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

IeDEA southern Africa, east Africa, and west Africa

Research output: Contribution to journalArticle

49 Citations (Scopus)

Abstract

Background HIV-1 viral load testing is recommended to monitor antiretroviral therapy (ART) but is not universally available. The aim of our study was to assess monitoring of first-line ART and switching to second-line ART in sub-Saharan Africa. Methods We did a collaborative analysis of cohort studies from 16 countries in east Africa, southern Africa, and west Africa that participate in the international epidemiological database to evaluate AIDS (IeDEA). We included adults infected with HIV-1 who started combination ART between January, 2004, and January, 2013. We defined switching of ART as a change from a non-nucleoside reverse-transcriptase inhibitor (NNRTI)-based regimen to one including a protease inhibitor, with adjustment of one or more nucleoside reverse-transcriptase inhibitors (NRTIs). Virological and immunological failures were defined according to WHO criteria. We calculated cumulative probabilities of switching and hazard ratios with 95% CIs comparing routine viral load monitoring, targeted viral load monitoring, CD4 monitoring, and clinical monitoring, adjusting for programme and individual characteristics. Findings Of 297 825 eligible patients, 10 352 (3%) switched to second-line ART during 782 412 person-years of follow-up. Compared with CD4 monitoring, hazard ratios for switching were 3.15 (95% CI 2.92-3.40) for routine viral load monitoring, 1.21 (1.13-1.30) for targeted viral load monitoring, and 0.49 (0.43-0.56) for clinical monitoring. Of 6450 patients with confirmed virological failure, 58.0% (95% CI 56.5-59.6) switched by 2 years, and of 15 892 patients with confirmed immunological failure, 19.3% (18.5-20.0) switched by 2 years. Of 10 352 patients who switched, evidence of treatment failure based on one CD4 count or viral load measurement ranged from 86 (32%) of 268 patients with clinical monitoring to 3754 (84%) of 4452 with targeted viral load monitoring. Median CD4 counts at switching were 215 cells per μL (IQR 117-335) with routine viral load monitoring, but were lower with other types of monitoring (range 114-133 cells per μL). Interpretation Overall, few patients switched to second-line ART and switching happened late in the absence of routine viral load monitoring. Switching was more common and happened earlier after initiation of ART with targeted or routine viral load testing.

Original languageEnglish (US)
Pages (from-to)e271-e278
JournalThe Lancet HIV
Volume2
Issue number7
DOIs
StatePublished - Jul 1 2015

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Africa South of the Sahara
Viral Load
Therapeutics
Reverse Transcriptase Inhibitors
CD4 Lymphocyte Count
HIV-1
Southern Africa
Eastern Africa
Western Africa
Protease Inhibitors
Treatment Failure
Nucleosides
Acquired Immunodeficiency Syndrome
Cohort Studies
Databases

ASJC Scopus subject areas

  • Infectious Diseases
  • Epidemiology
  • Immunology
  • Virology

Cite this

Monitoring and switching of first-line antiretroviral therapy in adult treatment cohorts in sub-Saharan Africa : Collaborative analysis. / IeDEA southern Africa, east Africa, and west Africa.

In: The Lancet HIV, Vol. 2, No. 7, 01.07.2015, p. e271-e278.

Research output: Contribution to journalArticle

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title = "Monitoring and switching of first-line antiretroviral therapy in adult treatment cohorts in sub-Saharan Africa: Collaborative analysis",
abstract = "Background HIV-1 viral load testing is recommended to monitor antiretroviral therapy (ART) but is not universally available. The aim of our study was to assess monitoring of first-line ART and switching to second-line ART in sub-Saharan Africa. Methods We did a collaborative analysis of cohort studies from 16 countries in east Africa, southern Africa, and west Africa that participate in the international epidemiological database to evaluate AIDS (IeDEA). We included adults infected with HIV-1 who started combination ART between January, 2004, and January, 2013. We defined switching of ART as a change from a non-nucleoside reverse-transcriptase inhibitor (NNRTI)-based regimen to one including a protease inhibitor, with adjustment of one or more nucleoside reverse-transcriptase inhibitors (NRTIs). Virological and immunological failures were defined according to WHO criteria. We calculated cumulative probabilities of switching and hazard ratios with 95{\%} CIs comparing routine viral load monitoring, targeted viral load monitoring, CD4 monitoring, and clinical monitoring, adjusting for programme and individual characteristics. Findings Of 297 825 eligible patients, 10 352 (3{\%}) switched to second-line ART during 782 412 person-years of follow-up. Compared with CD4 monitoring, hazard ratios for switching were 3.15 (95{\%} CI 2.92-3.40) for routine viral load monitoring, 1.21 (1.13-1.30) for targeted viral load monitoring, and 0.49 (0.43-0.56) for clinical monitoring. Of 6450 patients with confirmed virological failure, 58.0{\%} (95{\%} CI 56.5-59.6) switched by 2 years, and of 15 892 patients with confirmed immunological failure, 19.3{\%} (18.5-20.0) switched by 2 years. Of 10 352 patients who switched, evidence of treatment failure based on one CD4 count or viral load measurement ranged from 86 (32{\%}) of 268 patients with clinical monitoring to 3754 (84{\%}) of 4452 with targeted viral load monitoring. Median CD4 counts at switching were 215 cells per μL (IQR 117-335) with routine viral load monitoring, but were lower with other types of monitoring (range 114-133 cells per μL). Interpretation Overall, few patients switched to second-line ART and switching happened late in the absence of routine viral load monitoring. Switching was more common and happened earlier after initiation of ART with targeted or routine viral load testing.",
author = "{IeDEA southern Africa, east Africa, and west Africa} and Haas, {Andreas D.} and Olivia Keiser and Eric Balestre and Steve Brown and Emmanuel Bissagnene and Cleophas Chimbetete and Fran{\cc}ois Dabis and Davies, {Mary Ann} and Hoffmann, {Christopher J.} and Patrick Oyaro and Rosalind Parkes-Ratanshi and Reynolds, {Steven J.} and Izukanji Sikazwe and Kara Wools-Kaloustian and Zannou, {D. Marcel} and Gilles Wandeler and Matthias Egger and Andrew Boulle and Lucy Campbell and Morna Cornell and Leigh Johnson and Nicola Maxwell and Landon Myer and Michael Schomaker and Mireille Porter and Fred Nalugoda and Benjamin Chi and Frank Tanser and Christopher Hoffimann and Denise Naniche and Robin Wood and Kathryn Stinson and Geoffirey Fatti and Sam Phiri and Janet Giddy and Kennedy Malisita and Brian Eley and Michael Hobbins and Kamelia Kamenova and Olatunbosun Faturiyele and Matthew Fox and Hans Prozesky and Karl Technau and Shobna Sawry and Julia Bohlius and Nello Blaser and Janne Estill and Luisa Salazar-Vizcaya and Andreas Haas and Constantin Yiannoutsos",
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T1 - Monitoring and switching of first-line antiretroviral therapy in adult treatment cohorts in sub-Saharan Africa

T2 - Collaborative analysis

AU - IeDEA southern Africa, east Africa, and west Africa

AU - Haas, Andreas D.

AU - Keiser, Olivia

AU - Balestre, Eric

AU - Brown, Steve

AU - Bissagnene, Emmanuel

AU - Chimbetete, Cleophas

AU - Dabis, François

AU - Davies, Mary Ann

AU - Hoffmann, Christopher J.

AU - Oyaro, Patrick

AU - Parkes-Ratanshi, Rosalind

AU - Reynolds, Steven J.

AU - Sikazwe, Izukanji

AU - Wools-Kaloustian, Kara

AU - Zannou, D. Marcel

AU - Wandeler, Gilles

AU - Egger, Matthias

AU - Boulle, Andrew

AU - Campbell, Lucy

AU - Cornell, Morna

AU - Johnson, Leigh

AU - Maxwell, Nicola

AU - Myer, Landon

AU - Schomaker, Michael

AU - Porter, Mireille

AU - Nalugoda, Fred

AU - Chi, Benjamin

AU - Tanser, Frank

AU - Hoffimann, Christopher

AU - Naniche, Denise

AU - Wood, Robin

AU - Stinson, Kathryn

AU - Fatti, Geoffirey

AU - Phiri, Sam

AU - Giddy, Janet

AU - Malisita, Kennedy

AU - Eley, Brian

AU - Hobbins, Michael

AU - Kamenova, Kamelia

AU - Faturiyele, Olatunbosun

AU - Fox, Matthew

AU - Prozesky, Hans

AU - Technau, Karl

AU - Sawry, Shobna

AU - Bohlius, Julia

AU - Blaser, Nello

AU - Estill, Janne

AU - Salazar-Vizcaya, Luisa

AU - Haas, Andreas

AU - Yiannoutsos, Constantin

PY - 2015/7/1

Y1 - 2015/7/1

N2 - Background HIV-1 viral load testing is recommended to monitor antiretroviral therapy (ART) but is not universally available. The aim of our study was to assess monitoring of first-line ART and switching to second-line ART in sub-Saharan Africa. Methods We did a collaborative analysis of cohort studies from 16 countries in east Africa, southern Africa, and west Africa that participate in the international epidemiological database to evaluate AIDS (IeDEA). We included adults infected with HIV-1 who started combination ART between January, 2004, and January, 2013. We defined switching of ART as a change from a non-nucleoside reverse-transcriptase inhibitor (NNRTI)-based regimen to one including a protease inhibitor, with adjustment of one or more nucleoside reverse-transcriptase inhibitors (NRTIs). Virological and immunological failures were defined according to WHO criteria. We calculated cumulative probabilities of switching and hazard ratios with 95% CIs comparing routine viral load monitoring, targeted viral load monitoring, CD4 monitoring, and clinical monitoring, adjusting for programme and individual characteristics. Findings Of 297 825 eligible patients, 10 352 (3%) switched to second-line ART during 782 412 person-years of follow-up. Compared with CD4 monitoring, hazard ratios for switching were 3.15 (95% CI 2.92-3.40) for routine viral load monitoring, 1.21 (1.13-1.30) for targeted viral load monitoring, and 0.49 (0.43-0.56) for clinical monitoring. Of 6450 patients with confirmed virological failure, 58.0% (95% CI 56.5-59.6) switched by 2 years, and of 15 892 patients with confirmed immunological failure, 19.3% (18.5-20.0) switched by 2 years. Of 10 352 patients who switched, evidence of treatment failure based on one CD4 count or viral load measurement ranged from 86 (32%) of 268 patients with clinical monitoring to 3754 (84%) of 4452 with targeted viral load monitoring. Median CD4 counts at switching were 215 cells per μL (IQR 117-335) with routine viral load monitoring, but were lower with other types of monitoring (range 114-133 cells per μL). Interpretation Overall, few patients switched to second-line ART and switching happened late in the absence of routine viral load monitoring. Switching was more common and happened earlier after initiation of ART with targeted or routine viral load testing.

AB - Background HIV-1 viral load testing is recommended to monitor antiretroviral therapy (ART) but is not universally available. The aim of our study was to assess monitoring of first-line ART and switching to second-line ART in sub-Saharan Africa. Methods We did a collaborative analysis of cohort studies from 16 countries in east Africa, southern Africa, and west Africa that participate in the international epidemiological database to evaluate AIDS (IeDEA). We included adults infected with HIV-1 who started combination ART between January, 2004, and January, 2013. We defined switching of ART as a change from a non-nucleoside reverse-transcriptase inhibitor (NNRTI)-based regimen to one including a protease inhibitor, with adjustment of one or more nucleoside reverse-transcriptase inhibitors (NRTIs). Virological and immunological failures were defined according to WHO criteria. We calculated cumulative probabilities of switching and hazard ratios with 95% CIs comparing routine viral load monitoring, targeted viral load monitoring, CD4 monitoring, and clinical monitoring, adjusting for programme and individual characteristics. Findings Of 297 825 eligible patients, 10 352 (3%) switched to second-line ART during 782 412 person-years of follow-up. Compared with CD4 monitoring, hazard ratios for switching were 3.15 (95% CI 2.92-3.40) for routine viral load monitoring, 1.21 (1.13-1.30) for targeted viral load monitoring, and 0.49 (0.43-0.56) for clinical monitoring. Of 6450 patients with confirmed virological failure, 58.0% (95% CI 56.5-59.6) switched by 2 years, and of 15 892 patients with confirmed immunological failure, 19.3% (18.5-20.0) switched by 2 years. Of 10 352 patients who switched, evidence of treatment failure based on one CD4 count or viral load measurement ranged from 86 (32%) of 268 patients with clinical monitoring to 3754 (84%) of 4452 with targeted viral load monitoring. Median CD4 counts at switching were 215 cells per μL (IQR 117-335) with routine viral load monitoring, but were lower with other types of monitoring (range 114-133 cells per μL). Interpretation Overall, few patients switched to second-line ART and switching happened late in the absence of routine viral load monitoring. Switching was more common and happened earlier after initiation of ART with targeted or routine viral load testing.

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