title: Persistent difficulties in switching to second-line ART in sub-saharan Africa--a systematic review and meta-analysis.
abstract: OBJECTIVE
  Switching to second-line antiretroviral therapy (ART) largely depends on careful clinical assessment and access to biological measurements. We performed a systematic review and meta-analysis to estimate the incidence of switching to second-line ART in sub-Saharan Africa and its main programmatic determinants.
  
  
  METHODS
  We searched 2 databases for studies reporting the incidence rate of switching to second-line ART in adults living in sub-Saharan Africa. Data on the incidence rate of switching were pooled, and random-effect models were used to evaluate the effect of factors measured at the programme level on this incidence rate.
  
  
  RESULTS
  Nine studies (157,340 patients) in 21 countries were included in the meta-analysis. All studies considered patients under first-line ART and conditions to initiate ART were similar across studies. Overall, 3,736 (2.4%) patients switched to second-line ART. Incidence rate of switch was in mean 2.65 per 100 person-years (PY) (95% confidence interval: 2.01-3.30); it ranged from 0.42 to 4.88 per 100 PY and from 0 to 4.80 per 100 PY in programmes with and without viral load monitoring, respectively. No factors measured at the programme level were associated with the incidence rate of switching to second-line ART.
  
  
  CONCLUSIONS
  The low incidence rate of switching to second-line ART suggests that the monitoring of patients under ART is challenging and that access to second-line ART is ineffective; efforts should be made to increase access to second-line ART to those in need by providing monitoring tools, education and training, as well as a more convenient regimen.
authors.affiliation: Institut Pasteur, Emerging Diseases Epidemiology Unit, Paris, France.
authors.forename: Yoann
authors.initials: Y
authors.lastname: Madec
authors.affiliation: Institut Pasteur, Emerging Diseases Epidemiology Unit, Paris, France.
authors.forename: Sandrine
authors.initials: S
authors.lastname: Leroy
authors.affiliation: Institut Pasteur, Emerging Diseases Epidemiology Unit, Paris, France.
authors.forename: Marie-Anne
authors.initials: MA
authors.lastname: Rey-Cuille
authors.affiliation: SOLTHIS, Paris, France.
authors.forename: Florence
authors.initials: F
authors.lastname: Huber
authors.affiliation: Geneva University Hospital, HIV Unit, Department of Internal Medicine, Geneva, Switzerland.
authors.forename: Alexandra
authors.initials: A
authors.lastname: Calmy
mesh_terms: D000328:Adult; D017954:Africa South of the Sahara / Q000453:epidemiology; D023241:Antiretroviral Therapy, Highly Active; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male