High rate of virological re-suppression among patients failing second-line antiretroviral therapy following enhanced adherence support: A model of care in Khayelitsha, South Africa

Abstract

Objective. To describe and evaluate the outcomes of a support programme for patients with virological failure while receiving second-line antiretroviral therapy (ART) in South Africa. Method. We described a comprehensive medical and counselling patient support programme for patients receiving secondline ART and with two consecutive viral loads (VLs) >1 000 copies/ml. Patients with >3 months follow-up and at least one VL measurement after inclusion in the programme were eligible for analysis. Results. Of 69 patients enrolled in the programme, 40 had at least one follow-up VL and no known drug resistance at enrolment; 27 (68%) of these re-suppressed while remaining on second-line ART following enhanced adherence support. The majority (18/27; 67%) achieved re-suppression within the first 3 months in the programme. Five patients with diagnosed second-line drug resistance achieved viral re-suppression (<400 copies/ml) after being switched to third-line ART. Seven patients (7/40; 18%) did not achieve viral re-suppression after 9 months in the programme: 6 with known adherence problems (4 without drug resistance on genotype) and 1 with a VL <1 000 copies/ml. Overall, 3 patients (4%) died, 3 (4%) were lost to follow-up and 2 (3%) were transferred out. Conclusion.Our experience from a routine programme demonstrates that with targeted adherence support, the majority of patients who were viraemic while receiving second-line ART returned to an undetectable VL within 3 months. By increasing the time receiving second-line ART and decreasing the need for genotypes and/or third-line ART, this intervention may reduce costs.

Intensive adherence counselling for HIV‐infected individuals failing second‐line antiretroviral therapy in Johannesburg, South Africa

“…However, our results do show that a large proportion of patients with unsuppressed viral loads on second‐line can be maintained on these regimens. This is similar to the findings of a study conducted in the Western Cape where 68% (95% CI 54–82%) of patients failing second‐line ART achieved virologic resuppression with intensified adherence counselling . This is important because third‐line regimens are expensive and not available in most resource‐limited settings.…”

Relationship between untimed plasma lopinavir concentrations and virological outcome on second-line antiretroviral therapy

“…This approach might allow early tailored adherence interventions before virologic failure and selection of resistance mutations to facilitate viral re-suppression and optimise treatment outcome [25]. At less than US$50 per sample, one could imagine for instance the development and use of a simple point of care test that reported 'absence' or 'presence' of the drug at any pre-determined level.…”

Short term adherence tool predicts failure on second line protease inhibitor-based antiretroviral therapy: an observational cohort study

“…A threshold of 80% adherence measured by pharmacy refill in the previous 4 months could be used to identify patients needing enhanced adherence support and rationalise use of VL testing in resource-limited settings. Most patients on second line ART experiencing VF were able to achieve virologic suppression with intensified adherence support in a study at a clinic in South Africa [ 21 ]. VF on second line ART is likely a result of poor adherence rather than resistance as several studies have found a low proportion of major PI mutations in patients with VF on second line ART [ 10 ]-[ 12 ].…”