|Year : 2020 | Volume
| Issue : 1 | Page : 26-30
Virological and immunological profile of HIV patients on first-line antiretroviral therapy in north central Nigeria: a retrospective study
Nathan Y Shehu1, Victor B Ojeh2, Benjamin M Aya2, Augustine O Ebonyi3, Johnson Mafuka4, Simji S Gomerep1, Samson E Isa1, Oche O Agbaji1, Atiene S Sagay5
1 Department of Medicine, Jos University Teaching Hospital, Jos; AIDS Prevention Initiative in Nigeria (APIN), Jos University Teaching Hospital, Jos, Nigeria
2 AIDS Prevention Initiative in Nigeria (APIN), Jos University Teaching Hospital, Jos, Nigeria
3 AIDS Prevention Initiative in Nigeria (APIN), Jos University Teaching Hospital, Jos; Department of Paediatrics, Jos University Teaching Hospital, University of Jos, Jos, Nigeria
4 Department of Medicine, Jos University Teaching Hospital, Jos, Nigeria
5 AIDS Prevention Initiative in Nigeria (APIN), Jos University Teaching Hospital, Jos; Department of Obstetrics and Gynaecology, Jos University Teaching Hospital, University of Jos, Jos, Nigeria
|Date of Submission||09-Jul-2019|
|Date of Decision||15-Oct-2019|
|Date of Acceptance||14-Dec-2019|
|Date of Web Publication||20-May-2020|
Dr. Nathan Y Shehu
Department of Medicine, Jos University Teaching Hospital, Jos, Nigeria and AIDS Prevention Initiative in Nigeria (APIN), Jos University Teaching Hospital, Jos
Source of Support: None, Conflict of Interest: None
Background and Objectives: The use of Highly Active Antiretroviral Therapy (HAART) has dramatically improved the quality of life and overall survival of HIV patients. UNAIDS has set a target of viral suppression for 90% of those treated by 2020 in order to end the HIV epidemic. We set out to determine patients’ virologic and immunological response after medium term first-line ART. Methods: This retrospective study was done between April 2017 and May 2018 at the AIDS Prevention Initiative in Nigeria (APIN)-supported HIV clinic of the Jos University Teaching Hospital (JUTH), north central Nigeria. Included in this analysis were patients who had been on either TDF/FTC/EFV or AZT/FTC/NVP consistently for at least 12 months and who had at least 95% adherence based on pharmacy drug pick up. Data were analysed using SPSS version 23.0. Results: A total of 301 patients who met the inclusion criteria were studied of which 187 (62.1%) were females and the overall mean (SD) age was 40±9 years. There were 204 (67.8%) patients on AZT/FTC/NVP while 97 (32.2%) were on TDF/FTC/EFV. Overall, the CD4 count increased from a median (IQR) baseline of 201 cells/mm3 by the end of 12 months of HAART. Or was it 24 months you used? (112–284) to 488 cells/mm3 by the end of 12 months of HAART (344.5–628.0) P = <0.001. Their overall virological suppression was 86.7%, but was higher for the TDF/FTC/EFV arm 92.8% compared to the AZT/3TC/NVP arm 83.8% (P = 0.03). Conclusion: Overall, there was good virologic suppression and immunological response of patients on first-line ART. This suggests that with good adherence the UNAIDS target of viral suppression for 90% of those treated is achievable.
Keywords: HIV, immunological, response, suppression, virologic
|How to cite this article:|
Shehu NY, Ojeh VB, Aya BM, Ebonyi AO, Mafuka J, Gomerep SS, Isa SE, Agbaji OO, Sagay AS. Virological and immunological profile of HIV patients on first-line antiretroviral therapy in north central Nigeria: a retrospective study. J Med Trop 2020;22:26-30
|How to cite this URL:|
Shehu NY, Ojeh VB, Aya BM, Ebonyi AO, Mafuka J, Gomerep SS, Isa SE, Agbaji OO, Sagay AS. Virological and immunological profile of HIV patients on first-line antiretroviral therapy in north central Nigeria: a retrospective study. J Med Trop [serial online] 2020 [cited 2020 May 29];22:26-30. Available from: http://www.jmedtropics.org/text.asp?2020/22/1/26/284635
FNx01Nathan Y Shehu and Victor B Ojeh contributed equally.
| Introduction|| |
The 2010 global estimate of people living with Human Immunodeficiency Virus (HIV) was 33.4 million with about 22.5 million (68%) living in Sub-Saharan Africa. Eight countries in this region now account for almost one-third of all new HIV infections., The economies of many countries have been adversely affected by the HIV epidemic and it is estimated that there will be a decline of 10–22% of the labour work force of eight African countries, including Nigeria, by the year 2020.
The use of potent combination antiretroviral drugs (ARVs) comprising three drugs from two or more classes of ARVs is called Highly Active Antiretroviral Therapy (HAART). This has dramatically improved the quality of life and overall survival of individuals infected with HIV.
The goals of successful antiretroviral therapy (ART) is to prevent progression of the disease; prolong life and improve the quality of life; maximally suppress HIV RNA replication; achieve immune reconstitution with an increase in the quantity and quality of CD4+ cells; conveniently prescribe HAART regimen with low pill burden, few food requirements or limitations, infrequent dosing and to avoid adverse effects; provide regimens with favourable pharmacokinetic profile and a high threshold for development of drug resistance; and reduce the likelihood of HIV transmission.
The Joint United Nations Programme on HIV/AIDS (UNAIDS) and partners in 2014 launched the 90–90–90 targets. The aim was to diagnose 90% of all HIV-positive persons, provide ART for 90% of those diagnosed, and achieve viral suppression for 90% of those treated by 2020. The approved ART regimens in Nigeria are: tenofovir/emtricitabine/efavirenze (TDF/ FTC/EFV) and zidovudine/lamivudine/nevirapine (AZT/3TC/NVP). We set out to determine virologic and immunological response after medium term ART in order to guide decision making in antiretroviral therapy.
| Methodology|| |
This retrospective study covering a period of 12 months (April 2017 and May 2018) in patients 18 years and above at the AIDS Prevention Initiative in Nigeria (APIN)-supported HIV clinic of the Jos University Teaching Hospital (JUTH), north central Nigeria. The clinic is one of the largest HIV treatment centres in Nigeria. All patients that have been consistenly on either TDF/FTC/EFV or AZT/3TC/NVP antiretroviral drug regimens for 12 months and whose ART adherence based on pharmacy drug refill was at least 95% were included in the study [Figure 1]. We extracted baseline CD4 cell counts expressed as cells/mm3 (measured using Cyflow, Partec, Munster, Germany) and HIV viral load assay (measured using Cobas AmpliPrep/Cobas TaqMan HIV-1, v2, Roche Diagnostics GmbH, Mannheim, Germany) expressed as log copies/ml. All statistical analyses were performed using the Statistical Package for the Social Science (SPSS) version 23 for windows
|Figure 1: Recruitment of HIV patients on Tenofovir, Emtricitabine and Efavirenz or Zidovudine, Lamivudine and Nevirapine antiretroviral drug regimens, North Central Nigeria|
Click here to view
Data were presented as mean (SD) for continuous variables and frequency and percentages for categorical variables. Data which were not normally distributed were presented as median (IQR). Chi square test and Fisher’s Exact Test were used to determine the association between categorical variables. We used Wilcoxon sign rank to determine the statistical difference between CD4 counts and viral loads at baseline as well as at data collection. Kruskal Wallis H test was used to determine the significant difference between viral load and CD4 count between the ART regimens. Multivariate analysis was performed to determine factors independently associated with virologic suppression. Two-sided P-value<0.05 was considered statistically significant. Ethical approval for the study was obtained from Jos University Teaching hospital ethics Committee.
| Results|| |
A total of 301 patients that met the inclusion criteria were studied most (73%) were between 26 and 45 years, the mean age (SD) was 40 (9) years. There were 187 (62%) females, median (IQR) duration on ART was 67 months (50.82). Other baseline characteristics are presented in [Table 1] and [Table 2]. Overall virological suppression was 86.7%; [Figure 2] shows the virological profile of the patients. The TDF/FTC/EFV regimen had a higher virologic suppression of 93% than the AZT/3TC/NVP regimen 84% (P = 0.03).
|Table 1: Baseline characteristics of HIV patients on Tenofovir, Emtricitabine and Efavirenze or Zidovudine, Lamivudine and Nevirapine antiretroviral drug regimens, North Central Nigeria|
Click here to view
|Table 2: Univariate and multivariate logistics regression of virologic suppression of HIV patients on Tenofovir, Emtricitabine and Efavirenze or Zidovudine, Lamivudine and Nevirapine antiretroviral drug regimens, North Central Nigeria|
Click here to view
|Figure 2: Virologic profile of HIV patients on Tenofovir, Emtricitabine and Efavirenze or Zidovudine, Lamivudine and Nevirapine antiretroviral drug regimens, North Central Nigeria|
Click here to view
Overall, the CD4 count increased from a median (IQR) baseline of 201 cells/mm3 (112–284) to 488 cells/mm3 (344.5–628.0) P < 0.001. The trend of CD4 count profile is presented in [Figure 3]. There was no significant difference in CD4 count between TDF/FTC/EFV 452 (335–632) cells/mm3) and AZT/3TC/NVP 512(357–629) cells/mm3), P = 0.49. Factors found to be independently associated with good virologic suppression include type of regimen (TDF/FTC/EFV) and shorter duration on ART [Table 2]. However, sex and age were not found to be associated with good virological suppression.
|Figure 3: Immunological profile of HIV HIV patients on Tenofovir, Emtricitabine and Efavirenze or Zidovudine, Lamivudine and Nevirapine antiretroviral drug regimens, North Central Nigeria|
Click here to view
| Discussion|| |
Virologic suppression is an important outcome of antiretroviral therapy. It is imperative to appraise progress towards attaining the UNAIDS target of 90% virological suppression of HIV patients on treatment by the year 2020. Concerns have been made on how realistic the target is especially in low- and middle-income countries (LMIC)., We determined the virological suppression in high burden-LMIC setting − north central Nigeria.
The main finding of this study is the overall good virologic suppression almost approaching the UNAIDS 90% virologic suppression target of those treated. This is consistent with a similar study in Kwazulu-Natal, South Africa in 2017 that also showed good virologic suppression of 92–96%. Also, a systematic review by McMahon et al involving 69 countries showed a virological suppression of 84%. This shows that achieving 90% target of virologic suppression of those treated is possible in these settings.
We also found that the patients in the TDF/3TC/EFV arm achieved better virologic suppression than AZT/3TC/NVP. This is consistent with the findings of other studies.,,, This suggests that TDF/FTC/EFV was more potent than AZT/3TC/NVP However, in a study by Kimberly et al., Zidovudine based therapy had better virological suppression. However, in this study, the non-nucleoside reverse transcriptase inhibitor regimen used was nevirapine in the two ART regimens. We also found that TDF/FTC/EFV regimen is independently associated with good virologic suppression.
Shorter duration of ART was independently associated with virologic suppression. This implies that, the longer the patient is on ART the higher the likelihood of developing drug resistance mutations and hence poor virologic suppression. Bayu et al. demonstrated that virological failure was about 3–7 times higher in patients who were on ART for 24–47 months than those who were on ART for 6–24 months. This is consistent with other studies that demonstrated higher virological failure in patients on longer duration of ART treatment for 6–24 months.,We did not find virologic suppression independently associated with age or gender. This may imply that once there is good adherence there is likelihood of good virologic suppression irrespective of age or gender. Conversely, other studies demonstrated that older age and female gender predicted lower levels of viral load independent of ART regimen.,, The observed differences may be due to variation in levels of adherence, regimen and stage of the disease. These parameters differ from one study to another, which in part explains the basis for the discrepancies. Overall, there is good immunological response after medium term ART. This is likely due to relatively good median baseline CD4 count. Several studies have alluded to good immunological response when the baseline CD4 count is above 200cells/mm3., The TDF/3TC/EFV and AZT/3TC/NVP regimens showed similar immunological profile. This implies that good immunological response is possible with any of the first line regimen provided patients tolerate the ARVs. The limitation of this study was that some patients were either lost to follow up or switched regimen. Additionally, we did not characterise the drug-related side effects of the ARVs.
| Conclusion|| |
Overall, there was good virologic suppression and good immunological response in patients on first line ART. This suggests that with good adherence virologic suppression is achievable and the UNAIDS 90% goal is feasible. However, the AZT/3TC/NVP regimen falls below the UNAIDS target of 90% viral suppression. It is imperative to develop strategies to improve ART adherence, this would prevent against development virological failure due to drug resistance.
Research reported in this publication was supported by the Fogarty International Center (FIC), Office of the Director (OD/NIH), National Institute of Neurological Disorders and Stroke (NINDS/NIH) and the National Institute of Nursing Research (NINR/NIH) of the National Institutes of Health under Award Number D43 TW010130. This publication was facilitated, in part, by the US Department of Health and Human Services, Health Resources and Services Administration (U51HA02522- 01-01) and the Centers for Disease Control and Prevention (PS 001058) which supported HIV/AIDS treatment and care services at APIN, JUTH, Jos; The content is solely the responsibility of the authors and does not necessarily represent the views of the National Institutes of Health.
Financial support and sponsorship
Conflicts of interest
Authors declare no conflict of interest
| References|| |
World Health Organisation. Towards Universal Access; Scaling up priority HIV/AIDS interventions in the health sector. Geneva, WHO, 2010;3:25-35.
National Agency for the Control of AIDS. United Nations General Assembly Special Session (UNGASS) country progress report, Nigeria. Abuja. National Agency for the Control of AIDS. 2010;3:26-36.
AIDS prevention initiative in Nigeria Plus. Adult antiretroviral treatment protocol version 2.0. Abuja. AIDS prevention initiative in Nigeria Plus. 2009; 2.0 protocol 5.30.07; 1:7-9.
Idoko JA, Taiwo B, Murphy RL. Treatment and care of HIV disease. In: Adeyi O, Kanki PJ, Odutolu O, Idoko JA (eds). AIDS in Nigeria. 1st
ed Cambridge: Harvard Centre For Population and Development Studies, 2006; 72-408
90–90–90—An ambitious treatment target to help end the AIDS epidemic | UNAIDS. Available from: http://www.unaids
(accessedSep 1, 2016).
National Guidelines for HIV Prevention Treatment and Care National AIDS and STI’s Control Programme Federal Ministry of Health, 2016.
Levi J, Raymond A, Pozniak A, Vernazza P, Kohler P, Hill A. Can the UNAIDS 90–90–90 target be achieved? A systematic analysis of national HIV treatment cascades. BMJ Global Health 2016;1:e000010.
Hunt GM, Dokubo EK, Takuva S, de Oliveira T, Ledwaba J, Dube N et al.
Rates of virological suppression and drug resistance in adult HIV-1-positive patients attending primary healthcare facilities in KwaZulu-Natal, South Africa. Journal of Antimicrobial Chemotherapy 2017;72:3141-8.
Arribas JR, Pozniak AL, Gallant JE, Dejesus E, Gazzard B, Campo RE et al.
Tenofovir disoproxil fumarate, emtricitabine, and efavirenz compared with zidovudine/lamivudine and efavirenz in treatment-naive patients: 144-week analysis. J Acquir Immune Defic Syndr 2008;47:74-8.
Labhardt ND, Bader J, Lejone TI, Ringera I, Puga D, Glass TR, Klimkait T. Is zidovudine first-line therapy virologically comparable to tenofovir in resource-limited settings? Trop Med Int Health 2015;20:914-8.
Cheung CP, Lai WH, Shutter J. Zidovudine versus tenofovir-based antiretroviral therapy for the initial treatment of HIV infection in the ethnic minority region of Liangshan Prefecture, Sichuan Province, China: an observational cohort study. Journal of the International Association of Providers of AIDS Care 2017;16:189-93.
Pozniak AL, Gallant JE, DeJesus E, Arribas JR, Gazzard B et al.
Tenofovir disoproxil fumarate, emtricitabine, and efavirenz versus fixed dose zidovudine/lamivudine and efavirenz in antiretroviral naive patients: virologic, immunologic, and morphologic changes–a 96-week analysis. J Acquir Immune Defic Syndr 2006;43:535-40.
Scarsi KK, Eisen G, Darin KM, Meloni ST, Rawizza HE, Tchetgen EJ et al.
Superior Effectiveness of Zidovudine Compared With Tenofovir When Combined With Nevirapine-based Antiretroviral Therapy in a Large Nigerian Cohort, Clinical Infectious Diseases 2016;62:512-8 https://doi.org/10.1093/cid/civ928
Bayu B, Tariku A, Bulti AB, Habitu YA, Derso T et al.
Determinants of virological failure among patients on highly active antiretroviral therapy in University of Gondar Referral Hospital, Northwest Ethiopia: a case − control study. HIV/AIDS − Research and Palliative Care 2017;9:153-9.
Liégeois F, Vella C, Eymard-Duvernay S, Sica J, Makosso L, Mouinga-Ondémé A, Mongo AD, Boué V, Butel C, Peeters M, Gonzalez JP, Delaporte E, Rouet F. Virological failure rates and HIV-1 drug resistance patterns in patients on first-line antiretroviral treatment in semirural and rural Gabon. J Int AIDS Soc 2012;15:17985. doi: 10.7448/IAS.15.2.17985. PMID: 23199801; PMCID: PMC3510650.
Jobanputra K, Parker LA, Azih C, Okello V, Maphalala G, Kershberger B et al.
Factors associated with virological failure and suppression after enhanced adherence counselling, in children, adolescents and adults on antiretroviral therapy for HIV in Swaziland. PLoS One 2015;10:e0116144.
Rupérez M, Pou C, Maculuve S, Cedeño S, Luis L, Rodríguez J et al.
Determinants of virological failure and antiretroviral drug resistance in Mozambique. J Antimicrob Chemother 2015;70:2639-47.
Goodkin K, Shapshak P, Asthana D, Zheng W, Concha M, Wilkie FL et al.
Older age and plasma viral load in HIV-1 infection. AIDS 2004;18:S87-98.
Sang RKA, Miruka FO. Factors associated with virologic failure amongst adults on antiretroviral therapy in Nyanza Region Kenya. IOSR J Dent Med Sci 2016; 15:108-21
Asfaw A, Ali D, Eticha T, Alemayehu A, Alemayehu M, Kindeya F. CD4 cell count trends after commencement of antiretroviral therapy among HIV-infected patients in Tigray, Northern Ethiopia: A retrospective cross-sectional study. PLoS One 2015;10.
Moore RD, Keruly JC. CD4+ cell count 6 years after commencement of highly active antiretroviral therapy in persons with sustained virologic suppression. Clin Infect Dis 2007;44:441-6.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]