The National Health Laboratory Services, Johannesburg, Gauteng, South Africa
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
- * E-mail:
| | - Salome Charalambous
- The Aurum Institute, Johannesburg, Gauteng, South Africa
- School of Public Health, Faculty of Health Sciences, University of The Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Christopher J. Hoffmann
- The Aurum Institute, Johannesburg, Gauteng, South Africa
- Johns Hopkins University, School of Medicine, Baltimore, Maryland, United States of America
| | - Lynn Morris
- Centre for HIV and STIs, National Institute for Communicable Diseases of The National Health Laboratory Services, Johannesburg, Gauteng, South Africa
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
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Dorward J, Sookrajh Y, Gate K, Khubone T, Mtshaka N, Mlisana K, Ngobese H, Yende‐Zuma N, Garrett N. HIV treatment outcomes among people with initiation CD4 counts >500 cells/µL after implementation of Treat All in South African public clinics: a retrospective cohort study. J Int AIDS Soc 2020; 23:e25479. [PMID: 32319203 PMCID: PMC7174836 DOI: 10.1002/jia2.25479] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 01/30/2020] [Accepted: 03/05/2020] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION The World Health Organisation recommends to Treat All people with HIV, irrespective of CD4 count. However, people with CD4 counts >500 cells/µL may be asymptomatic and therefore less motivated to adhere to antiretroviral therapy (ART). We aimed to assess whether people initiated with CD4 counts >500 cells/µL had worse treatment outcomes compared to those initiated at lower CD4 counts. METHODS We performed a retrospective cohort study among non-pregnant adults initiating ART at eight public clinics in South Africa between September 2016, when Treat All was implemented, and August 2017. We assessed whether initiation CD4 count >500 cells/µL was associated with the outcomes of attrition (death, lost to follow-up or treatment interruption >180 days), and viraemia >1000 copies/mL, by twelve months using Cox proportional hazards and Poisson regression models. RESULTS AND DISCUSSION Among 4952 patients initiating ART, the median age was 32.4 years (interquartile range (IQR) 27.2 to 39.7), 58.9% were women and 30.3% had an initiation CD4 count >500 cells/µL. After twelve months, 3382 (68.3%) were retained in care, 303 (6.1%) had transferred to another clinic, 1010 (20.4%) were lost to follow-up, 232 (4.7%) had a treatment interruption >180 days and 25 (0.5%) were known to have died. Overall, 1267 experienced attrition at a median time of 91 days (IQR 23 to 213), with 302 of these (23.8%) experiencing attrition immediately after their ART initiation visit. Among those in care at twelve months with viral load results, 4.6% had viraemia. In multivariable analysis, the hazard of attrition was similar between patients newly eligible for ART with CD4 counts >500 cells/µL compared to those with CD4 ≤500 cells/µL (adjusted hazard ratio 1.03, 95% confidence interval (CI) 0.90 to 1.17). The risk of viraemia was lower among patients with CD4 counts >500 cells/µL compared to those with CD4 ≤500 cells/µL (adjusted risk ratio 0.58, 95% CI 0.37 to 0.92). CONCLUSIONS After implementation of Treat All in South African public clinics, we found that patients newly eligible for ART with initiation CD4 counts >500 cells/µL had comparable or better outcomes compared to those with lower CD4 counts. These finding support ongoing implementation of Treat All in our setting.
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Affiliation(s)
- Jienchi Dorward
- Centre for the AIDS Programme of Research in South Africa (CAPRISA)University of KwaZulu–NatalDurbanSouth Africa
- Nuffield Department of Primary Care Health SciencesUniversity of OxfordOxfordUnited Kingdom
| | - Yukteshwar Sookrajh
- eThekwini Municipality Health Unit, eThekwini MunicipalityDurbanSouth Africa
| | - Kelly Gate
- Bethesda HospitalUbomboSouth Africa
- Department of Family MedicineUniversity of KwaZulu‐NatalDurbanSouth Africa
| | - Thokozani Khubone
- eThekwini Municipality Health Unit, eThekwini MunicipalityDurbanSouth Africa
| | - Nomsa Mtshaka
- eThekwini Municipality Health Unit, eThekwini MunicipalityDurbanSouth Africa
| | - Koleka Mlisana
- Centre for the AIDS Programme of Research in South Africa (CAPRISA)University of KwaZulu–NatalDurbanSouth Africa
- National Health Laboratory ServiceJohannesburgSouth Africa
- School of Laboratory Medicine and Medical SciencesUniversity of KwaZulu‐NatalDurbanSouth Africa
| | - Hope Ngobese
- eThekwini Municipality Health Unit, eThekwini MunicipalityDurbanSouth Africa
| | - Nonhlanhla Yende‐Zuma
- Centre for the AIDS Programme of Research in South Africa (CAPRISA)University of KwaZulu–NatalDurbanSouth Africa
| | - Nigel Garrett
- Centre for the AIDS Programme of Research in South Africa (CAPRISA)University of KwaZulu–NatalDurbanSouth Africa
- Discipline of Public Health MedicineSchool of Nursing and Public HealthUniversity of KwaZulu‐NatalDurbanSouth Africa
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Dorward J, Drain PK, Osman F, Sookrajh Y, Pillay M, Moodley P, Garrett N. Short Communication: Early Antiretroviral Therapy Is Associated with Better Viral Suppression and Less HIV Drug Resistance After Implementation of Universal Treatment in South Africa. AIDS Res Hum Retroviruses 2020; 36:297-299. [PMID: 31663368 DOI: 10.1089/aid.2019.0206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
All people living with HIV should receive antiretroviral therapy (ART), but those with CD4 counts >500 cells/mm3 at ART initiation ("early initiators") may be less motivated to adhere to treatment, compared with those with CD4 counts <200 cells/mm3 ("late initiators"). We performed a cross-sectional analysis among HIV-positive adults who had a viral load taken at 6 months after first-line ART initiation in a South African public clinic. Retrospective HIV drug resistance testing was performed on all samples with a viral load >1,000 copies/mL. We used Poisson regression models with robust variance to evaluate associations between early ART initiation and viral suppression <40 copies/mL. We assessed HIV drug resistance using descriptive statistics. Of 390 participants enrolled between February and August 2017, 60% were women and median age was 32 years [interquartile range (IQR) 27-38]. At ART initiation, median CD4 count was 366 cells/mm3 (IQR 204-546), and 30% were early initiators with CD4 > 500 cells/mm3. In multivariable analysis, early initiators were more likely to be virally suppressed compared with late initiators (adjusted risk ratio: 1.29, 95% confidence interval: 1.13-1.46). All 18 participants with viral load >1,000 copies/mL had successful genotyping, which identified drug resistance in 14/18 (77.8%). Among early initiators, drug resistance was detected in only 1/117 (0.9%), compared with 11/93 (11.8%) among late initiators. In conclusion, among people receiving ART in a South African public clinic, early initiators had better viral suppression after 6 months and less drug resistance than late initiators, which further supports universal treatment. Clinical trials registration: NCT03066128.
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Affiliation(s)
- Jienchi Dorward
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Paul K. Drain
- Department of Global Health, Schools of Medicine and Public Health, University of Washington, Seattle, Washington
- Department of Medicine, School of Medicine, University of Washington, Seattle, Washington
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington
| | - Farzana Osman
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Yukteshwar Sookrajh
- Prince Cyril Zulu Communicable Disease Centre, eThekwini Municipality, Durban, South Africa
| | - Melendhran Pillay
- Department of Virology, Inkosi Albert Luthuli Central Hospital, Cato Manor, Durban, South Africa
| | - Pravikrishnen Moodley
- Department of Virology, Inkosi Albert Luthuli Central Hospital, Cato Manor, Durban, South Africa
| | - Nigel Garrett
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
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Byonanebye DM, Semitala FC, Katende J, Bakenga A, Arinaitwe I, Kyambadde P, Musinguzi P, Biraro IA, Byakika-Kibwika P, Kamya MR. High viral suppression and low attrition in healthy HIV-infected patients initiated on ART with CD4 above 500 cells/µL in a program setting in Uganda. Afr Health Sci 2020; 20:132-141. [PMID: 33402901 PMCID: PMC7750048 DOI: 10.4314/ahs.v20i1.18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The World Health Organization recommends antiretroviral therapy (ART) for all HIV-infected patients at all CD4 counts. However, there are concerns that asymptomatic patients may have poorer viral suppression and high attrition. OBJECTIVES We sought to determine attrition and viral suppression among healthy HIV-infected patients initiated on ART in program settings. METHODS This cross-sectional study enrolled ART-experienced patients attending two PEPFAR-supported, high-volume clinics in Kampala, Uganda. Eligible patients were >18 years and had completed at least six months on ART. Participants were interviewed on socio-demographics, ART history and plasma viral load (VL) determined using Abbott Real-time. Predictors of viral suppression (<75 copies/ml) were determined using multivariate logistic regression. RESULTS Overall, 267 participants were screened, 228 were eligible and 203 (89%) retained in care (visit within 90 days). Of the 203 participants, 115 (56.7%) were key-populations. Viral suppression was achieved in 173 patients (85%; 95% CI, 80.3%-90.1%). The factors associated with viral suppression were prior VL tests (AOR 6.98; p-value <0.001) and receiving care from a general clinic (AOR 5.41; p=0.009). CONCLUSION Asymptomatic patients initiated on ART with high baseline CD4 counts, achieve high viral suppression with low risk of attrition. VL monitoring and clinic type are associated with viral suppression.
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Affiliation(s)
| | - Fred C Semitala
- Makerere University College of Health Sciences, Kampala, Uganda
- Makerere University Joint AIDS Program, Kampala, Uganda
| | | | - Alex Bakenga
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Irene Arinaitwe
- Makerere University College of Computing and Information Science
| | | | | | | | | | - Moses R Kamya
- Makerere University College of Health Sciences, Kampala, Uganda
- Infectious Diseases Research Collaboration, Kampala Uganda
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Pillay T, Cornell M, Fox MP, Euvrard J, Fatti G, Technau KG, Sipambo N, Prozesky H, Eley B, Tanser F, Johnson LF. Recording of HIV viral loads and viral suppression in South African patients receiving antiretroviral treatment: a multicentre cohort study. Antivir Ther 2020; 25:257-266. [PMID: 32960187 DOI: 10.3851/imp3371] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Viral suppression in patients on antiretroviral treatment (ART) is critical to reducing HIV transmission and HIV-related mortality. Although many studies have evaluated factors associated with viral suppression, few have assessed the extent to which missing viral load data may bias results. METHODS We included data on all patients starting ART from 2005 to 2019 in eight South African cohorts participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) collaboration. Multivariable logistic regression models were used to determine factors associated with having a viral load measurement within 2 months of a scheduled testing date and having a viral load <400 RNA copies/ml ('viral suppression'). In a sensitivity analysis, missing viral loads were imputed based on patients' clinical and demographic characteristics and outcomes. RESULTS Viral load tests were scheduled in 603,549 and 77,423 intervals in adults and children, respectively, but test results were recorded in only 40.7% and 41.2%, respectively. The proportion of recorded results suppressed was 85.7% in adults and 72.4% in children. After imputation of missing viral load measurements, viral suppression reduced slightly in adults (85.3%) and increased in children (73.2%). Predictors of virological suppression in adults, which included female sex, older age, higher baseline CD4+ T-cell count and recent testing year, were similar in the main analysis and after imputing missing viral loads. CONCLUSIONS Although viral load information was frequently missing in the South African setting, estimates of viral suppression and predictors of viral suppression did not change substantially after adjusting for missing data.
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Affiliation(s)
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Matthew P Fox
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.,Department of Global Health, Boston University School of Public Health, Boston, MA, USA.,Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Geoffrey Fatti
- Kheth'Impilo AIDS Free Living, Cape Town, South Africa.,Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | - Karl-Günter Technau
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, Department of Paediatrics and Child Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Nosisa Sipambo
- Harriet Shezi Children's Clinic, University of the Witwatersrand, Johannesburg, South Africa
| | - Hans Prozesky
- Division of Infectious Diseases, Tygerberg Academic Hospital, University of Stellenbosch, Cape Town, South Africa
| | - Brian Eley
- Red Cross War Memorial Children's Hospital and the Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Frank Tanser
- Lincoln International Institute for Rural Health, University of Lincoln, Lincoln, UK.,Africa Health Research Institute, Somkhele, KwaZulu-Natal, South Africa.,School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.,Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Leigh F Johnson
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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