Cardoso Sandra W, Luz Paula M, Velasque Luciane, Torres Thiago S, Tavares Isabel C, Ribeiro Sayonara R, Moreira Ronaldo I, Veloso Valdilea G, Moore Richard D, Grinsztejn Beatriz
BMC Infect Dis. 2014 Dec 19;14:699. doi: 10.1186/s12879-014-0699-5.
World-wide, the notable expansion of HIV/AIDS treatment programs in resource-limited settings has lead to an increasing number of patients in need of second-line cART. To adequately address and prepare for this scenario, critical assessments of the outcomes of second-line cART are particularly relevant in settings where monitoring strategies may be inadequate. We evaluated virologic outcomes of second-line combination antiretroviral therapy (cART) among HIV-infected individuals from Brazil.
This study was conducted at the Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, at Rio de Janeiro, Brazio. For this study we included all patients who started first-line and second-line cART between 2000 and 2013. Second-line cART required a switch in the anchor drug of first-line cART. We evaluated time from second-line start to virologic failure and factors associated with increased risk of failure using multivariable Cox proportional hazards regression models.
Among the 1,311 patients who started first-line cART a total of 386 patients (29.5%) initiated second-line cART, out of which 35.0% and 60.6% switched from their first-line to their second-line cART when their HIV RNA was undetectable and after documented virologic failure, respectively. At second line cART initiation, median age was 38 years [interquartile range (IQR): 31-45years]. Median CD4 count was significantly different for patients starting second-line cART undetectable [412 cells/mm3 (IQR: 240-617)] compared to those starting second-line cART after documented virologic failure [230 cells/mm3 (IQR: 118-322.5)] (p < 0.01). Median time from second-line cART initiation to failure was also significantly different for patients starting second-line cART undetectable compared to those who with documented virologic failure (log-rank test p < 0.01). Multivariable Cox models showed that younger age, lower education, and HIV RNA level were independently associated with an increased hazard of second-line failure among those with documented virologic failure at start of second-line cART.
We have shown that in a middle-income country with universal access to cART, having a detectable HIV RNA at the start of second-line cART as well as younger age and lower education negatively impact second-line outcomes. Our findings could guide HIV treatment efforts as to which strategies would help maximize the durability of these regimens.
在全球范围内，资源有限地区的艾滋病毒/艾滋病治疗项目显著扩展，导致需要二线抗逆转录病毒联合治疗（cART）的患者数量不断增加。为了充分应对这一情况并做好准备，在监测策略可能不足的环境中，对二线cART的结果进行关键评估尤为重要。我们评估了巴西艾滋病毒感染者接受二线联合抗逆转录病毒治疗（cART）的病毒学结果。
本研究在巴西里约热内卢的奥斯瓦尔多·克鲁兹基金会国家传染病研究所埃万德罗·查加斯研究所进行。在本研究中，我们纳入了2000年至2013年间开始一线和二线cART的所有患者。二线cART需要更换一线cART的主要药物。我们使用多变量Cox比例风险回归模型评估从二线治疗开始到病毒学失败的时间以及与失败风险增加相关的因素。
在开始一线cART的1311名患者中，共有386名患者（29.5%）开始二线cART，其中分别有35.0%和60.6%的患者在其艾滋病毒RNA检测不到时以及在记录的病毒学失败后从一线转换到二线cART。在开始二线cART时，中位年龄为38岁[四分位间距（IQR）：31 - 45岁]。与在记录的病毒学失败后开始二线cART的患者相比，在艾滋病毒RNA检测不到时开始二线cART的患者的中位CD4细胞计数有显著差异[412个细胞/mm³（IQR：240 - 617）]与[230个细胞/mm³（IQR：118 - 322.5）]（p < 0.01）。与有记录的病毒学失败的患者相比，在艾滋病毒RNA检测不到时开始二线cART的患者从二线cART开始到失败的中位时间也有显著差异（对数秩检验p < 0.01）。多变量Cox模型显示，在二线cART开始时已有记录的病毒学失败的患者中，年龄较小、教育程度较低和艾滋病毒RNA水平与二线失败风险增加独立相关。
我们已经表明，在一个普遍可获得cART的中等收入国家，二线cART开始时艾滋病毒RNA可检测到以及年龄较小和教育程度较低对二线治疗结果有负面影响。我们的研究结果可以指导艾滋病毒治疗工作，确定哪些策略有助于最大限度地提高这些治疗方案的持久性。
