Title : Antiretroviral resistance among HIV-infected patients in the upper southern region of Thailand
Abstract:
The trend of HIV infected people in Thailand has been declining since 2000. Owing to the Thailand's National Access to Antiretroviral Program for People who have AIDS (NAPHA) program promoting access to antiretroviral drugs, the use of antiretroviral drugs has been widespread, and by 2022, the new infected cases are expected to be 9,200. Since HIV-infected patients are given more antiretroviral drugs, drug resistance accordingly increases. The aim of this study was to assess the situation of HIV-infected patients receiving antiretroviral therapy, the prevalence of drug resistance, patterns of HIV-1 genotypic mutation, and relevant factors influencing antiretroviral resistance in HIV-infected patients in the upper southern region of Thailand.
This research was a retrospective descriptive study. Data of laboratory results were obtained from 37 hospitals in 7 provinces of Thailand between October 1, 2020 and September 30, 2021. Laboratory results data were analyzed using a proportion. The HIV-1 genotypic mutation was detected by next generation sequencing a region of reverse transcriptase, protease and integrase. Patient histories, including sex, age, antiretroviral regimen, duration of antiretroviral therapy, and number of mutated positions were also analyzed using Chi-square.
Of the 10,283 patients, 57.2% were male and 42.8% were female, with the average age of 39.6 years. Most patients (93.3%) had a viral load<200 copies/ml and 2.0% of patients had a virological failure (viral load 200-999 copies/ml), and 4.7 % of patients had a viral load>1,000 copies/ml. The prevalence of antiretroviral drug resistance was 3.2%. Non-nucleoside reverse transcriptase inhibitors (NNRTIs) were the most common antiretroviral drug resistance, followed by nucleoside reverse transcriptase inhibitors (NRTIS), protease inhibitors (PI), and integrase inhibitors (II) at 76.0%. 47.4%, 5.9% and 1.7%, respectively. The mostly mutation associated with NNRTIs resistance was K103N, followed by Y181C, reflecting high level resistance to nevirapine (NVP) and efavirenz (EFV). Whereas M184V and K65R were mostly found in NRTIS, reflecting high level resistance to lamivudine (3TC), emtricitabine (FTC) and tenofovir (TFD).
Among 234 resistant patients, factors of age, antiretroviral regimen, duration of antiretroviral therapy, and number of mutated positions were significantly associated with NRTIs and NNRTIs resistance, while PI and II resistance were related to antiretroviral regimen and number of mutated positions. These findings could guide decisions regarding the appropriate selection of antiretroviral therapy for HIV-infected patients in Thailand. Furthermore, the situation of HIV-infected patients in the 7 provinces who had been successfully treated with antiretroviral drugs to suppress the virus in their blood and reduced their viral load to undetectable levels has reached 82.5%, exceeding the UNAIDS “90-90-90” strategy. Nonetheless, patients who had virological failure and viral load>1000 copies/ml, but no mutations have been found need to be monitored and further investigated.
Audience take away:
- The audience can use this research model and methodology to study the drug resistance situation in their country. Importantly, even if we can control the number of HIV infected patients, resistance remains a major problem. Knowledge of local resistance patterns can help in choosing appropriate drugs.
- In the Thai health system, there are no rights that patients can access to the detection of mutations before starting antiretroviral therapy. Previous studies have shown that the results of the mutation detection before receiving antiretroviral drugs can be used to effectively select the antiretroviral regimen, therefore what we can do is to monitor the situation of HIV in patients who have already received antiretroviral drugs. Similarly, if the audience’s country policy does not provide the detection of mutations before starting antiretroviral therapy, they should study in patients who have received antiretroviral drugs instance. Data from patients receiving antiretroviral drugs also reflects the situation of drug resistance.
- This research will help the audience to identify the antiretroviral resistance patterns found in their country, leading to the proper selection of the antiretroviral drug, the trend of the mutations found, which indicate the type of resistant drug. In addition, audience should advise patients to take drugs regularly to reduce drug resistance and encourage them to visit the hospital regularly for viral load testing. Therefore, if everyone follows the guidelines, viral load in the blood can be maintained and controlled below 20 copies/ml, thereby reducing transmission of the virus to others.
- Yes, other faculty can use this research to expand their research and teaching. You can use the research question “How about the situation of infected patients?” and “How about the situation of drug resistance?” expand to your research on other pathogens. Studies of drug resistance in all pathogens are crucial in considering new drug therapies for patients.
- Yes, this research offers a practical solution to the problem that can make a designer's job easier and more efficient. All staff, including physicians, nurses and medical technologists, will receive research data to help improve the quality of care for HIV-infected patients.
- Yes, this research improves and provides new information to assist with a problem. In Thailand, the situation of HIV-infected patients studying is less well studied. This study is also the first study in the upper southern region of Thailand and is based on results from 37 hospitals covering 7 provinces. Therefore, we receive new information to solve the problem. In addition, if all regions of Thailand carry out such a study, we will get complete information inside the country.
- This study also investigates the relevant factors influencing antiretroviral resistance in HIV-infected patients. The result indicates that age, antiretroviral regimen, duration of antiretroviral therapy, and number of mutated positions had factors significantly associated with drug resistance. Age 31-40 are the age range with the greatest impact on drug resistance. NNRTI-based regimens are the most potent antiretroviral regimens affecting drug resistance. Duration of antiretroviral therapy exceeds 24 months, and mutations in less than 3 positions are highly correlated factors for drug resistance. Therefore, medical staffs should focus on these patient groups.
- Studying prevalence and patterns of drug resistance can assess the therapeutic effect and predict the trend of resistance to antiretroviral in the future. Results from this study led to a review of the antiretroviral regimen guidelines for the new HIV-infected patients. Increasing the number of viral load testing per year in a group of patients who have viral load 200-999 copies/ml, including patients with more than 1,000 copies/ml virus, but no mutations have been found by repeat viral load testing when the number of viral more than 1,000 copies/ml in the next time.
- Data from this study will help medical staffs consult and educate patients before pre-treatment in order to improve and monitor therapeutic cooperation. This thing will improve the quality of patient care and achieve goals for future AIDS epidemic management. -In Thailand, we follow the UNAIDS “90-90-90” strategy. Results from this study indicate that we achieved the target of HIV-infected patients who have been successfully treated with antiretroviral drugs to suppress the virus in their blood and reduce their viral load to undetectable levels with 82.5% (target must be more than 80%). This result makes us know that the policy is appropriate for our region.
