Background. An exploratory subanalysis of the ODIN trial was performed to evaluate the efficacy of darunavir/ritonavir (DRV/r) 800/100 mg OD versus 600/100 mg BID in patients who were NNRTI-experienced but PI-naïve. Methods. ODIN was a phase III, 48-week study comparing DRV/r OD versus BID in 590 treatment-experienced patients with no DRV resistance-associated mutations (RAMs) at screening. Patients received DRV/r 800/100 mg OD or DRV/r 600/100 mg BID plus ≥2 NRTIs. Of the 590 patients randomized, 272 (46%) were NNRTI-experienced but PI-naïve. Results. Overall, 272 patients received DRV/r OD (n = 135) or BID (n = 137) plus ≥2 optimised NRTIs. The mean age was 39 years; 35% were female; 27% were Black, 24% Caucasian, 26% Oriental/Asian, and 23% other races; 17% were recruited in South Africa; and 48% had non-B HIV-1 subtypes. Mean baseline plasma HIV-1 RNA load was 4.10 log10 copies/mL; median CD4 cell count was 258 cells/μL. At week 48, 111/135 (82%) of DRV/r OD and 109/137 (80%) of DRV/r BID patients achieved an HIV-1 RNA load <50 copies/mL. No patient developed primary PI RAMs. Conclusion. DRV/r 800/100 mg OD in combination with ≥2 optimised NRTIs led to virological suppression <50 copies/mL in 82% of NNRTI-experienced, PI-naïve patients by week 48. Approximately 12 million people with HIV infection in developing countries are taking two nucleoside reverse transcriptase inhibitors (NRTIs) and a nonnucleoside reverse transcriptase inhibitor (NNRTI) for first-line treatment  . In deveThe standard second-line antiretroviral treatment (ART) recommended by the World Health Organization (WHO) for resource-limited settings is two NRTIs and a ritonavir-boosted protease inhibitor (PI/r) . The twoA large randomized trial comparing ATV/r with DRV/r in treatment-naïve patients has shown virological benefits of DRV/r 800/100 mg once daily versus atazanavir/ritonavir . Taken tThe ODIN trial evaluated the efficacy and safety of DRV/r in treatment-experienced patients who had no DRV resistance-associated protease mutations at baseline. The trial compared two DRV/r doses: 800/100 mg once daily and 600/100 mg twice daily in combination with at least two NRTIs and showed overall noninferiority of the OD arm compared with the BID arm , 13.If DRV/r is to be proposed as part of second-line ART regimens in low-income countries, it will be mainly used in PI-naïve patients who have experienced failure of first-line NNRTI-based therapy. Since the ODIN trial included both PI-naïve and PI-experienced subjects, the objective of this exploratory analysis was to evaluate the efficacy and safety of DRV/r in the subset of patients who were NNRTI-experienced but PI-naïve at study entry and relate the findings to the activity of the NRTI backbone, thereby providing evidence to guide treatment choices for second-line therapy.The methods of the ODIN trial have been described in detail elsewhere . BrieflyResistance mutations were scored according to Virtual Phenotype . The activity of the NRTIs used for each patient was calculated by assigning a value of 1 for drugs with full susceptibility and 0 for those with any resistance.All patients signed written informed consent and the protocol was approved by local and national ethics committees.In this analysis, we describe the efficacy and safety of the patients who had received no protease inhibitors before baseline. The percentage of patients with HIV-1 RNA suppression below 50 or 400 copies/mL was analysed using the Time to Loss of Virological Response (TLOVR) algorithm. Clinical and laboratory adverse events were graded by severity using the Division of AIDS (DAIDS) grading scale. The analyses were exploratory in nature. The trial had not been powered to compare the treatment groups for this subset of patients.μL in 42% of patients and the baseline HIV-1 RNA level was at least 100,000 copies/mL in 8%. Overall, 27% of the patients were Black, 26% were Oriental or Asian, and 42% were recruited in either Africa or Asian countries. A range of HIV-1 subtypes were found in the patients. The most common HIV-1 subtype was B (52%), but 19% of patients had HIV-1 subtype C and a further 26% of patients had recombinant subtypes . The most common NRTIs used in DRV/r 800/100 mg OD and the DRV/r 600/100 mg BID arms comprised tenofovir (85.9% and 82.5% resp.), zidovudine (72.6% and 66.4%), and lamivudine (51.1% and 60.6%), whereas use of stavudine (18.5% and 16.8%), emtricitabine (14.8% and 16.1%), abacavir (14.1% and 12.4%), and didanosine (3.7% and 5.1%) was less common. For patients with genotypic results available at baseline, the percentage with 0, 1, or ≥2 sensitive NRTIs in their randomised treatment was well-balanced between the treatment arms  patients in the DRV/r 800/100 mg OD arm with HIV-1 RNA suppression below 50 copies/mL  versus 109/137 (80%) patients in the DRV/r 600/100 mg BID arm . The corThis exploratory analysis aimed to provide evidence of the virological efficacy of DRV/r in combination with at least two optimised NRTIs as second-line ART following failure of first-line NNRTI-based therapy. After 48 weeks of treatment, 82% of subjects showed HIV-1 RNA suppression below 50 copies/mL. The 800/100 mg once daily dose showed similar efficacy to the 600/100 mg twice daily dose, but with trends for fewer serious adverse events (4% versus 7%) and fewer discontinuations for adverse events (1% versus 4%). These findings support the use of DRV/r 800/100 mg once daily, in PI-naïve patients who have failed NNRTI-based therapy.There are several limitations to this analysis, if the results are to be extrapolated to people failing NNRTI-based ART in low- or middle-income countries. First, the trial selection criteria could have excluded important groups of people who may need treatment with DRV/r, such as pregnant or breastfeeding women or those with active AIDS defining illnesses or laboratory abnormalities. Clinical trials of DRV/r in such settings should have as few selection criteria as possible in order to mirror real-life clinical practice. Secondly, the patients were tested for drug resistance at baseline, and their background NRTI treatment was optimized based on the results. Routine testing for drug resistance at the time of virological failure of first-line ART is not the current standard of care in most low-income countries, and this may have overestimated the efficacy of DRV/r in a setting where resistance testing is not affordable. Thirdly, there was no comparison with other PI/r-based regimens widely used in low- or middle-income countries and it is therefore not possible to estimate potential differences in efficacy or safety between DRV/r and alternative treatments. Finally, this was a post hoc comparison of the treatment groups in the subset of PI-naïve patients; the trial was not powered to compare the treatments in this subgroup. Finally, there was a wide range of ages included in the study (18–77 years). The effects of darunavir/ritonavir in elderly patients who may have other comorbidities need to be studied in more detail.The current WHO 2013 guidelines for resource-limited settings recommend second-line treatment with a PI/r combined with two NRTIs . Use of In conclusion, the PI-naïve patients in the ODIN study had similar rates of HIV-1 RNA suppression on the 800/100 mg once daily and 600/100 mg twice daily doses. The efficacy was also similar for patients with different HIV-1 subtypes and for those with 0, 1, or 2 active NRTIs in their treatment backbone. More randomised studies are needed to compare the efficacy of DRV/r, ATV/r, and LPV/r in second-line treatment of PI-naïve patients, in combination with either nucleoside analogues or integrase inhibitors.


Our objective was to describe viral suppression and antiretroviral (ARV) resistance mutations in an ongoing cohort of perinatally-infected HIV+ (PHIV+) pregnant women. Descriptive analysis was performed using SPSS 18.0. From 2011 to 2014, we followed 22 PHIV+ pregnant women. Median age at prenatal entry was 19 years (Interquartile range (IQR) 17.6–21.0); 86% had an AIDS diagnosis; 81% had disclosed their HIV status to partner 11. The median age at HIV diagnosis was 8.3 y (IQR 4.0–13.6), the median age at sexual debut was 16 years (IQR 14–18). At the time of prenatal care initiation, four (18%) were on their first antiretroviral treatment (ART), eight (36%) in their second regimen and nine (41%) in their third regimen or beyond, and one had no data. Seventeen of 22 (77%) had HIV-viral load (VL) > 50 copies/mL at prenatal care entry, 16 had a genotyping exam performed. Seventeen of 22 PHIV+ had VL results near delivery: 7/17 (41%) had VL < 50 copies/mL. Among those who had genotyping at prenatal entry, 11/16 (69%) had mutations associated with ARV resistance. The most frequent major mutations were K103N, M184V, T215, M41L, D67N at reverse transcriptase gene and M46, I54V and V82A at protease gene. No vertical transmissions occurred. Management of pregnancy among PHIV+ is challenging. Individualized ART are needed to achieve viral suppression in a highly ART-exposed subpopulation. Individuals with perinatally-acquired human immunodeficiency virus type 1 (HIV) infection (PHIV+) are frequently diagnosed and started on antiretroviral therapy (ART) during the first months or years of life. The global expansion in the use of pediatric ART has resulted in a significant decrease in mortality rates among PHIV+, many of whom are now sexually active adolescents or young adults ,3,4. VerA resistance mutation is a mutation in a virus gene that allows the virus to become resistant to treatment with a particular antiviral drug. The term was first used in the management of HIV, the first virus in which genome sequencing was routinely used to look for drug resistance. Most antiretroviral drugs target HIV enzymes encoded by specific genes, reverse transcriptase, protease, or integrase. These enzymes are processed protein products of the HIV pol gene, a viral structural protein .Our main objective was to describe viral suppression and ARV resistance mutations in an ongoing cohort of PHIV+ pregnant adolescents and women in Rio de Janeiro, Brazil.We analyzed pregnancy data among confirmed PHIV+ women followed at a referral unit for prevention of mother-to-child transmission (PMTCT). Sociodemographic and clinical data, including treatment data, were collected routinely upon enrollment and during follow-up. Women with viral load (VL) > 1000 copies/mL at enrollment underwent HIV genotyping testing using the TRUGENE HIV-1 DNA sequencing platform. This platform detects HIV genomic mutations in the protease and reverse transcriptase regions of HIV, that are the most common mutations found among antiretroviral experienced individuals in our clinical settings . The genFrom February 2011 to August 2014, 630 HIV-infected pregnant women were enrolled in the PMTCT program. Among these, 22 (3.5%) were PHIV+. The median age at enrollment for the 22 PHIV+ was 18.5 years (Interquartile Range (IQR): 17.6–21.0), 71% were non-white, 86% had an AIDS-defining diagnosis according to CDC criteria, and 81% had disclosed their HIV status to the current sexual partner. The median number of years of formal education was nine years (IQR: 6.5–11).The median age at HIV diagnosis was 8.3 years (IQR: 4.0–13.6), the median age at sexual debut was 16 years (IQR: 14–18), and 71% conceived while using antiretrovirals (ARV). At enrollment, 4/22 (18%) were on their first ART regimen, 8/22 (36%) on their second regimen, and 9/22 (41%) on at least their third ART regimen (1/22 had no ARV data available). Prenatal care was initiated at a median gestational age of 14 weeks (IQR: 9.0–20). At enrollment, 17/22 (77%) had a viral load (VL) > 50 copies/mL, and 17/22 (77%) had a VL assay result near delivery with 7/17 (41%) having a VL < 50 copies/mL at that time. Sixteen women had viral genotype testing at prenatal entry, and all received highly active antiretroviral therapy (HAART) during pregnancy. All patients with VL > 50 copies/mL near delivery had a cesarean section. Among those with VL < 50 copies/mL, three had a vaginal delivery and four had a cesarean section for obstetric indications. There was one spontaneous abortion.Infants’ mean gestational age was 38 weeks (IQR: 37–39), there were four preterm infants (18%). Mean birth weight was 2814 gr (IQR: 2.43–3.17) and mean birth length was 47 cm (IQR = 46–49). None of the infants were HIV-infected.A small proportion of pregnant women followed at our PMTCT unit acquired their HIV infection perinatally, and this analysis updates information available regarding this specific population. The main limitation of our study is the small sample, due to the rarity of this event, however this is a population of significant interest as more perinatally infected individuals have children of their own.The median age of pregnant PHIV+ was similar to what was recently observed in the United States and Italy ,14. The Among this group of PHIV+, we found a higher prevalence of diagnosis disclosure to sexual partners, as compared to PHIV+ in Africa and the UK/Ireland ,15. ThisAt enrollment, only 5/22 (23%) of PHIV+ had a VL below 50 copies/mL, but close to delivery this percentage increased to 41%. Our results are comparable to those from a US cohort that found 60% of pregnant PHIV+ with a VL below 400 copies/mL  and worset al. [Most of our patients have been exposed to at least two ART regimens and the observed suboptimal viral suppression among PHIV+ at enrollment is probably associated with non-adherence to ART and the presence of viral resistance. In a systematic review that included studies published from 1990 to 2011 with 1980 PHIV+ on ART from 26 countries, Sánchez et al.  found dret al. . In our et al. . K103N met al. . Similaret al. . T215 coet al. . 154 V iThe gestational age of infants born to PHIV+ are similar to that described in cohorts in Italy and New York ,21 whereDespite advances in HIV treatment, ART management during the pregnancies of PHIV+ is especially challenging. New drugs, effective counseling, strategies and interventions targeting patient retention and individualized ART regimens are needed and may be crucial to achieve viral suppression in a highly ART-exposed subpopulation with expected adherence difficulties.


Due to its good tolerability, favourable cardiovascular risk-profile, low-pill burden and cost, nevirapine-based regimens are an attractive simplification strategy for patients with suppressed viral load (VL). However, current guidelines recommend caution if nevirapine (NVP) is prescribed in males and females with CD4 counts above 400 or 250 cells/µL, respectively. The aim of this study is to determine the prevalence and risk factors associated with development of toxicity or treatment discontinuation in patients switching to NVP-based regimens.Retrospective chart review of HIV-infected patients with suppressed VL who switched from a PI-based regimen to a NVP-based regimen in four HIV clinics in Argentina, between 1997 and 2013. Bivariate and multivariate analyses were performed to explore factors associated with treatment discontinuation. High CD4 count was defined as CD4-cell count ≥400 or 250 cells/µL in males and females, respectively.Of 218 patients included, 165 (75.7%) were male; 21 (9.6%) were co-infected with HCV and/or HBV. Median baseline (BSL) CD4 count: 138 cells/µL (IQR: 64–276). At switch, patients had a median age of 38 years (IQR: 33.4–43.8) and had been suppressed for a median of 1.4 years (IQR: 0.6–2.2); 138 patients (63.3%) had high CD4-cell counts: among females, median CD4 count at switch was 462 (IQR: 330–709) cells/µL; among males, 433 (IQR: 305–595) cells/µL. Thirty-six patients (13.5%) presented NVP-related toxicity , 29 (13.3%) discontinued NVP. Median time to development to toxicity: 32 days (IQR: 15–75). In bivariate analysis, chronic hepatitis was the only variable associated with development of toxicity . In multivariate analysis, no statistical significant associations were observed between either development of toxicity or treatment discontinuation and gender, chronic hepatitis, age or CD4-cell count at BSL or at switch .In our study, switching to a NVP-based regimen in patients with undetectable VL was associated with a low incidence of skin or liver toxicity, and treatment discontinuation. Moreover, these were unrelated to the CD4-cell count. Our findings suggest that, in contrast with ART-naïve patients, switching to NVP-based regimens could be a safe strategy for patients with suppressed viremia regardless of the CD4-cell count.


For some TDRM it has been shown that they revert to wild type while other mutations persist in the absence of therapy. To understand the mechanisms explaining persistence we investigated the We selected 31 individuals infected with HIV-1 harboring frequently observed TDRM such as M41L or K103N in reverse transcriptase (RT) or M46L in protease. In all these samples, polymorphisms at non-TDRM positions were present at baseline . Extensive analysis of viral evolution of protease and RT demonstrated that the majority of TDRM (51/55) persisted for at least a year and even up to eight years in the plasma. During follow-up only limited selection of additional polymorphisms was observed (median: 1).in vitro replicative capacity than the corresponding site-directed mutant viruses.To investigate the impact of frequently observed TDRM on the replication capacity, mutant viruses were constructed with the most frequently encountered TDRM as site-directed mutants in the genetic background of the lab strain HXB2. In addition, viruses containing patient-derived protease or RT harboring similar TDRM were made. The replicative capacity of all viral variants was determined by infecting peripheral blood mononuclear cells and subsequently monitoring virus replication. The majority of site-directed mutations  decreased viral replicative capacity; only protease mutation L90M did not hamper viral replication. Interestingly, most patient-derived viruses had a higher in vivo evolution of protease and RT harbouring frequently observed TDRM in the plasma. This is in line with the high in vitro replication capacity of patient-derived viruses harbouring TDRM compared to site-directed mutant viruses harbouring TDRM. As site-directed mutant viruses have a lower replication capacity than the patient-derived viruses with similar mutational patterns, we propose that (baseline) polymorphisms function as compensatory mutations improving viral replication capacity.We demonstrate limited  The viral enzymes reverse transcriptase (RT) and protease were the first targets of antiretroviral therapy and the most commonly used drug regimens still aim at inhibiting these viral proteins . In resoThe majority of transmitted drug-resistant viruses contain limited resistance profiles to single drug classes. Nucleoside RT inhibitor (NRTI) mutations are the most frequently observed transmitted drug resistance mutations (TDRM). Especially thymidine analogue mutations (TAMs) M41L and T215 variants, that have been selected by drugs extensively used in the past, are often observed in newly diagnosed patients ,5, as siIt is generally acknowledged that most drug resistance mutations decrease the replicative capacity (RC) of HIV-1 ,8. As suHowever, follow-up of patients diagnosed with HIV-1 harboring TDRM has revealed that TAMs, PI- and NNRTI-related TDRM often persist for prolonged periods ,13-25. TThe aim of our study was to gain more insight in the mechanisms causing persistence of drug resistant HIV-1 variants after transmission. Therefore, we investigated the molecular evolution of HIV-1 protease and RT harboring the most frequently observed TDRM in great detail. The majority of TDRM persisted during the follow-up, and only few additional polymorphisms were selected during this period. Most patient-derived viruses had a higher RC than the corresponding site-directed mutant viruses, indicating that persistence can be explained by a high replication capacity of most transmitted drug resistant HIV-1 variants.in vivo evolution of transmitted drug resistant HIV variants, we selected 31 patients from four European countries  who were diagnosed in 2001 to 2008 with an HIV variant harboring a frequently observed TDRM . Patients were included if a plasma sample was available at one year (10–14 months) after diagnosis if therapy was not yet initiated. If available, a third time point before start of treatment was investigated. Prior negative HIV tests were available for 14 patients, revealing that at least nine patients had been infected for less than two years. The majority of the patients were men having sex with men (MSM), which is the most important route of transmission in Western Europe. The median plasma HIV-RNA in our group of patients was 4.6 log copies/ml, comparable to the median HIV-RNA observed in the SPREAD-programme in 2002–2006 (4.8 log copies/ml). The median baseline CD4 count was 653 cells/mm3, which is higher than the median observed in the SPREAD programme (343 cells/mm3) [To investigate the Surveillance studies demonstrated that most transmitted drug resistant HIV-1 variants harbor resistance against a single drug class ,4. In liThe vast majority 51/55) of TDRM persisted during the first year of follow-up. For 24/31 patients a third and sometimes a fourth genotypic analysis was performed at a median of 28 months (range: 14–99 months) after the first sample. During this more extensive follow-up period of up to eight years, all resistance mutations present at one year after diagnosis persisted in the plasma  additional polymorphisms in protease during the first year of follow-up. Likewise, viruses harboring drug-resistance mutations in RT selected a median of 1 (range 0–3) additional RT polymorphisms .The RC of p46I and p46L was similar to controls HIV-M184I and –V, indicating a diminished replication. The RT variant pK103N had an RC comparable to HIV-WT and the RC of pL90M was higher than HIV-WT. For M41L, it has been described that V60I and S162A function as compensatory mutations in transmitted HIV-1 variants . We seleInterestingly, except for the pM41L variant, all patient-derived viruses had a higher RC than the corresponding site-directed mutants  restoring viral RC explain the in vivo persistence of TDRM. The stability of transmitted drug resistant HIV-1 variants can facilitate onward transmission of these viruses.In conclusion, we confirmed persistence of the most frequently observed TDRM. All transmitted HIV-1 variants harbored additional polymorphisms, with limited selection of additional mutations. Limited reversion of TDRM is in concordance with the high Ethical requirements differ between countries according to national legislation. In countries where a national surveillance system was established, legally no informed consent was needed. In other countries, approval was obtained by the institutional medical ethical review committees. All data were anonymized at national level.Patients from four countries participating in the SPREAD-programme  were included. For all included patients, a baseline genotypic resistance test performed on a plasma sample within three months after diagnosis of HIV-1 infection revealed at least one mutation on a position associated with transmitted drug resistance as described in the mutation list as recommended by the WHO . PatientGenotypic resistance tests were performed by population sequencing of the viral protease and part of reverse transcriptase using commercially available assays or in-house methods covering at least amino acids 4–99 of protease and amino acids 30–249 of RT. All laboratories collaborated in the quality control program of ESAR to ensure high quality genotypic data . To inveMutations M46I, M46L and L90M in protease and M41L, M41L + T215Y and K103N in RT were introduced in HXB2 by site-directed mutagenesis using the previously described vector systems CP-MUT and NRT-MUT  and the Baseline patient-derived viral protease genes harboring M46I, M46L, L90M or I54V + V82A + L90M or the N-terminus of RT containing M41L, M41L + T69S + L210E + T215S or K103N were introduced into HXB2 using the same vector system .50 was determined by end-point dilution in MT2 cells, demonstrating similar replication in this T cell line in all cases. A random clone was selected and quantified by p24 ELISA  for the RC analysis.Clones were obtained and sequence analysis was performed to verify resemblance to population sequences. Subsequently, at least three recombinant virus stocks were generated by Lipofectamine 2000 (Invitrogen) transfection of HEK293T cells according to manufacturer’s guidelines. TCID6 phytohaemagglutinin-stimulated (2 mg/L) donor PBMCs with the equivalent of 40 ng HIV-1 p24 for two hours. Subsequently, cells were washed twice and maintained for 14 days in RPMI1640 with L-glutamine (BioWhittaker), 10% fetal bovine serum (Biochrom AG), 10 mg/L gentamicin (Gibco) and 5 U/ml IL-2. Cell-free supernatant was harvested daily for monitoring of the p24 production. The RC of either the SDM-viruses or the patient-derived viruses was compared to the RC of control viruses . By comparing viruses containing only the mutation(s) or gene of interest in the exact same HIV-WT background, it is possible to determine the impact of these relevant mutation(s) or genes on viral RC. For all viruses, replication curves were performed in four biological replicates divided over two independent experiments. The mean p24 production of two replicates within representative experiments are indicated in Figure PBMCs were isolated from HIV-seronegative blood donors by Ficoll-Paque density gradient centrifugation and stored in liquid nitrogen until use. To minimize differences between batches caused by variation between donors, each batch of PBMCs consisted of five combined donors. The RC of the virus panel was determined by infecting 5×10


We previously found that a very low geno2pheno false positive rate (FPR ≤2%) defines a viral population associated with low CD4 cell count and the highest amount of X4-quasispecies. In this study, we aimed at evaluating whether FPR ≤2% might impact on the viro-immunological response in HIV-1 infected patients starting a first-line HAART.3) and on the time to achieve virological success (the first HIV-RNA measurement <50 copies/mL from HAART initiation) was evaluated by survival analyses.The analysis was performed on 305 HIV-1 B subtype infected drug-naïve patients who started their first-line HAART. Baseline FPR (%) values were stratified according to the following ranges: ≤2; 2–5; 5–10; 10–20; 20–60; >60. The impact of genotypically-inferred tropism on the time to achieve immunological reconstitution . By 12 months of therapy the rate of immunological reconstitution was overall 75.5%, and it was significantly lower for FPR ≤2 (54.1%) in comparison to other FPR ranks . The overall proportion of patients achieving virological success was 95.5% by 12 months of therapy. Multivariable Cox analyses showed that patients having pre-HAART FPR ≤2% had a significant lower relative adjusted hazard [95% C.I.] both to achieve immunological reconstitution  and to achieve virological success  than those with pre-HAART FPR >60%.Beyond the genotypically-inferred tropism determination, FPR ≤2% predicts both a poor immunological reconstitution and a lower virological response in drug-naïve patients who started their first-line therapy. This parameter could be useful to identify patients potentially with less chance of achieving adequate immunological reconstitution and virological undetectability. For this reason, the classical phenotypic assays, such as Trofile One of the most widely used tools for tropism determination is geno2pheno [coreceptor] (G2P) Notably, beyond the crude tropism determination, some recent studies (including ours) provided new important information about the relevance of FPR in terms of association with viro-immulogical parameters and X4-tropic intra-patient quasispecies prevalence. Indeed, by a cross-sectional study we demonstrated that within the context of genotypically-inferred CXCR4 tropism, the FPR ≤2% defines (far better than 10%-FPR) a viral population associated with low CD4 count, with potentially greater cytopathic effect, and with more advanced disease both in HAART-naïve and HAART-experienced patients In view of all these considerations, the aim of this longitudinal study was to evaluate whether FPR ≤2% at the moment of starting HAART might be associated with viro-immunological responses of the first-line regimen.HIV-1 infected patients starting a first-line regimen not including CCR5-antagonists in several clinical centres from Italy and France were selected on the basis of the following criteria: i) B subtype infected; ii) age ≥18 years; iii) V3-genotyping test available at therapy starting (in the time-window from 6 months before to the moment of therapy initiation); iv) pre-HAART CD4 cell count and viral load measurements available in the time-window from 3 months before to 1 week after HAART initiation; v) at least one CD4 cell count and viral load measurement available after 6 months of therapy. In patients with more than 1 viral load or CD4 cell count before HAART started, the last measurement was considered as pre-HAART value.Approval by Ethics Committee was deemed unnecessary because, under Italian law, such an approval is required only in the hypothesis of clinical trials on medicinal products for clinical use . This research was conducted on [samples and] data already available, and not collected for this study. CD4 cell counts were previously determined for each patient only for clinical reasons and not for research. All samples and data used in the study were previously anonymized, according to the requirements set by Italian Data Protection Code (leg. decree 196/2003) and by the General authorizations issued by the Data Protection Authority.10 copies/mL Flow cytometry from whole blood was used to determine CD4 cell counts at each study visit. Depending on methodologies available at the different clinical centers participating in this study, plasma viremia was determined using three different assays: the Roche Cobas CA/CTM version 2.0 , the Abbott RealTime HIV-1 , and the VERSANT HIV-1 Version 3.0  pol gene (containing the entire protease and the first 240/335 amino acids of the reverse transcriptase open reading frame) and of HIV-1 gp120 V3-loop was performed using plasma samples collected from the patients before their first-line therapy. For about 90% (N = 274) of plasma samples, pol genotypic tests used in this analysis were performed by means of a commercially available kit  according to the manufacturer's recommendations Sequencing of HIV-1 pol and gp120 V3 loop sequencing were performed by using the technique of ANRS  For the remaining 31 plasma samples, HIV-1 et al., 2009 http://regaweb.med.kuleuven.be/software/rega_algorithm/), based on the sum of genotype sensitivities to all drugs prescribed in the HAART. GSS for single drugs was scored as 0 (resistant virus), 0.5 (virus with intermediate resistance) and 1 (susceptible virus).To estimate the prevalence of transmitted drug resistance at the start of HAART, the list of mutations reported by Bennett http://coreceptor.bioinf.mpi-inf.mpg.de/HIV-1 co-receptor usage was determined from the V3 nucleotide sequence by using the G2P algorithm available at the following website All the analyses were performed using the statistical R open source environment (version 3.0.2) and the software package SPSS (version 19.0) for Windows .3To estimate the time to achieve immunological reconstitution and viral load undetectability, Kaplan-Meier curves were used. Log-rank test for trend was implemented for FPR values stratified. To estimate the predictive impact of genotypically-inferred tropism on immunological reconstitution and virological success, Cox proportional hazard models were used. Immunological reconstitution was defined as a CD4 cell count gain from HAART initiation of at least 150 cells/mmCox's analysis was performed, evaluating the proportional hazards assumption, on the full set of patients, regardless of therapy changes. Patients that interrupted therapy for any reason were censored at the moment of the treatment stopping. In the multivariable Cox proportional hazard model, the variables used as potential confounders were: FPR , age, gender, risk factor, pre-HAART CD4 cell count, pre-HAART viremia, hepatitis C coinfection, year of starting treatment, transmitted drug resistance, third drug used , nucleos(t)ide reverse transcriptase inhibitor (NRTI) backbone used, number of drugs being used (≤3 vs. >3 drugs).3.Since the prevalence of X4- or dual/mixed-tropic variants tends to be increased by decreasing CD4 cell count levels Pre-HAART viremia values were stratified in the following ranks: ≤30,000; 30,001–100,000; 100,001–300,000; 300,001–500,000; 500,001–1,000,000 and >1,000,000 copies/mL.3. About half of patients showed HIV-1 viral load >100,000 copies/mL; in particular, 10.5% and 6.6% of patients had viremia 500,001–1,000,000 and >1,000,000 copies/mL, respectively. Twenty-four (7.9%) patients were coinfected with hepatitis C virus.Overall, 305 patients satisfying all criteria were included in the present analysis. Baseline characteristics are summarized in Nearly all patients were treated with a modern genotype-tailored HAART, including currently recommended drugs; 93% (N = 285) of patients started their first antiretroviral regimen after 2008, and 95% (N = 290) were treated with at least 2 NRTIs  in combination with either an NNRTI  or a ritonavir-boosted PI . Thirty-two patients (10.5%) were treated with raltegravir, mainly administered in combination with 2 NRTIs +1 ritonavir-boosted PI . No significant correlation between the third drug used and the different FPR levels was observed (data not shown). The majority of patients attended a high compliance level (87.2%). Transmitted drug resistance was found in around 8% of patients.Nearly all patients (99%) have been treated with effective therapy with GSS ≥3.V3 genotypic tropism test was performed in a median  time of 20 (5–47) days before HAART start. The proportions of patients infected with X4- or R5-tropic viruses according to different FPRs are represented in In the overall population, the median time to achieve immunological reconstitution, defined as described in the 3 during the viremia drop or under virological suppression.Among patients who achieved immunological reconstitution, the 92.9% reached a CD4 cell count gain ≥150 cells/mmStratifying patients by using the classical 10% FPR cut-off, only a trend of difference in the rates of immunological reconstitution was observed in X4-infected patients (72.3%) compared to R5-infected patients (77.5%)  . By Cox Repeating all the survival analyses by excluding patients with FPR ≤2%, all the associations between genotypically-inferred tropism and immunological response were lost (data non shown).3 had a higher hazard to achieve immunological reconstitution compared with those with CD4 cell count ≤50 cells/mm3. Among the other confounders, patients taking ziduvudine + lamivudine had a lower hazard to achieve immunological reconstitution compared to those taking tenofovir + emtricitabine. Very high pre-HAART viremia  was significantly associated with a higher hazard to reach immunological reconstitution.Regarding the other potential confounders evaluated, all the results are summarized in By Kaplan-Meier estimates, overall the median time (95% C.I.) to achieve virological success was 4.0 (3.7–4.5) months. The overall probability of achieving virological success was 95.5% at 12 months. No difference in terms of rates of virological suppression was observed between X4- and R5-infected patients regardless of FPR levels (data not shown). However, by univariable Cox analysis, patients with FPR ≤2% showed a significantly lower hazard to achieve virological success compared to patients with FPR >60% (relative hazard [95% C.I]: 0.51 (0.29–0.90); p = 0.019) . By multRepeating all the analyses by excluding patients with FPR ≤2%, all the associations between genotypically-inferred assessed tropism and virological response were lost (data non shown).Among the other confounders, very high pre-HAART viremia  was significantly associated with poorer virological response, as previously observed By this longitudinal study we found that FPR ≤2% is an independent predictor of both a poor immunological reconstitution and a lower virological response in HIV-1 B subtype infected patients who have initiated their first-line antiretroviral regimen. Repeating our analyses by excluding patients with FPR ≤2%, all the associations between genotypically-inferred tropism and viro-immunological response were lost, confirming the crucial role of FPR ≤2%.These results reinforce our hypothesis that the highest intra-patient prevalence of X4 variants is found in patients with very low FPRs 3 (data not shown). Also in this case, patients with FPR ≤2% showed the lowest probability (83.4%) compared to those having higher FPR ranks. Thus, these findings suggest that the negative effect of a very low FPR is maintained in the long term in patients starting first HAART, and its predictive value could be relevant to identifying patients with a blunted increase in their CD4 cell counts. Ad hoc studies to clarify the role of tropism in long term suppressed HIV-1 patients are needed to confirm these results.The analysis described in the results section refers to a time frame of 12 months. By extending our analysis to 36 months of treatment, more than 90% of patients achieved a gain of CD4 cell count ≥150 cells/mmFindings about immunological reconstitution are reported in the ArTEN and ANRS 130 APOLLO studies: genotypically-assessed viral tropism (with FPR set at 10% and 5.75%) did not seem to impact on the extent of CD4 cell count recovery on antiretroviral therapy Our data also show a relationship between FPR ≤2% and virological response. Indeed, by both uni-and multivariable Cox analyses we found a lower hazard to achieve virological suppression for this FPR range if compared with the others, suggesting that patients carrying a pure X4 tropic virus are potentially in a compromised immunological status and consequently might have a lower and/or delayed virological suppression after first-line HAART. These findings are in agreement with the results obtained in the ArTEN study in which HIV-1 B subtype X4-infected patients showed a lower virologic response compared to those R5-infected at 48 weeks from their first-line HAART This study may have some limitations. First, tropism was inferred by the analysis of only V3 sequences. Indeed, it is known that other residues outside of V3 loop within gp120 and gp41 could be relevant for viral coreceptor usage Furthermore, we did not evaluate the potential role of therapy compliance on viro-immunological response. It is known that less adherent patients have a higher risk of death and of inadequate CD4+ count recovery Finally, it would be interesting to evaluate the relationship between immunological reconstitution and genotypically-inferred tropism in patients with acute infection. However, this category of patients could not be assessed in this analysis, since in clinical practice the diagnosis is frequently made after a time of infection that cannot be quantified.In conclusion, our findings show that FPR ≤2% defines patients carrying a viral population significantly associated with both poorer immunological reconstitution and lower and/or delayed virological response in HIV-1 B infected patients starting their first-line therapy. These data reinforce a previous suggestion that FPR ≤2% may not only identify those patients whose virus is insensitive to CCR5-inhibitors, but can also be useful to identify patients potentially with less chance of achieving adequate viro-immunological response.Table S1Factors related to immunological and virological response in HIV-1 infected patients starting their first-line HAART (Cox Models).(DOC)Click here for additional data file.


No controlled clinical trials had studied the role of maraviroc (MRV) in fully suppressed patients .MRV-cohort is an observational, retrospective, multicentric (27 sites) large cohort study of patients starting MRV in clinical practice under different circumstances, with at least 48 weeks of follow-up. For the present analysis we selected all those patients starting with an HIV-RNA<50 copies/mL. Demographics, baseline CD4 cell count, past history of antiretroviral treatment (ART), tropism, reasons for MRV use, MRV based therapy and change/end of MRV use were assessed. Paired analysis of lipid, hepatic and kidney profile changes and univariate and multivariate analyses of HIV-RNA<50 copies/mL at 48 weeks were explored.3, 46% were HCV+ and 4.5% AgHBs+. Tropism information was available in 197 (94% R5). Median length of prior ARTV was 10.7 years, with exposure to a median of three drug families. Main reasons for prescribing MRV were: toxicity 38%, inmunodiscordance 23%, simplification 19% and admission in a clinical trial 10.4%. MRV based therapies used were MRV+2NRTIs 9%, MRV+PI 46%, MRV+PI+other 40% and MRV+other 5%. At 48 weeks, 23% of patients had changed or finished MRV therapy due to toxicity 2.4%, virological failure 2%, immunological failure 1.2%, simplification 3,2%, trial requirement 9.7%, medical decision 2.8%, treatment suspension 1.2% and unknown 0.4%. At 48 weeks, no significant changes were observed in lipid, hepatic or kidney profiles, and 85% of patients remained with HIV-RNA<50 copies/mL. Focusing on viral response univariate and multivariate models did not show any significant baseline variable explaining viral failure.We included 247 out of 667 subjects from the entire cohort. At study entry, their median age was 47 years, 23% were women, 31% MSM, 49% had CDC category C, median CD4+ counts were 468 cells/mmIn clinical practice MRV was used, mostly in R5 positive patients, with adequate efficacy and tolerance, but important number of patients changed due to non-clinical reasons. In this scenario neither reason for use of MRV nor MRV-based therapy explained viral failure.


To assess the current frequency of ART-associated grade 3–4 transaminase elevations (TE) and grade 4 total bilirubin elevations (TBE) in HIV-infected patients with chronic hepatitis B and/or C, who start a new regimen of ART.A total of 192 pre-treated or treatment-naive HIV infected patients with HBV and/or HCV-coinfection who started ART in eight Southern Spanish centers from July/2011-December/2013, were followed for 12 months in this prospective study.Forty-one (21.4%) subjects had been naïve to ART, median (IQR) follow-up was 11.6 (5.6–12.9) months. The most frequently initiated NRTI were tenofovir/emtricitabine [49 patients (25.5%)]. Eighty-nine (46.4%) patients started a ritonavir-boosted protease inhibitor and 77 (40.1%) individuals a NNRTI. Raltegravir and maraviroc were initiated in 24 (12.5%) and 9 (4.7%) individuals. Ten  patients presented grade 3 TE, while 8  subjects showed grade 4 TBE. No episodes of grade 4 TE or ART discontinuation due to hepatotoxic events were observed. The use of ritonavir-boosted atazanavir was the only independent predictor for grade 4 TBE  in an analysis adjusted for age, sex and baseline HIV-RNA levels, while no factor could be independently associated with grade 3–4 TE.Currently, the frequency of severe ART-associated TE and TBE under real-life conditions in patients with chronic viral hepatitis is similar to what has been reported previously. However, episodes of grade 4 TE are less frequent and severe TE appears to be of lesser concern. Hepatotoxic events associated with antiretroviral drugs, including liver transaminase elevations (TE), acute liver failure and death, are of high concern in HIV-infected patients. Coinfection with hepatitis viruses can promote the development of ART-induced TE –6. NeverData on the current rates of TE observed among HIV-infected patients with hepatitis virus coinfection obtained in the clinical practice have been described within different cohorts –5, 13–20The aim of this study was to evaluate the frequency of hepatotoxicity, determined by grade 3 or 4 TE and grade 4 total bilirubin elevations (TBE), in patients with chronic hepatitis B or C, during the first year after starting one or more currently used antiretroviral drug within one single cohort under real-life conditions.ClinicalTrials.gov ID: NCT01908660) if they fulfilled the following criteria: i) older than 18 years; ii) initiation of one or more antiretroviral drugs; iii) chronic HCV infection as confirmed by HCV antibodies in plasma, as well as a positive HCV viral load determined by PCR and/or chronic HBV infection as detected by positive serum HBV surface antigen (HBsAg) and iv) absence of hepatotoxicity events two months prior to the baseline visit. Clinical visits and blood tests were scheduled at the moment of initiation of the new ART, as well as at weeks 4, 12, 24, 36 and 48. The follow-up was stopped if the patient initiated treatment against HCV or at the moment of discontinuation of one or more antiretroviral drug due to any cause.Pre-treated or treatment-naïve HIV-infected patients who attended the Infectious Diseases Units of eight Southern Spanish centers from July 2011 to December 2013 were consecutively included in this prospective multicentric study , the Department of Health and Human Services of the USA (DHHS) or the European AIDS Clinical Society (EACS) at the time of prescription –23. The Grade 3 and 4 TE were defined according to the baseline alanine aminotransferase (ALT) and apartate aminotransferase (AST) values . In patit-test for normal distribution and the Mann-Whitney U-test otherwise. Categorical variables were expressed as number  and were analyzed by means of the χ2-test or the Fisher’s test, when applicable. In order to compare the CD4 cell counts and the HIV viral loads at baseline and the end of follow-up, the Wilcoxon Signed Rank test and the McNemar test were applied, respectively. Finally, a logistic regression model was created with those factors that showed an association with the outcome variables in the univariate analysis with a p<0.2, as well as age and sex, in order to identify independent risk factors for the outcome variables. The adjusted odds ratios and the respective 95% CI were calculated. Statistical analysis was performed using the SPSS statistical software package release 22.0  and STATA 9.0 .The outcome variable of this study was the development of grade 3 or 4 TE during follow-up. Additionally, grade 4 TBE were analyzed as secondary outcome variable. Comparative analyses of TE and TBE were carried out for the different antiretroviral drugs that were initiated in this study, as well as for age, sex and other potential factors that could influence the development of grade 3 or 4 TE or grade 4 TBE. Continuous variables were expressed as median (IQR) and were compared using the Student’s The study was designed and performed according to the Helsinki declaration and was approved by the Ethics Committee of the Valme University Hospital  and the Spanish Agency for Drugs and Sanitary Products . All patients gave their written informed consent before being included in the study.A total of 192 patients were included in the analysis. The median (IQR) follow-up of the study population was 11.6 (5.6–12.9) months and the median (IQR) nadir CD4 cell count was 183 (67.8–274) cells/mL. Sixty-five (33.9%) individuals had received treatment against HCV infection without reaching sustained virologic response. Of these, 38 (58.5%) were non-responders, 8 (12.3%) had discontinued due to adverse events, 7 (10.8%) individuals had relapsed and 4 (6.2%) patients had developed a virologic breakthrough. The remaining 8 (12.3%) patients had dropped out voluntarily. Patient characteristics at the moment of starting a new ART combination are displayed in A total of 342 drug initiations were registered. Among the newly introduced regimens, 77 (40.1%) involved a NRTI, 89 (46.4%) a PI/r and 77 (40.1%) a NNRTI, respectively. The detailed proportions of the drugs within these groups that were subject to change are displayed in One-hundred and fourteen (59.4%) patients remained with the new ART until the end of the study follow-up of 48 weeks. The detailed reasons for ART discontinuation or premature stop of follow-up are depicted in A total of 10  individuals developed grade 3 TE: 9 (4.9%) of the HIV/HCV-coinfected patients versus 1 (11.1%) of the HIV/HBV-coinfected individuals. No case of grade 4 TE was observed. Regimens and coinfection status of these patients are listed in To our knowledge, this is the first study to evaluate the hepatic safety of current ART administered in clinical practice within a single prospective cohort consisting of a large sample of patients with chronic viral hepatitis. The frequency of grade 3 or 4 TE, as well as grade 4 TBE, associated with frequently used antiretroviral drug combinations in clinical practice is low in this setting.To date, little information on hepatic safety of multiple ART regimens under current real-life conditions is available ,5,20. OuIn the history of safety studies involving antiretroviral drugs, the question of whether the presence of advanced fibrosis has an impact on the prevalence of ART-induced hepatotoxic events has risen especially regarding the hepatitis virus coinfected population ,32. HoweA considerable number of patients started a new ART regimen with the prospect of possible initiation of treatment against HCV infection. This is not surprising since the study was conducted at the beginning of the era of direct-acting antivirals (DAA) against hepatitis C. In this context, in 2012, the protease inhibitors telaprevir and boceprevir were the first DAA approved for treatment against chronic hepatitis C in HIV/HCV-coinfected patients in Europe . UnfortuSustained virological response to therapy against HCV infection leads to a marked decrease in the risk of drug-related liver toxicity in HIV/HCV-coinfected patients . This faThis study has limitations. Due to the high variety of possible ART regimens, some drugs were applied to a lesser extent. Still, the antiretroviral drugs approved at the time of the recruitment of patients were administered in an adequate number and the composition of the regimens studied herein well reflect the situation of ART during the inclusion period. Finally, most recently approved drugs like dolutegravir and elvitegravir/cobicistat were not available during patient recruitment and should be considered in future study designs.In conclusion, currently applied ART regimens can be considered safe in HIV-infected patients with viral hepatitis and advanced liver damage did not impact on the development of severe laboratory abnormalities analyzed herein. Although the frequencies are similar to what has been reported previously, the severity of hepatotoxic side effects have decreased throughout the last years and are unlikely to lead to treatment discontinuations.


It is remarkable that no case of drug resistance against dolutegravir (DTG) in first-line therapy has yet been described in the scientific literature in spite of the fact that this anti-HIV integrase inhibitor was 1) approved by the Food and Drug Administration (FDA) of the United States in July of 2013 [First, it should be noted that several clinical trials have documented the superiority of triple drug regimens that include an integrase inhibitor over those that are based on use of either a HIV protease inhibitor or a non-nucleoside reverse transcriptase inhibitor (RTI) , 3.Second, it is important to point out that the non-occurrence of drug resistance against DTG in initial therapy also extends to the nucleoside compounds with which it has been co-utilized in a triple drug therapeutic regimen –5. This A third point is that the FDA approval of DTG in 2013 has led to the use of this compound by HIV-positive patients in some of the poorest areas of the United States, including inner-city Washington, DC, the South Bronx, and inner-city Los Angeles. In these areas, rates of co-infection by a variety of co-morbid agents such as HCV are high and levels of adherence to antiretroviral (ARV) drug regimens have been reported to be low –10. ThesTo start, it is not true that resistance against DTG cannot occur if this drug is not used in first-line therapy. A variety of studies have, in fact, documented that prior failure with either raltegravir (RAL) or elvitegravir (EVG), the first two FDA-approved HIV integrase inhibitors, can compromise future responsiveness to DTG , 13. ThiThis has led to the hypothesis that DTG-resistant variants of HIV will not be detected following first-line therapy in plasma and other body fluids , either In fact, several studies have shown that the use of DTG as an initial integrase inhibitor in patients who had previously failed other regimens and who had limited treatment options also favoured the selection of the R263K mutation associated with limited resistance against DTG . What isPADDLE  by Figueroa et al. of Buenos Aires, Argentina, demonstrated that the use of only two drugs, DTG plus 3TC, in combination as initial therapy led to profound reductions in viral load over 48 weeks without viral rebound or the development of resistance in all patients tested [The 15th European AIDS Conference (EACS) has now provided additional data in support of the above hypothesis. First, a small 20-patient study termed s tested .et al. and Katlama et al. presented at EACS 2015 dealt with the topic of initial suppression of HIV viral load to below 50 copies/ml by traditional ARV chemotherapy followed by maintenance only on DTG monotherapy [Two other studies by Rojas otherapy , 20. It otherapy , 13, 21.otherapy , lower votherapy .These findings are consistent with predictions that might be made from prior results that drug resistance against DTG in first-line therapy has not occurred over two and one-half years since the initial use of this drug in disadvantaged populations in the United States and more than five years since the first use of DTG in clinical trials conducted on previously drug-naive patients throughout the world.What now are the implications that we should consider?Resistance against DTG has never been reported in clinical trials of first-line therapy  more than two years after its approval by the FDA.Resistance against the nucleos(t)ide RTIs with which DTG has been co-utilized has never been reported in the peer-reviewed scientific literature following first-line therapy. These clinical findings are without precedent.The mutations in HIV integrase that are selected by DTG and that confer low-level resistance to it result in greatly diminished viral replication capacity and integrase activity that may be incompatible with viral survival .No compensatory mutations that would restore viral replication in the aftermath of DTG resistance have ever been observed.DTG has a very long half-life of activity both within cells and in biochemical assays .DTG is one of the safest and best-tolerated drugs in the armamentarium, can be co-formulated and requires only once-daily dosing.DTG has minimal drug-drug interactions with other ARV compounds and with other drugs used to treat HCV as well as unrelated conditions including tuberculosis.First, there should be little doubt that DTG should now form a cornerstone of all current efforts aimed to promote the concept of treatment as prevention. The reasons for this recommendation are as follows:In addition, consideration should be given to the possibility that the non-occurrence of drug resistance against DTG in initial therapy, a finding that is without precedent, may mean that we might actually be able to entertain the possibility of treatment interruption of DTG-based therapy followed by its reintroduction at a future time, without having to worry about the emergence of DTG resistance mutations. Such a possibility could conceivably usher in new ideas aimed at attaining a functional cure of HIV infection, if a means could be found to convert archived wild-type viruses into more attenuated forms that contain the mutations associated with minimal DTG resistance that also impair viral replicative capacity .At the very least, we seem to be moving rapidly toward a recommendation that DTG should be everyone's first choice as a drug to use in initial HIV therapy.


In DUET, etravirine (ETR) 200 mg bid had durable efficacy and a favourable safety profile versus placebo, both arms with an optimised background regimen (BR) including darunavir/ritonavir (DRV/r). TMC125IFD3002  investigated ETR plus ARVs other than DRV/r.This was a 48 week, Phase IV, open-label, single-arm, multicentre study. HIV-1-infected treatment-experienced adult patients on=8 weeks ARV therapy prior to screening, switching either for virologic failure (VF)  or regimen simplification/AEs (RS/AE) (VL<50 c/mL), received active ETR 200 mg bid with an investigator-selected BR of =1 active ARVs, but excluding DRV/r or NRTIs only. The primary objective was to evaluate safety, tolerability and pharmacokinetics (PK).10 c/mL and CD4+ count 238 versus 410.5 cells/mm3. Overall, 96% previously used <2 NNRTIs and 99% used=5 PIs; median number of BL NNRTI RAMs was 2, PI RAMs 5 and NRTI RAMs 1. Overall, most common BR ARVs were PIs (83%), mostly lopinavir/r (62%) and mostly used alone (20%) or with 1 or 2 NRTIs (61%). Raltegravir was used in 9% of patients. Most frequent AEs (any cause/grade) were diarrhoea (17%) and URTI (8%). Incidence of grade 3–4 AEs was 13%, serious AEs 5% , AEs leading to discontinuation 4%, AEs possibly related to ETR 23% and AEs of interest: rash (any type) 4%, hepatic 6% and neuropsychiatric 3%. At week 48, VF and RS/AE virologic responses  were: 48% (74/155) and 75% (42/56), respectively. VF rates were 42% and 13%; 10% and 13% had no VL data in the week 48 window. The percentage of patients adherent to treatment (assessed based on PK sampling plus ETR pill count) was 47% (69/148) and 57% (30/53), in VF and RS/AE, respectively. Median CD4+ count (NC=F) increases were 0.0 and 24.0 cells/mm3. In 29/49 of VFs with genotypic data at failure, ETR RAMs emerging in =5 patients were Y181C, E138A and M230L. The geometric mean ETR AUC12h was 4877 ng.h/mL and C0h 293 ng/mL (N=199).Of 211 treated patients, 55% were female, 61% black/African American. 155 patients (73%) had baseline (BL) VL=50 c/mL versus 56 (27%) with BL VL<50 c/mL. Between these two latter subgroups, median BL VL was 4.42 versus 1.28 logResults of this study were consistent with those for ETR in other similar populations and support the use of ETR 200 mg bid with a non-DRV/r based BR.


In a multivariate analysis adjusting for a number of sociodemographic and clinical variables, high current CD4+ T cell count (>660 cells/mm3) was most strongly associated with lower adherence to ART (assessed as a continuous variable) during a two-month period immediately following the measurements of variables (P = 0.008). The twice-per-day (versus once-per-day) dosing regimen was also significantly associated with lower adherence (P = 0.014). In a second multivariate analysis aimed at determining the predictors of suboptimal (<100% of the doses taken) adherence, high current CD4+ T cell count was again the strongest independent predictor of suboptimal adherence to ART (P = 0.015), and the twice-per-day dosing regimen remained associated with suboptimal adherence (P = 0.025). The association between suboptimal adherence and virological suppression was significant in patients with high CD4+ T cell counts, but not in patients with low or intermediate CD4+ T cell counts , suggesting that apart from promoting suboptimal adherence, high CD4+ T cell count also strengthens the effect of adherence on virological suppression. Therefore, sustained efforts to emphasize continued adherence are necessary, especially for patients with high CD4+ T cell counts.High levels of adherence to antiretroviral therapy (ART) are necessary for achieving and maintaining optimal virological suppression, as suboptimal adherence leads to therapy failure and disease progression. It is well known that adherence to ART predicts therapy response, but it is unclear whether clinical outcomes of ART predict adherence. To examine the predictive power of current CD4 High CD4+ count, coupled to undetectable plasma viral load, delivers a reassuring message of success on ART to the patient, whereas low CD4+ count despite virological suppression may signal that the therapy is not working as it should. Because the patients’ perceptions of ART influence adherence [+ count may therefore be a predictive factor for adherence to therapy. However, it is difficult to speculate about the exact effect that CD4+ count could have on adherence. For example, a high CD4+ count, signaling therapy success, may either encourage a patient to be more adherent, or it may, on the contrary, result in the decreased attention to taking all antiretroviral drugs each day. In the latter case, timely behavioral intervention is important.The CD4dherence ,8, CD4+ + count on adherence. Moreover, studies that did report such an association provided conflicting results [+ count and electronically monitored adherence to ART, while controlling for a number of sociodemographic and clinical variables, in 133 Dutch patients on suppressive ART.Surprisingly, to date no study has specifically addressed, and very few studies have mentioned, the influence of current CD4 results ,10. The We conducted a cross-sectional analysis of 133 Dutch patients visiting the HIV outpatient clinic of the Academic Medical Center  in 2005–2006, who were participating in a randomized controlled trial investigating the effects of a behavioral intervention to increase adherence. The results of the trial were reported previously . Patient+ T cell count, nadir CD4+ T cell count, and current plasma viral load detectability. Adherence was measured electronically using MEMS-cap pill bottles  during two-month periods immediately following the assessment of variables. MEMS-cap pill bottles recorded the moments of bottle opening electronically. Adherence as measured by MEMS was defined as the percentage of prescribed doses actually taken during the assessment period, and was calculated by dividing the number of times the pill bottle had been opened by the number of times it should have been opened, multiplied by 100.The time period analyzed in the current study corresponds to a two-month adherence monitoring period between patient inclusion and randomization . Besides+ count on virological suppression and effects of adherence on virological suppression in different CD4+ count strata. Cochran–Mantel–Haenszel test was used to compare the effects of adherence on virological suppression between patients with high vs. low or intermediate CD4+ T cell counts. GeLM, ROC curve analysis, and logistic regression were performed using IBM SPSS Statistics 22 (available at: http://www.spss.com). Mann-Whitney and Fisher’s tests were performed using GraphPad Prism 5.01 (available at: http://www.graphpad.com). Cochran–Mantel–Haenszel test was performed using a spreadsheet available at http://www.biostathandbook.com/cmh.html. All statistical tests were two-sided. P values of <0.05 were considered statistically significant.Explanatory power of the sociodemographic and clinical variables was examined both for adherence as a continuous variable and for <100% adherence versus 100% adherence. This cutoff was based on fitting receiver operating characteristic (ROC) curve and Fisher’s exact tests to determine the most clinically significant cutoff value of adherence for virological suppression. Continuous predictors were dichotomized by tertiles to high, intermediate, and low categories with intermediate category used as a reference category. For the univariate analysis of adherence as a continuous variable, nonparametric Mann-Whitney tests were used to compare adherence values between different categories of a given predictor, and a generalized linear model (GeLM) using a rank-transformed dependent variable was fitted for the multivariate analysis. To analyze the predictive value of variables for suboptimal adherence (<100%), we used logistic regression (enter method). Fisher’s exact tests were used to determine effects of CD4+ T cell count of 590 cells/mm3. Median CD4+ T cell count nadir was 150 cells/mm3. Low-level plasma viral load was detectable (>50 copies/ml) in 7.1% of patients. Adherence was high in this patient cohort: 73.7% of patients demonstrated adherence of >95% and 51.1% of patients were 100% adherent. Only 9.0% of patients demonstrated <80% adherence.Patient characteristics are shown in + T cell count (highest tertile: >660 cells/mm3) were significantly associated with lower adherence . High CD4+ T cell count nadir and longer time on therapy with undetectable plasma viral load were associated with higher adherence with borderline significance .We started with analyzing the factors associated with adherence as a continuous variable. In the univariate analysis, a twice-per-day dosing regimen, heterosexual transmission route, and high current CD4dherence . In the P = 0.016).Because we sought to determine the predictors of a clinically significant adherence level, we next established the most clinically significant cutoff value of adherence for prediction of detectable plasma viral load. To this end, we used the plasma viral load values measured directly after the adherence assessment period. The proportion of virologically suppressed patients  was 83.6% in all patients, 66.7% in patients with <80% adherence, 78.3% in patients with 80–94% adherence, 76.7% in patients with 95–99% adherence, and 92.1% in patients with 100% adherence . This su+ T cell count (>660 cells/mm3) and a twice-per-day dosing regimen were significantly associated with suboptimal adherence (P = 0.015 and 3.27 (1.16–9.17), P = 0.025, respectively). Therefore, high current CD4+ T cell count was the strongest independent predictor of suboptimal adherence.Next, we determined the predictors of suboptimal (<100%) adherence to ART. In the univariate analysis, high current CD4dherence . Both th+ T cell count on adherence translates into the effect of high current CD4+ T cell count on virological suppression. Immediately after the adherence assessment period, plasma viral load was detectable in 8 out of 43 (18.6%) patients with high CD4+ count, compared with 11 out of 79 (13.9%) patients with low or intermediate CD4+ count. Thus, the overall contribution of high current CD4+ T cell count to the detectability of plasma viral load was insignificant (OR (95% CI): 1.41 (0.52–3.83), P = 0.60). Finally, to determine whether the effects of adherence on virological suppression differed among patients with high versus low or intermediate CD4+ T cell counts, we stratified the patients based on their CD4+ counts and analyzed the predictive value of suboptimal adherence for plasma viral load detectability separately in both strata . However, in patients with high CD4+ counts, 28.6% of patients with suboptimal adherence, but no patients with optimal adherence, had detectable plasma viral load (P = 0.036). The effect of adherence on virological suppression was stronger in patients with high vs. low or intermediate CD4+ counts (P = 0.047). Therefore, apart from promoting suboptimal adherence, high CD4+ T cell count also appeared to boost the effect of adherence on virological suppression.Next, we determined whether the effect of high current CD4h strata . In pati+ counts could be expected to influence adherence. Indeed, in our cohort, patients with high (>660 cells/mm3) current CD4+ counts were, on average, six times more likely to demonstrate suboptimal adherence as compared to patients with intermediate (450–660 cells/mm3) CD4+ T cell counts. Interestingly, patients with intermediate CD4+ counts did not demonstrate higher rates of suboptimal adherence compared to patients with low (<450 cells/mm3) CD4+ T cell counts. This suggests that the relationship between CD4+ count and adherence is nonlinear and that only patients with relatively high CD4+ counts demonstrate suboptimal adherence. Further studies in larger cohorts are necessary to address these issues.A number of factors associated with suboptimal adherence to ART have been identified previously, such as younger age, greater pill burden, lower education level, side effects of therapy, and interference with other activities ,12,13,14+ count on ART and adherence to therapy. One study [+ count, whereas another study reported the opposite effect [+ count, whereas our patients had been on continuous ART for a median of 50.6 months before they entered the study and did not interrupt therapy throughout the study. It is possible that this can explain the difference between the effects of current CD4+ T cell count on adherence observed by O’Connor et al. and our study. Interestingly, Venkatesh et al. reported higher odds of suboptimal adherence by higher current CD4+ count and by longer time on ART [+ count on adherence observed in our study, as longer time on ART was not associated with poor adherence. This is in line with the results of Cambiano et al. who studied long-term trends in adherence to ART in >2,000 patients and found that adherence does not decrease with time on therapy [To our knowledge, very few studies have previously reported an association between current CD4ne study  reportede effect . Howevere effect . In conte effect . In addie effect  receivede on ART . They ar therapy . However therapy .+ count on the subsequent adherence to ART. Some studies reported an association between higher (>200 or >250 cells/mm3) baseline CD4+ count and lower adherence [+ count predicted treatment interruptions but not lower average adherence [+ count, high nadir CD4+ count (which for most patients coincided with the moment of ART initiation) was not associated with suboptimal adherence. This might reflect the fact that our patients on average had been more than 4 years on therapy before the study was initiated and their behavior might therefore have been more dependent on the perception of their current than of their pre-therapy health status.Several groups studied an effect of baseline (pre-therapy) CD4dherence , whereasdherence . A recendherence . In our + count, the only variable significantly associated with suboptimal adherence in the multivariate analysis was twice-per-day dosing regimen, as compared with the once-daily regimen, confirming other studies that have reported decreasing adherence as the number of pills per day increases [Besides the high current CD4ncreases ,20,21.In this cohort, 100% adherence was found to be the only significant cutoff value of adherence for prediction of detectable plasma viral load. Also, levels of virological suppression in patients with 100% adherence were higher than in other adherence strata, including patients with 95–99% adherence . This is+ T cell count was not significantly associated with virological suppression, it was found to strengthen the effects of suboptimal adherence on the virological suppression. These effects were significant in patients with high CD4+ T cell counts but not in patients with low or intermediate CD4+ T cell counts. It is possible that in patients with lower CD4+ counts, other factors, such as increased immune activation [+ counts, these factors are insignificant or absent.Although CD4tivation , influen+ count on adherence may be different among patients of non-European descent treated in the Netherlands. In general, the results of this study are applicable only to similar populations as described in this report. Another limitation is that the patients included in this analysis had chosen to enroll in a behavioral intervention to increase adherence, and while data for this study were collected before the intervention began, it is still important to consider that patients may have made changes in their adherence to therapy after inclusion. Another limitation relates to our adherence measurement method: as MEMS only indicates if the bottle was open and not if the medication was actually taken, we cannot exclude some slight overestimation of adherence due to “curiosity events”. A final limitation is that our study was not designed to detect a behavioral mechanism that is mediating the effect of high CD4+ count on adherence. Thus, our results warrant further studies to establish such underlying mechanisms.Our study has some limitations. One limitation is that it was focused on native Dutch patients only. The observed effect of CD4+ T cell count and twice-per-day dosing regimen significantly predicted suboptimal adherence. It is possible that patients who are aware of their high CD4+ count  may pay less attention to taking medications than patients with lower CD4+ counts, as they feel that it is less crucial to maintain optimal adherence. However, as we and others have shown that even modest nonadherence to ART may result in residual virus replication [+ T cell counts.In conclusion, in this cohort of 133 patients with relatively long time on ART, good immune reconstitution, good virological suppression, and high overall electronically measured adherence, high current CD4lication ,27, sustS1 Fig(PDF)Click here for additional data file.S1 Table(PDF)Click here for additional data file.


Treatment failure (TF) in patients receiving antiretroviral therapy against human immunodeficiency virus (HIV) is always a concern. To examine the correlates associated with TF in patients living in the Colombian Caribbean city of Barranquilla, an aspect that was poorly studied in this region.Treatment failure was evaluated in a cross-sectional study from virological, immunological and clinical standpoints. It was established that 29.5% of patients under highly active antiretroviral therapy (ART) could be considered in TF. Among those, virological failure was most frequent (20.9%), followed by immunological- (14.0%) and clinical failure (4.7%). In patients showing lack of adherence to the treatment, the likelihood of suffering from TF and virogical failure were respectively increased by 6.67-fold and 12.19-fold, compared with patients showing good adherence. Although there was no statistically significant association, TF tended to be more frequent in young adults, in patients with low income and, low level of education. When ART regimens were compared, there was no apparent difference in TF between regimens based on non-nucleoside reverse transcriptase inhibitors and those based on protease inhibitors. This is very important in the context of recent ART strategies, such as early-initiated ART, aimed at achieving long-term infection control.  Is confirmed the importance of treatment adherence to avoid TF and further highlights the importance of educating HIV-infected patients in all parts of the world, especially those individuals with a lower socio-economic status.  Despite the drawbacks in the development of a successful vaccine against HIV 3 after 12 months of treatment. Clinical failure is defined by WHO as the appearance of any morbidity associated to category 4, despite 6 months of treatment -Treatment failure may be classified as virological, immunological and clinical failure. Virological failure is defined as an increase of more than 1,000 copies of RNA /mL or the re-appearance of a signal after a period during which it has been undetectable. The World Health Organization (WHO) defines immunological failure as a decline trend in CD4 T cells count despite 6 months of treatment, or a failure to increase the CD4 T cells counts above 100 cells/mm-Preventing the development of TF is critical, since such condition imposes a regimen change to successfully treat HIV-infected individuals experiencing TF. Such regimen change would mean an increase in treatment-associated costs et al. According to WHO statistics, 170,000 HIV-infected people have been diagnosed in Colombia. Among those, 21,000 people are receiving ART, which only represents 39% of the 54,000 people considered to require therapy Even though there was no statistically significant association, sociodemographic characteristics showed a tendency of TF to be associated with younger adults, low income, or low level of education; while being in middle or upper socio-economic class was prone to be a protective factor. When antiretroviral therapies (ART) regimens were compared in the context of treatment failure, there was no difference between those based on non-nucleoside reverse transcriptase inhibitors with those based on protease inhibitors.A cross-sectional study was conducted to characterize the response of HIV-infected patients under treatment enrolled in one of the leading clinical centers at Barranquilla for at least two years. After obtaining IRB's approval, the clinical registries of 385 HIV-infected patients were reviewed, from which 129 patients were chosen based on the following criteria: aged older than 18 years, who had complete records in terms of both CD4 count and viral load (2 times a year), and who have been followed clinically for at least 1 year. From HIV-infected people enrolled in the clinic, those that were pregnant or non-treated due to good immunological standing were excluded from the study.From each patient, socio-demographical characteristics that were taken into account for the study included age, gender, socio-economical class, level of education. On the other hand, the regimen treatment and its duration in years were also recorded. The regimen treatment was classified according to those using non-nucleoside, reverse transcriptase inhibitors (e.g. Efavirenz) or protease inhibitors (e.g. Lopinavir). Adherence to treatment was measured by establishing the ratio between the amounts of drug that were ingested to the quantity of the medication that was provided by the clinical center. The cut-off for an acceptable adherence ratio was estimated to be ≥80%.CD4 count and viral load as well as patient's clinical status were used to determine treatment failure and the respective classification . (TruCount CD4 BD and NucliSENS EasyQ HIV-1 2.0). (r). Such evaluation was conducted using bivariate analysis through contingency tables 2x2, in which each variable was crossed with each one of the TF categories. The independence of the different variables was confirmed and a chi-square test was used. In those cases where a value recorded in a cell was below than 5.0, a Fisher test was used. A p <0.05 was chosen as statistical significance.Patient's data were systematically recovered from the clinical registry and stored in a way that erases any personal identifier. Such data were analyzed through descriptive statistics using the statistical package SPSSSeventy-eight patients were excluded. Among them, 27 were excluded due to incomplete clinical registries; 19 due to an age lower than 18 years old; 30 due to a treatment period less than 1 year; 1 pregnant woman at the time of the study; and 1 non-treated patient due to good immunological status. Among those 129 patients that complied with the inclusion criteria: 50% were younger than 39.6 years; 72.9% were males; 69.8% belong to the lowest levels of socio-economic status (1 and 2), 27.1% was classified as middle class (3 and 4), and 3.1% was at the highest socio-economic status (5 and 6); and only 45.0% reached a degree in a technical / vocational school, while 55% did not finish high school .Therapeutic failure was identified in 38 patients (29.5% of the studied patients); among them, 27 were male (71.0%) and 11 were female (29.0%). Some of the patients with therapeutic failure simultaneously had more than one kind of failure . Virological failure was the most frequent event (20.9%) followed by the immunological (14.0%) and the clinical failure (4.7%).p= 0.007) (p< 0.001)  followed by immunological failure (30%). None of these patients suffered clinical failure. Bivariate models showed that those patients with non-acceptable adherence were 6.67 more likely to experience therapeutic failure than those who had good adherence  ; in the < 0.001) .p= 0.059). Neither was a statistical association found when the following variables were studied in the context of treatment failure: age , gender , and education .Most of the events of therapeutic failure were seen in those patients that were in the lower rank of the socio-economic status (34.4%) compared with those seen in patients belonging to middle or upper rank of the socio-economic class (18.0%). However, such correlation did not reach statistical significance   Efavirenz + Lamivudine + Zidovudine (29.5%), (2) Lamivudine + Zidovudine + Ritonavir + Lopinavir (14.0%), (3) Abacavir + Lamivudine + Ritonavir + Lopinavir (5.4%), (4) Abacavir + Lamivudine + Efavirenz (5.4%), and (5) Atazanavir + Zidovudine + Ritonavir + Lopinavir (4.7%). A large share of individual treatment regimens was assigned to few patients; overall they represent 41.1% of the 129 patients enrolled for this study. The different sets of antiretroviral therapies provided to the patients were grouped in two types: as those based on non-nucleoside reverse transcriptase inhibitors and those based on protease inhibitors. No association was found between the type of treatment regimen and the occurrence of treatment failure.  ., , The current study was conducted to determine which kind of treatment failures were more frequently found in a representative sample of HIV-infected patients living in Barranquilla, a major Caribbean coastal city in Colombia. On the other hand, factors recorded in the clinical registries were examined for their association to treatment failure and to its respective classes. It was found that 29% of those patients receiving antiretroviral therapy suffered treatment failure. Such percentage was close to previous percentage found in other countries with a gross domestic product similar to Colombia Although it cannot be considered statistically significant, the current study also indicated a higher percentage of treatment failure in male patients. Previous studies conducted in China also highlighted male gender as a significant risk factor for high mortality in the context of ART resistance Virological failure was the most frequent treatment failure found in the studied population, around 20.9% of the HIV-infected people under treatment, which was similar to previous reports Although there was not significant association between socio-demographical aspects, such as economic status and education, with treatment failure, it was clearly observed that most of the HIV-infected people belonged to the lower socio-economic status (69.8%). In addition, most of them had not finished high school (55.0%). The combination of these 2 factors has been previously reported to be associated with virus transmission in a community with lacks an adequate education and information regarding the infection , When antiretroviral therapies (ART) regimens were compared in the context of treatment failure, there was no difference between those based on non-nucleoside reverse transcriptase inhibitors with those based on protease inhibitors. This fact is very important in the context of the recent ART strategies, such as early-initiated ART, aiming at achieving long-term infection control and the search for a functional HIV cure. When those antiretroviral regimens that were only provided to few patients are grouped, these patients were found to be 5.46 more likely to suffer from treatment failure than those treated with the newest antiretroviral regimen Efavirenz + Lamivudine + Zidovudine . In the Overall, these results have concurred about the importance of learning about treatment failure causes to properly treat HIV-infected individuals in a large city in Colombia, a place where the limited resources need such vigilance to help us taking the proper clinical decisions.


Immunological and virological status of HIV-infected individuals entering the Brazilian public system over time was analyzed. We evaluated the impact of ART on virological, immunological and antiretroviral resistance over time.CD4+ T cell counts, viral loads and genotypes from patients over 13 years old from 2001–2011 were analyzed according to demographic data. We compared groups using parametric t-tests and linear regression analysis in the R statistical software language.−8), lower in older patients (p< 1 x 10−8) and lower in less developed regions (p = 1.864 x 10−5). Percentage of treated patients with undetectable viral loads increased linearly from 46% (2001) to 77% (2011), was lower among women (p = 2.851 x 10−6), younger ages (p = 1 x 10−3), and in less developed regions (p = 1.782 x 10−4). NRTI acquired resistance was 86% in 2001–3 and decreased over time. NNRTI resistance increased from 2001-3(50%) to 2006–9 (60%), PI resistance decreased from 2001–3 (60%) to 2009 (40%), and 3-class resistance was stable over time around 25%. Subtype prevalence comprised B (75.3%), B/F recombinants (12.2%), C (5.7%), F (5.3%) and B/C recombinants (1.5%), with regional variations. Three-class resistance was 26.5% among Bs, 22.4% among Fs and 17.2% among Cs.Mean baseline CD4+ T cell counts varied from 348 (2003) to 389 (2009) and was higher among women (p = 1.1 x 10HIV diagnosis occurs late, especially among elderly Brazilians. Younger individuals need special attention due to poor virological response to treatment. Antiretroviral Resistance profile is subtype related. As a result, AIDS-related mortality rates, which peaked in 1995/1996, have continually declined [Brazil has 757,042 reported AIDS cases as of December 2014. More than a decade ago, Brazil took a major step in the fight against HIV/AIDS by making antiretrovirals available free of cost to all infected citizens. As of October 2014, almost 400,000 individuals were under antiretroviral treatment (ART) out of almost 589,000 diagnosed HIV-infected individuals  as well as several unique recombinant forms, which may result from lower adherence among young adults due to more disordered lifestyles.The Brazilian population presents several HIV subtypes, including clades B, F and C; a number of circulating recombinant forms, such as CRF_28B/F, CRF_29B/F, CRF_31B/C, CRF_38B/F, CRF_39B/F and CRF_46B/F  from patients over 13 years of age from 2001–2009 and treatment responses until 2011. Results from pregnant women have been excluded from this analysis for basal CD4+ T cell counts, since HIV testing among pregnant women is compulsory in Brazil, and the immunological status of pregnant women does not reflect the overall status of HIV-1 infected women.https://github.com/jameshunterbr/HIVProfileBrazil, with open access to public.The above-mentioned data bank receives information on CD4+ T cell counts, viral load and genotypes only from public centers, which contain almost all the data from HIV patients followed in Brazil. The database automatically captures the results of above tests from the laboratory network of the Brazilian Ministry of Health. Submission to the database of the data on antiretroviral treatment is mandatory for all Brazilian patients, including those followed in the private health sector. The data bank compiles this information for its internal use and it is not available to public. We gathered all epidemiological and raw data used in these analyses and deposited them at To determine basal CD4+ T cell counts and viral loads, we analyzed only the first results available for each patient who was not on ART. There is no data on the time of HIV-1 diagnosis and on the time elapsed from diagnosis to first CD4+ T cell count determination. However, local guidelines recommend that CD4 determinations should be performed as soon as HIV infection diagnosis is determined. To evaluate the virological and immunological antiretroviral response, we selected one entry (the first) for individuals with more than six months of treatment each year. Therefore, the number of samples analyzed corresponds to the number of patients analyzed. VL determinations in the Brazilian public system derive from a single commercial methodology according to national regulations. We considered VLs to be below detection limits if there were <400 RNA copies/mL of plasma. ART adherence Information for specific patients was not available.http://forrest.ime.usp.br:3001/resistencia. Only major mutations were analyzed from the mutation list provided by the IAS-USA [http://189.28.129.134/; if a pair of sequences with similarity above 99% was detected, only one of the duplicated sequences was included for analysis. HIV-1 subtype assignment was performed using the Los Alamos Recombinant Identification Program (RIP) (http://hivweb.lanl.gov/RIP/RIPsubmit.html). Analyzed sequences can be accessed at GenBank, accession numbers KT741029—KT748519.We studied a total of 18,849 genotypes from distinct individuals experiencing virological antiretroviral failure between 2001 and 2009 . AntiretSamples were considered to have resistance to 3 antiretroviral classes if they had at least one major mutation associated with resistance to nucleoside analogue reverse transcriptase inhibitors (NRTI), non-nucleoside analogue reverse transcriptase inhibitors (NNRTI), and protease inhibitors (PI) .We analyzed the virological data according to gender, age and regions. Brazil contains 5 geographic regions: the more developed and wealthier Southeast region, followed by the South, Central-west, Northeast and North regions. Information on transmission HIV routes was not available for analysis.We performed linear regressions on the data that indicated trends and t-tests to compare groups using the R statistical software system . For allhttp://www.aids.gov.br/publicacao/2014/boletim-epidemiologico-2014).The evidence shows that late presentation for care is prevalent in Brazil, since all available data was used. Therefore, the distribution of individuals by gender, age and country regions in the samples analyzed is compared with the corresponding information available in the Brazilian HIV/AIDS reports for the same time period (3 (48.36% in 2001 and 52.33% in 2009). One-third of patients presented with CD4+ T cell counts below 200/mm3 , representing the year each patient started follow-up medical care. The mean CD4+ T cell counts were stable from 2001 to 2009, varying from 348 (2003) to 389 (2009) . Half of−8. Cf., −8). Older patients (> 50 years old) presented with significantly lower CD4+ levels than the 22–50 group . Half the individuals over 50 years old presented with CD4+ T cell counts below 200/mm3 . We also conducted a t-test comparing the Southeast and the North regions (those with the greatest difference in means). This confirmed that CD4+ T cell counts between these regions is significantly different .Immunological status varied according to the geographical regions, with higher CD4+ T cell counts in the Southeast and South regions, followed by the Central West, North and Northeast regions . We firs10 copies/mL of plasma, and also tended to be higher among men , and lower among older patients   .−8. The regression line explained 97.8% of the variation in the data (adjusted R2). As with viral load, a linear regression demonstrated the significance of this growth in the mean CD4+ T cell counts in individuals in treatment over time. The slope of the regression line is 16.22 . This regression line explains 97.6% of the variation in the data.We next evaluated the antiretroviral efficacy in treated individuals in Brazil. To do so, we evaluated the VL and CD4 results for individuals in treatment from 2001 to 2011. First, we were able to detect differences in antiretroviral exposure since the third drug used in highly active antiretroviral therapy (HAART) has dramatically changed over time, specifically when unboosted PIs gave way to NNRTIs and boosted PI-based regimens, as shown in −3), but not statistically different between genders or among regions  whereas resistance to NNRTIs increased . PI resistance also decreased  (2 = 0.260 and p = 2.42x 10−1). On average, 8% of the genomes sequenced were revealed to be wild type strains, which did not change over the time of analysis.We next evaluated the impact of antiretroviral use and antiretroviral resistance over time at a population level. A previous analysis using the same data set with smaller sample size have already been published . The per3x 10−3) . The incpol sequences for which genotype tests have been performed among individuals experiencing antiretroviral virologic failure. Overall, the most prevalent HIV-1 pol genotype was clade B, which accounted for 75.3% of sequences, followed by B/F recombinants (12.2%), C (5.8%), F (5.3%) and B/C recombinants (1.5%). We compared the percentage of patients in the South regions who exhibit clades B and C with the national proportions for the same clades to test if the South region represented a significantly different distribution of clades. The percentage for clade B appears significantly different than the concentration of this clade in all of Brazil. During the study period, clade B only represented 42.5% of patients in the south against 74.5% for the other regions. A two-sided t-test showed this to be significant with t = 6.43 on 7.9 df and a p-value of 2.2x 10−4 The C clade demonstrates an even greater difference among regions (34.5% of patients in the South versus 6.2% of patients in the other regions). This difference is significant as well .We were able to access the HIV-1 clade profile of 18,613 −2). Difference among clades for patients with resistance to two antiretroviral classes was not significant. Clade F was largest with 55.1% on average followed by 53.4% among clade B and 51.1% among clade C . There appears to be a difference among clades for patients who suffered no resistance to antivirals. Again, clade C predominated among these patients with 15.7%, followed by clade F (9.92%) and clade B (8.66%) (t = 2.2146 with 11.998 df and p = 4.69 x 10−2). Combined resistance to three antiretroviral classes appears to be clade-related because it was higher on average among clade B (26.5%), followed by clade F (22.4%) and clade C (17.2%) viruses  [Early detection of HIV cases is fundamental because initiating treatment to maximize survival and decrease HIV viremia in a population can also reduce HIV transmission . In thisnd 2010) , and simnd 2010) , France nd 2010)  and Portnd 2010) . Around nd 2010)  Ireland nd 2010) , and Pornd 2010) .This analysis produced many interesting results. First, women presented with higher CD4+ T cell counts upon their initial HIV diagnosis, but this observation does not mean that this population looked for health assistance earlier than men, since uninfected women naturally tend to have higher CD4+ T cell counts than men . In factAs also seen in USA and Canada , basal Cvis-a-vis HIV-1 subtype distribution since DNA sequencing analyses have been performed only among individuals experiencing antiretroviral virologic failure.Our data also has some evidence that late presentation for care may be poverty-related. As described before, CD4 cell levels at presentation for care were higher in the Southeast region, followed by the South, Central West, Northeast and North regions. However, significant differences have been detected only between Southeast and Northeast regions. This exactly coincides with the level of social and economic development of each Brazilian region. However, we recognize that this is a limitation of the current study. We were not able to compare the immunological status of antiretroviral naïve individuals As expected, we detected an increase in ART virological efficacy over time. This reflects the improvements in antiretroviral drugs and treatment strategies over time. The immunological benefits at a population level can also be easily observed because the median CD4+ T cell counts in treated individuals increased over time. We note, however, that in 2001, less than 50% of individuals under antiretroviral therapy had VLs below 400 copies/mL . As in oAs previously described, we also note that younger individuals need special attention since they had the poorest virological outcomes under ART . This maAlthough virological success rates have improved over time, nearly 23% of patients receiving ART were still viremic in 2011 . It can There was stable 3-class resistance over time. We should closely monitor this trend to create interventions to minimize the emergence of multi-drug resistant HIV strains. As our data shows, there is a differential prevalence of resistance to three antiretroviral classes among different clades, which may deserve further investigation.Finally, the co-circulation of different HIV-1 clades in Brazil should be carefully followed up. The first HIV-1 recombinant strains were indeed described in Brazil . SubsequWe recognize that the retrospective nature of our analysis and the absence of data such as the time of seroconversion for the analyzed individuals are limitations of this study. However, we were able to sort out a number of “real-life” features of the HIV epidemic in Brazil, a developing country with widespread access to antiretrovirals. These details reveal that we still need to improve our ability to diagnose HIV infection earlier and we need to focus more to the needs of women in treatment and the elderly population, as well as to less-developed regions. The efficacy of antiretrovirals, although improving, is still far from optimal, and antiretroviral resistance is a major problem.S1 Table(XLSX)Click here for additional data file.S2 Table(XLSX)Click here for additional data file.