title: Intensive adherence counselling for HIV-infected individuals failing second-line antiretroviral therapy in Johannesburg, South Africa.
abstract: In resource-limited settings, where genotypic drug resistance testing is rarely performed and poor adherence is the most common reason for treatment failure, programmatic approaches to handling treatment failure are essential. This study was performed to describe one such approach to adherence optimisation.
  
  
  
  This was a single-arm study of patients on second-line protease inhibitor (PI)-based antiretroviral therapy (ART) with a HIV-1 RNA ≥400 copies/ml in Johannesburg, South Africa, between 1 March 2012 and 1 December 2013. Patients underwent enhanced adherence counselling. Those with improved adherence and a repeat viral load of >1000 copies/ml underwent HIV-1 drug resistance testing. We describe results using simple proportions and 95% confidence intervals.
  
  
  
  Of the 400 patients who underwent targeted adherence counselling after an elevated viral load on second-line ART, 388 (97%) underwent repeat viral load testing. Most of these (n = 249; 64%, 95% CI 59-69) resuppressed (<400 copies/ml) on second line. By the end of follow-up (1 March 2014), among the 139 (36%, 95% CI: 31-41%), who did not initially resuppress after being targeted, 106 had a viral load >400 copies/ml, 11 switched to third line, 5 were awaiting third line, 4 had died and 13 were lost to follow-up. Among the unsuppressed, 48 successfully underwent resistance testing with some resistance detected in most (41/48).
  
  
  
  Most (64%) second-line treatment failure in this clinic is related to adherence and can be overcome with careful adherence support. Controlled interventions are needed to determine what the optimal approach is to improving second-line outcomes and reducing the need for third-line ART.
authors.affiliation: Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.|Department of Global Health, Boston University School of Public Health, Boston, MA, USA.|Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.
authors.forename: Matthew P
authors.initials: MP
authors.lastname: Fox
authors.affiliation: Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.|Right to Care, Johannesburg, South Africa.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Berhanu
authors.affiliation: Department of Haematology and Molecular Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Kim
authors.initials: K
authors.lastname: Steegen
authors.affiliation: Right to Care, Johannesburg, South Africa.|Clinical HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Cindy
authors.initials: C
authors.lastname: Firnhaber
authors.affiliation: Clinical HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Prudence
authors.initials: P
authors.lastname: Ive
authors.affiliation: Right to Care, Johannesburg, South Africa.
authors.forename: David
authors.initials: D
authors.lastname: Spencer
authors.affiliation: Right to Care, Johannesburg, South Africa.
authors.forename: Sello
authors.initials: S
authors.lastname: Mashamaite
authors.affiliation: Task Applied Science, Cape Town, South Africa.
authors.forename: Sadiyya
authors.initials: S
authors.lastname: Sheik
authors.affiliation: Witkoppen Health and Welfare Center, Johannesburg, South Africa.
authors.forename: Ingrid
authors.initials: I
authors.lastname: Jonker
authors.affiliation: Department of Haematology and Molecular Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Pauline
authors.initials: P
authors.lastname: Howell
authors.affiliation: Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Lawrence
authors.initials: L
authors.lastname: Long
authors.affiliation: Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Denise
authors.initials: D
authors.lastname: Evans
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active; D018791:CD4 Lymphocyte Count; D003376:Counseling; D024882:Drug Resistance, Viral; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000821:virology; D015497:HIV-1; D006801:Humans; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance; D011446:Prospective Studies; D013019:South Africa; D017211:Treatment Failure; D019562:Viral Load
chemical_list: D019380:Anti-HIV Agents
keywords: Afrique subsaharienne; HIV genotyping; antiretroviral therapy; fallo en el tratamiento; fallo virológico; genotipaje del VIH; génotypage du VIH; inhibidor de proteasas; inhibiteur de protéase; lopinavir; protease inhibitor; second-line antiretroviral therapy; sub-Saharan Africa; third-line antiretroviral therapy; thérapie antirétrovirale; traitement antirétroviral de deuxième ligne; traitement antirétroviral de troisième ligne; tratamiento antirretroviral; tratamiento antirretroviral de segunda línea; tratamiento antirretroviral de tercera línea; treatment failure; virologic failure; África subsahariana; échec du traitement; échec virologique