Predicting the need for third-line antiretroviral therapy by identifying patients at high risk for failing second-line antiretroviral therapy in South Africa

By  Dr Dorina Onoya  Cornelius Nattey  Eric Budgell, Liudmyla van den Berg  Dr Mhairi Maskew  Dr. Denise Evans  Kamban Hirasen  Dr. Lawrence Long  Dr. Matthew Fox  |  | 

Although third-line antiretroviral therapy (ART) is available in South Africa’s public sector, its cost is substantially higher than first and second line. Identifying risk factors for failure on second-line treatment remains crucial to reduce the need for third-line drugs. We conducted a case–control study including 194 adult patients (‡18 years; 70 cases and 124 controls) who initiated second-line ART in Johannesburg, South Africa. Unconditional logistic regression was used to assess predictors of virologic failure (defined as 2 consecutive viral load measures ‡1000 copies/mL, ‡3months after switching to second line). Variables included a social instability index, ART adherence, self-reported as well as diagnosed adverse drug reactions (ADRs), HIV disclosure, depression, and factors affecting access to HIV clinics. Overall 60.0% of cases and 54.0% of controls were female. Mean ages of cases and controls were 41.8 – 9.6 and 43.3 – 8.0, respectively. Virologic failure was predicted by ART adherence <90% [odds ratio (OR) 4.7; 95% confidence interval (95% CI): 2.1–10.5], younger age (<40 years of age; OR 0.6; 95% CI: 0.3–1.1), high social instability (OR 3.8; 95% CI: 1.30–11.5), self-reported ADR (OR 1.9; 95% CI: 1.0–3.5), disclosure to friends/colleagues rather than partner/relatives (OR3.4; 95%CI: 1.3–9.1), and medium/high depression compared to low/no depression (OR 4.4; 95% CI: 1.5–13.4). Our results suggest complex socioeconomic factors contributing to risk of virologic failure, possibly by impacting ART adherence, among patients on second-line therapy in South Africa. Identifying patients with possible indicators of nonadherence could facilitate targeted interventions to reduce the risk of second-line treatment failure and mitigate the demand for third-line regimens.

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