Sustained virological response on second-line antiretroviral therapy following virological failure in HIV-infected patients in rural South Africa

Abstract

Objective: This study aims to describe the virological, immunological and clinical efficacy of protease inhibitor (PI)-based second-line antiretroviral therapy (ART) in rural South Africa.

Methods: An observational cohort study was performed on 210 patients (including 39 children) who initiated PI-based second-line therapy at least 12 months prior to data collection. Biannual clinical, immunological and virological monitoring was performed. Primary endpoints were adequate virological response (plasma HIV-1 RNA<400 copies/ml), full virological suppression (plasma HIV-1 RNA<50 copies/ml) and treatment failure (virological failure (plasma HIV-1 RNA>1000 after initial virological response) or on-going viremia (plasma HIV-1 RNA never<400 copies/ml for more than six months)). Data were analyzed by an on-treatment (OT) and intention-to-treat (ITT) approach. Analyses were primarily performed on the group of patients who switched following first-line virological failure.

Results: Median duration of follow-up after switch to second-line treatment was 20 months [IQR 11-35]. 191 patients had switched to second-line ART due to first-line virological failure. 139/191 of them (72.8%, ITT) were in care and on treatment at the end of follow-up and 11/191 (5.8%, ITT) had died. After twelve months, an adequate virological response was seen in 92/128 patients (71.9%, OT), of which 78/128 (60.9%, OT) experienced full virological suppression. Virological response remained stable after 24 months. Virological efficacy was similar amongst adult and pediatric patients. As in first-line ART, we observed a lack of correlation between virological failure and WHO-defined immunological failure.

Conclusions: Good virological outcomes following first-line failure can be achieved with PI-based, second-line antiretroviral therapy in both adult and pediatric patients in rural South Africa. Retention rates were high and virological outcomes were sustainable during the two-year follow-up period, although persisting low-level viremia occurred in a subset of patients. The observed viro-immunological dissociation emphasizes the need for virological monitoring.

Figure 1. Virological outcome at end of follow-up; N = 191.

Patients who switched following first-line treatment failure. N: number of patients, VL: plasma HIV-1 viral load. Full virological suppression: plasma HIV-1 RNA<50 copies/ml, low viral replication: 501000 copies/ml after initial VL<400 copies/ml, on-going viremia: plasma HIV-1 RNA never<400 copies/ml. Indefinite outcome: duration of follow-up <6 months without adequate virological response.

Figure 2. Initial full virological suppression (plasma HIV-1 RNA<50 copies/ml).

Patients who switched following first-line treatment failure. N: number of patients at risk.