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High Rates of Survival, Immune Reconstitution, and Virologic Suppression on Second-Line Antiretroviral Therapy in South Africa

Fox, Matthew P DSc, MPH*†; Ive, Prudence MBBCH; Long, Lawrence MCom; Maskew, Mhairi MBBCH, MSc‡§; Sanne, Ian MBBCH‡§

JAIDS Journal of Acquired Immune Deficiency Syndromes: April 1st, 2010 - Volume 53 - Issue 4 - p 500-506
doi: 10.1097/QAI.0b013e3181bcdac1
Epidemiology and Social Science

To determine rates of survival, viral suppression, and immunologic change after 1 year on second-line antiretroviral therapy, we conducted a cohort study among 328 patients initiated on zidovudine, didanosine, and lopinavir/ritonavir. All patients who switched to standard second-line therapy at a large urban public-sector clinic in Johannesburg, South Africa, were included. A year after initiating second-line therapy 243/313 [78%; 95% confidence interval (CI) 73%-82%], subjects were alive and in care. Further, 203/262 (77%; 95% CI: 72%-82%) had a suppressed viral load by 1 year. Mean CD4 gain by 12 months was 133 cells/μL (95% CI: 106-160). Patients on second-line therapy had a small decreased likelihood of being alive and in care by 1 year [hazard ratio (HR) 0.84; 95% CI: 0.73-0.97] as time-matched comparisons on first-line antiretroviral therapy (ART). Patients switched before 2 viral loads >1000 (HR 1.68; 95% CI: 1.08-2.61), and those switched for reasons not related to noncompliance with first-line (HR 1.83; 95% CI: 1.14-2.93) were more likely to achieve virologic suppression by 1 year on second-line ART. As rates of treatment failure over the first year on second-line therapy were low, provision of second-line treatment to patients who fail their first-line ART should be considered a high priority in resource-poor settings.

From the *Center for Global Health and Development, Boston University, Boston, MA; †Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa; ‡Clinical HIV Research Unit, Department of Medicine, University of the Witwatersrand, Johannesburg, South Africa; and §Right to Care, Johannesburg, South Africa.

Received for publication March 18, 2009; accepted July 31, 2009.

Supported by the United States Agency for International Development (USAID) under the terms of agreement 674-A-00-08-00007-00 with Right to Care and by the South Africa Mission of USAID under the terms of Cooperative Agreement GHSA-00-00020-00, Country Research Activity (G/PHN/HN/CS). The opinions expressed herein are those of the authors and do not necessarily reflect the views of USAID, the Themba Lethu Clinic, or Right to Care.

Similar data have been presented previously at the 16th Conference on Retroviruses and Opportunistic Infections 2009 abstract L-140. Results differ slightly as the definition of failure was revised and more data on patients became available.

Conflict of interest: Right to care provided some of the funding for the current research and also supports the provision of treatment for the patients in the study.

Correspondence to: Matthew Fox, DSc, MPH, Center for Global Health and Development, Boston University, Crosstown Center, 3rd Floor, 801 Massachusetts Ave., Boston, MA 02118 (e-mail:

© 2010 Lippincott Williams & Wilkins, Inc.