Genotype guided salvage therapy in public HIV clinics at public health systems of Sao Paulo, Brazil
R. Rodrigues1, C.M.P. Vazquez2, S.Q. Rocha3, D.M. Ferreira Junior4, R. Almeida5, P. Braga6, L. Hornke7, A.J. Silva1, L. Brigido1, Sao Paulo HIV Salvage Workgroup
1Instituto Adolfo Lutz, Virology, Sao Paulo, Brazil, 2Instituto de Infectologia Emilio Ribas, Sao Paulo, Brazil, 3Centro de Referencia DST/Aids de Sao Paulo, Sao Paulo, Brazil, 4Centro de Referencia DST/Aids de Araçatuba, Aracatuba, Brazil, 5Faculdade de Medicina - UNESP, Botucatu, Brazil, 6Escola de Enfermagem - FMUSP, Sao Paulo, Brazil, 7Centro de Referencia DST/Aids de Barueri, Barueri, Brazil
Background: Genotype guided salvage therapy (GGST) is a strategy to improve clinical outcome, but studies of its impact are limited. We evaluated patients performing genotype and initiating subsequent salvage therapy at Public Health Services in Sao Paulo State.
Methods: Clinical, ARV history, CD4 and Viral load were obtained from clinical charts. HIV sequencing was performed from plasma RNA. Drug resistance mutations were evaluated at Stanford database. Epi6 and Stata was use for statistical analysis.
Results: Clinical information was obtained from 607 patients (67% males) from Jan 2005 to Dec 2009, 49% exposed to three ARV classes, 72% with nadir CD4< 200 and median time on ARV of 7.8 years. After GGST, 62% had at least one undetectable viral load (aviremic) and 47% were aviremic at last observation (median follow up, 85 wks 25th 75th 48-120 wks). The proportion of aviremic increased with time, from 34% up to wk 13 to 54% after wk 77. Change of salvage therapy in 25% due to intolerance or failure did not improve virological outcome. Most patients (75%) had a net gain of TCD4. Multivariable analysis (Log rank) showed TCD4 at entry and viremia at collection significantly associated to aviremia pos GGST. Among 360 with genotypic data, mutations at protease but not at RT were associated to lack of virological success.
Conclusion: About half of patients, most with advance disease, were able to suppress viremia but lack of control group allows us only to suggest the benefit of genotype test. Low TCD4 levels at entry, higher viral load at genotype and the presence of protease mutations impacted the virological outcome. The sustainability of these results would be favored by the implementation of comprehensive care policies that address specific issues of these patients. Strategies to foster clinical care before TCD4 falls to low counts are a major public health issue.
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