Lyall
Lancet HIV. 2015 Apr;2(4):e151-8. doi: 10.1016/S2352-3018(15)00021-1.
About a third of children with HIV have virological failure within 2 years of beginning antiretroviral treatment (ART). We assessed the probability of switch to second-line ART or virological re-suppression without switch in children who had virological rebound on first-line ART in the UK and Ireland.
In this study, we used data reported to the Collaborative HIV Paediatric Study (CHIPS), a national multicentre observational cohort. We included children with virological rebound (confirmed viral load>400 copies per mL after suppression<400 copies per mL) on first-line ART. We did a competing-risk analysis to estimate the probability of switch to second-line treatment, confirmed resuppression (two consecutive viral load measurments<400 copies per mL) without switch, and continued viral load above 400 copies per mL without switch. We also assessed factors that predicted a faster time to switch.
Of the 900 children starting first-line ART who had a viral load below 400 copies per mL within a year of starting treatment, 170 (19%) had virological rebound by a median of 20·6 months (IQR 9·7–40·5). At rebound, median age was 10·6 years (5·6–13·4), median viral load was 3·6 log10 copies per mL (3·1–4·2), and median CD4% was 24% (17–32). 89 patients (52%) switched to second-line ART at a median of 4·9 months (1·7–13·4) after virological rebound, 53 (31%) resuppressed without switch (19 [61%] of 31 patients on a first-line regimen that included a protease inhibitor and 31 [24%] of 127 patients on a first-line regimen that included a non-nucleoside reverse transcriptase inhibitor; NNRTI), and 28 (16%) neither resuppressed nor switched. At 12 months after rebound, the estimated probability of switch was 38% (95% CI 30–45) and of resuppression was 27% (21–34). Faster time to switch was associated with a higher viral load (p<0·0001), later calendar year at virological rebound (p=0·02), and being on an NNRTI-based or triple nucleoside reverse transcriptase inhibitor-based versus protease-inhibitor-based first-line regimen (p=0·001).
A third of children with virological rebound resuppressed without switch. Clinicians should consider the possibility of resuppression with adherence support before switching treatment in children with HIV.
NHS England (London Specialised Commissioning Group).
约三分之一的儿童在开始抗逆转录病毒治疗（ART）后 2 年内出现病毒学失败。我们评估了在英国和爱尔兰，对接受一线 ART 后病毒学反弹的儿童，在不进行转换的情况下，切换至二线 ART 或病毒学抑制而不反弹的可能性。
在这项研究中，我们使用了向合作性 HIV 儿科研究（CHIPS）报告的数据，这是一项全国性多中心观察性队列研究。我们纳入了在一线 ART 时病毒学反弹（在抑制后<400 拷贝/mL 时确认病毒载量>400 拷贝/mL）的儿童。我们进行了竞争风险分析，以估计切换至二线治疗、无转换确认重新抑制（两次连续的病毒载量测量<400 拷贝/mL）和无转换继续病毒载量>400 拷贝/mL的可能性。我们还评估了预测切换时间更快的因素。
在开始一线 ART 的 900 名一年内病毒载量低于 400 拷贝/mL 的儿童中，170 名（19%）在中位时间 20.6 个月（9.7-40.5）时出现病毒学反弹。在反弹时，中位年龄为 10.6 岁（5.6-13.4），中位病毒载量为 3.6 log10 拷贝/mL（3.1-4.2），中位 CD4%为 24%（17-32）。在病毒学反弹后中位 4.9 个月（1.7-13.4）时，89 名（52%）患者切换至二线 ART，53 名（31%）无转换重新抑制（31 名[61%]接受包含蛋白酶抑制剂的一线方案，127 名[24%]接受包含非核苷类逆转录酶抑制剂的一线方案；NNRTI），28 名（16%）既未重新抑制也未转换。在反弹后 12 个月时，预计转换的概率为 38%（95%CI 30-45），重新抑制的概率为 27%（21-34）。更快的切换时间与更高的病毒载量（p<0.0001）、病毒学反弹时较晚的年份（p=0.02）和接受 NNRTI 或三联核苷逆转录酶抑制剂而非蛋白酶抑制剂一线方案（p=0.001）有关。
三分之一的病毒学反弹儿童无需转换即可重新抑制。在对 HIV 儿童进行治疗转换之前，临床医生应考虑在出现病毒学反弹时通过保持治疗依从性支持来重新抑制病毒的可能性。
英国国民保健制度（伦敦专门委员会）。
