Genotyping and outcomes of presumptive second line ART failure cases switched to third line or maintained on second line ART in Mumbai, India.

Naresh Gill,Khine Wut Yee Kyaw,Petros Isaakidis,Miriam Arago Galindo,Stobdan Kalon,Homa Mansoor,Chinmay Laxmeshwar,Sarthak Rastogi,Mrinalini Das,Rafael Van Den Bergh,Marcel Yotebieng

doi:10.1371/journal.pone.0225631

Abstract

BackgroundHIV programs are increasingly confronted with failing antiretroviral therapy (ART), including second-line regimens. WHO has provided guidelines on switching to third-line ART. In a Médecins Sans Frontières clinic in Mumbai, India, receiving referred presumptive second-line ART failure cases, an evidence-based protocol consisting of viral load (VL) testing, enhanced adherence counselling (EAC) and genotype for switching was implemented.ObjectiveTo document the outcome and genotype of presumptive second-line ART failure cases switched to third-line or maintained on second-line ART.DesignRetrospective cohort study of patients referred between January 2011 and September 2017.ResultsThe cases (n = 120) were complex with median 9.2 years of ART exposure, poor adherence at baseline, and exposure to multiple ART regimens other than recommended by WHO. Out of 90 evaluated cases, 39(43%) were maintained on second-line ART. Forty-nine (54%) were ever switched to third-line ART. Twelve months virological suppression was 72% in the second-line and 93% in the third-line ART cohort, while retention in care was 80% and 94% respectively. Genotyping showed 62% resistance for PIs, and 52% triple class resistance to NRTIs, NNRTIs and PIs. Resistance was noted for the new class of integrase inhibitors, and for different drugs without any documented previous exposure to the same drug.ConclusionAdopting WHO guidelines on switching ART regimens and provision of EAC can prevent unnecessary switching/exposure to third-line ART regimens. Genotyping is urgently required in national HIV programs, which currently use only the exposure history of patients for switching to third-line ART regimens.

Highlights

HIV infection is a global health problem
In a Medecins Sans Frontières clinic in Mumbai, India, receiving referred presumptive secondline antiretroviral therapy (ART) failure cases, an evidence-based protocol consisting of viral load (VL) testing, enhanced adherence counselling (EAC) and genotype for switching was implemented
Adopting World Health Organization (WHO) guidelines on switching ART regimens and provision of EAC can prevent unnecessary switching/exposure to third-line ART regimens

Summary

Introduction

HIV infection is a global health problem. Since the beginning of the epidemic, more than 70 million people have been infected with the virus. About 36.9 million people were reported to be living with HIV and AIDS (PLHA) at the end of 2017 and 59% were on antiretroviral therapy (ART) [1]. In order to reach the third target (90% of all people on ART achieving viral suppression), it is essential that PLHA; 1) receive appropriate treatment regimens, including second and third line ART regimens in the case of therapeutic failure, 2) are not exposed to such regimens unnecessarily, and 3) receive adherence counselling and other support throughout their treatment. HIV programs are increasingly confronted with failing antiretroviral therapy (ART), including second-line regimens. In a Medecins Sans Frontières clinic in Mumbai, India, receiving referred presumptive secondline ART failure cases, an evidence-based protocol consisting of viral load (VL) testing, enhanced adherence counselling (EAC) and genotype for switching was implemented.

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Conclusion