Médecins Sans Frontières, Mumbai, India.
Médecins Sans Frontières, Brussels, Belgium.
PLoS One. 2019 Nov 21;14(11):e0225631. doi: 10.1371/journal.pone.0225631. eCollection 2019.
HIV programs are increasingly confronted with failing antiretroviral therapy (ART), including second-line regimens. WHO has provided guidelines on switching to third-line ART. In a Médecins Sans Frontières clinic in Mumbai, India, receiving referred presumptive second-line ART failure cases, an evidence-based protocol consisting of viral load (VL) testing, enhanced adherence counselling (EAC) and genotype for switching was implemented.
To document the outcome and genotype of presumptive second-line ART failure cases switched to third-line or maintained on second-line ART.
Retrospective cohort study of patients referred between January 2011 and September 2017.
The cases (n = 120) were complex with median 9.2 years of ART exposure, poor adherence at baseline, and exposure to multiple ART regimens other than recommended by WHO. Out of 90 evaluated cases, 39(43%) were maintained on second-line ART. Forty-nine (54%) were ever switched to third-line ART. Twelve months virological suppression was 72% in the second-line and 93% in the third-line ART cohort, while retention in care was 80% and 94% respectively. Genotyping showed 62% resistance for PIs, and 52% triple class resistance to NRTIs, NNRTIs and PIs. Resistance was noted for the new class of integrase inhibitors, and for different drugs without any documented previous exposure to the same drug.
Adopting WHO guidelines on switching ART regimens and provision of EAC can prevent unnecessary switching/exposure to third-line ART regimens. Genotyping is urgently required in national HIV programs, which currently use only the exposure history of patients for switching to third-line ART regimens.
艾滋病毒项目越来越多地面临抗逆转录病毒治疗（ART）失败的情况，包括二线方案。世卫组织已提供了关于切换至三线 ART 的指南。在印度孟买的无国界医生组织诊所，接收转介的推定二线 ART 失败病例，实施了一项基于证据的方案，包括病毒载量（VL）检测、强化依从性咨询（EAC）和用于切换的基因型。
记录切换至三线或维持二线 ART 的推定二线 ART 失败病例的结局和基因型。
2011 年 1 月至 2017 年 9 月期间转介的患者的回顾性队列研究。
这些病例（n = 120）情况复杂，中位 ART 暴露时间为 9.2 年，基线时依从性差，且接触了多种不符合世卫组织建议的 ART 方案。在评估的 90 例病例中，39 例（43%）维持二线 ART。49 例（54%）曾切换至三线 ART。二线和三线 ART 队列的 12 个月病毒学抑制率分别为 72%和 93%，而保留在治疗中的比例分别为 80%和 94%。基因型检测显示 PI 的耐药率为 62%，NRTIs、NNRTIs 和 PI 的三联耐药率为 52%。注意到新的整合酶抑制剂类药物和不同药物的耐药性，而没有任何先前暴露于同一药物的记录。
采用世卫组织关于切换 ART 方案的指南和提供 EAC 可以防止不必要地切换/暴露于三线 ART 方案。国家艾滋病毒项目迫切需要进行基因型检测，目前仅根据患者的暴露史来切换至三线 ART 方案。
