Epicentre, Médecins Sans Frontières, Paris, France.
OCP, Médecins Sans Frontières, Nairobi, Kenya.
J Acquir Immune Defic Syndr. 2021 Jul 1;87(3):883-888. doi: 10.1097/QAI.0000000000002689.
Patients hospitalized with advanced HIV have a high mortality risk. We assessed viremia and drug resistance among differentiated care services and explored whether expediting the switching of failing treatments may be justified.
Hospitals in the Democratic Republic of (DRC) Congo (HIV hospital) and Kenya (general hospital including HIV care).
Viral load (VL) testing and drug resistance (DR) genotyping were conducted for HIV inpatients ≥15 years, on first-line antiretroviral therapy (ART) for ≥6 months, and CD4 ≤350 cells/µL. Dual-class DR was defined as low-, intermediate-, or high-level DR to at least 1 nucleoside reverse transcriptase inhibitor and 1 non-nucleoside reverse transcriptase inhibitor. ART regimens were considered ineffective if dual-class DR was detected at viral failure (VL ≥1000 copies/mL).
Among 305 inpatients, 36.7% (Kenya) and 71.2% (DRC) had VL ≥1000 copies/mL, of which 72.9% and 73.7% had dual-class DR. Among viral failures on tenofovir disoproxil fumarate (TDF)-based regimens, 56.1% had TDF-DR and 29.8% zidovudine (AZT)-DR; on AZT regimens, 71.4% had AZT-DR and 61.9% TDF-DR, respectively. Treatment interruptions (≥48 hours during past 6 months) were reported by 41.7% (Kenya) and 56.7% (DRC). Approximately 56.2% (Kenya) and 47.4% (DRC) on TDF regimens had tenofovir diphosphate concentrations <1250 fmol/punch (suboptimal adherence). Among viral failures with CD4 <100 cells/µL, 76.0% (Kenya) and 84.6% (DRC) were on ineffective regimens.
Many hospitalized, ART-experienced patients with advanced HIV were on an ineffective first-line regimen. Addressing ART failure promptly should be integrated into advanced disease care packages for this group. Switching to effective second-line medications should be considered after a single high VL on non-nucleoside reverse transcriptase inhibitor-based first-line if CD4 ≤350 cells/µL or, when VL is unavailable, among patients with CD4 ≤100 cells/µL.
患有晚期 HIV 的住院患者死亡率较高。我们评估了差异化护理服务中的病毒载量和耐药性，并探讨了加快失败治疗的转换是否合理。
刚果民主共和国（HIV 医院）和肯尼亚（包括 HIV 护理的综合医院）的医院。
对≥15 岁、接受一线抗逆转录病毒治疗（ART）≥6 个月且 CD4 ≤350 个细胞/µL 的住院 HIV 患者进行病毒载量（VL）检测和耐药性（DR）基因分型。双耐药定义为至少对 1 种核苷逆转录酶抑制剂和 1 种非核苷逆转录酶抑制剂存在低、中或高水平耐药。如果在病毒失败时（VL≥1000 拷贝/mL）检测到双耐药，则认为 ART 方案无效。
在 305 名住院患者中，36.7%（肯尼亚）和 71.2%（刚果民主共和国）的 VL≥1000 拷贝/mL，其中 72.9%和 73.7%有双耐药。在基于替诺福韦二吡呋酯（TDF）的方案中，56.1%的病毒失败患者有 TDF 耐药，29.8%有齐多夫定（AZT）耐药；在 AZT 方案中，分别有 71.4%和 61.9%的患者有 AZT 耐药和 TDF 耐药。过去 6 个月中有 41.7%（肯尼亚）和 56.7%（刚果民主共和国）的患者报告有治疗中断（≥48 小时）。在 TDF 方案中，约 56.2%（肯尼亚）和 47.4%（刚果民主共和国）的患者替诺福韦二磷酸浓度<1250 fmol/打孔（药物依从性不佳）。在 CD4 <100 个细胞/µL 的病毒失败患者中，76.0%（肯尼亚）和 84.6%（刚果民主共和国）的患者正在使用无效方案。
许多患有晚期 HIV 的住院、有 ART 治疗经验的患者正在使用无效的一线方案。对于这一人群，应将及时解决 ART 失败问题纳入晚期疾病护理方案中。如果 CD4≤350 个细胞/µL，或在无法获得病毒载量时，如果 CD4≤100 个细胞/µL，在基于非核苷逆转录酶抑制剂的一线方案单次高病毒载量后，应考虑更换有效的二线药物。
