J Acquir Immune Defic Syndr. 2021 Apr 1. doi: 10.1097/QAI.0000000000002689. Online ahead of print.
BACKGROUND: Patients hospitalized with advanced HIV have a high mortality risk. We assessed viremia and drug resistance amongst differentiated care services and explored whether expediting the switching of failing treatments may be justified.
SETTING: Hospitals in the Democratic Republic of Congo (HIV hospital), and Kenya (general hospital including HIV care).
METHODS: Viral Load (VL) testing and drug resistance (DR) genotyping were conducted for HIV-inpatients ≥15 years, on first-line ART for ≥6 months, and CD4≤350 cells/µL. Dual-class DR was defined as low, intermediate, or high-level DR to at least one NRTI and one NNRTI. ART-regimens were considered ineffective if dual-class DR was detected at viral failure (VL ≥1000 copies/ml).
RESULTS: Among 305 inpatients, 36.7% (Kenya) and 71.2% (DRC) had VL ≥1,000copies/mL, of which 72.9% and 73.7% had dual-class DR. Among viral failures on TDF-based regimens, 56.1% had TDF-DR and 29.8% 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). 56.2% (Kenya) and 47.4% (DRC) on TDF-regimens had TFV-DP concentrations <1250fmol/punch (suboptimal adherence). Among viral failures with CD4<100 cells/µL, 76.0% (Kenya) and 84.6% (DRC) were on ineffective regimens.
CONCLUSIONS: 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 NNRTI-based first-line if CD4≤350 cells/µL or, when VL is unavailable, among patients with CD4≤100 cells/µL.