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Lack of awareness of treatment failure among HIV-1-infected patients in Guinea-Bissau - a retrospective cohort study

Sanne Jespersen, Bo Langhoff Hønge, Candida Medina, David da Silva Té, Faustino Gomes Correira, Alex Lund Laursen, Christian Erikstrup, Lars Østergaard, Christian Wejse, for the Bissau HIV Cohort study group


Introduction: With more people receiving antiretroviral treatment (ART), the need to detect treatment failure and switch to second-line ART has also increased. We assessed CD4 cell counts (as a marker of treatment failure), determined whether patients were properly switched to second-line treatment, and mortality according to treatment failure among HIV-infected patients in Guinea-Bissau.

Methods: In this retrospective cohort study, adult patients infected with HIV-1 receiving ≥6 months of ART at an HIV clinic in Bissau were included from June 2005 to July 2014, and were followed until January 2015. Treatment failure was defined as 1) a fall in CD4 count to baseline (or below) or 2) CD4 levels persistently below 100 cells/µL after ≥6 months of ART. Cox hazard models, with time since 6 months of ART as time-varying coefficients, were used to estimate the hazard ratio for death and loss to follow-up.

Results: We assessed 1,591 HIV-1-infected patients for immunological treatment failure. Treatment failure could not be determined in 594 patients (37.3%) because of missing CD4 cell counts. Among the remaining 997 patients, 393 (24.7%) experienced failure. Only 39 patients (9.9%) with failure were switched from first- to second-line ART. The overall switching rate was 3.1 per 100 person-years. Mortality rate were higher in patients with than without treatment failure, adjusted hazard rate ratio (HRR) 10.0 (95% CI. 0.9-107.8), 7.6 (95% CI: 1.6-35.5), and 3.1 (95% CI: 1.5-6.3) in the first, second and following years, respectively. During the first year of follow-up, patients experiencing treatment failure had a higher risk of being lost to follow-up than patients not experiencing treatment failure, adjusted HRR 4.4 (95% CI: 1.7-11.8).

Conclusion: We found a high rate of treatment failure, an alarmingly high number of patients where treatment failure could not be assessed, and a low rate of switching to a second-line therapy. This could lead to an increased risk of resistance development and excess mortality.

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Journal of the International AIDS Society | eISSN 1758-2652 | Editors-in-Chief: Susan Kippax and Kenneth Mayer

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