The Pediatric Infectious Disease Journal Publish Ahead of Print

DOI: 10.1097/INF.0b013e318279c800
Antiretroviral Regimens Containing a Single Protease Inhibitor Increase Risk of Virologic Failure in
Young HIV-Infected Children
Elisabetta Walters,1* FCPaed, MMed, Kirsten Reichmuth,2 MBChB, Angela Dramowski,3

FCPaed, MMed, MSc

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FCPaed, MMed, Ben J. Marais,4 PhD, Mark F. Cotton,3 FCPaed, PhD, and Helena Rabie,3

Abbreviated Title: Antiretroviral Failure after Ritonavir Use

Running Head: Antiretroviral Failure

Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape

Town, South Africa

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Department of Paediatrics, University of Cape Town, South Africa

Tygerberg Childrens Hospital, Department of Paediatrics and Child Health, Stellenbosch University,

Cape Town, South Africa

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Sydney Institute for Emerging Infections and Biosecurity, Department of Paediatrics & Child Health,

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The Children's Hospital at Westmead, University of Sydney, Australia

*Corresponding author.
Address for correspondence:
Desmond Tutu TB Centre,
Faculty of Medicine and Health Sciences,
P O Box 19063,
Tygerberg 7505
Tel: +27 21 9389177
Fax: +27 21 9389719
Cell: +27 82 5594522
Email: ewal@sun.ac.za
EW received support from the Faculty of Medicine and Health Sciences at Stellenbosch University
(employing institution) for travel related to this work in 2011 (3rd Pediatric HIV Workshop in Rome,

Italy). All the authors declare they have no further conflicts of interest.

Keywords: antiretroviral therapy, tuberculosis, virologic failure

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Rifampin-based tuberculosis (TB) treatment can cause sub-therapeutic concentrations of

protease-inhibitors (PI) and virologic failure in children receiving antiretroviral therapy (ART).
Among 217 children on ART, TB co-treatment (in 78) was associated with virologic failure.
Ritonavir-based single PI ART regimen predicted virologic failure (adjusted odds ratio 3.7, 95%

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confidence interval 1.5-8.9, p=0.004) on multivariate analysis.

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INTRODUCTION
HIV-infected children receiving antiretroviral therapy (ART) and tuberculosis (TB) co-treatment
experience drug interactions. Significant reductions in plasma lopinavir (LPV) concentrations
occur in patients on rifampin-based TB treatment (1), due to induction of hepatic CYP3A

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enzymes. Prolonged sub-therapeutic LPV levels may result in virologic failure with selection of
protease inhibitor (PI) mutations. We report risk factors for virologic failure in a cohort of HIVinfected children (36% with TB co-treatment) from Cape Town, South Africa.
MATERIALS AND METHODS

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Study design and data collection

We conducted a retrospective cohort study of all HIV-infected children <13 years of age who
started combination ART at Tygerberg Childrens Hospital from 1 January 2003 to 31 December
2005. We collected data on TB episodes, viral load (VL) and CD4 counts until December 2008.
We divided the cohort into those receiving concomitant ART and TB treatment (co-treatment
group), and those who only received ART (ART-only group).

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Definitions

We defined co-treatment as 2 weeks of overlapping ART and TB treatment. Standard TB

treatment included isoniazid (INH), rifampin (RMP) and pyrazinamide (PZA) for 2 months,
followed by INH and RMP for 4 months. (2)Ethambutol was added in cases with extensive

pulmonary or extrapulmonary TB and ethionamide in TB meningitis. The first-line ART regimen

for children <3 years of age included 2 nucleoside reverse transcription inhibitors (NRTI) with a
PI, LPV/r; efavirenz was given as the third drug for children >3years or >10kg. National
guidelines until 2008 also recommended switching from LPV/r to standard-dose RTV during TB
co-treatment and to use RTV rather than LPV/r in infants <6 months of age, with a switch to

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LPV/r once over 6 months.(3) According to routine practice, all children had VL and CD4
counts monitored every 6 months from ART initiation. We defined virologic failure as 2
consecutive VL values > 5000 copies/mL and viral suppression as VL < 400 copies/mL.
Children who were transferred out or lost to follow-up before the first 6-month visit were

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excluded from analysis.

Any TB episode for which a child received TB therapy was included. A TB diagnosis in the
setting was typically made on clinical grounds, based on persistent unexplained

cough/unresponsive pneumonia, fever or poor growth, contact with a documented adult TB

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source case or a tuberculin conversion, and a suggestive chest radiograph. Two sputum samples
(or gastric aspirates in young children) were also sent for mycobacterial culture but treatment
was usually started before results were available.
Statistical analysis

Data were entered into a Microsoft Access 2010 database, and analyzed using Stata/IC 11.1
software (Copyright 2009 StataCorp LP, College Station, Texas, USA). Categorical variables

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were compared using the chi-squared or Fishers Exact test. Chi-squared test for trend was used to
analyze ordered categorical data. Numerical data were analyzed using the Wilcoxon sum-rank
test. Logistic regression was used to calculate odds ratios with 95% confidence intervals, and
was used for multivariate analysis of factors predictive of virologic failure. Kaplan-Meier

groupings were compared by the log rank test. A p-value of 0.05 was considered significant.
Ethics approval was granted by the Health Research Ethics Committee at Stellenbosch
University (project number N06/08/167).

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RESULTS
Data for 217 children were analyzed, 139 with ART only and 78 with HIV and TB co-treatment.
Children receiving co-treatment had lower weight-for-age Z-scores (-3.52 vs. -1.91, p<0.0001)
and CD4 counts (11.5% vs. 14%, p 0.034), while VL at baseline was similar between groups

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(Table 1, supplemental digital content). Given that children receiving co-treatment were
significantly younger (median 21 months vs. 36 months, p<0.001), a larger proportion of
children in the co-treated group received PI-based ART (73.1% vs. 42.5%, p<0.0001).

Median duration of follow-up from initiation of ART was 19.7 (14.7 24.2) months in the co-

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treated and 34.2 (17.4 45.1) months in the ART only groups. At 6 months, among children with
available data, virologic suppression was achieved in 29/60 (48%, 95%CI 35-61%) co-treated vs.
74/111 (67%, 95%CI 58-76%) children on cART only (p= 0.016). At 12 months, these
proportions were 34/62 (55%, 95%CI 38-72%) vs. 73/99 (74%, 95%CI 64-84%) respectively
(p=0.01).

In total, 41/217 (18.9%) children experienced virologic failure. By ART regimen, at 6 months

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67/77 (87.0%) receiving an NNRTI were suppressed compared to 41/53 (77.4%) receiving
LPV/r (p=0.15) and 24/41 (58.5%) receiving RTV only (p=0.05 LPV/r vs. RTV, p=0.0005
NNRTI vs. RTV). At 12 months, 92% receiving an NNRTI were suppressed, compared to 82.2
% receiving LPV/r (p=0.11) and 68.3% receiving RTV (p=0.13 LPV/r vs. RTV, p=0.001 NNRTI

vs. RTV). Full univariate analysis is summarized in Table 2 (supplemental digital content). Ever
having received RTV, regardless of TB co-treatment, was associated with four-fold odds of
failure compared to other ART (OR 4.1, 95% CI 1.8-9.3, p=0.0001). TB co-treatment and severe
malnutrition were also associated with virologic failure. Of co-treated children, 23/78 (29.5%)
failed compared to 18/139 (12.9%) of those on ART only (OR 2.8 p=0.004). Young age showed

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a trend towards higher risk of failure (Figure 1 - supplemental digital content) with a significant
increase in risk in those age <3 years who received TB co-treatment (OR 3.46, 95% CI 1.388.94, p=0.003).
Of the 23 co-treated children who failed, 18 (87.5%) were on a RTV-based regimen. Odds of

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failure in co-treated children on RTV-based ART were higher than children on other ART
regimens (OR 2.59, 95% CI 0.77-10.11, p=0.09). On multiple logistic regression only baseline
viral load and RTV-based ART predicted virologic failure. After adjusting for sex, age group,

nutritional state and baseline CD4 count, the predictive effect of RTV was strongest, with odds

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ratio for failure of 3.66 (95% CI 1.51-8.89).

Earlier time-to-failure was associated with co-treatment, young age and RTV-based ART (Figure
1). In the co-treated group 7.1% and 16.3% of children had failed by month 12 and 18
respectively, vs. 1.7% and 2.4% in the ART-only group (p<0.001). Among infants age <1 year,
5.7% and 12.4% failed by 12 and 18 months respectively, compared to 1.1% and 1.7% of
children age >5 years (p<0.001). Among children on RTV-based ART, 6.9% and 18.5% failed

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by 12 and 18 months, compared to 1.1% and 2.4% of those on NNRTI (p=0.0001). The rate of
virologic failure in children on LPV/r remained constant at 3.7% at 12, 18 and 24 months.
DISCUSSION

This study highlights the vulnerability of young HIV-infected children to poor ART outcomes if

exposed to less potent ART regimens. In this cohort, co-treated children were severely immune
suppressed and significantly younger than those receiving ART only. Young age as a risk factor
for virologic failure has been described previously. (4, 5) Our analysis suggests that a single PI
ritonavir-based ART regimen was the primary cause of this groups poorer virologic outcomes,
although it is impossible to discount the potential effect of TB co-treatment in this group. Use of

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ritonavir-based ART regimens has since been discontinued, with other studies confirming
inferior rates of virologic suppression. (6, 7) We showed that higher baseline VL also
independently predicted virologic failure: young HIV-infected children typically commence
ART at very high VL, and this is likely an additional risk factor for failing ART.

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Currently the recommended strategy to maintain adequate lopinavir levels in children on PIbased ART requiring TB co-treatment is to add ritonavir to standard lopinavir/ritonavir (LPV/r)
combination therapy, aiming for a lopinavir/ritonavir ratio of 1:1 (super-boosted lopinavir) in

order to counteract the rifampin effect (1). Doubling the dose of LPV/r is easier, but was found

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not to give adequate lopinavir exposure (8). However, both strategies were shown to give similar
rates of virologic suppression at 12 months in field studies from South Africa (7, 9), comparable
to suppression rates in children without TB. Giving super-boosted lopinavir to children
presents numerous practical challenges, including difficulty administering two unpalatable
syrups and ensuring correct dosing. The development of sprinkles may help to overcome some of
these challenges.

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Alternative strategies to optimize anti-TB treatment of young HIV-infected children should also
be explored. The use of rifabutin in place of rifampin is being studied in children on LPV/r(10);
the use of new-generation fluoroquinolones should be investigated. Studies of efavirenz use in
children below 3 years of age are underway but the use of nevirapine in prevention of perinatal

HIV transmission may limit its usefulness for treatment. Finally, there is an urgent need for
effective implementation of TB preventive strategies among young HIV-infected children to
avoid the need for tuberculosis co-treatment.
Due to the retrospective nature of the study, we could not assess treatment adherence. This may
impact ART outcomes, since the excessive medication burden of co-treated children may reduce

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adherence. Additional comorbidities and medications were not recorded. Substantial numbers of
children were lost to follow up or transferred to local clinics, resulting in a small sample size for
full analysis. We also did not assess the consequences of virologic failure, such as change to
second line ART and long term clinical response.

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In conclusion, young children with high baseline viral loads are at risk for virologic failure and
require potent ART regimens. Ritonavir should not be used as single PI. Efavirenz with TB co-

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treatment resulted in good virologic outcomes.

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Ren Y, Nuttall JJ, Egbers C, Eley BS, Meyers TM, Smith PJ, et al. Effect of rifampicin

on lopinavir pharmacokinetics in HIV-infected children with tuberculosis. J Acquir Immune

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Health Do, editor.2004.

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South African National department of Health: Guidelines for the management of HIV-

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Protease inhibitor resistance in South African children with virologic failure. The Pediatric
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Frohoff C, Moodley M, Fairlie L, Coovadia A, Moultrie H, Kuhn L, et al. Antiretroviral

therapy outcomes in HIV-infected children after adjusting protease inhibitor dosing during
tuberculosis treatment. PLoS One. 2011;6(2):e17273. PMCID: 3044164.
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McIlleron H, Ren Y, Nuttall JJ, Fairlie L, Rabie H, Cotton M, et al. Lopinavir exposure is

insufficient in children given double doses of lopinavir/ritonavir during rifampicin-based

treatment for tuberculosis. . Antiviral Therapy. 2011;16(3):417-21.

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9.

Zanoni BC, Phungula T, Zanoni HM, France H, Feeneya ME. Impact of tuberculosis

cotreatment on viral suppression rates among HIV-positive children initiating HAART. AIDS.
2010;25:49-55.
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Moultrie H. Dosing, Safety and Pharmacokinetic Profile of Rifabutin in Children

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http://clinicaltrials.gov/show/NCT01259219.

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Receiving Concomitant Treatment With Kaletra [cited 2012 23 Feb]; Available from:

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Figure legend
Figure 1. Kaplan-Meier estimates of time to virologic failure, stratified by age, antiretroviral

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(ART) regimen, TB co-treatment and nutritional status

Kaplan-Meier estimates of time to virological failure, stratified by:

Age

ART third drug

1.00
0.95
0.90
0.85
0.80

p=0.0003

12 18 24 30 36 42 48 54 60 66 72

12 18 24 30 36 42 48 54 60 66 72

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<=1y

1-3y

3-5y

6 12 18 24 30 36 42 48 54 60 66 72

months on ART

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RIT

NNRTI

Nutritional status

p<0.0001

ART only

LPV/r

>5y

TB co-treatment

p<0.0001

months on ART

months on ART

1.00
0.95
0.90
0.85
0.80

1.00
0.95
0.90
0.85
0.80

1.00
0.95
0.90
0.85
0.80

p=0.0014

12 18 24 30 36 42 48 54 60 66 72

months on ART

TB cotreated

WFAZ >-3

WFAZ <=-3

Figure 1. Kaplan-Meier estimates of time to virological failure, stratified by age, ART regimen,
1
TB co-treatment and nutritional status

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Figure 1. Odds of virological failure in HIV-infected children on antiretroviral therapy

(ART), irrespective of TB co-treatment

.2

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.4

Odds
.6

.8

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1.2

Odds of failure by age group

Age group

Age groups: 1: <1year; 2: 1-2years; 3: 3-5years; 4: 6-13 years

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Figure 1. Odds of virological failure in HIV-infected children on antiretroviral

therapy (ART), irrespective of TB co-treatment

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Table 1. Baseline characteristics at ART1 initiation

TB and ART

ART only

Total

(n=78)

(n=139)

(n=217)

p-value

36 (46.2)

73 (52.5)

109 (50.2)

0.368

21 (9 42)

36 (16 70)

28 (14 64)

0.0009

Male, n (%)

(IQR2)
WFA3 z-score, median
(IQR)

-3.52

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Age in months, median

-1.91

-2.32

(-4.68 to -2.21) (-2.95 to -0.65)

(-3.78 to-1.03)

<0.0001
0.034

11.5 (7 16)

14 (8 22)

13 (8 19)

log10 HIV viral load,

5.74

5.70

5.72

median (IQR)

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CD4% , median (IQR)

(4.99 6.51)

(4.99 6.21)

(4.99 6.31)

NNRTI4-based, n (%)

21 (26.9)

79 (56.8)

100 (46.1)

PI5-based, n (%)

57 (73.1)

60 (43.2)

117 (53.9)

43 (55.1)

11 (7.9)

54 (24.5)

14 (17.9)

49 (35.3)

63 (29.0)

RTV6

LPV/r7

IQR: Inter-Quartile Range;

<0.0001

WFA: weight-for-age;

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ART: anti-retroviral therapy;

0.379

NNRTI: non-nucleoside reverse transcriptase inhibitor; 5PI: protease inhibitor; 6RTV:

ritonavir; 7LPV/r: ritonavir-boosted lopinavir

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Table 2. Univariate analysis of risk factors for virological failure

Number

Odds ratio (95% CI)

P-value

1.0

0.626

analyzed
Male

217/217

Female
Nutrition

WFA1 >-3

0.84 (0.43 1.67)

198/217

WFA -3
WFA >-2

ART2 regimen

No

198/217

1.0

0.022

2.59 (1.14 5.84)

217/217

Yes

1.0

0.004

2.81 (1.40 5.63)

NNRTI3
PI4

190/217

1.0

1.81 (0.83 4.05)

0.11

RTV5

4.12 (1.81-9.27)

0.0001

LPV/r6

0.43 (0.13-1.13)

0.07

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3rd drug

0.010

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treatment

1.0

2.65 (1.27 5.54)

WFA -2
TB co-

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Gender

WFA: weight-for-age; 2 ART: anti-retroviral therapy;

NNRTI: non-nucleoside reverse

transcriptase inhibitor; 4 PI: protease inhibitor; 5RTV: ritonavir 6LPV/r: ritonavir-boosted

lopinavir

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