Division of Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden.
AIDS. 2010 Jul 17;24(11):1679-87. doi: 10.1097/QAD.0b013e32833a097b.
We assessed risk factors for viremia and drug resistance among long-term recipients of antiretroviral therapy (ART) in South Africa.
In 2008, we conducted a cross-sectional study among patients receiving ART for 12 months or more. Genotypic resistance testing was performed on individuals with a viral load higher than 400 RNA copies/ml. Multiple logistic regression analysis was used to assess associations.
Of 998 participants, 75% were women with a median age of 41 years. Most (64%) had been on treatment for more than 3 years. The prevalence of viremia was 14% (n = 139): 12% (102/883) on first-line [i.e. nonnucleoside reverse-transcriptase inhibitor (NNRTI)-based regimen] and 33% (37/115) on second-line (i.e. protease inhibitor (PI)-based regimen) ART. Of viremic patients, 78% had drug resistance mutations. For NRTIs, NNRTIs and PIs, the prevalence of mutations was 64, 81 and 2%, respectively, among first-line failures and 29, 54 and 6%, respectively, among second-line failures. M184V/I, K103N and V106A/M were the most common mutations. Significant risk factors associated with viremia on first-line regimen included concurrent tuberculosis treatment [odds ratio (OR) 6.4, 95% confidence interval (CI) 2.2-18.8, P < 0.01] and a recent history of poor adherence (OR 2.7, 1.3-5.6, P = 0.01). Among second-line failures, attending a public clinic (OR 4.6, 95% CI 1.8-11.3, P < 0.01) and not having a refrigerator at home (OR 6.7, 95% CI 1.2-37.5, P = 0.03) were risk factors for virological failure.
Risk factors for viral failure were line regimen dependent. Second-line ART recipients had a higher rate of viremia, albeit with infrequent PI drug resistance mutations. Measures to maintain effective virologic suppression should include increased adherence counseling, attention to concomitant tuberculosis treatment and heat-stable formulations of second-line ART regimens.
我们评估了南非长期接受抗逆转录病毒疗法（ART）的患者中病毒血症和耐药性的危险因素。
2008 年，我们对接受 ART 治疗 12 个月或以上的患者进行了一项横断面研究。对病毒载量高于 400 RNA 拷贝/ml 的个体进行基因型耐药性检测。采用多因素 logistic 回归分析评估相关性。
在 998 名参与者中，75%为女性，中位年龄为 41 岁。大多数（64%）治疗时间超过 3 年。病毒血症的患病率为 14%（n=139）：12%（102/883）在一线[即非核苷逆转录酶抑制剂（NNRTI）为基础的方案]，33%（37/115）在二线[即蛋白酶抑制剂（PI）为基础的方案]。在病毒血症患者中，78%有耐药性突变。对于 NRTIs、NNRTIs 和 PIs，一线失败患者的突变发生率分别为 64%、81%和 2%，二线失败患者的突变发生率分别为 29%、54%和 6%。M184V/I、K103N 和 V106A/M 是最常见的突变。与一线方案病毒血症相关的显著危险因素包括同时接受结核病治疗[比值比（OR）6.4，95%置信区间（CI）2.2-18.8，P<0.01]和近期服药依从性差（OR 2.7，1.3-5.6，P=0.01）。二线治疗失败患者中，在公立诊所就诊（OR 4.6，95%CI 1.8-11.3，P<0.01）和家中无冰箱（OR 6.7，95%CI 1.2-37.5，P=0.03）是病毒学失败的危险因素。
病毒失败的危险因素与方案线有关。二线 ART 治疗者病毒血症发生率较高，尽管耐药性突变罕见。为维持有效的病毒抑制，应包括增加服药依从性咨询、关注同时接受结核病治疗以及二线 ART 方案中热稳定制剂。
