Reasons for first line ART modification over the years during the ART scale up in Uganda
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AIDS Research and Therapy Open Access
RESEARCH
Reasons for first line ART modification over the years during the ART scale up in Uganda B. Castelnuovo*, F. Mubiru, I. Kalule and A. Kiragga
Abstract Background: During the initial scale up of ART in sub-Saharan Africa, prescribed regimens included drugs with high potential for toxicity (particularly stavudine). More recently a growing number of patients requires second line treatment due to treatment failure, especially following the expansion of viral load testing. We aim to determine the reasons and risk factors for modification of first line ART across the years. Methods: We included patients started on standard first line ART (2NRTI + 1 NNRTI) between 2005 and 2016 at the Infectious Diseases Institute, Kampala, Uganda. We described the reasons for treatment modification categorized in (1) toxicity (2) treatment failure (3) other reason (new TB treatment, new pregnancy). We used Cox proportional hazard to identify factors associated with treatment modification due to toxicity. Results: We included 14,261 patients; 9114 (63.9%), were female, the median age was 34 years (IQR: 29–40), 60.8% were in WHO stage 3 and 4. The median BMI and CD4 count were 21.9 (IQR: 19.6–24.8) and 188 cell/µL (IQR: 65–353) respectively; 27.5% were started on stavudine, 46% on zidovudine, and 26.5% on a tenofovir containing regimens. We observed 6248 ART modifications in 4868/14,261 patients (34.1%); 1615 were due to toxicity, 1077 to treatment failure, 1330 to contraindications, and 1860 patients following WHO recommendation of phasing out stavudine and substituting with another NRTI. Modification for drug toxicity declined rapidly after the phase out of stavudine (2008), while switches to second line regimes increased after the implementation of viral load monitoring (2015). Patients with normal BMI compared to underweight, (HR: 0.79, CI 0.69–0.91), with CD4 counts 200–350 cells/µL compared to 1000 were switched to second line; after the implementation of viral load monitoring patients with 2 consecutive viral measurements > 75 copies/ml are considered for switch to second line. Patients and follow up
This study was a retrospective analysis of all patients started at IDI on standard first line ART (2NRTI + 1 nonnucleoside/nucleotide reverse transcriptase (NNRTI)) since the program inception in 2005 up to the end of 2016 with the closure of the database at the end of 2017 In our program at each visit after ART start the provider (a doctor or a nurse, depending on the general health condition of the patient [23]) takes the medical history, vital signs and performs physical examination. ART regimen, adherence, toxicity and laboratory tests are also reviewed, and ART and other medications are prescribed. The information obtained during the clinic visits is entered in real time by the health providers into the IDI electronic medical record system, the Integrated Clinic Enterprise Application (ICEA) [24]. ART regimens are pre-coded and entered by choosing the correct code from a drop do
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