187390 Impact of an mDAART intervention on virological outcome in HIV-patients treated in Burkina Faso and Mali

Monday, October 27, 2008: 8:45 AM

Catherine M. Pirkle, MSc , Unité de Santé Internationale, Université de Montréal, Montréal, QC, Canada
Catherine Boileau, MSc, PhD , Institute for Health and Social Policy, McGill University, Montreal, QC, Canada
Vinh-Kim Nguyen, MD, PhD , Unité de Santé Internationale, Université de Montréal, Montréal, QC, Canada
Nimâ Machouf , Clinique médicale l'Actuel, Montréal, QC, Canada
Souleymane Aboubacrine, MD , Hôpital National du Point G, Bamako, Mali
Pascal Antoine Niamba, MD , Centre Hospitalier Universitaire Yalgado-Ouédraogo, Ouagadougou, Burkina Faso
Joseph Drabo, MD , Centre hospitalier national, Ouagadougou, Burkina Faso
Samuel Koala, MD, MPh , Projet Fonds Mondial de lutte contre le SIDA,la tuberculose et le paludisme, Ouagadougou, Burkina Faso
Cecile Tremblay, MD PhD , Faculté de médecine - Microbiologie et immunologie, Université de Montréal, Montréal, QC, Canada
Selim Rashed, MD , Faculté de médecine - Pédiatrie, Université de Montréal, Montréal, QC, Canada
     
Objective: This study explores whether viral load measurements can be used in resource-limited settings to target those in need of adherence assistance. It was hypothesised that high viral loads („d500 copies/ml) were the result of poor antiretroviral treatment (ART) adherence and amenable to improvement with adherence assistance.

Design: In a multi-centred cohort of patients recruited from 3 community (n =218) and 3 hospital-based (n = 388) HAART delivery sites in Ouagadougou (Burkina Faso) and Bamako (Mali), we conducted single-arm pilot study from November 2003 to March 2004. In this study, we offered one month of modified directly observed antiretroviral treatment (mDAART) with weekly follow-up visits from pharmacists or adherence counsellors. Eligible patients consisted of treatment-experienced cohort participants who had initiated a HAART regimen at least 6 months before study enrolment and had a viral load of greater than 500 copies/ml.

Methods: mDAART participants completed an adherence questionnaire. Viral load and genotypic analyses were conducted on samples taken prior to and after the intervention. The primary study outcome was the log difference in plasma viral load (pVL) after the 1 month mDAART intervention. The intervention was considered effective when there was a decrease of at least one log10 in pVL following the intervention.

Results: Viral load testing was used to screen 606 patients receiving ART in 6 sites in Burkina Faso and Mali. 85 patients had a pVL > 500 copies/ml (range 508 to 160 000) and of those, 56 patients agreed to, and completed, both the mDAART intervention and adherence questionnaire. MDAART was effective in over a third of the intervention participants, while in two thirds, no decrease in pVL was observed. The majority of mDAART participants had major resistance mutations before starting the mDAART intervention.

Conclusions: pVL measurement was useful to identify patients who needed adherence counselling. However, because it was performed six or more months after commencing treatment, the adherence intervention came too late for most participants, as they had already developed important resistance mutations that could have been avoided with better laboratory monitoring. Resistance mutations are an important concern for ART treatment in these settings.

Learning Objectives:
1) Articulate important barriers to ART treatment in resource-limited settings with limited laboratory monitoring 2) Evaluate the role that viral load monitoring may play in targeting those in need of adherence assistance 3) Recognise the impact of resistance mutations on ART scale-up in Africa

Keywords: HIV/AIDS, Antiretroviral Combination Therapy

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I have been responsible for the analysis of the results, the literature review, and the writing of the associated publication.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.

See more of: HIV/AIDS 1
See more of: International Health