Switching to second-line antiretroviral therapy in resource-limited settings: comparison of programmes with and without viral load monitoring

Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland.
AIDS (London, England) (Impact Factor: 5.55). 07/2009; 23(14):1867-74. DOI: 10.1097/QAD.0b013e32832e05b2
Source: PubMed

ABSTRACT In high-income countries, viral load is routinely measured to detect failure of antiretroviral therapy (ART) and guide switching to second-line ART. Viral load monitoring is not generally available in resource-limited settings. We examined switching from nonnucleoside reverse transcriptase inhibitor (NNRTI)-based first-line regimens to protease inhibitor-based regimens in Africa, South America and Asia.
Multicohort study of 17 ART programmes. All sites monitored CD4 cell count and had access to second-line ART and 10 sites monitored viral load. We compared times to switching, CD4 cell counts at switching and obtained adjusted hazard ratios for switching (aHRs) with 95% confidence intervals (CIs) from random-effects Weibull models.
A total of 20 113 patients, including 6369 (31.7%) patients from 10 programmes with access to viral load monitoring, were analysed; 576 patients (2.9%) switched. Low CD4 cell counts at ART initiation were associated with switching in all programmes. Median time to switching was 16.3 months [interquartile range (IQR) 10.1-26.6] in programmes with viral load monitoring and 21.8 months (IQR 14.0-21.8) in programmes without viral load monitoring (P < 0.001). Median CD4 cell counts at switching were 161 cells/microl (IQR 77-265) in programmes with viral load monitoring and 102 cells/microl (44-181) in programmes without viral load monitoring (P < 0.001). Switching was more common in programmes with viral load monitoring during months 7-18 after starting ART (aHR 1.38; 95% CI 0.97-1.98), similar during months 19-30 (aHR 0.97; 95% CI 0.58-1.60) and less common during months 31-42 (aHR 0.29; 95% CI 0.11-0.79).
In resource-limited settings, switching to second-line regimens tends to occur earlier and at higher CD4 cell counts in ART programmes with viral load monitoring compared with programmes without viral load monitoring.

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Available from: Mar Pujades-Rodríguez, Sep 28, 2015
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    • "Regular virological monitoring has been shown to be useful both in resource rich and resource limited settings [7,8]. However, due to cost implications, this is not currently recommended for routine use in most developing country settings. "
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    • "As ART is becoming more affordable and accessible, inexpensive laboratory tests are also needed to monitor the progression of disease in HIV infected individuals living in resource-limited settings, where HIV burden is usually high1. HIV treatment can be managed without routine laboratory assessment2, but CD4+ T cell count monitoring allows the evaluation of disease progression3, and viral load testing can increase adherence and facilitate timely switching of failing regimens, minimizing the development of resistance45. Thus, use of a combination of CD4 counts and HIV viral load testing in the management of ART provides higher prognostic estimation of the risk of disease progression than does the use of either test alone67. "
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    The Indian Journal of Medical Research 12/2011; 134(6):823-34. DOI:10.4103/0971-5916.92628 · 1.40 Impact Factor
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    • "For these reasons, the 2010 WHO recommendations are likely to amplify debate on the importance of routine viral load testing compared with other resource-constrained decisions. Published data are insufficient to guide this decision [1-6,8,9]. "
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