Treatment outcomes of over 1000 patients on second‐line, protease inhibitor‐based antiretroviral therapy from four public‐sector HIV treatment facilities across Johannesburg, South Africa

Abstract

ObjectivesTo report predictors of outcomes of second‐line ART for HIV treatment in a resource‐limited setting.MethodsAll adult ART‐naïve patients who initiated standard first‐line treatment between April 2004 and February 2012 at four public‐sector health facilities in Johannesburg, South Africa, experienced virologic failure and initiated standard second‐line therapy were included. We assessed predictors of attrition (death and loss to follow‐up [≥3 months late for a scheduled visit]) using Cox proportional hazards regression and predictors of virologic suppression (viral load <400 copies/ml ≥3 months after switch) using modified Poisson regression with robust error estimation at 1 year and ever after second‐line ART initiation.ResultsA total of 1236 patients switched to second‐line treatment in a median (IQR) of 1.9 (0.9‐4.6) months after first‐line virologic failure. Approximately 13% and 45% of patients were no longer in care at 1 year and at the end of follow‐up, respectively. Patients with low CD4 counts (<50 vs. ≥200, aHR: 1.85; 95% CI: 1.03–3.32) at second‐line switch were at greater risk for attrition by the end of follow‐up. About 75% of patients suppressed by 1 year, and 85% had ever suppressed by the end of follow‐up.ConclusionsPatients with poor immune status at switch to second‐line ART were at greater risk of attrition and were less likely to suppress. Additional adherence support after switch may improve outcomes.

Second-line HIV treatment failure in sub-Saharan Africa: A systematic review and meta-analysis

“…The study participants of 26 studies were adults [19, 23–25, 27, 34, 40, 42–60], while that of 2 studies [22, 61] and 5 studies [6, 41, 62–64] were children and mixed age groups, respectively. Sixteen studies (n = 16) were from southern Africa [23, 27, 43, 45–52, 57, 58, 60, 62, 64]; 7 studies were from eastern Africa [22, 34, 40, 53, 55, 61, 63]; 5 studies were from western Africa [25, 41, 42, 44, 54]; and 5 studies were from mixed regions in SSA [6, 19, 24, 55, 59]. The second-line HIV treatment regimens received by the study participants were PI-based, 18 of them with ritonavir-boosted PI-based ART [24, 25, 27, 40, 42, 44, 45, 48, 49, 52–56, 58, 60, 61, 63] and 15 of them with no ritonavir in their PI-based ART regimens [6, 19, 22, 23, 34, 41, 43...…”

Retention in care and virological failure among adult HIV+ patients on second-line ART in Rwanda: a national representative study

“…Among the 181,921 individuals on ART in Rwanda [9], 174,252 (95.8%) received first-line ART and 7625 (4.2%) received second-line ART by 31st December 2016 while 44 patients were on third line ART [16]. Figure 1 presents a flow diagram of the second line ART Rwanda study sites and the patient selection process.

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Cohort profile: the Right to Care Clinical HIV Cohort, South Africa

“…The need for second-line treatment has been growing as treatment scale up has continued, but there is little robust data on outcomes among patients who have already failed a first-line regimen. 34 With data on 1435 patients on second-line ART between 2004 and 2013, we found that a low CD4 count (<50 cells/mm 3 ) at the time of switch was strongly predictive of mortality (adjusted HR (aHR) vs ≥200 cells/mm 3 : 3.76; 95% CI: 1.87 to 7.57) as was a high viral load (≥50 000 copies/mL vs 1000–4999 copies/mL aHR: 2.01; 95% CI: 1.07 to 3.77). 33 The results suggest that earlier switch would likely benefit patients failing first-line before disease progresses to severe immunosuppression.…”