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ART for Refugee Populations
Getting Creative With ART Switch in Ukrainian Migrants: The Polish Experience

Released: December 15, 2023

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Key Takeaways
  • Displaced Ukrainian people living with HIV likely will no longer have access to their usual ART, necessitating a switch to a new regimen.
  • Polish healthcare professionals adapted their ART treatment guidelines to streamline switches to regimens that are readily available.
  • These principles may be applied to other areas experiencing an influx of migrant and refugee populations to avoid interruptions in ART.

Surpassed only by Russia, Ukraine bears the highest burden of HIV in Europe, with more than 200,000 people estimated to be living with HIV and 37.1 new infections diagnosed per 100,000 people in 2021, prior to the start of the war.

In 2019, Ukraine had made significant progress toward the UNAIDS 90-90-90 Fast-Track targets to end the epidemic, with successful programs providing antiretroviral therapy (ART) to more than 130,000 individuals (80% of people living with HIV), a notable increase from approximately 98,000 individuals in 2017 (72% of people living with HIV). This progress likely has been disrupted since the Russian invasion.

More than 80% of these individuals were prescribed a generic single-tablet regimen of dolutegravir (DTG)/lamivudine (3TC)/tenofovir disoproxil fumarate (TDF), an effective combination with a high genetic barrier to resistance. This regimen typically is available only in low- or middle-income countries, as DTG remains under patent protection in high-income countries.

Displacement of Ukrainian Citizens Affects Their HIV Treatment
Following the Russian invasion, a considerable number of Ukrainian individuals living with HIV were seeking refuge and medical care elsewhere in Europe, with the highest proportion concentrated in Poland. These displaced people required follow-up HIV care within the framework of existing healthcare systems, where DTG/3TC/TDF as a generic single-tablet regimen is not available. This required many people with viral suppression to switch ART regimens, while taking care to maintain efficacy and safety.

Principles to Guide the Switch
For people living with HIV migrating from Ukraine to Poland, who are already under duress, creative strategies are needed to systematically switch regimens and minimize adverse outcomes due to treatment interruptions.

To aid in decision-making, we updated the Polish antiretroviral treatment guidelines with the goal of maximizing available agents when switching from DTG/3TC/TDF.

  • First, the switch of the nucleos(t)ide reverse-transcriptase inhibitors primarily should be within the same analogue group (eg, cytosine nucleoside analogues 3TC to FTC or TDF to tenofovir alafenamide [TAF]).
  • Second, agents with a higher genetic barrier to resistance are preferred (namely, integrase strand transfer inhibitors), while retaining the core agent class, if possible.

In our national experience, this translated to 37.1% of individuals switching to once-daily DTG plus FTC/TDF, followed by bictegravir/FTC/TAF in 32.4% and once-daily DTG plus FTC/TAF in 8.6%. Efavirenz-based treatments also mostly were switched within class, largely to a doravirine/3TC/TDF single-tablet combination.

Emergence of integrase inhibitor resistance in individuals failing treatment was infrequent, but detected. Individuals switched to DTG-based regimens maintained high rates of virologic suppression at 91.7%.

Implications of the A6 HIV-1 Variant
In the Ukrainian migrant and refugee population, baseline genotypic resistance data are not widely available, but the majority of people living with HIV are expected to have the A6 HIV-1 variant. This variant historically has been associated with HIV outbreaks in people who inject drugs and heterosexual populations from regions that formerly were part of the Soviet Union, and this may have implications on treatment outcomes.

We must be cautious about implementing long-acting cabotegravir plus rilpivirine in this population because of the predominance of the A6 variant and the lack of data on genotypic drug susceptibility to rilpivirine. To address this gap, Polish clinical centers are implementing a strategy of DNA-based ART susceptibility testing by providing genotypic drug resistance analyses not only to individuals with ART failure, but also to all newly diagnosed Ukrainian migrants.

Data recently presented at EACS 2023 confirm that 91.5% of newly diagnosed migrants from Ukraine had the A6 variant, and 14.4% had baseline rilpivirine resistance. Given concerns for virologic failure, particularly in people with rilpivirine resistance–associated mutations in addition to the A6 subtype, I refrain from prescribing this regimen for Ukrainian migrants until more clinical data emerge. 

In summary, within-class adjustments proved to be effective and well accepted in a suppressed migrant patient population. However, the characteristics of the predominantly circulating HIV variant in this population should be considered before implementation of novel treatment strategies, such as long-acting injectables.

I hope that lessons learned from our experience may be useful to other areas with increases in migrant populations who are in search of innovative strategies to remove barriers to ART continuation using available resources.

Your Thoughts?
What can we learn about ART switch strategies from the practices used by Polish healthcare professionals for Ukrainian migrants? Leave a comment to join the discussion.