Abstract
BackgroundIn the Asia-Pacific region many countries have adopted the WHO’s public health approach to HIV care and treatment. We performed exploratory analyses of the factors associated with first major modification to first-line combination antiretroviral therapy (ART) in resource-rich and resource-limited countries in the region.MethodsWe selected treatment naive HIV-positive adults from the Australian HIV Observational Database (AHOD) and the TREAT Asia HIV Observational Database (TAHOD). We dichotomised each country’s per capita income into high/upper-middle (T-H) and lower-middle/low (T-L). Survival methods stratified by income were used to explore time to first major modification of first-line ART and associated factors. We defined a treatment modification as either initiation of a new class of antiretroviral (ARV) or a substitution of two or more ARV agents from within the same ARV class.ResultsA total of 4250 patients had 961 major modifications to first-line ART in the first five years of therapy. The cumulative incidence (95% CI) of treatment modification was 0.48 (0.44–0.52), 0.33 (0.30–0.36) and 0.21 (0.18–0.23) for AHOD, T-H and T-L respectively. We found no strong associations between typical patient characteristic factors and rates of treatment modification. In AHOD, relative to sites that monitor twice-yearly (both CD4 and HIV RNA-VL), quarterly monitoring corresponded with a doubling of the rate of treatment modifications. In T-H, relative to sites that monitor once-yearly (both CD4 and HIV RNA-VL), monitoring twice-yearly corresponded to a 1.8 factor increase in treatment modifications. In T-L, no sites on average monitored both CD4 & HIV RNA-VL concurrently once-yearly. We found no differences in rates of modifications for once- or twice-yearly CD4 count monitoring.ConclusionsLow-income countries tended to have lower rates of major modifications made to first-line ART compared to higher-income countries. In higher-income countries, an increased rate of RNA-VL monitoring was associated with increased modifications to first-line ART.
Highlights
The introduction of combination antiretroviral therapy (ART) has dramatically changed the management of HIV infection
Of the Australian HIV Observational Database (AHOD) patients excluded from the analysis, 2111 (62%) were not included due to timing of ART initiation (ART initiation date .2 years prior to enrolment) and 158 (5%) were excluded as they received mono/duo therapy prior to first-line ART
Of the TREAT Asia HIV Observational Database (TAHOD) patients excluded from the analysis, 2444 (41%) were not included due to the timing of ART initiation and 115 (2%) were excluded for prior mono/duo therapy exposure
Summary
The introduction of combination antiretroviral therapy (ART) has dramatically changed the management of HIV infection. In high-income countries where access to ART is widely available, an effective regimen usually consists of a combination of antiretrovirals selected from five classes, where each class targets independent viral replication processes. In high-income countries, initial ART regimens are individualized in order to minimise toxicity and adverse events, and maximise tolerability and efficacy of treatment. This is done to facilitate the chance of good adherence and thereby successful long-term HIV treatment outcomes. We performed exploratory analyses of the factors associated with first major modification to first-line combination antiretroviral therapy (ART) in resource-rich and resource-limited countries in the region
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