HIV treatment failure-a retrospective analysis of patients receiving 2nd line ARVS at the Tshepong wellness clinic
Date
2016-10-25
Authors
Motse, Kagiso Grace
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Abstract
Background: Expansion of the antiretroviral (ARV) programme has led to an increasing number of patients requiring second line ARV therapy. Little is known about the outcomes and factors influencing the success of second line regimens in South Africa, a resource limited setting.
Objectives: To report the treatment outcomes of patients on second line ARVs, and factors predisposing to treatment failure.
Methods: We conducted a retrospective record review of patients receiving Lopinavir/ritonavir (lpv/rtv) containing second line ARVs at a public hospital in Klerksdorp, South Africa.
Results: In the two years to December 2012, 383 potentially eligible patients were included in the study. 160 were excluded due to: switches due to adverse drug reactions (14%) or absence of an HIV viral load (VL) after second line regimen change (26%). Of the 223 included patients, median age was 42 years (IQR, 36 – 49), and 58% were women. Overall, median baseline CD4 count at first ARV initiation was 96 cells/mm3 (IQR, 36 – 160) and at initiation of lpv/rtv was 179 cells/mm3 (IQR, 101 – 275). The median VL at second line initiation was 46,838 (IQR, 21,341-151,333). Median follow up was 62 months (IQR, 46 – 83) since first line ARV initiation and 27 months (IQR: 19-42) since second line initiation; 47% of patients had suppressed VL on second line ARVs with a median time to suppression of seven months (IQR, 6 – 12 months) after switch. By Kaplan Meier survival analysis, the
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mean time to second line treatment failure from initiation of ARVs was 43.6 months. The median CD4 count and HIV VL at the time of the regimen switch was 148 cells/mm3 (IQR, 71-221) and 49,000 copies/ml (IQR, 12,000-176,400), respectively. Thirty six (16%) of study patients had genotypic drug resistance studies performed. Of these, 75% had significant NRTI and NNRTI mutations. There were no clinically significant PI mutations. Using univariate and multivariate analysis, predictors of treatment failure were as follows: 1) patients never suppressed on first line therapy (HR 1.798, 95% CI 1.239 – 2.610) and 2) age > 49 years (HR 1.577, 95% CI 1.159 – 2.942).
Conclusion: This study showed that there is an high rate of failure on second line ARVs in this resource-limited setting with increasing age and failure to suppress on first line therapy associated with treatment failure. Adherence is a major patient mediated factor, which fosters the selection of resistance mutations. Based on earnest results, second line ARVs would be effective in all the patients who received resistance testing. Reinforcement of adherence and compliance measures is needed, clinicians require training, and the role of resistance testing in these patients needs to be evaluated.
Description
A research report submitted in partial fulfilment of the requirements for the degree: MMED (internal medicine), University of the Witwatersrand
February 2016