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The New England Journal of Medicine
Downloaded from nejm.org on July 18, 2014. For personal use only. No other uses without permission.
Copyright 2014 Massachusetts Medical Society. All rights reserved.
Second-Line HIV Therapy in Africa
n engl j med 371;3 nejm.org july 17, 2014
243
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income countries with mainly genotyping-guided
selection of NRTIs and viral-load monitoring.
23
We also found that the raltegravir combination
had a safety profile similar to that of the NRTI
combination and may therefore be an alternative
second-line regimen in resource-rich settings where
individualized therapy is feasible. The trend toward
a modest advantage of raltegravir with respect to
the increase in the CD4+ count, without differ-
ences in viral-load suppression, may reflect inde-
pendent effects of raltegravir on T-cell activation
or survival,
24,25
but there was no associated clinical
benefit at week 96. Follow-up to week 144 will as-
sess longer-term outcomes and cost-effectiveness,
P
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NRTIs Raltegravir Lopinavir Darunavir
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NRTI Raltegravir Monotherapy
Figure 2. Viral-Load Suppression and Drug Resistance at Week 96.
Panel A shows the proportion of patients with various levels of viral-load
suppression. Panel B shows the proportion of patients with intermediate- or
high-level drug resistance. Resistance to NRTIs is limited to drugs taken dur-
ing the trial and excludes resistance to lamivudine or emtricitabine. In the
two panels, I and T bars indicate 95% confidence intervals. The outcomes at
week 48 are provided in Figure S3 in the Supplementary Appendix.
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244
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The New England Journal of Medicine
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Second-Line HIV Therapy in Africa
n engl j med 371;3 nejm.org july 17, 2014
245
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data that are essential for evaluating a new regi-
men before large-scale implementation.
We did not establish the noninferiority of
protease-inhibitor monotherapy to combination
therapy with NRTIs with respect to the primary
end point, and monotherapy resulted in inferior
viral-load suppression, which was associated with
increased protease-inhibitor resistance. On the ba-
sis of these findings, the data and safety monitor-
ing committee recommended the discontinuation
of the monotherapy group, and all patients in
that group were switched to combination therapy.
Several previous, noncomparative studies and one
small, randomized study have suggested that pro-
tease-inhibitor monotherapy may be promising
for second-line therapy in resource-limited set-
tings.
26-28
The other small 48-week comparative
trial in Thailand showed that protease-inhibitor
monotherapy was inferior to protease-inhibitor
therapy plus NRTIs on the basis of lower rates
of viral-load suppression to a level under 50 copies
per milliliter (with only a trend toward lower
rates of suppression to a level under 400 copies
per milliliter and little protease-inhibitor resis-
tance).
29
Since outcomes with protease-inhibitor mono-
therapy are better when treatment is initiated
after viral-load suppression,
6,30,31
we used an induc-
tion approach with raltegravir. A longer induction
period or a strategy including regular viral-load
monitoring with immediate NRTI reintensification
after viral-load rebound might have produced
better outcomes, but such a regimen would be
challenging to implement and would diminish
the potential practical and cost advantages of
protease-inhibitor monotherapy in resource-
limited settings. Although protease-inhibitor
monotherapy may be a reasonable management
strategy for individualized therapy, our findings
indicate that it is not appropriate as a standard-
ized regimen in the public health approach.
Nevertheless, the similar clinical and CD4+
outcomes in the NRTI and monotherapy groups
provide reassurance that even when a regimen
does not fully suppress the viral load, it can still
provide benefits.
The comparison of the NRTI group with the
monotherapy group allowed us to assess the
contribution of NRTIs to second-line regimens
in a population with first-line treatment failure
and extensive NRTI cross-resistance, with NRTIs
selected on the basis of simple algorithms with-
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The new engl and journal o f medicine
n engl j med 371;3 nejm.org july 17, 2014
246
out genotypic testing. In this setting, which is
typical of most sub-Saharan African antiretroviral
programs, the finding of substantial residual
NRTI activity was remarkable. This may partly
derive from the first use of tenofovir as a second-
line therapy in many patients, although a sub-
stantial proportion of patients had tenofovir re-
sistance at baseline. Results may also reflect
residual antiviral-drug activity despite resistance
or maintenance of viral populations with reduced
replicative capacity (especially with the use of
lamivudine, with the maintenance of the M184V
mutation).
32,33
Our findings can probably be gen-
eralized to settings in which viral-load monitor-
ing is used to detect first-line treatment failure
earlier with less cross-resistance or settings in
which resistance testing is available to guide the
selection of NRTIs. In such settings, viral-load
suppression in patients receiving combination
therapy with an NRTI and a protease inhibitor
might improve slightly, but this would decrease
the likelihood of finding that a raltegravir combi-
nation is superior or that protease-inhibitor mono-
therapy is noninferior to an NRTI combination.
Similar rates of adverse events in the NRTI
group as compared with the other groups and
the low incidence of specific NRTI-attributable
toxic effects (e.g., renal failure or severe anemia)
are reassuring, especially given the challenges of
routine laboratory safety monitoring in these set-
tings. When we began this study, the riskbenefit
ratio of retaining NRTIs in second-line therapy
was unclear, but our findings of substantial ef-
ficacy and minimal additional toxicity strongly
support their use.
In conclusion, we found that boosted protease-
inhibitor therapy plus two NRTIs, administered
without testing of genotypic resistance or regu-
lar viral-load monitoring and with limited labo-
ratory safety monitoring, had activity that was
not surpassed by alternative regimens considered
to be feasible in this setting.
Supported by a grant from the European and Developing
Countries Clinical Trials Partnership (IP.2007.33011.003), with
funding from the Medical Research Council, United Kingdom;
Instituto de Salud Carlos III, Spain (A107/90015); Irish Aid,
Ireland; Swedish International Development Cooperation
Agency, Sweden; Instituto Superiore di Sanit, Italy; Merck;
and the World Health Organization. Substantive in-kind con-
tributions were made by the Medical Research Council Clinical
Trials Unit, United Kingdom; CINECA, Bologna, Italy; Janssen
Diagnostics, Beerse, Belgium; GlaxoSmithKline/ViiV Health-
care, United Kingdom; and Abbott Laboratories, United States.
Trial medication was donated by AbbVie, Merck, Pfizer, GSK,
and Gilead. The MalawiLiverpoolWellcome Trust Clinical
Research Programme, University of Malawi College of Medi-
cine, receives core funding from the Wellcome Trust United
Kingdom.
Disclosure forms provided by the authors are available with
the full text of this article at NEJM.org.
We thank all the patients and staff from all the centers who
participated in this study.
1. Gilks CF, Crowley S, Ekpini R, et al.
The WHO public-health approach to anti-
retroviral treatment against HIV in resource-
limited settings. Lancet 2006;368:505-10.
2. Global update on HIV treatment 2013:
results, impact and opportunities. Geneva:
World Health Organization, 2013.
3. Consolidated guidelines on the use of
antiretroviral drugs for treating and pre-
venting HIV infection: recommendations
for a public health approach. Geneva:
World Health Organization, 2013.
4. Manasa J, Lessells RJ, Skingsley A, et
al. High-levels of acquired drug resistance
in adult patients failing first-line antiretro-
viral therapy in a rural HIV treatment pro-
gramme in KwaZulu-Natal, South Africa.
PLoS One 2013;8(8):e72152.
5. Humphreys EH, Chang LW, Harris J.
Antiretroviral regimens for patients with
HIV who fail first-line antiretroviral ther-
apy. Cochrane Database Syst Rev 2010;6:
CD006517.
6. Arribas JR, Delgado R, Arranz A, et al.
Lopinavir-ritonavir monotherapy versus
lopinavir-ritonavir and 2 nucleosides for
maintenance therapy of HIV: 96-week analy-
sis. J Acquir Immune Defic Syndr 2009;51:
147-52.
7. Clumeck N, Rieger A, Banhegyi D, et
al. 96 Week results from the MONET trial:
a randomized comparison of darunavir/
ritonavir with versus without nucleoside
analogues, for patients with HIV RNA
<50 copies/mL at baseline. J Antimicrob
Chemother 2011;66:1878-85.
8. Valantin MA, Lambert-Niclot S, Flandre
P, et al. Long-term efficacy of darunavir/
ritonavir monotherapy in patients with
HIV-1 viral suppression: week 96 results
from the MONOI ANRS 136 study. J Anti-
microb Chemother 2012;67:691-5.
9. Antiretroviral therapy for HIV infec-
tion in adults and adolescents: recom-
mendations for a public health approach.
2010 revision. Geneva: World Health Or-
ganization, 2010.
10. Stanford University HIV drug resistance
database (http://hivdb.stanford.edu).
11. WHO case definitions of HIV for sur-
veillance and revised clinical staging and
immunological classification of HIV- related
disease in adults and children. Geneva:
World Health Organization, 2006.
12. Lifson AR, Belloso WH, Davey RT, et
al. Development of diagnostic criteria for
serious non-AIDS events in HIV clinical
trials. HIV Clin Trials 2010;11:205-19.
13. National Institutes of Health, Divi-
sion of AIDS. Division of AIDS table for
grading the severity of adverse events
(clarification 9). Bethesda, MD: National
Institute of Allergy and Infectious Dis-
ease, 2004.
14. Peto R, Pike MC, Armitage P, et al.
Design and analysis of randomized clini-
cal trials requiring prolonged observation
of each patient. I. Introduction and de-
sign. Br J Cancer 1976;34:585-612.
15. Department of Health and Human
Services, Food and Drug Administration,
Center for Drug Evaluation and Research.
Guidance for industry human immu-
nodeficiency virus-1 infection: developing
antiretroviral drugs for treatment. 2013
(http://www.fda.gov/downloads/Drugs/
GuidanceComplianceRegulatoryInformation/
Guidances/UCM355128.pdf).
References
The New England Journal of Medicine
Downloaded from nejm.org on July 18, 2014. For personal use only. No other uses without permission.
Copyright 2014 Massachusetts Medical Society. All rights reserved.
Second-Line HIV Therapy in Africa
n engl j med 371;3 nejm.org july 17, 2014
247
16. Idem. Guidance for industry non-
inferiority clinical trials. 2010 (http://www
.fda.gov/downloads/Drugs/.../Guidances/
UCM202140.pdf).
17. van Buuren S. Multiple imputation of
discrete and continuous data by fully con-
ditional specification. Stat Methods Med
Res 2007;16:219-42.
18. van Buuren S, Boshuizen HC, Knook
DL. Multiple imputation of missing blood
pressure covariates in survival analysis.
Stat Med 1999;18:681-94.
19. Ajose O, Mookerjee S, Mills EJ, Boulle
A, Ford N. Treatment outcomes of patients
on second-line antiretroviral therapy in
resource-limited settings: a systematic
review and meta-analysis. AIDS 2012;26:
929-38.
20. Casotti JA, Passos LN, Oliveira FJ, Ce-
rutti C Jr. Factors associated with para-
doxical immune response to antiretroviral
therapy in HIV infected patients: a case
control study. BMC Infect Dis 2011;11:306.
21. Zoufaly A, an der Heiden M, Kollan C,
et al. Clinical outcome of HIV-infected
patients with discordant virological and
immunological response to antiretroviral
therapy. J Infect Dis 2011;203:364-71.
22. Reynes J, Trinh R, Pulido F, et al.
Lopinavir/ritonavir combined with ral-
tegravir or tenofovir/emtricitabine in anti-
retroviral-naive subjects: 96-week results
of the PROGRESS study. AIDS Res Hum
Retroviruses 2013;29:256-65.
23. SECOND-LINE Study Group. Ritonavir-
boosted lopinavir plus nucleoside or nu-
cleotide reverse transcriptase inhibitors
versus ritonavir-boosted lopinavir plus ral-
teg ravir for treatment of HIV-1 in fection in
adults with virological failure of a standard
first-line ART regimen (SECOND-LINE): a
randomised, open-label, non-inferiority
study. Lancet 2013;381:2091-9.
24. Negredo E, Massanella M, Puertas
MC, et al. Early but limited effects of ral-
tegravir intensification on CD4 T cell re-
constitution in HIV-infected patients with
an immunodiscordant response to anti-
retroviral therapy. J Antimicrob Chemo-
ther 2013;68:2358-62.
25. Cooper A, Garca M, Petrovas C,
Yama moto T, Koup RA, Nabel GJ. HIV-1
causes CD4 cell death through DNA-
dependent protein kinase during viral in-
tegration. Nature 2013;498:376-9.
26. Bartlett JA, Ribaudo HJ, Wallis CL, et
al. Lopinavir/ritonavir monotherapy after
virologic failure of first-line antiretroviral
therapy in resource-limited settings.
AIDS 2012;26:1345-54.
27. Manosuthi W, Kiertiburanakul S,
Amorn nimit W, et al. Treatment outcomes
and plasma level of ritonavir-boosted lo-
pin avir monotherapy among HIV-infected
patients who had NRTI and NNRTI fail-
ure. AIDS Res Ther 2009;6:30.
28. Gilks CF, Walker AS, Dunn DT, et al.
Lopinavir/ritonavir monotherapy after
24 weeks of second-line antiretroviral
therapy in Africa: a randomized controlled
trial (SARA). Antivir Ther 2012;17:1363-73.
29. Bunupuradah T, Chetchotisakd P,
Ananworanich J, et al. A randomized com-
parison of second-line lopinavir/ritonavir
monotherapy versus tenofovir/lamivudine/
lopinavir/ritonavir in patients failing
NNRTI regimens: the HIV STAR study.
Antivir Ther 2012;17:1351-61. [Erratum,
Antivir Ther 2012;17:1389-90.]
30. Cameron DW, da Silva BA, Arribas JR,
et al. A 96-week comparison of lopina vir-
ritonavir combination therapy followed
by lopinavir-ritonavir monotherapy versus
efavirenz combination therapy. J Infect
Dis 2008;198:234-40.
31. Delfraissy JF, Flandre P, Delaugerre C,
et al. Lopinavir/ritonavir monotherapy or
plus zidovudine and lamivudine in anti-
retroviral-naive HIV-infected patients. AIDS
2008;22:385-93.
32. Deeks SG, Wrin T, Liegler T, et al. Vi-
rologic and immunologic consequences of
discontinuing combination antiretroviral-
drug therapy in HIV-infected patients with
detectable viremia. N Engl J Med 2001;344:
472-80.
33. Deeks SG, Hoh R, Neilands TB, et al.
Interruption of treatment with individual
therapeutic drug classes in adults with
multidrug-resistant HIV-1 infection. J Infect
Dis 2005;192:1537-44.
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