Lack of awareness of treatment failure among HIV‐1‐infected patients in Guinea‐Bissau – a retrospective cohort study

Sanne Jespersen,Candida Medina,Christian Wejse,Christian Erikstrup,Faustino Gomes Correira,David Da Silva Té,Bo Langhoff Hønge,Alex Lund Laursen,Lars Østergaard

doi:10.7448/ias.18.1.20243

Abstract

IntroductionWith more people receiving antiretroviral treatment (ART), the need to detect treatment failure and switch to second-line ART has also increased. We assessed CD4 cell counts (as a marker of treatment failure), determined the rate of switching to second-line treatment and evaluated mortality related to treatment failure among HIV-infected patients in Guinea-Bissau.MethodsIn this retrospective cohort study, adult patients infected with HIV-1 receiving ≥6 months of ART at an HIV clinic in Bissau were included from June 2005 to July 2014 and followed until January 2015. Treatment failure was defined as 1) a fall in CD4 count to baseline (or below) or 2) CD4 levels persistently below 100 cells/µL after ≥6 months of ART. Cox hazard models, with time since six months of ART as the time-varying coefficient, were used to estimate the hazard ratio for death and loss to follow-up.ResultsWe assessed 1,591 HIV-1-infected patients for immunological treatment failure. Treatment failure could not be determined in 594 patients (37.3%) because of missing CD4 cell counts. Among the remaining 997 patients, 393 (39.4%) experienced failure. Only 39 patients (9.9%) with failure were switched from first- to second-line ART. The overall switching rate was 3.1 per 100 person-years. Mortality rate was higher in patients with than without treatment failure, with adjusted hazard rate ratios (HRRs) 10.0 (95% CI: 0.9–107.8), 7.6 (95% CI: 1.6–35.5) and 3.1 (95% CI: 1.5–6.3) in the first, second and following years, respectively. During the first year of follow-up, patients experiencing treatment failure had a higher risk of being lost to follow-up than patients not experiencing treatment failure (adjusted HRR 4.4; 95% CI: 1.7–11.8).ConclusionsWe found a high rate of treatment failure, an alarmingly high number of patients for whom treatment failure could not be assessed, and a low rate of switching to a second-line therapy. These factors could lead to an increased risk of resistance development and excess mortality.

Highlights

With more people receiving antiretroviral treatment (ART), the need to detect treatment failure and switch to second-line ART has increased
The study population consisted of HIV-1 monoinfected adults who were diagnosed at Hospital National Simao Mendes (HNSM) and whose ART was initiated between June 2005, when the clinic opened, and July 2014
Patients on ART were considered lost to follow-up (LTFU) if they had not visited the clinic for six months

Summary

Introduction

With more people receiving antiretroviral treatment (ART), the need to detect treatment failure and switch to second-line ART has increased. Mortality rate was higher in patients with than without treatment failure, with adjusted hazard rate ratios (HRRs) 10.0 (95% CI: 0.9Á107.8), 7.6 (95% CI: 1.6Á35.5) and 3.1 (95% CI: 1.5Á6.3) in the first, second and following years, respectively. Conclusions: We found a high rate of treatment failure, an alarmingly high number of patients for whom treatment failure could not be assessed, and a low rate of switching to a second-line therapy. These factors could lead to an increased risk of resistance development and excess mortality. In accordance with WHO guidelines, most HIV-1-infected patients in Africa initiate ART with two nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs) and one non-nucleotide reverse transcriptase inhibitor (NNRTI), with the NNRTI being either nevirapine (NVP) or efavirenz (EFV) [4]

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