High rate of virological failure and low rate of switching to second-line treatment among adolescents and adults living with HIV on first-line ART in Myanmar, 2005-2015

Abstract

BackgroundThe number of people living with HIV on antiretroviral treatment (ART) in Myanmar has been increasing rapidly in recent years. This study aimed to estimate rates of virological failure on first-line ART and switching to second-line ART due to treatment failure at the Integrated HIV Care program (IHC).MethodsRoutinely collected data of all adolescent and adult patients living with HIV who were initiated on first-line ART at IHC between 2005 and 2015 were retrospectively analyzed. The cumulative hazard of virological failure on first-line ART and switching to second-line ART were estimated. Crude and adjusted hazard ratios were calculated using the Cox regression model to identify risk factors associated with the two outcomes.ResultsOf 23,248 adults and adolescents, 7,888 (34%) were tested for HIV viral load. The incidence rate of virological failure among those tested was 3.2 per 100 person-years follow-up and the rate of switching to second-line ART among all patients was 1.4 per 100 person-years follow-up. Factors associated with virological failure included: being adolescent; being lost to follow-up at least once; having WHO stage 3 and 4 at ART initiation; and having taken first-line ART elsewhere before coming to IHC. Of the 1032 patients who met virological failure criteria, 762 (74%) switched to second-line ART.ConclusionsWe found high rates of virological failure among one third of patients in the cohort who were tested for viral load. Of those failing virologically on first-line ART, about one quarter were not switched to second-line ART. Routine viral load monitoring, especially for those identified as having a higher risk of treatment failure, should be considered in this setting to detect all patients failing on first-line ART. Strategies also need to be put in place to prevent treatment failure and to treat more of those patients who are actually failing.

Uptake of routine viral load testing among people living with HIV and its implementation challenges in Yangon region of Myanmar: a mixed-methods study

“…A study conducted while targeted VL testing was in practice reported uptake of VL testing in about 34% of the PLHIV receiving care under the ‘Integrated HIV Care’ (IHC) programme 15. The VL testing uptake among those availing ART services at public health facilities remained unknown.…”

First-line antiretroviral treatment and virological response among HIV adult patients at an accredited HIV care center, Cameroon

“…The greater VR among PLHIV on first-line regimens is observed and reported wherever HIV infection prevails throughout Low-and Middle-Income Countries. The variation in proportion of patients failing first-line ART observed in the field is remarkably high and variable, ranging from 8 to 16.9% in Africa [11][12][13][14][15][16][17][18][19] and from 8.9 to 13% elsewhere [20][21][22]. The few retrospective studies conducted at Accredited HIV Care Center (AHCC) in the Northwest, Southwest and Littoral regions of Cameroon have shown treatment failure on first-line ART between16 and 23.2% [2,[23][24][25].…”

<p>HIV-1 Drug Resistance in ART-Naïve Individuals in Myanmar</p>

“…47 Currently, tenofovir (TDF), lamivudine (3TC)/emtricitabine (FTC) and efavirenz (EFV) is the preferentially and frequently used ART first-line regime for initiation of ART in ART-naïve individuals in Myanmar and the patients receiving TDF+3TC+EFV regimen had better adherence and were less likely to switch to a protease inhibitor-containing second-line ART regimen. 24,39 Therefore, increasing the coverage of the first-line regimen will benefit most ART-naïve individuals, and contribute to the control of TDRs. In spite of this, in view of high HIV-1 genetic diversity and high prevalence of TDRs in ART-naïve individuals in the China-Myanmar border region, the molecular monitoring of HIV-1 drug resistance should be strengthened.…”

“…23 A recent study focusing on Burmese adolescents and adults receiving first-line ART during 2005 to 2015 reported a high rate (3.2 per 100 person-years follow-up) of virological failure but a low opportunity (1.4 per 100 person-years follow-up) to switch to secondline ART regimens. 24 High prevalence of drug resistance among ART-treated individuals can spread HIV-1 drug resistance to ART-naïve individuals, and lead to a high proportion of VF in the latter after they initiate ART. 9,25,26 Northern Myanmar borders Yunnan, China, and is the hardest-hit region by the HIV-1 epidemic.…”