Abstract
In a randomized comparison of nevirapine or abacavir with zidovudine plus lamivudine, routine viral load monitoring was not performed, yet 27% of individuals with viral failure at week 48 experienced resuppression by week 96 without switching. This supports World Health Organization recommendations that suspected viral failure should trigger adherence counseling and repeat measurement before a treatment switch is considered.
Highlights
Combination antiretroviral therapy has led to declining morbidity and mortality in resource-poor settings [1, 2], and scale-up at the end of 2012 had reached 9.7 million human immunodeficiency virus (HIV)–infected individuals worldwide [3]
Viral failure as defined by WHO [4] was almost 3-fold higher with triple nucleoside reverse transcriptase inhibitors (NRTIs) containing ZDV/3TC/ABC compared to that seen in ZDV/3TC/NVP–treated individuals, and supports the recommendation that this combination not be used for firstline therapy in adults when alternative drugs are available
There was a high prevalence of extensive NRTI cross-resistance following viral failure at week 96, with almost half of patients in each treatment arm having ≥3 TAMs, consistent with other studies in resource-limited settings [10, 11]
Summary
Combination antiretroviral therapy (cART) has led to declining morbidity and mortality in resource-poor settings [1, 2], and scale-up at the end of 2012 had reached 9.7 million human immunodeficiency virus (HIV)–infected individuals worldwide [3]. Optimal utilization of first-line cART and switch to second-line therapy in resource-poor settings is a priority. Organization (WHO) guidelines recommend routine viral load monitoring (VLM), and switch to second-line therapy is recommended after 2 viral load measurements >1000 copies/mL following adherence counseling [4]. The WHO document recognizes that the evidence base for VLM itself is weak Given that such a monitoring strategy is likely to be a huge burden for most resource-limited settings, it is important to increase the evidence base. The Development of Anti Retroviral Therapy in Africa (DART) study compared clinical monitoring only with clinical and laboratory monitoring (CD4 and routine blood tests including biochemistry and full blood count), with switch to second-line therapy on clinical and immunologic criteria. We report virologic outcomes at 96 weeks, demonstrating substantial resuppression following earlier viremia despite not switching
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