Efficacy of Second-Line Antiretroviral Therapy Among People Living With HIV/AIDS in Asia

Abstract

Background Roughly 4% of the 1.25 million patients on antiretroviral therapy (ART) in Asia are using second-line therapy. To maximize patient benefit and regional resources it is important to optimize the timing of second-line ART initiation and use the most effective compounds available. Methods HIV positive patients enrolled in the TREAT Asia HIV Observational Database who had used second-line ART for ≥6 months were included. ART use and rates and predictors of second-line treatment failure were evaluated. Results There were 302 eligible patients. Most were male (76.5%) and exposed to HIV via heterosexual contact (71.5%). Median age at second-line initiation was 39.2 years, median CD4 cell count was 146 cells/mm3, and median HIV viral load was 16,224 copies/mL. Patients started second-line ART before 2007 (n=105), 2007-2010 (n=147) and after 2010 (n=50). Ritonavir-boosted lopinavir and atazanavir accounted for the majority of protease inhibitor use after 2006. Median follow-up time on second-line was 2.3 years. The rates of treatment failure and mortality per 100 patient/years were 8.8 (95%CI 7.1 to 10.9) and 1.1 (95%CI 0.6 to 1.9), respectively. Older age, high baseline viral load and use of a protease inhibitor other than lopinavir or atazanavir were associated with a significantly shorter time to second-line failure. Conclusions Increased access to viral load monitoring to facilitate early detection of first-line ART failure and subsequent treatment switch is important for maximizing the durability of second-line therapy in Asia. Although second-line ART is highly effective in the region, the reported rate of failure emphasizes the need for third-line ART in a small portion of patients.

Predictors of treatment failure on second-line antiretroviral therapy among adults in northwest Ethiopia: a multicentre retrospective follow-up study

“…25 34 35 However, the incidence of failure found by this study is lower than a multicentred study conducted in Asia and Africa, which found an overall incidence of 195 per 1000 person-years 36. The reason for this might be due to the difference in follow-up periods.…”

Clinical and Virologic Outcomes After Changes in First Antiretroviral Regimen at 7 Sites in the Caribbean, Central and South America Network

“…In addition, the predictive power of patient outcomes on ART-1 for the most serious adverse events, even after changes in therapy, highlights the potential benefit of focusing resources to enhance monitoring of those patients experiencing blunted CD4 response, and of course, toxicities while on their initial regimen. Though this may seem an obvious course of action and is essentially in line with recent recommendations for first line therapy by the United States (40) and the World Health Organization (41), the execution and logistics involved are not trivial in resource-limited settings (42). Further, despite the implication of these findings that prescription of an initial regimen with maximal antiviral activity and a low side-effect/toxicity profile would be the surest bulwark against accelerated disease progression, again, the plausibility of implementing this practice is greatly dependent on the most readily available antiretroviral agents (43,44).…”

The treatment outcomes of antiretroviral substitutions in routine clinical settings in Asia; data from the TREAT Asia HIV Observational Database (TAHOD)

“…Current WHO guidelines recommend use of a ritonavir‐boosted protease inhibitor (PI) in combination with dual NRTIs after failure on a first line NNRTI‐based regimen, which is widely practiced in Asia . A prior TREAT Asia HIV Observational Database (TAHOD) study reported that among 302 patients with first‐line treatment failure, 73% switched to a dual NRTI plus boosted PI regimen . Use of ritonavir‐boosted lopinavir (LPV/r) or atazanavir (ATV/r) compromised the majority of boosted PI use beyond 2006 in this cohort .…”

“…A prior TREAT Asia HIV Observational Database (TAHOD) study reported that among 302 patients with first‐line treatment failure, 73% switched to a dual NRTI plus boosted PI regimen . Use of ritonavir‐boosted lopinavir (LPV/r) or atazanavir (ATV/r) compromised the majority of boosted PI use beyond 2006 in this cohort . Most commonly used NRTIs for second‐line treatment were lamivudine/emtricitabine (3TC/FTC), tenofovir (TDF) and zidovudine (AZT), accounting for 76.5%, 44.4% and 32.1% of all patients respectively .…”

“…Use of ritonavir‐boosted lopinavir (LPV/r) or atazanavir (ATV/r) compromised the majority of boosted PI use beyond 2006 in this cohort . Most commonly used NRTIs for second‐line treatment were lamivudine/emtricitabine (3TC/FTC), tenofovir (TDF) and zidovudine (AZT), accounting for 76.5%, 44.4% and 32.1% of all patients respectively .…”