Suboptimal adherence associated with virologic failure and resistance
mutations among patients on 1st line HAART in Bangalore, India
Presented by Maria Ekstrand (United States).
M. Ekstrand1,2,3, A. Shet2,4, S. Chandy5, G. Singh5, R. Shamsundar6, V. Madhavan7, S. Saravanan7, N. Kumarasamy7
1University of California, San Francisco, Medicine, San Francisco, United States, 2St John's Research Institute, Bangalore, India, 3University of California Berkeley, School of Public Health, Berkeley, United States, 4St John's National Academy of Health Sciences, Pediatrics, Bangalore, India, 5St John's National Academy of Health Sciences, Medicine, Bangalore, India, 6St John's National Academy of Health Sciences, Microbiology, Bangalore, India, 7YRGCARE, Chennai, India
Background: This study was conducted to examine the relationship
between adherence, viral load (VL) and resistance mutations among public and
private clinic outpatients receiving first-line HAART in Bangalore, India.
Methods: We recruited a cohort of 552 outpatients receiving HAART. Viral load testing was conducted for all study participants. HIV-1 genotypic resistance testing was performed for n=92 with VL>1,000 copies/mL. Interpretation of drug resistance mutations was performed according to the Stanford database (http://hivdb.stanford.edu/hiv). Past month adherence and treatment interruptions of >48 hours were assessed via self-report.
Results: 6% (n=34) of participants reported < 95% past
month adherence and 20% (n=110) reported a history of >48 hr treatment
interruptions. Combining the two adherence measures, 23% (n=123) were
classified as “suboptimally-adherent”.
Overall, 24% (n=132) had detectable VL, (median
=8,850 c/mL, IQR 1,175-147,688 c/mL). All adherence measures were significantly
associated with VL, with 42% of suboptimally-adherent, and 19% of optimally-adherent
patients showing virological failure (p< .0001).
Among the 92 samples with VL >1,000,
69% (n=63) had 1+ NRTI mutations, with M184V being the most common (62%, n=57)
and 44% (n=40) having thymidine analogue mutations (TAMS). 72% (n=66) had 1+
NNRTI mutations and 23% (n=21) had 3+ NNRTI mutations. Adherence was
significantly associated (p< .02) with mutations when treatment
interruptions were included, with 87% of “suboptimally-adherent” patients
having at least one mutation.
Conclusions: Our findings
illustrate for the first time the strong association between suboptimal
adherence, treatment failure and worsening drug resistance among patients on
first-line HAART in India. The predictive value of standard adherence measures
was improved by including data on treatment interruptions. The observed
mutations can jeopardize future treatment options, especially in light of
limited access to 2nd line treatments. Research is needed to
examine individual, family and structural reasons for treatment interruptions. Culturally-appropriate
techniques are needed to improve both types of adherence in this setting.
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