Use of third line antiretroviral therapy in Latin America.

Carina Cesar,Valdiléa Gonçalves Veloso,Bryan E Shepherd,Brenda Crabtree-Ramirez,Massimo Ghidinelli,Claudia P Cortes,Omar Sued,Valeria Fink,Jose Luis Castro,Eduardo Gotuzzo, ,Pedro Cahn,Adriana Duran,Cathy A Jenkins,Catherine C Mcgowan,Denis Padgett

doi:10.1371/journal.pone.0106887

Abstract

BackgroundAccess to highly active antiretroviral therapy (HAART) is expanding in Latin America. Many patients require second and third line therapy due to toxicity, tolerability, failure, or a combination of factors. The need for third line HAART, essential for program planning, is not known.MethodsAntiretroviral-naïve patients ≥18 years who started first HAART after January 1, 2000 in Caribbean, Central and South America Network (CCASAnet) sites in Argentina, Brazil, Honduras, Mexico, and Peru were included. Clinical trials participants were excluded. Third line HAART was defined as use of darunavir, tipranavir, etravirine, enfuvirtide, maraviroc or raltegravir. Need for third line HAART was defined as virologic failure while on second line HAART.ResultsOf 5853 HAART initiators followed for a median of 3.5 years, 310 (5.3%) failed a second line regimen and 44 (0.8%) received a third line regimen. Cumulative incidence of failing a 2nd or starting a 3rd line regimen was 2.7% and 6.0% three and five years after HAART initiation, respectively. Predictors at HAART initiation for failing a second or starting a third line included female sex (hazard ratio [HR] = 1.54, 95% confidence interval [CI] 1.18–2.00, p = 0.001), younger age (HR = 2.76 for 20 vs. 40 years, 95% CI 1.86–4.10, p<0.001), and prior AIDS (HR = 2.17, 95% CI 1.62–2.90, p<0.001).ConclusionsThird line regimens may be needed for at least 6% of patients in Latin America within 5 years of starting HAART, a substantial proportion given the large numbers of patients on HAART in the region. Improved accessibility to third line regimens is warranted.

Highlights

Unprecedented global efforts have resulted in the rapid expansion of access to highly active antiretroviral therapy (HAART) throughout the world
As HIV/AIDS treatment programs have expanded in resource-limited settings (RLS), an increasing number of people living with HIV have needed second-line regimens
In Latin America and the Caribbean (LAC), the percentage of individuals receiving second-line regimens is higher than that reported in other RLS: 27% of patients are receiving second-line regimens compared with 0.05% in other regions of the developing world [2,3]

Summary

Introduction

Unprecedented global efforts have resulted in the rapid expansion of access to highly active antiretroviral therapy (HAART) throughout the world. In LAC, the percentage of individuals receiving second-line regimens is higher than that reported in other RLS: 27% of patients (ranging from 4 to 43%) are receiving second-line regimens compared with 0.05% in other regions of the developing world [2,3]. This may in part be due to specific characteristics of the Americas region, such as the age of national programs, with many patients starting HAART before 2000, the use of individualized approaches for treating HIV-infected persons, access to broader HAART options, and an increasing frequency of viral load determinations. The need for third line HAART, essential for program planning, is not known

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