University of Heidelberg

Virological Failure and Drug Resistance in Patients on Antiretroviral Therapy after

Documented Treatment Interruption

in Lilongwe, Malawi

J. Lübbert, H. Tweya, T. Chaweza, J. Mwafilaso, H.Ramroth, S. Phiri,

P. Schnitzler, F. Neuhann

Background

•Located in Malawi‘s capital: Lilongwe

•Operates 2 day hospitals: Lighthouse Clinic Martin Preuss Centre

•Since 2004: Free access to ART in the public sector

•Largest public sector ART provider in central region > 14,000 patients enrolled in ART Program in

2008-2009

ART in Malawi

•1st line: Triomune (NVP, 3TC and d4T)

•Alternative 1st line: EFV for NVP ZDV for d4T

•2nd line: ZDV, 3TC, TDF, LPV/r

Study Population

14,120 patients received ART (2008/2009)14,120 patients received ART (2008/2009)

341 eligible patients 341 eligible patients Documented treatment

interruptionDocumented treatment

interruptionReturn to

careReturn to

care Restart 1st lineRestart 1st line

133 patients were examined for CD4 cell count and HIV RNA levels

133 patients were examined for CD4 cell count and HIV RNA levels

40 patients had HIV RNA levels

> 1000 copies/ml

40 patients had HIV RNA levels

> 1000 copies/ml

93 patients had HIV RNA levels <1000 copies/ml

93 patients had HIV RNA levels <1000 copies/ml

36 patients genotyping successful

36 patients genotyping successful

4 patients genotyping

not successful

4 patients genotyping

not successful

≥ 2 months after re-initiation

Virological Failure

Characteristics of patients with confirmed virological failure (HIV-1 RNA >1000 copies/ml) ; (n=40)Variable Median or percentage

Females 62,5 %Age (years) 29 (IQR 24-38)CD4 cell count (cells/µl)

242 (IQR 168-349)

<50 2,8 % 51-200 27,8 % >200 61,1 %HIV RNA (copies/ml) 79 542 (IQR 3664 - 98 636) <10 000 40 % 10 001-100 000 37,5 % >100 000 22,5 %

Virological Failure II

Drug Resistance Related Mutations

•No Resistance Mutation n= 4•Resistance Mutation n=32•NRTI Mutation n=27•NNRTI Mutation n=32

Patterns of Drug Resistance

Key Findings

•After documented treatment interruption 2/3 resuppressed with Malawi’s 1st line

regimen

•HIV RNA levels > 1000 copies/ml 88,9% had drug resistance mutations

•Treatment interruption = major risk factor for virological failure.

•Frequent lost of NNRTIs as a treatment option

•All patients maintained the option for the current 2nd line treatment in Malawi

Limitations

•Limited sample size

•Drug resistance only determined in patients who returned to clinic

•Above average knowledge about HIV/AIDS, ART and importance of drug adherence at Lighthouse clinic ?

1st line1st line

Conclusion

1st line1st lineARTART ??

≥ 2 months 1st line1st line

VLVL

2nd line

• Dr Sam Phiri• Hannock Tweya and team• B2C team• Staff (Lighthouse and Martin Preuss)• Kamuzu Central Hospital Laboratories• UNC Laboratories, Lilongwe/Malawi

Thank you very much for your attention!