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Recycling tenofovir better than zidovudine switch for HIV

Elvira Manzano
01 Sep 2020

Recycling tenofovir after failure of first-line treatment vs switching to second-line zidovudine is associated with better care retention, adherence, and viral load suppression in HIV patients, especially when combined with atazanavir boosted with ritonavir, a new study presented at AIDS 2020 Virtual has shown.

WHO guidelines recommend an optimized NRTI* backbone for second‐line antiretroviral treatment (ART), including switching from tenofovir to zidovudine, if first-line treatment fails.

However, the side effects of zidovudine, including nausea, anaemia, and limb fat loss, make it an unattractive option for second-line treatment. The twice-daily dosing of zidovudine also  poses adherence issues to some patients.

“Treatment toxicity and pill burden should be taken into consideration when selecting a treatment regimen after first-line failure,” said study investigator Dr Samuel Pierre from the GHESKIO Centres, Research in Port‐au‐Prince, Haiti.

An alternative second-line option is to recycle tenofovir as part of a new combination, based on limited evidence that recycling the drug contributes to viral suppression despite the presence of the K65R mutation.

Tenofovir recycling: What’s the evidence?

ART adherence is crucial for long-term HIV treatment success. There is good evidence that recycling tenofovir in the second-line setting may contribute to viral suppression, said Pierre.

In the current retrospective review, the researchers sought to determine if continued use of tenofovir in second-line treatment would work well for adult HIV patients in Haiti vs switching to zidovudine. Patients were on first-line regimen of tenofovir, lamivudine, and efavirenz and were switched to a second-line regimen that included ritonavir-boosted protease inhibitor (bPI), in combination with either tenofovir/lamivudine (TDF/3TC) or zidovudine/lamivudine (AZT/3TC). Adherence based on pharmacy refill data and viral suppression below 200 copies/mL within 12 months of switching were assessed. [AIDS 2020 Virtual, abstract OAB0405]

Of 1,017 patients (509 women, median age 40.7 years), 284 were switched to AZT/3TC and 733 continued with TDF/3TC. Retention in care did not differ between switchers and non-switchers (83 percent for each group).

Lower viral load, better adherence with tenofovir

Viral suppression in patients with ≥90 percent adherence was better in the TDF/3TC group than in the AZT/3TC group (p<0.016). Non-switchers were significantly more likely to have a viral load below 200 copies/mL on their first viral load test after 12 months, with more than half of them having an undetectable viral load during that period (p<0.001).

Predictors of viral suppression included recycled TDF/3TC (odds ratio [OR], secondary or higher education level (OR, 1.53), and being married/living together (OR, 1.51).

In terms of adherence, non-switchers had significantly better adherence – 48 percent had adherence of ≥90 percent vs 38 percent for switchers (p=0.006).

Further analysis of outcomes according to the second-line bPI showed that non-switchers on atazanavir were significantly more likely than switchers to be retained in care after 12 months, to have 12-month adherence >90 percent, and to have a first viral load test below 200 copies/mL.

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Most Read Articles
23 Dec 2019
At a Menarini-sponsored symposium held during the Asian Pacific Society Congress, renowned cardiologist Prof John Camm provided the latest evidence for chronic stable angina with or without concomitant diseases, with a special focus on the antianginal agent ranolazine and combination therapies. The event was chaired and moderated by Dr Dante Morales from the University of the Philippines College of Medicine.
11 Aug 2020
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3 days ago
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