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SOUTH AFRICA’S NATIONAL THIRD-LINE ART COHORT: DESCRIPTIVE ANALYSIS
Francesca Conradie1, Matthew Fox2, Michelle A. Moorhouse1, Gary Maartens3, Willem D. Venter1, Mahomed-Yunus Moosa4, Khadija Jamaloodien5
1Univ of the WItswatersrand, Johannesburg, South Africa,2Boston Univ, Boston, MA,3Univ of Cape Town, Cape Town, South Africa,4Univ of KwaZulu-Natal, Durban, South Africa,5South African Natl Dept of Hlth, Pretoria, South Africa
The World Health Organization recommends that national antiretroviral therapy (ART) programs in resource limited settings develop policies for third-line ART. South Africa, with the largest HIV treatment program, is one of the only countries in sub-Saharan Africa that has access to third-line ART for patients who have failed both first-line non-nucleoside reverse transcriptase inhibitors (NNRTI) and second-line protease inhibitor (PI) based ART. We report on 152 public-sector patients in South Africa for whom third line treatment was requested. This may be the largest public sector cohort on third line agents in sub-Saharan Africa.
Third-line ART for adults in the public sector in South Africa is accessed through a national committee that assesses eligibility and makes regimen recommendation on each case. Criteria for third-line treatment include a minimum of one year of PI based ART with virologic failure despite adherence optimization and a genotypic antiretroviral resistance test (GART) showing PI resistance. We present a cross-sectional analysis and descriptive statistics on this cohort. PI resistance was defined by a resistance mutation score of ≥15 on the Stanford University HIV Drug resistance Database.
152 patients were submitted to the national third line committee between Aug 2013 and July 2014 and granted access to third line. Median age was 41 years (IQR: 24-47) and 60% were female. The median CD4 count and viral load was 170 (IQR: 127-337) and 17013 (IQR: 396-104178) respectively. In terms of second line ART, 5% started before 2005, 22% started second line between 2004 and 2009 and 62% started second-line between 2008 and 2011.Of the 146 (96%) patients with resistance test results, 74% and 77% had resistance (≥15) to efavirenz and nevirapine respectively. 85%, 72%, 69% and 92% had resistance to lamivudine, zidovudine, tenofovir and abacavir respectively, while 97% and 98% had resistance to lopinavir and atazanavir respectively. In addition 57% and 37% had resistance to darunavir and etravirine respectively. Of the 146, 145 were initiated on a third-line regimen containing either raltegravir (n=106), darunavir (n=145) or etravirine (n=33) or some combination thereof. Among those with at least one viral load post resistance testing (n=117), a large proportion (94%, n = 102) were able to resuppress their viral load to below 400 copies/ml
Despite high levels of resistance, viral suppression was high in a programmatic roll out of third line ART.