Table 2.
Outcomes after 15 years from t0 of the five policy options, according to prevalence of NNRTI resistance at t0 among people starting ART
| t0 (2017) | 15 years after t0 (2032)
|
|||||
|---|---|---|---|---|---|---|
| Current policy | bPI as first-line regimen* | Pre-ART resistance testing† | Viral load monitoring‡ | Single viral load test at 6 months§ | ||
| Proportion on a bPI–based regimen¶ | ||||||
|
| ||||||
| <5% | 7% (6–8) | 18% (16–20) | 59% (57–61) | 22% (19–25) | 17% (14–21) | 19% (16–21) |
| 5% to <10% | 7% (6–9) | 19% (17–23) | 61% (58–64) | 24% (21–30) | 20% (16–26) | 21% (18–26) |
| 10% to <15% | 8% (7–10) | 23% (19–27) | 63% (60–66) | 30% (25–35) | 25% (20–32) | 25% (21–31) |
| 15% to <20% | 9% (7–11) | 26% (21–33) | 66% (61–71) | 35% (29–43) | 31% (24–40) | 30% (24–38) |
| 20% to <25% | 10% (9–11) | 29% (24–34) | 69% (63–72) | 40% (34–45) | 37% (30–42) | 35% (29–40) |
| ≥25% | 10% (9–11) | 31% (27–35) | 70% (66–73) | 43% (39–46) | 39% (35–43) | 36% (33–41) |
|
| ||||||
| Of people starting ART, proportion having NNRTI resistance (in majority virus)|| | ||||||
|
| ||||||
| <5% | 4% (2–5) | 25% (15–36) | 11% (5–19) | 22% (13–33) | 21% (11–29) | 24% (14–35) |
| 5% to <10% | 8% (5–10) | 32% (20–44) | 14% (7–23) | 28% (18–40) | 27% (16–38) | 31% (19–42) |
| 10% to <15% | 12% (10–15) | 41% (29–51) | 17% (9–26) | 36% (26–46) | 35% (24–45) | 39% (27–49) |
| 15% to <20% | 17% (15–20) | 48% (37–58) | 20% (11–31) | 44% (33–54) | 42% (32–52) | 46% (36–56) |
| 20% to <25% | 22% (20–24) | 54% (44–63) | 22% (12–32) | 49% (40–57) | 47% (36–56) | 51% (40–59) |
| ≥25% | 26% (25–29) | 57% (51–65) | 24% (14–34) | 52% (44–60) | 50% (41–55) | 53% (44–61) |
|
| ||||||
| Of people starting ART, proportion having any resistance (in majority virus)||** | ||||||
|
| ||||||
| <5% | 5% (3–6) | 28% (17–41) | 20% (10–30) | 26% (16–38) | 25% (14–36) | 28% (16–40) |
| 5% to <10% | 8% (6–11) | 36% (23–49) | 26% (14–38) | 33% (22–46) | 32% (20–45) | 35% (22–48) |
| 10% to <15% | 13% (11–16) | 45% (33–57) | 33% (20–45) | 43% (30–54) | 41% (29–53) | 44% (32–55) |
| 15% to <20% | 19% (16–22) | 53% (42–64) | 40% (27–53) | 51% (39–63) | 49% (37–61) | 52% (41–63) |
| 20% to <25% | 24% (22–26) | 60% (49–70) | 45% (32–58) | 58% (47–66) | 56% (43–65) | 58% (46–68) |
| ≥25% | 28% (26–32) | 64% (56–73) | 49% (37–60) | 60% (51–72) | 59% (51–68) | 61% (51–69) |
|
| ||||||
| Of people on ART 1 year after starting ART, proportion with viral suppression | ||||||
|
| ||||||
| <5% | 80% (73–86) | 69% (60–78) | 83% (75–89) | 80% (71–87) | 71% (62–80) | 70% (60–79) |
| 5% to <10% | 77% (64–84) | 63% (49–74) | 81% (69–89) | 77% (64–85) | 66% (52–76) | 65% (51–75) |
| 10% to <15% | 67% (46–78) | 52% (35–64) | 74% (58–84) | 68% (49–79) | 55% (39–67) | 54% (37–66) |
| 15% to <20% | 49% (40–70) | 36% (26–54) | 61% (51–78) | 53% (43–73) | 40% (30–58) | 40% (30–57) |
| 20% to <25% | 45% (39–52) | 31% (25–39) | 58% (51–69) | 49% (42–59) | 35% (28–46) | 34% (28–44) |
| ≥25% | 44% (38–49) | 30% (25–35) | 59% (53–64) | 50% (44–57) | 34% (27–41) | 33% (27–38) |
|
| ||||||
| Of people on ART, proportion with viral suppression | ||||||
|
| ||||||
| <5% | 84% (80–86) | 83% (79–86) | 88% (86–90) | 86% (83–88) | 87% (83–90) | 84% (80–86) |
| 5% to <10% | 82% (73–85) | 81% (74–85) | 87% (82–90) | 84% (79–88) | 85% (79–89) | 82% (75–85) |
| 10% to <15% | 74% (56–82) | 75% (61–81) | 83% (69–88) | 80% (66–85) | 81% (70–85) | 77% (65–82) |
| 15% to <20% | 56% (53–76) | 62% (56–77) | 70% (67–84) | 67% (63–82) | 71% (66–82) | 66% (61–78) |
| 20% to <25% | 54% (52–58) | 59% (55–64) | 68% (67–70) | 65% (63–68) | 69% (66–74) | 64% (60–68) |
| ≥25% | 54% (52–56) | 58% (55–62) | 68% (67–69) | 65% (63–67) | 69% (65–72) | 64% (61–67) |
|
| ||||||
| Death rate | ||||||
|
| ||||||
| <5% | 2·8 (2·2–3·7) | 2·5 (2·0–3·1) | 2·2 (1·6–2·7) | 2·3 (1·8–3·0) | 2·4 (1·8–3·0) | 2·4 (1·9–3·0) |
| 5% to <10% | 3·1 (2·3–4·6) | 2·7 (2·0–3·6) | 2·2 (1·7–2·9) | 2·4 (1·9–3·3) | 2·5 (1·9–3·3) | 2·6 (2·0–3·5) |
| 10% to <15% | 4·1 (2·8–7·4) | 3·1 (2·4–4·9) | 2·4 (1·9–3·4) | 2·8 (2·2–4·4) | 2·8 (2·2–4·0) | 2·9 (2·3–4·4) |
| 15% to <20% | 7·0 (3·6–8·5) | 4·5 (2·7–6·1) | 3·1 (2·1–4·2) | 4·0 (2·4–5·3) | 3·6 (2·4–4·9) | 3·8 (2·5–5·2) |
| 20% to <25% | 7·6 (6·0–8·7) | 5·0 (3·7–6·0) | 3·4 (2·6–4·1) | 4·4 (3·4–5·3) | 3·9 (3·2–4·9) | 4·3 (3·4–5·2) |
| ≥25% | 7·7 (6·4–8·5) | 5·0 (4·4–5·6) | 3·4 (2·9–4·1) | 4·4 (3·6–5·2) | 3·8 (3·3–4·8) | 4·0 (3·6–4·8) |
Data are median proportion (90% range), or death rate per 100 person-years (90% range). Results are based on 5000 programmatic scenarios, according to prevalence of NNRTI resistance at t0 in people starting ART, as follows: <5%, n=451; 5% to <10%, n=1800; 10% to <15%, n=1518; 15% to <20%, n=807; 20% to <25%, n=376; ≥25%, n=48. ART=antiretroviral therapy. bPI=boosted protease inhibitor. NNRTI=non-nucleoside reverse transcriptase inhibitor. NRTI=nucleoside reverse transcriptase inhibitor.
Change of the standard NNRTI-based regimen to a bPI-based first-line regimen.
Individual-level resistance testing before ART initiation to detect key NNRTI mutations to inform whether use of an NNRTI-based or bPI-based regimen is optimal as first-line treatment.
Introduction of routine (6 month, 12 month, then annual) viral load monitoring, replacing 6 monthly CD4 cell count monitoring.
A single routine measurement of viral load 6 months after start of ART, with routine CD4 cell count monitoring. In this last scenario, if viral load is >1000 copies per mL, the test is repeated 6 months later; if viral load remains at >1000 copies per mL, a switch to second-line treatment is effected.
First-line or second-line.
Including women who have taken antiretroviral drugs for the prevention of mother-to-child transmission.
Including NNRTI, NRTI, or PI resistance.