Switching to second-line antiretroviral therapy in resource-limited settings: comparison of programmes with and without viral load monitoring
Keiser, O.; Tweya, H.; Boulle, A.; Braitstein, P.; Schecter, M.; Brinkhof, M.W.G.; Dabis, Fçois.; Tuboi, S.; Sprinz, E.; Pujades-Rodriguez, M.; Calmy, A.; Kumarasamy, N.; Nash, D.; Jahn, A.; MacPhail, P.; Lüthy, R.; Wood, R.; Egger, M.; Balestre, E.; Brinkhof, M.; Dabis, Fçois.; Egger, M.; Graber, C.; Fatzer, B.; Keiser, O.; Lewden, C.; Pujades, M.; Schechter, M.; Keiser, O.; Tweya, H.; Boulle, A.; Braitstein, P.; Schechter, M.
Aids 23(14): 1867-1874
2009
ISSN/ISBN: 0269-9370 PMID: 19531928 DOI: 10.1097/qad.0b013e32832e05b2Document Number: 209102
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.