title: Second-line failure and first experience with third-line antiretroviral therapy in Mumbai, India.
abstract: BACKGROUND
  There are limited data on the failure of second-line antiretroviral therapy (ART) and the use of third-line ART in people living with HIV in resource-limited settings. Since 2011, the Médecins Sans Frontières (MSF) HIV/tuberculosis programme in Mumbai, India, has been providing third-line ART to patients in care.
  
  
  OBJECTIVE
  To describe the experiences and programmatic challenges during management of suspected second-line ART failure and third-line ART therapy for patients living with HIV, including the use of HIV viral load (VL) testing.
  
  
  METHODS
  This was a retrospective, observational cohort study of patients with suspected second-line ART treatment failure, who were followed for at least 12 months between January 2011 and March 2014.
  
  
  RESULTS
  A total of 47 patients with suspected second-line failure met the inclusion criteria during the study period. Twenty-nine of them (62%) responded to enhanced adherence support, had a subsequent undetectable VL after a median duration of 3 months and remained on second-line ART. The other 18 patients had to be initiated on a third-line ART regimen, which consisted of darunavir-ritonavir, raltegravir, and one or more appropriate nucleoside or nucleotide reverse transcriptase inhibitors, based on the results of HIV genotype testing. Of the 13 patients for whom follow-up VL results were available, 11 achieved virological suppression after a median duration of 3 months on third-line ART (interquartile range: 2.5-3.0). No serious treatment-related adverse events were recorded.
  
  
  CONCLUSIONS
  With intensive counselling and adherence support in those suspected of failing second-line ART, unnecessary switching to more expensive third-line ART can be averted in the majority of cases. However, there is an increasing need for access to third-line ART medications such as darunavir and raltegravir, for which national ART programmes should be prepared. The cost of such medications and inadequate access to VL monitoring and HIV genotype testing are currently major barriers to optimal management of patients failing second-line ART.
authors.affiliation: Médecins Sans Frontières, Mumbai, India.
authors.forename: Samsuddin
authors.initials: S
authors.lastname: Khan
authors.affiliation: Médecins Sans Frontières, Mumbai, India.
authors.forename: Mrinalini
authors.initials: M
authors.lastname: Das
authors.affiliation: Médecins Sans Frontières, Mumbai, India.
authors.forename: Aristomo
authors.initials: A
authors.lastname: Andries
authors.affiliation: Infectious Diseases Department, Mahatma Gandhi Medical College, Mumbai, India.
authors.forename: Alaka
authors.initials: A
authors.lastname: Deshpande
authors.affiliation: Médecins Sans Frontières, Mumbai, India.
authors.forename: Homa
authors.initials: H
authors.lastname: Mansoor
authors.affiliation: Southern Africa Medical Unit (SAMU), Médecins Sans Frontières, Cape Town, South Africa.
authors.forename: Peter
authors.initials: P
authors.lastname: Saranchuk
authors.affiliation: Médecins Sans Frontières, Mumbai, India; msfocb-asia-epidemio@brussels.msf.org.
authors.forename: Petros
authors.initials: P
authors.lastname: Isaakidis
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D007194:India / Q000453:epidemiology; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D012189:Retrospective Studies; D017211:Treatment Failure; D016896:Treatment Outcome; D019562:Viral Load
chemical_list: D019380:Anti-HIV Agents
keywords: HIV; India; adherence; antiretroviral therapy; counselling; genotyping; viral load
references.citation: Ann Intern Med. 2009 Aug 18;151(4):241-51, W-52
references.pmid: 19687491
references.citation: Clin Infect Dis. 2012 May;54 Suppl 4:S245-9
references.pmid: 22544182
references.citation: J Acquir Immune Defic Syndr. 2014 Feb 1;65(2):e82-4
references.pmid: 24442229
references.citation: AIDS. 2012 May 15;26(8):929-38
references.pmid: 22313953
references.citation: Antivir Ther. 2008;13 Suppl 2:1-13
references.pmid: 18578063
references.citation: JAMA. 2010 Jul 21;304(3):303-12
references.pmid: 20639564
references.citation: PLoS One. 2012;7(7):e40781
references.pmid: 22792406
references.citation: J Int AIDS Soc. 2013 Jan 31;16:18004
references.pmid: 23374858
references.citation: J Acquir Immune Defic Syndr. 2011 Sep 1;58(1):23-31
references.pmid: 21694603