Abstract
BACKGROUND: Emergence of HIV-1 drug resistance is at times an inevitable and anticipated consequence of antiretroviral therapy (ART) failure. We examined drug resistance patterns and virus re-suppression among subtype C-infected South African patients receiving first-line ART. METHODS: Treatment records of 431 patients on NNRTI-containing regimens for a median of 45 months were analyzed. Patients with viral load (VL) >400 copies/mL were followed and drug resistance mutations (DRM) were re-assessed. Associations between clinical/demographic measures and drug resistance/virologic outcomes were examined using Fisher exact and ordinal and logistic regression. RESULTS: Ten percent of patients (43/431) were viremic at enrollment (98% previously suppressed); sequences were obtained from 38/43. Of those, 82% had 1-7 DRM. In bivariate analysis remote exposure to single-dose nevirapine or prior ART; higher CD4 counts; lower VL; and >6 months of virologic failure were significantly associated with number of DRM. Of 25 viremic patients followed for a median of 8 months on a continued first-line regimen, 12 (48%) re-suppressed, six with K103N and three with M184V. Thirteen (52%) had continued virologic failure which was significantly associated with detectable VL>6 months prior to enrollment and number of DRM. CONCLUSION: Among these HIV-1 subtype C-infected patients, DRM numbers and patterns were associated with prior exposure to sub-optimal ART, adherence and duration of virologic failure. Viral re-suppression in the presence of K103N and M184V challenges assumptions about drug resistance. In resource-limited settings, where genotyping and alternative drug options are unavailable, continuing first-line treatment, reinforcing adherence and regular virologic monitoring may be effective even after virologic failure.
Highlights
Emergence of HIV-1 drug resistance is at times an inevitable and anticipated consequence of antiretroviral therapy (ART) failure
Risk factors contributing to virologic failure and drug resistance in sub-Saharan Africa include incomplete adherence [1,11,30,36], treatment interruptions [39,41], low CD4 cell counts [14,15,21,41] low body weight before ART initiation [21] and prior exposure to single dose nevirapine for prevention of mother-to-child transmission and/or dual nucleoside treatment [6,22,25]
Patient characteristics (Table 1) displays characteristics of the 431 patients who had been on ART for at least 12 months where 75% were females, 96% were born in South Africa, 90% had above primary school education and the median age at study enrollment was 38 years
Summary
Emergence of HIV-1 drug resistance is at times an inevitable and anticipated consequence of antiretroviral therapy (ART) failure. We examined drug resistance patterns and virus re-suppression among subtype C-infected South African patients receiving first-line ART. More than 1 million HIV-1 subtype C infected patients in South Africa are receiving antiretroviral therapy (ART) [43]. In 2004 a national treatment program was initiated, including a first-line regimen containing a non-nucleoside reverse transcriptase inhibitor (NNRTI), either efavirenz or nevirapine, in combination with NRTI, stavudine or zidovudine, and lamivudine [27] The virologic outcomes of firstline regimens among subtype C-infected people in South Africa are comparable to those among subtype B infected patients in Switzerland, where approximately 10% of patients experience virologic failure after 12 months and up to 25% experience virologic failure by two years on ART [20]. Wallis et al [42] in Johannesburg
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