Adoption of evidence-informed guidelines in prescribing protease inhibitors for HIV-Tuberculosis co-infected patients on rifampicin and effects on HIV treatment outcomes in Uganda

Frank Mulindwa,Fred C Semitala,Priscilla Haguma,Barbara Castelnuovo,Dennis Kalibbala,Bruce Kirenga,Martin Muddu

doi:10.1186/s12879-021-06533-6

Abstract

BackgroundWe aimed to determine how emerging evidence over the past decade informed how Ugandan HIV clinicians prescribed protease inhibitors (PIs) in HIV patients on rifampicin-based tuberculosis (TB) treatment and how this affected HIV treatment outcomes.MethodsWe reviewed clinical records of HIV patients aged 13 years and above, treated with rifampicin-based TB treatment while on PIs between1st—January -2013 and 30th—September—2018 from twelve public HIV clinics in Uganda. Appropriate PI prescription during rifampicin-based TB treatment was defined as; prescribing doubled dose lopinavir/ritonavir- (LPV/r 800/200 mg twice daily) and inappropriate PI prescription as prescribing standard dose LPV/r or atazanavir/ritonavir (ATV/r).ResultsOf the 602 patients who were on both PIs and rifampicin, 103 patients (17.1% (95% CI: 14.3–20.34)) received an appropriate PI prescription. There were no significant differences in the two-year mortality (4.8 vs. 5.7%, P = 0.318), loss to follow up (23.8 vs. 18.9%, P = 0.318) and one-year post TB treatment virologic failure rates (31.6 vs. 30.7%, P = 0.471) between patients that had an appropriate PI prescription and those that did not. However, more patients on double dose LPV/r had missed anti-retroviral therapy (ART) days (35.9 vs 21%, P = 0.001).ConclusionWe conclude that despite availability of clinical evidence, double dosing LPV/r in patients receiving rifampicin-based TB treatment is low in Uganda’s public HIV clinics but this does not seem to affect patient survival and viral suppression.

Highlights

We aimed to determine how emerging evidence over the past decade informed how Ugandan HIV clinicians prescribed protease inhibitors (PIs) in HIV patients on rifampicin-based tuberculosis (TB) treatment and how this affected HIV treatment outcomes
The management of HIV-TB co-infected patients on second line PI-based antiretroviral therapy (ART) becomes complicated by drug-drug interactions [27], a scenario more common in resource-limited settings without rifabutin
We evaluated electronic medical records of 671 People living with HIV (PLHIV) who were concurrently treated with protease inhibitors and anti-TB therapy

Summary

Introduction

We aimed to determine how emerging evidence over the past decade informed how Ugandan HIV clinicians prescribed protease inhibitors (PIs) in HIV patients on rifampicin-based tuberculosis (TB) treatment and how this affected HIV treatment outcomes. Mulindwa et al BMC Infect Dis (2021) 21:822 patients along the entire cascade from prevention [4, 5], diagnosis [6,7,8,9,10,11,12], timing for initiation of HIV or TB treatment [13, 14] and recognition of drug-drug interactions [15,16,17] Translation of this evidence into practice has remained variable especially in sub-Saharan Africa where the burden of both diseases is very high [20, 21]. Because of cost, many lowmiddle income countries are yet to avail it in their HIVTB programs more so in sub-Sahara African countries where the HIV-TB burden is highest [26, 29,30,31,32,33]

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