Second-line antiretroviral therapy: long-term outcomes in South Africa

• Type of Material: Article
• Authors: Rirchard A. Murphy, University of Southern California School of Medicine; Henry Sunpath, McCord Hospital; Carmen Castilla, University of Medicine and Dentistry of New Jersey; Shameez Ebrahim, McCord Hospital; Richard Court, University of Cape Town; Hoang Nguyen, Johns Hopkins Bloomberg School of Public Health; Daniel Kuritzkes, Brigham and Women's Hospital; Vincent Marconi, Emory University; Jean B Nachega, Stellenbosch University
• Language: English
• Date: 2012-10-01
• Publisher: Lippincott, Williams & Wilkins
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2012 by Lippincott Williams & Wilkins
• Final Published Version (URL): http://dx.doi.org/10.1097/QAI.0b013e3182615ad1
• Title of Journal or Parent Work: Journal of Acquired Immune Deficiency Syndromes
• ISSN: 1525-4135
• Volume: 61
• Issue: 2
• Start Page: 158
• End Page: 163
• Grant/Funding Information: The project was supported in part by the IDSA Medical Scholars Program, the Arnold P. Gold Foundation Medical Student Scholarship, Partners AIDS Research Center, McCord Hospital, and by NIH grants K24-RR016482 and P30 AI060354.
• Keywords: resource-limited settings; ADULTS; South Africa; SURVIVAL; FAILURE; second-line antiretroviral therapy; Immunology; ADHERENCE; Life Sciences & Biomedicine; Science & Technology; RESISTANCE; Infectious Diseases; adherence
• Research Categories: Biology, Virology; Health Sciences, Immunology; Health Sciences, Epidemiology

Abstract

Currently, boosted protease inhibitor-containing regimens are the only option after first-line regimen failure available for patients in most resource-limited settings, yet little is known about long-term adherence and outcomes. METHODS: We enrolled patients with virologic failure (VF) who initiated lopinavir/ritonavir-containing second-line antiretroviral therapy (ART). Medication possession ratios were calculated using pharmacy refill dates. Factors associated with 12-month second-line virologic suppression [viral load (VL) < 50 copies/mL] and adherence were determined. RESULTS: One hundred six patients (median CD4 count and VL at failure: 153 cells/mm and 28,548 copies/mL, respectively) were enrolled. Adherence improved after second-line ART switch (median adherence 6 months prior, 67%; median adherence during initial 6 months of second-line ART, 100%; P = 0.001). Higher levels of adherence during second-line ART was associated with virologic suppression at month 12 of ART (odds ratio 2.5 per 10% adherence increase, 95% CI 1.3 to 4.8, P = 0.01). Time to virologic suppression was most rapid among patients with 91%-100% adherence compared with patients with 80%-90% and < 80% adherence (log rank test, P = 0.01). VF during 24 months of second-line ART was moderate (month 12: 25%, n = 32/126; month 18: 21%, n = 23/112; and month 24: 25%, n = 25/99). CONCLUSIONS: The s witch to second-line ART in South Africa was associated with an improvement in adherence, however, a moderate ongoing rate of VF-among approximately 25% of patients receiving second-line ART patients at each follow-up interval-was a cause for concern. Adherence level was associated with second-line ART virologic outcome, helping explain why some patients achieved virologic suppression after switch and others did not.