Background: The World Health Organization has recommended that national antiretroviral therapy (ART) programs in resource limited settings develop policies for third-line ART. South Africa, with the largest HIV treatment program in the world, 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) based ART and second-line protease inhibitor (PI) based ART. We report on 190 public-sector patients in South Africa for whom third line treatment was requested. This is believed to be the largest public sector cohort on third line agents in sub-Saharan Africa. Methods: Third-line ART for adults in the public sector in South Africa is accessed through a national committee that assesses eligibility and makes regimen recommendations on each individual 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. Results: 189 patients were submitted to the national third line committee between August 2013 and July 2014 Twenty three patients were excluded, one did not have a GART and 23 had no PI resistance. Median age was 40 years (IQR: 35-46). The median CD4 count and viral load around the time of submission was 238 (IQR: 93-415) and 34387 (IQR: 5376-85338) respectively. About half of patients started ART between 2004 when the ART rollout began and 2007, though 13% started earlier. Of the 166 patients with resistance test results, 74% and 75% had high level resistance (mutation score ≥15) to efavirenz and nevirapine respectively. 85%, 71%, 68% and 79% had resistance to lamivudine, zidovudine, tenofovir and abacavir respectively, while 86% and 71% had resistance to lopinavir and atazanavir respectively. In addition 47% and 32% had resistance to darunavir and etravirine respectively. Of the 166, 87% (n=145) were initiated on a third-line regimen containing either raltegravir (n=107), darunavir (n=144) or etravirine (n=33) or some combination thereof. Discussion: Our analysis shows that patients failing second line treatment with PI resistance have a high level of resistance to drugs available in the public sector in sub-Saharan Africa.
Conference: IWHOD 2015, Catania, Sicily, 26-28 March 2015