High efficacy of lopinavir/r-based second-line antiretroviral treatment after 24 months of follow up at ESTHER/Calmette Hospital in Phnom Penh, Cambodia

Family Health International, Phnom Penh, Cambodia.
Journal of the International AIDS Society (Impact Factor: 5.09). 03/2011; 14(1):14. DOI: 10.1186/1758-2652-14-14
Source: PubMed


The number of patients on second-line highly active antiretroviral therapy (HAART) regimens is increasing in resource-limited settings. We describe the outcomes after 24 months for patients on LPV/r-based second-line regimens followed up by the ESTHER programme in Phnom Penh, Cambodia.
Seventy patients who initiated second-line HAART regimens more than 24 months earlier were included, and immuno-virological data analyzed. HIV RNA viral load was determined by real-time RT-PCR. HIV-1 drug resistance was interpreted according to the ANRS algorithm.
Of the 70 patients, two were lost to follow up, three died and 65 (92.8%) remained on second-line treatment after 24 months of follow up (median duration of treatment: 27.4 months). At switch to second-line, the median CD4 T cell count was 106 cells/mm³ and the median viral load was 4.7 Log10. Second-line regimens prescribed were ddI/3TC/LPV/r (65.7%), ddI/TDF/LPV/r (10.0%), ddI/AZT/LPV/r (8.6%) and TDF/3TC/LPV/r (7.1%). The median CD4 T cell gain was +258 cells/mm³ at 24 months (n = 63). After 24 months of follow up, 92.3% (60/65) of the patients presented undetectable viral loads, giving an overall treatment success rate of 85.7% (CI: 75.6- 92.0) in intent-to-treat analysis.
These data suggest that a LPV/r-based second-line regimen is associated with a high rate of virological suppression and immune reconstitution after 24 months of follow up in Cambodia.

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    • "Recent meta-analysis of 19 studies found that that proportion of patients achieving viral suppression dropped from 78% at 6 months to 62% at 36 months of starting second-line regimen [8]. However, there was substantially heterogeneity between studies, with some studies reporting success rates of around and more than 90% [13-16]. In our study more than 80% of patients consistently had undetectable levels of viral load after 6 months of second-line ART. "
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    • "Early diagnosis of treatment failure can, therefore, support strategies for treatment adherence, and transform treatment failure into successful treatment prior to the establishment of a resistance [59]; (2) the currently practiced diagnosis of treatment failure based on immuno-clinical results is responsible for excess switches in treatment regimens since its specificity is low [60,61]; generalizing viral load measurements would, therefore, prevent unnecessary decisions to switch to second-line regimens [58,62]; (3) virological failure precedes immuno-clinical failure; using immuno-clinical criteria for switching treatment regimens implies continuation of ineffective treatment for a longer period of time and, therefore, an accumulation of nucleosides reverse transcriptase inhibitors (NRTI) resistance which affects the remainant choices for NRTI use in second-line regimens [62]; (4) existing cost-effectiveness models suggest that monitoring viral load in routine may be cost-effective [63]. Although cost-effective, plasma viral load comes with a cost. "
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