A cross-sectional study to evaluate second line virological failure and elevated bilirubin as a surrogate for adherence to atazanavir/ritonavir in two urban HIV clinics in Lilongwe, Malawi

BMC Infectious Diseases

Research Article

Tom Heller¹  Salem Gugsa¹  Colin Speight¹  Petros Tembo¹  Hannock Tweya²  Sam Phiri³  Robertino Lim⁴  Dennis Miyoge Ongubo⁵  Christopher Chikhosi Stanley⁶  McNeil Ngongondo⁶  Mina C. Hosseinipour⁷  Richard Broadhurst⁸ 

[1] Lighthouse Trust, Lilongwe, Malawi;Lighthouse Trust, Lilongwe, Malawi;The International Union Against Tuberculosis and Lung Disease, Paris, France;Lighthouse Trust, Lilongwe, Malawi;University of North Carolina School of Medicine, Chapel Hill, USA;Department of Public Health, University of Malawi, College of Medicine, School of Public Health and Family Medicine, Lilongwe, Malawi;Tufts University School of Medicine, Boston, USA;Tulane University School of Public Health and Tropical Medicine, New Orleans, USA;University of North Carolina Project, Lilongwe, Malawi;University of North Carolina Project, Lilongwe, Malawi;University of North Carolina School of Medicine, Chapel Hill, USA;University of North Carolina School of Medicine, Chapel Hill, USA;

关键词: Virological failure;    Atazanavir/ritonavir;    Second line;    Antiretroviral therapy;    Bilirubin;    Adherence;    Surrogate;   

DOI  :  10.1186/s12879-017-2528-0

 received in 2017-03-07, accepted in 2017-06-06,  发布年份 2017

来源: Springer

【 摘 要 】

BackgroundMalawi’s national antiretroviral therapy program provides atazanavir/ritonavir–based second line regimens which cause concentration-dependent rise in indirect bilirubin. We sought to determine if elevated bilirubin, as a surrogate of atazanavir/ritonavir adherence, can aid in the evaluation of second line virological failure in Malawi.MethodsWe conducted a cross-sectional study of HIV-infected patients ≥15 years who were on boosted protease inhibitor-based second line antiretroviral therapy for at least 6 months in two urban HIV clinics in Lilongwe, Malawi. Antiretroviral therapy history and adherence data were extracted from the electronic medical records and blood was drawn for viral load, complete blood count, total bilirubin, and CD4 cell count at a clinic visit. Factors associated with virological failure were assessed using multivariate logistic regression model.ResultsOut of 376 patients on second line antiretroviral therapy evaluated, 372 (98.9%) were on atazanavir/ritonavir-based therapy and 142 (37.8%) were male. Mean age was 40.9 years (SD ± 10.1), mean duration on second line antiretroviral therapy was 41.9 months (SD ± 27.6) and 256 patients (68.1%) had elevated bilirubin >1.3 mg/dL. Overall, 35 (9.3%) patients had viral load >1000 copies/ml (virological failure). Among the virologically failing vs. non-failing patients, bilirubin was elevated in 34.3% vs. 72.0% respectively (p < 0.001), although adherence by pill count was similar (62.9% vs. 60.7%, p = 0.804). The odds of virological failure were higher for adults aged 25–40 years (adjusted odds ratio (aOR) 2.5, p = 0.048), those with CD4 cell count <100 (aOR 17.5, p < 0.001), and those with normal bilirubin levels (aOR 5.4, p < 0.001); but were lower for the overweight/obese patients (aOR 0.3, p = 0.026). Poor pill count adherence (aOR 0.7, p = 0.4) and male gender (aOR 1.2, p = 0.698) were not associated with second line virological failure.ConclusionsAmong patients receiving atazanavir/ritonavir-based second line antiretroviral therapy, bilirubin levels better predicted virological failure than pill count adherence. Therefore, strategic use of bilirubin and viral load testing to target adherence counseling and support may be cost-effective in monitoring second line antiretroviral therapy adherence and virological failure. Drug resistance testing targeted for patients with virological failure despite elevated bilirubin levels would facilitate timely switch to third line antiretroviral regimens whenever available.

【 授权许可】

CC BY   
© The Author(s). 2017