‘Drug resistance among HIV patients cause for concern’

Even as government data shows a 30% decline in new cases of human immunodeficiency virus (HIV) infection in Mumbai since 2015, a study by international humanitarian

Even as government data shows a 30% decline in new cases of human immunodeficiency virus (HIV) infection in Mumbai since 2015, a study by international humanitarian group Doctors without Borders suggests many patients are developing drug resistance either because they’re not following treatment protocol or they’ve been infected with a drug-resistant strain of the virus.

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Doctors Without Borders conducted a seven-year-long study, titled ‘Genotyping and outcomes of presumptive second line ART [antiretroviral treatment] failure cases switched to third line or maintained on second line ART in Mumbai, India’, which was published last week in PLOS, an international medical journal. ART focuses on reducing viral loads (VL) in patients and improving their immunity.

The study looked at 91 patients at a clinic in Khar, run by Doctors without Borders. These patients were being given the more advanced, second-line treatment after they developed drug resistance to the first line of drugs. Of these, 30 patients showed improvement after receiving counselling about the importance of following the suggested drug regimen. “We found out that 30% were not adhering with the ART regimes. But through enhanced adherence counselling, we could retain them in care and control their VL,” said Dr Stobdan Kalon, India medical advisor, Doctors without Borders.

Of the remaining 61 patients, 24 did not exhibit drug resistance and 37 did not show any improvement in VL during the second-line treatment because they were resistant to the administered cocktail of drugs.

Among those with a drug-resistant strain of HIV, one-third were resistant to the drug Abacavir while one fifth were resistant to Stavudine, both of which are among the drugs administered under a second-line treatment regimen as nucleoside reverse transcriptase inhibitors (NRTI). Drug resistance was also found in lower percentages for other drugs administered as part of different second-line treatments, such as Efavirenz (26%), Nevirapine (12%), Lopinavir (12%).

“Patients often opt out of treatment or don’t follow the regimen properly. For example, an HIV-infected pregnant woman takes the treatment to save her child from the infection. But she discontinues it after the delivery,” said Dr IS Gilada, president, AIDS Society of India (ASI).

Genotyping to find whether genetic mutations in the virus had caused an increase in VL showed that many patients had developed resistance because they had been infected with a drug-resistant strain. Genotyping examines how genetics determine specific traits or disease in a population group. “At times, a person gets infected with drug-resistant patient, it gets transmitted with the resistant gene. Therefore, it is recommended to perform genotyping for patients who don’t improve after counselling rather than just relying on prior use history of patients,” Stobdan said.

In Mumbai, second-line ART is available at ART Plus centres at King Edward Memorial (KEM) Hospital, Lokmanya Tilak Municipal Hospital, Sir JJ Hospital and BYL Nair hospital. None of the ART centres have genotyping facilities. “Other than private set-ups, the facility of genotyping isn’t available in any national programme ART centres. We would recommend the national programme introduce this test,” said Stobdan. It costs ₹5,000 to ₹15,000 for genotype testing at private centres.

Gilada pointed out that patients who stay on ART for longer periods tend to develop resistance to the drugs. “In India, almost 5% of new infected patients are found to be already resistant. So, like in the United States , the ART centres [in India] should perform the drug-resistance tests ,” he said.