Second-line Antiretriviral Therapy in Northern Tanzania

Omari, Habib

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Last Modified

March 19, 2019

Creator

Omari, Habib
- Affiliation: Gillings School of Global Public Health, Department of Epidemiology

Abstract

Following rapid expansion of anti-retroviral therapy (ART) in resource limited settings, some patients are failing and require switching to second line ART. The diagnosis of treatment failure in these settings depends on relatively poorly performing WHO immunological failure criteria. As a consequence, physicians are reluctant to switch patients to second-line and hence, times to switch to second line varies substantially in different programs. Despite the efforts to address the importance of ART adherence, some patients receiving second-line ART are still non-adherent. Limited treatment options underscore the need to explore adherence as well as switching times among patients receiving second-line. A review of 637 adolescents and adults meeting WHO immunological failure criteria was conducted. Immediate and delayed switching to second-line ART were defined when switching happens at < 3 and ≥ 3 months respectively following failure diagnosis. Those receiving secondline were administered questionnaires that assessed adherence. Optimal and suboptimal cumulative adherence were defined as percentage adherence of ≥ 90% and < 90% respectively. Cox proportional hazard marginal structural models were used to assess the effect of switching to second-line ART and the risk of opportunistic infections and binomial regression models were used to assess the prevalence of suboptimal adherence percentage by pre-switch adherence status. Among 322 participants who had suboptimal adherence to firstline ART, 117 (36.3%) had suboptimal adherence to second-line ART compared to 17/114 (14.9%) who had optimal adherence to first-line. Of 637 participants 74% (n=471) were either delayed or did not switch to second-line. Participants who had suboptimal adherence to first-line ART were more likely to have suboptimal adherence to second-line ART (APR 2.4, 95% CI 1.5 – 3.9).Switching to second-line ART reduced the risk of opportunistic infections (adjusted hazards ratio [AHR] 0.4, 95% CI 0.2 – 0.6). Compared to patients who switched to second-line ART immediately after failure diagnosis is made, those who delayed switching exhibited a trend toward more opportunistic infections (AHR 1.7, 95% CI 0.6 – 4.4). Interventions to improve adherence to patients with suboptimal adherence prior to switch as well as increasing physician’s awareness about when to switch to second-line ART is critical to improve patient outcomes.

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