University of Heidelberg Virological Failure and Drug Resistance

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 • 1 st line: Triomune (NVP, 3 TC and d 4 T) • Alternative 1 st line: § EFV for NVP § ZDV for d 4 T • 2 nd line: ZDV, 3 TC, TDF, LPV/r

Study Population 14, 120 patients received ART (2008/2009) 341 eligible patients Documented treatment interruption Return to care Restart 1 st line 133 patients were examined for CD 4 cell count and HIV RNA levels ≥ 2 months after re 40 patients had HIV RNA levelsinitiation 93 patients had HIV RNA levels > 1000 copies/ml 36 patients genotyping successful 4 patients genotyping not successful <1000 copies/ml

Virological Failure Characteristics of patients with confirmed virological failure (HIV-1 RNA >1000 copies/ml) ; (n=40) Variable Females Age (years) CD 4 cell count (cells/µl) <50 51 -200 >200 HIV RNA (copies/ml) <10 000 10 001 -100 000 >100 000 Median or percentage 62, 5 % 29 (IQR 24 -38) 242 (IQR 168 -349) 2, 8 % 27, 8 % 61, 1 % 79 542 (IQR 3664 - 98 636) 40 % 37, 5 % 22, 5 %

Virological Failure II

Drug Resistance Related Mutations • • No Resistance Mutation NRTI Mutation NNRTI Mutation n= 4 n=32 n=27 n=32

Patterns of Drug Resistance

Key Findings • After documented treatment interruption 2/3 resuppressed with Malawi’s 1 st 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 2 nd 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 ?

Conclusion ≥ 2 months 1 st line ART 1 st line ? 1 st line VL 2 nd line

• Dr Sam Phiri • Hannock Tweya and team • B 2 C team • Staff (Lighthouse and Martin Preuss) • Kamuzu Central Hospital Laboratories • UNC Laboratories, Lilongwe/Malawi Thank you very much for your attention!