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Factors associated to first line antiretroviral therapy (ART) failure among HIV/AIDS patients at Sanglah Hospital, Bali


Background and purpose: The incidence of first line ART failure is increasing in the South East Asia region. The main referral hospital in Bali has recorded an increased use of second line ART due to the first line ART failure. This study aims to explore risk factors associated to first line ART failure.

Methods: A case control study was conducted among people living with HIV and AIDS at Sanglah Hospital Denpasar who started first line ART between 2004 and 2013. Cases were those who diagnosed as having clinical treatment failure and still on treatment in 2015. Controls were those with no treatment failure. Sex and year of ART initiation were matched between case and control. Data were obtained from medical records that include initial regiments, HIV mode of transmission, the WHO HIV clinical stage, CD4 count, opportunistic infections, body mass index, hemoglobin level, and drug substitution at the beginning and during treatment. Risk factors were analysed using logistic regression.

Results: Out of 68 HIV/AIDS patients with clinical ART failure, 72.1% were confirmed with immunological and 36.8% were confirmed with virological failure. Median time before treatment failure was 3.5 years. Factors associated to ART failure were HIV clinical stage IV (AOR=3.43; 95%CI=1.65-7.13) and being widow/widower (AOR=4.85; 95%CI=1.52-15.53). Patients with TB co-infection have a lower risk for treatment failure due to early diagnosis and treatment through TB-HIV program (AOR=0.32; 95%CI=0.14-0.70).

Conclusions: Higher HIV clinical stage at ART initiation increases the risk of treatment failure. HIV-TB co-infection indirectly reduces the risk of treatment failure.


  1. Ministry of Health of Indonesia. Pedoman Nasional Tatalaksana Klinis Infeksi HIV dan Terapi Antiretroviral Pada Orang Dewasa [National Guideline on Clinical Management of HIV Infection and ART for Adult]. Jakarta: KementerianKesehatan RI; 2011.
  2. WHO-HIV Treatment. Global Update on HIV Treatment 2013; Result, Impact and Opportunities. Geneva Switzerland: Publications of the World Health Organization; 2013.
  3. WHO-Technical Report. Antiretroviral Medicines in Low and Middle Income Countries: Forecasts of Global and Regional Demand for 2014-2018. Geneva Switzerland: Publications of the World Health Organization; 2015.
  4. Duong, A.T., Kato, M., Bales. Costing Analysis of National HIV Treatment and Care Program in Vietnam. JAcquir Immune DeficSyndr; 2014; 65: 1-7.
  5. Long L., Fox M., Sannea I., Rosena S. The high cost of second-line antiretroviral therapy for HIV/AIDS in South Africa; 2010; 24 : 915–919.
  6. Castelnuovo B., John L.D., Lutwama F., Ronald A., Spacek L.A., Bates M., Kamya M.R., Colebunders R. Three-Year Outcome Data of Second-Line Antiretroviral Therapy in Ugandan Adults: Good Virological Response but High Rate of Toxicity. Journal of the International Association of Physicians in AIDS Care; 2009; 8: 52-59.
  7. Yuniar Y., Syaripuddin M., Isakh B.M., 2014. Manajemen Logistik Obat Antiretroviral di Indonesia [Logistic Management of Antiretroviral in Indonesia]. Buletin Penelitian Sistem Kesehatan; 201.; 17: 125–134.
  8. WHO-HIV/AIDS Media Center. Key Facts HIV/AIDS. Geneva Switzerland: Publications of the World Health Organization; 2015.
  9. Madec Y., Leroy S., Cuille M.A.R., Huber F., Calmy A. Persistent Difficulties in Switching to Second-Line ART in Sub-Saharan Africa — A Systematic Review and Meta-Analysis. PLoS One; 2014; 9(4): e95820.
  10. Trotter A.B., Hong S.Y., Srikantiah P., Abeyewickreme I., Bertagnolio S., Jordan M. R. Systematic Review of HIV Drug Resistance in the World Health Organization Southeast Asia Region. AIDS Rev; 2013; 15 (3): 162-170.
  11. Subuh M. Laporan Perkembangan HIV-AIDS Triwulan I Tahun 2015 [HIV/AIDS Update Report First Trimester 2015]. Surat Edaran pada Pertemuan Monitoring dan Evaluasi Nasional HIV-AIDS Tengah Semester 2015. Jakarta 8-12 Juni; 2015.
  12. Fox M.P., Van Cutsem G., Giddy J., Maskew M., Keiser O, Prozesky H., Wood R., Hernan M.A., Sterne J.A.C., EggerM., Boulle A. 2009. Rates and Predictors of Failure of First-line Antiretroviral Therapy and Switch to Second-line ART in South Africa. J Acquir Immune DeficSyndr; 2012;60(4): 428–437.
  13. Chandya S., SinghaG., HeylenbE., GandhicM., EkstrandM.L. Treatment switching in South Indian patients on HAART: What are the predictors and consequences.AIDS Care; 2011; 23(5): 569–577.
  14. Palombi L., Marazzi M.C., Guidotti G., Germano P., Buonomo E., Scarcella P., Altan A.D., Zimba I.D.V.M., Lio M.M.S., Luca A.D. Incidence and Predictors of Death, Retention, and Switch to Second-Line Regimens in Antiretroviral-Treated Patients in Sub-Saharan African Sites with Comprehensive Monitoring Availability. Clinical Infectious Diseases -Oxford University; 2009; 48(1): 115-122
  15. Abah I.O., Darin K.M., Ebonyi A.O., Ugoagwu P., Ojeh V.B., Nasir N., Falang K. D., Olaitan O., Agbaji O., Idoko J., Kanki P., Patterns and Predictors of First-Line Antiretroviral Therapy Modification in HIV-1-Infected Adults in a Large Urban Outpatient Cohort in Nigeria, Journal of the International Association of Providers of AIDS Care; 2015; 14(4) : 348-354.
  16. Hawkins C, Achenbach C., Fryda W., Ngare D., Murphy R. Antiretroviral Durability and Tolerability in HIV-Infected Adults Living in Urban Kenya. J Acquir Immune DeficSyndr; 2007; 45: 304–310.
  17. Penot P., Hema A., Bado G., Kabore F., Sore I., Sombie D., Traore JR., Schmid JB.G., Fontanet A., Slama L., Sawadogo A.B., Laurent C.. The vulnerability of men to virologic failure during antiretroviral therapy in a public routine clinic in Burkina Faso. Journal of the International AIDS Society; 2014, 17:18646.
  18. Jiamsakul A., Sungkanuparph S., Law M., Kantor R., Praparattanapan J., Li P.C.K., Phanuphak P., Merati T., Ratanasuwan W., Lee C.K.C., Ditangco R., Mustafa M., Singtoroj T., Kiertiburanakul S. HIV Multidrug Resistance at First Line Antiretroviral Failure and Subsequent VirologicalRespone in Asia. Journal of the International AIDS Society; 2014, 17:19053-19063.
  19. Robbins G.K., Daniels B., Zheng H., Chueh H., Meigs J.B., Freedberg K.A. Predictors of Antiretroviral Treatment Failure in an Urban HIV Clinic. J Acquir Immune DeficSyndr; 2007; 44 (1): 30-37.
  20. Fibriani A., Wisaksana R., Indrati A., Hartantri Y., Vijver D., Schutten M., Alisjahbana B., Sudjana P., Boucher C.A.B., Crevel R., Ven A. Virological Failure and Drug Resistance during First Line Anti-Retroviral Treatment in Indonesia. J. Med. Virol; 2013; 85:1394–1401.
  21. Beaudrap P.D., Thiam M., Diouf A., Toure-Kane C., Ngom-Guèye N.F., Vidal N., Mboup S., Ndoye I., Sow P.S., Delaporte E. Risk of Virological Failure and Drug Resistance during First and Second-Line Antiretroviral Therapy in a 10-Year Cohort in Senegal: Results From the ANRS 1215 Cohort. J Acquir Immune DeficSynd; 2013; 62: 381–387.
  22. Vanobberghen F.M., Kilama B., Wringe A., Ramadhani A., Zaba B., Mmbando D., Todd J.. Immunological failure of first-line and switch to second-line antiretroviral therapy among HIV-infected persons in Tanzania: analysis of routinely collected national data. Tropical Medicine and International Health; 2015; 20 (7): 880–892.
  23. Charles M., Leger P.D., Severe P., Guiteau C., Apollon A., Gulick R.M., Johnson W.D., Pape J.W., Fitzgerald D.W. Virologic, clinical and immunologic responses following failure of first-line antiretroviral therapy in Haiti. Journal of the International AIDS Society; 201;, 15:17375
  24. Gras G., Schneider M.P., Cavassini M., Lucht F., Loilier M., Verdon R., Bernard L., Parienti J.J. Patterns of Adherence to Raltegravir-Based Regimens and the Risk of Virological Failure among HIV-Infected Patients: The RALTECAPS Cohort Study. J Acquir Immune DeficSyndr; 2012; 61 (3): 265-269.
  25. Jespersen S., Hønge B.L., Medina C., Te D.S., Correira F.G., Laursen A.L., Erikstrup C., Østergaard L., Wejse1 C. Lack of awareness of treatment failure among HIV-1-infected patients in Guinea-Bissau -a retrospective cohort study. Journal of the International AIDS Society; 2015; 18:20243.
  26. Leng X., Liang S., Ma Y., Dong Y., Kan W., Goan D., Hsi J.H., Liao L., Wang J., He C., Zhang H., Xing H., Ruan Y., Shao Y. HIV virological failure and drug resistance among injecting drug users receiving first-line ART in China. BMJ Open; 2014; 4: e005886.
  27. Caseiro M.M., Golegã A.A.C., Etzel A., Diaz R.S. Characterization of Virologic Failure After an Initially Successful 48-Week Course of Antiretroviral Therapy in HIV/AIDS Outpatients Treated in Santos, Brazil. The Brazilian Journal of Infectious Disease; 2008; 12(3):162-166.
  28. Lynen L., An S., Koole O., Thai S., Ros S., Munter P., Sculier D., Arnould L., Fransen K., Menten J., Boelaert M., Ende J., Colebunders R. 2008. An Algorithm to Optimize Viral Load Testing in HIV-Positive Patients with Suspected First-Line Antiretroviral Therapy Failure in Cambodia. J Acquir Immune DeficSyndr 2009; 52: 40–48.
  29. Bali Provincial Health Office. Profil Dinas Kesehatan Provinsi Bali. [Profile of Bali Provincial Health Office]. Denpasar. Dinas Kesehatan Provinsi Bali; 2015.
  30. Susila Utama Made, Parwati Merati Tuti. Association of Opportunistic Infections with HIV RNA and CD4 Cell Count in Pre ARV and ARV Failure at The Care Support Treatment Clinic of Sanglah Hospital Bali. Journal of Epidemiological Research; 2016; 2 (2): 13-17.
  31. Ghate M., Deshpande S., Tripathy S., Nene M., Gedam P., Godbole S., Thakar M., Risbud A., Bollinger R., Mehendale S., Incidence of common opportunistic infections in HIV-infected individuals in Pune, India: analysis by stages of immunosuppression represented by CD4 counts. International Journal of Infectious Diseases; 2009; 13: 1-8
  32. Dikromo Ngatwanto Parto, Antariksa Budhi, Nawas Arifin. 2008. Factors Associated to Success Tuberculosis Therapy of Co-infection TB-HIV Patients in Persahabatan Hospital, Jakarta-Indonesia. J Respir Indo; 2011; 31 (1).
  33. Gandhi Neel R, Anthony P. Moll, UmeshLalloo, Robert Pawinski, Kimberly Zeller, PraviMoodley, Eugene Meyer, Gerald Friedland. Successful Integration of Tuberculosis and HIV Treatment in Rural South Africa. J Acquir Immune DeficSyndr; 2009;50:37–43
  34. Owiti P., Zachariah R., Bissel K., Kumar A. M. V., Diero L., Carter E. J., Gardner A.2012. Integrating Tuberculosis and HIV Services in Rural Kenya, Uptake and Outcomes. Public Health Action; 2015; 5(1): 36–44
  35. Caseiro M.M., Golegã A.A.C., Etzel A., Diaz R.S. Characterization of Virologic Failure After an Initially Successful 48-Week Course of Antiretroviral Therapy in HIV/AIDS Outpatients Treated in Santos, Brazil. The Brazilian Journal of Infectious Diseases; 2008; 12 (3):162-166.
  36. Sungkanuparph S., Groger R.K., Overton E.T., Fraser V.J., Powderly W.G. 2006. Persistent Low Level Viraemia and Virological Failure in HIV-1 Infected Patients Treated with Highly Active Antiretroviral Therapy. HIV Medicine; 2006; 7: 437–441.
  37. Ma Y., Zhao D., Yu L., Bulterys M., Robinson M.L., Zhao Y., Dou Z., Chiliade Z., Wei X., ZhangF. Predictors of virologic failure in HIV-1-infected adults on first line antiretroviral therapy in eight provinces in China.Clinical Infectious Diseases; 2009; 50 : 264-271
  38. ChaiwarithRomanee, WachirakaphanCharussri, KotarathititumWilai, PraparatanaphanJutharat, Sirisanthana Thira, SupparatpinyoKhuanchai. Sensitivity and Specificity of Using CD4 Measurement and Clinical Evaluation to Determine Antiretroviral Treatment Failure in Thailand. International Journal of Infectious Diseases; 2007; 11: 413—416.
  39. GsponeraT., PetersenbM., EggeraM., PhiridS., MaathuiseM.H., BoullecA., MusondadfP., TweyadH., PetereK., ChigB.H., KeiseraO. The Causal Effect of Switching to Second–line ART in Programmes without Access to Routine Viral Load Monitoring. AIDS; 201; 26(1): 57–65.
  40. Gilks Charles F., Walker A. Sarah, Munderi Paula, Kityo Cissy, Reid Andrew, Katabira Elly, Goodall Ruth L, Grosskurth Heiner, Mugyenyi Peter, Hakim James, Gibb Diana M. A Single CD4 Test with 250 cells/mm3 Threshold Predicts Viral Suppression in HIV-Infected Adults Failing First-Line Therapy by Clinical Criteria. Published: Feb 21, 2013 pone.0057580

How to Cite

Astiti, C. I. S. D., Sawitri, A. A. S., & Merati, K. T. P. (2017). Factors associated to first line antiretroviral therapy (ART) failure among HIV/AIDS patients at Sanglah Hospital, Bali. Public Health and Preventive Medicine Archive, 5(1), 3–8.


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