Abstract
BackgroundIntroduction of antiretroviral therapy (ART) in sub-Saharan Africa was a hot debate due to many concerns about adherence, logistics and resistance. Currently, it has been significantly scaled up. However as the WHO clinico-immunological approaches for initiation and monitoring of ART in the region lacks viral load determination and drug resistance monitoring, HIV infected adults and children may be at risk for “unrecognized” virologic failure and the subsequent development of antiretroviral drug resistance. This study evaluates the virological efficacy and immunological recovery of HIV/AIDS patients under ART.MethodsConsecutive HIV-1 infected adults (N = 100) and children (N = 100) who have been receiving ART for up to 6 years at Gondar University Hospital, Ethiopia were enrolled following the WHO protocol for assessment of acquired drug resistance. Magnitude of viral suppression, genotypic drug resistance mutations and patterns of CD4+ T cell recovery were determined using standard virological and immunological methods.ResultsVirological suppression (HIV RNA < 40 copies/ml) was observed in 82 and 87% of adults and children on a median time of 24 months on ART, respectively. Mutation K103N conferring resistance to non nucleoside reverse transcriptase inhibitors and thymidine analogue mutations (M41L, L210W) were found only in one adult and child patient, respectively. Median CD4+ T cell count has increased from baseline 124 to 266 (IQR: 203–306) and 345 (IQR: 17–1435) to 998 (IQR: 678–2205) cells/mm3 in adults and children respectively after 12 months of ART. Nevertheless, small but significant number of clinically asymptomatic adults (16%) and children (13%) had low level viraemia (HIV-1 RNA 41–1000 copies/ml).ConclusionsMajority of both adults (82%) and children (87%) who received ART showed high viral suppression and immunological recovery. This indicates that despite limited resources in the setting virological efficacy can be sustained for a substantial length of time and also enhance immunological recovery irrespective of age. However, the presence of drug resistance mutations and low level viraemia among clinically asymptomatic patients highlights the need for virological monitoring.
Highlights
Introduction of antiretroviral therapy (ART) in sub-Saharan Africa was a hot debate due to many concerns about adherence, logistics and resistance
African patients with very low CD4+ T cell counts have a high risk of mortality both before and during the initial months of ART [16,17] and advanced pre-treatment immunodeficiency is reported to be associated with reduced capacity for restoration of CD4+ T cell counts and its functional responses during ART [18,19,20]
The 82% suppression rates and the low level of HIV drug resistance in adults with a median time of 24 months on first line ART in the present study from Ethiopia demonstrates a high level of effectiveness of the antiretroviral agents in the setting
Summary
Introduction of antiretroviral therapy (ART) in sub-Saharan Africa was a hot debate due to many concerns about adherence, logistics and resistance. African patients with very low CD4+ T cell counts have a high risk of mortality both before and during the initial months of ART [16,17] and advanced pre-treatment immunodeficiency is reported to be associated with reduced capacity for restoration of CD4+ T cell counts and its functional responses during ART [18,19,20]. This raises the concern that many patients entering ART programmes in sub-Saharan Africa may have limited potential for immune recovery. The limited access of paediatric regimens, the challenges of paediatric ART adherence and the likelihood of HIV drug resistance development raise great public health concern about drug resistance in children receiving ART [21]
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