Incidence and Predictors of Death, Retention, and Switch to Second‐Line Regimens in Antiretroviral‐Treated Patients in Sub‐Saharan African Sites with Comprehensive Monitoring Availability

Palombi, Leonardo; Marazzi, Maria Cristina; Guidotti, Giovanni; Germano, Paola; Buonomo, E; Scarcella, P; Altan, A Doro; Zimba, I; Lio, Massimo Magnano San; Luca, Andrea De

doi:10.1086/593312

Cited by 99 publications

(106 citation statements)

References 37 publications

(38 reference statements)

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“…During the study period, 54 (11.1%) patients died, and this compares well with other studies that had similar rates of mortality [21,22]. Of interest is that the mortality rate of patients with HIV-TB coinfection on anti-TB therapy was similar to that of patients without TB with similar median duration to death of 13 weeks.…”

Section: Discussionsupporting

confidence: 81%

“…A previous study in Tanzania showed a mortality rate of 30% in patients coinfected with HIV and TB in the absence of HAART, and these deaths were associated with HIV infection, low CD4 + T-cell counts, low Karnofsky scores and high viral loads [18]. Other studies also show that the majority of the deaths occur within 3 months of starting HAART, with predictors of mortality being anaemia, severe malnutrition, male sex, lower baseline CD4 + T-cell counts and a more advanced clinical stage of infection [19][20][21][22]. CD4 + T-cell counts dramatically alter the clinical presentation of TB because cell-mediated immunity is essential to host defence against mycobacterial infection.…”

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confidence: 99%

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Risk Factors for Mortality among HIV-Positive Patients with and without Active Tuberculosis in Dar Es Salaam, Tanzania

et al. 2012

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Background: The aim of this study was to describe risk factors for mortality and clinical characteristics of HIVinfected patients with and without tuberculosis (TB) coinfection. Methods: A cohort of HIV-infected patients with CD4 + T-cell counts of ≤200 cells/ml was recruited, consisting of 255 HIV-infected patients without active TB and 231 patients with active TB. All received a well-supervised treatment with an efavirenz-based HAART, and those coinfected with TB received appropriate anti-TB treatment. They were followed up for 48 weeks after HAART initiation. Results: Common presenting symptoms in HIV-only patients were fever (36.5%), headache (34.5%), skin rash (34.5%) and weight loss (32%), while in HIV-TB patients the symptoms were weight loss (58%), cough (57.6%), night sweats (44.6%) and fever (34.2%). HIV-TB patients had significantly lower body mass index, Karnofsky scores and haemoglobin levels compared to those infected with HIV only, despite similar baseline CD4 + T-cell counts. Overall, 12 (4.7%) HIV patients developed TB and 7 (3%) HIV-TB patients had worsening of their TB symptoms during the study period. Mortality was similar in the two groups, being 10.9% (16 deaths per 100 person years) and 11.3% (17 deaths per 100 person years) in HIV-only and HIV-TB patients, respectively. Overall, more males (13.1%) died compared to females (9.6%). Predictors of mortality were presence of oral candidiasis, Kaposi's sarcoma, low Karnofsky score, and low baseline white blood cell and CD4 + T-cell counts. Conclusions: The outcomes following well-supervised treatment of HIV-TB patients are similar to those in patients with HIV alone. Predictors of mortality were those of advanced disease.

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Section: Discussionsupporting

confidence: 81%

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confidence: 99%

Risk Factors for Mortality among HIV-Positive Patients with and without Active Tuberculosis in Dar Es Salaam, Tanzania

et al. 2012

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“…23,24,25 A multi-cohort analysis from Mozambique, Malawi and Guinea-Conakry also found that patients with low baseline CD4 and patients who started treatment in earlier calendar years had higher probability of switching. 26 The DART trial in Uganda and Zimbabwe compared three-monthly CD4 count monitoring and clinical monitoring and found higher switching rates in the CD4 monitoring arm. 27 Similarly, the ANRS 12110 trial in Cameroon reported that patients in whom VL and CD4 cell counts were measured every 6 months had higher rates of switching than patients assigned to clinical monitoring.…”

Section: Discussionmentioning

confidence: 99%

Monitoring and switching of first-line antiretroviral therapy in adult treatment cohorts in sub-Saharan Africa: collaborative analysis

et al. 2015

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Background HIV-1 viral load (VL) testing is recommended to monitor antiretroviral therapy (ART) but not universally available. We examined monitoring of first-line and switching to second-line ART in sub-Saharan Africa, 2004–2013. Methods Adult HIV-1 infected patients starting combination ART in 16 countries were included. Switching was defined as a change from a non-nucleoside reverse-transcriptase inhibitor (NNRTI)-based regimen to a protease inhibitor (PI)-based regimen, with a change of ≥1 NRTI. Virological and immunological failures were defined per World Health Organization criteria. We calculated cumulative probabilities of switching and hazard ratios with 95% confidence intervals (CI) comparing routine VL monitoring, targeted VL monitoring, CD4 cell monitoring and clinical monitoring, adjusted for programme and individual characteristics. Findings Of 297,825 eligible patients, 10,352 patients (3·5%) switched during 782,412 person-years of follow-up. Compared to CD4 monitoring hazard ratios for switching were 3·15 (95% CI 2·92–3·40) for routine VL, 1·21 (1·13–1·30) for targeted VL and 0·49 (0·43–0·56) for clinical monitoring. Overall 58.0% of patients with confirmed virological and 19·3% of patients with confirmed immunological failure switched within 2 years. Among patients who switched the percentage with evidence of treatment failure based on a single CD4 or VL measurement ranged from 32·1% with clinical to 84.3% with targeted VL monitoring. Median CD4 counts at switching were 215 cells/µl under routine VL monitoring but lower with other monitoring (114–133 cells/µl). Interpretation Overall few patients switched to second-line ART and switching occurred late in the absence of routine viral load monitoring. Switching was more common and occurred earlier with targeted or routine viral load testing.

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“…In a larger cohort analysis of factors associated with modification to the first ART regimen in the Asia–Pacific region (major modification defined as starting a new class or substituting two or more antiretrovirals from within the same class) no significant difference according to gender was reported. 15 Similarly, a retrospective study from sub-Saharan Africa reporting on 3749 participants from three African countries found that male sex was a predictor of mortality after starting ART, but that gender was not a predictor of the switch to a second-line combination. 16 In contrast, a recent study from Canada examined outcomes and factors associated with switching for non-virological failure and reported that switching at least twice was less likely if you were male (adjusted odds ratio 0.53 95% CI 0.39–0.71).…”

Section: Discussionmentioning

confidence: 99%

How do outcomes compare between women and men living with HIV in Australia? An observational study

Giles

Zapata

Wright³

et al. 2016

Sex. Health

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Background Gender differences vary across geographical settings and are poorly reported in the literature. The aim of this study was to evaluate demographics and clinical characteristics of participants from the Australian HIV Observational Database (AHOD), and to explore any differences between females and males in the rate of new clinical outcomes, as well as initial immunological and virological response to antiretroviral therapy. Methods Time to a new clinical end-point, all-cause mortality and/or AIDS illness was analysed using standard survival methods. Univariate and covariate adjusted Cox proportional hazard models were used to evaluate the time to plasma viral load suppression in all patients that initiated antiretroviral therapy (ART) and time to switching from a first-line ART to a second-line ART regimen. Results There was no significant difference between females and males for the hazard of all-cause mortality [adjusted hazard ratio: 0.98 (0.51, 1.55), P = 0.67], new AIDS illness [adjusted hazard ratio: 0.75 (0.38, 1.48), P = 0.41] or a composite end-point [adjusted hazard ratio: 0.74 (0.45, 1.21), P = 0.23]. Incident rates of all-cause mortality were similar between females and males; 1.14 (0.61, 1.95) vs 1.28 (1.12, 1.45) per 100 person years. Virological response to ART was similar for females and males when measured as time to viral suppression and/or time to virological failure. Conclusion This study supports current Australian HIV clinical care as providing equivalent standards of care for male and female HIV-positive patients. Future studies should compare ART-associated toxicity differences between ART-associated toxicity differences between men and women living with HIV in Australia.

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Incidence and Predictors of Death, Retention, and Switch to Second‐Line Regimens in Antiretroviral‐Treated Patients in Sub‐Saharan African Sites with Comprehensive Monitoring Availability

Abstract: In an antiretroviral treatment program employing comprehensive monitoring, the probability of switching to second-line therapy was limited. Regular pickup of medication was a predictor of survival and was also strongly predictive of patient retention.

Cited by 99 publications

References 37 publications

Risk Factors for Mortality among HIV-Positive Patients with and without Active Tuberculosis in Dar Es Salaam, Tanzania

Risk Factors for Mortality among HIV-Positive Patients with and without Active Tuberculosis in Dar Es Salaam, Tanzania

Monitoring and switching of first-line antiretroviral therapy in adult treatment cohorts in sub-Saharan Africa: collaborative analysis

How do outcomes compare between women and men living with HIV in Australia? An observational study

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