Hepatitis B (HB) vaccination is recommended for people with human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS). We aimed to assess the immune response to the HB vaccine and associated factors using the standard vaccination schedule among people with HIV (PWH) in China. A prospective study was carried out from 2016 to 2020 in Beijing, China. PWH were given three 20 μg doses of recombinant HB vaccine at 0, 1, and 6 months. Blood samples were taken within 4–6 weeks after each dose to evaluate the anti-HBs levels. A total of 312 participants completed vaccination and serologic testing. The seroconversion (anti-HBs ≥ 10 IU/L) rates following the first, second, and third doses of the vaccine were 35.6% (95% CI: 30.3–40.9%), 55.1% (95% CI: 49.6–60.7%), and 86.5% (95% CI: 82.8–90.3%), respectively, and the geometric means of the anti-HBs titers were 0.8 IU/L (95% CI: 0.5–1.6 IU/L), 15.7 IU/L (95% CI: 9.4–26.3 IU/L), and 241.0 IU/L (95% CI: 170.3–341.1 IU/L), respectively. In multivariate analysis, after three doses of vaccination, age, CD4 cell count, and HIV-RNA viral load were significantly associated with strong, moderate, and weak response, respectively. These findings confirm that these personal health conditions are related to the HB response. HB vaccination in PWH using the standard schedule was still highly effective in the context of early treatment initiation, especially among participants aged 30 years and younger. Historically, hepatitis B virus (HBV) infection has been a major public health concern in the Asia–Pacific region, particularly in China ,2. PeoplHB vaccination is recommended in PWH as the most important HB prevention method. Numerous studies have been carried out to determine an optimal vaccination schedule, and the seroconversion rates for HB vaccines in these studies varied widely depending on the schedule and number of doses, ranging from 34% to 88.6% ,10,11. TFurthermore, the seroconversion rate of the HB vaccine may be associated with age, sex, CD4 cell count, CD4/CD8 ratio, and HIV-RNA viral load in PWH . These fFor these reasons, we conducted this study to assess the immune response to HB vaccination and influencing factors using the standard vaccination schedule among HIV-infected adults in China.We carried out a prospective study of HB vaccination using the standard schedule in PWH from 2016 to 2020 in Beijing, China. The study site was Beijing Youan Hospital, a facility that specializes in treating infectious diseases and is certified to administer vaccinations for adults. This hospital receives almost 60% of the PWH treated in Beijing.PWH aged ≥18 years with an HIV infection or AIDS qualified to take part in the study if they had never received an HB vaccine and had negative HB surface antigen (HBsAg), HB surface antibody (anti-HBs), and HB core antibody (anti-HBc) tests. Individuals with contraindications to HB vaccination were excluded. Participants were given three 20 μg doses of yeast-derived recombinant HB vaccine at 0, 1, and 6 months. Within 4–6 weeks after each dose, blood samples were taken to evaluate anti-HBs levels.Each person was compensated with an approximately CNY 80 value travel allowance as well as one free counseling service per follow-up visit.An in-person interview was conducted when participants received their first dose of the vaccine. Demographic and personal health data were collected, including sex, age, education, marriage status, place of birth, income, concomitant diseases , and related behavior. Participants were also asked to provide medical reports covering their HIV/AIDS diagnosis date, prior HIV/AIDS treatment, CD4 cell count, CD4/CD8 ratio, and HIV-RNA viral load over the last three months. Participants who did not have these reports were tested for free before administration of the first dose of the vaccine.HBsAg, anti-HBs, and anti-HBc were tested quantitatively at baseline and at each follow-up using the chemiluminescent microparticle immunoassay . The lower and upper detection limits for anti-HBs titer were 2 and 1000 IU/L, respectively. CD4 cell counts were tested using a four-color flow cytometry . The HIV-RNA pla sma viral load was determined using the COBAS AMPLICOR HIV-1 Monitor Test , with a lower detection limit of 40 copies/mL.The primary outcome was the seroconversion rate, defined as the proportion of respondents with anti-HBs titers of 10 IU/L or higher. Considering the lower and upper detection limits for anti-HBs titer, maximum likelihood estimation for censored, log-transformed antibody titers was used to calculate geometric mean titers (GMTs) and their 95% confidence intervals (95% CI) .t-test, the Kruskal–Wallis test, or Mann–Whitney test was performed to analyze continuous variables. The Cochran–Armitage trend test was used for age-specific seroconversion rates. Multiple comparisons of GMTs between age groups and CD4 count groups were adjusted using SNK.Descriptive statistical analysis was conducted to determine the mean (SD) or median (interquartile range) for each continuous variable and the frequency for each categorical variable. To explore the factors associated with response after each HB vaccination series, categorical factors were compared between respondents and non-respondents using the chi-square test or Fisher’s exact test. Student’s < 10 IU/L) were the four categorical dependent variables, and base category was the group of no response. Independent variables that were significant at p < 0.1 in the univariate analysis were included, and those with p < 0.12 were retained in the polytomous logistic regression models using the stepwise method. To ensure the robustness of the models, the independent variable and intercept which are not statistically significant in logit functions were eliminated, and in such cases the parameters would be adjusted accordingly until all the models and the independent variables included had significant statistics. Adjusted odds ratios and 95% confidence intervals were estimated by the models. Statistical significance was determined at p < 0.05. SPSS 21.0 was used for all statistical analyses.Polytomous logistic regression was used to analyze factors associated with four levels of immune responses in month 1, month 2, and month 7. Strong response (anti-HBs ≥ 1000 IU/L), moderate response (100 IU/L ≤ anti-HBs > 1000 IU//L), weak response (10 IU/L ≤ anti-HBs > 100 IU/L), and no response . Some participants (6.4%) had other chronic and sexually transmitted diseases. Nearly one-third of the patients had smoked in the past 6 months. The baseline characteristics of the participants are shown in Of the 312 patients, the mean age at enrollment was 34 years (ranging from 18 to 73 years); 95.8% were male, and no one identified themselves as transgender; 81% of the participants were born outside Beijing; and 58.3% had a college degree or higher degree. Nearly two-thirds of the participants had never been married. The majority (88%) of patients were men who had sex with men (MSM). The mean age at HIV diagnosis was 31.4 years. Most patients (98%) used HARRT; the median duration of HARRT was two years. Before their first vaccine dose, 81 patients (26.0%) had a CD4 cell count of less than 350 cells/mmp = 0.0001; After the first, second, and third doses of the vaccine, the seroconversion rates were 35.6% (95% CI: 30.3–40.9%), 55.1% (95% CI: 49.6–60.7%), and 86.5% (95% CI: 82.8–90.3%), respectively, and the geometric mean titers (GMTs) of anti-HBs were 0.8 IU/L (95% CI: 0.5–1.6 IU/L), 15.7 IU/L (95% CI: 9.4–26.3 IU/L), and 241.0 IU/L (95% CI: 170.3–341.1 IU/L), respectively. As Compared with non-respondents, respondents were younger (mean age: 33.3 vs. 38.7 years), less likely to have been married (69.6% vs. 50.0%), and more highly educated (college education or higher: 61.1% vs. 40.5%) .3) and CD4/CD8 ratios (median: 0.56 vs. 0.38), and were more likely to have an HIV-RNA viral load lower than 40 copies/mL (77.8% vs. 52.4%). Age at HIV diagnosis was correlated with age at enrollment . Respondents were also less likely to have other sexually transmitted and chronic diseases (4.8% vs. 16.7%).Respondents were diagnosed with HIV earlier than non-respondents (mean age: 30.5 vs. 36.8 years). They had spent longer using HARRT (median: 2.0 vs. 1.0 years), had higher CD4 cell counts  and level of education  were significantly associated with the moderate and weak response to the first dose of the vaccine. Age was significantly associated with all levels of response to the second dose of the vaccine in month 2. In month 7, following the complete course of vaccination, three factors, age, HIV-RNA viral load, and CD4 cell count, were associated with all levels of response .3 and those with CD4 cell counts of 350–500 cells/mm3 , slightly lower than among those with ≥500 cells/mm3 . Patients with an HIV-RNA viral load of <40 copies/mL had significantly higher anti-HBs GMTs  than those with an HIV-RNA viral load ≥40 copies/mL .According to the multivariate analysis in month 7, the main indicators of efficacy were age, CD4 cell count, and HIV-RNA viral load. The GMTs of anti-HBs in the groups based on these factors are shown in This study is the first prospective analysis to explore the effectiveness of the HB vaccine and associated factors using the standard dosing schedule among HIV-infected adults in China. We found that the proportion of respondents one month after receipt of all three vaccine doses was 86.5%, showing that vaccination with 20 μg recombinant HB vaccine at 0, 1, and 6 months was effective in adults with HIV/AIDS in China. Our findings also demonstrated that the CD4 cell counts and HIV-RNA viral load had independent effects on the response after age was considered. Concomitant diseases showed a slight trend towards decreasing the proportion of respondents.At the end of 2020, there were an estimated 1,053,000 PWH in China . Among n3 or higher or included patients regardless of whether they had received an HB vaccine in the past. In contrast, our study included participants with lower CD4 cell counts who had never received an HB vaccination. Our findings, therefore, reflect that currently, the standard schedule is the most accessible way to protect PWH from HB infection in China, with a higher seroconversion rate observed in younger subgroups. We also observed that more than 67% of PWH achieved a moderate or strong anti-HBs response. GMT in this study was 241.0 IU/L. Long-term persistence of response has been associated with anti-HBs titer after vaccination [The standard vaccination schedule is more accessible for HIV-positive adults in China than schedules requiring higher dosages or a longer duration. This study shows that its effectiveness is slightly higher than that of the same schedule and close to that reported with a higher dosage and a longer duration. A large randomized trial evaluating three-dose 20 μg and four-dose 40 μg HB vaccination schedules in adults with HIV reported seroconversion rates of 65% and 82%, respectively ,22, whilcination ,26. Our Compared with healthy adults in China , the resFurthermore, this study tracked the proportion of respondents and anti-HBs GMT following each vaccine dose. After two doses, the response rate and GMT were only 55.1% and 15.7 IU/L, respectively. A third dose substantially improved the vaccine effectiveness. Therefore, in clinical practice, it is essential to complete the standard vaccination schedule; otherwise, patients with lower anti-HBs titers will not be fully protected by the vaccine.In addition, we have reported the factors associated with the four levels of immune responses following each dose. Age at enrollment was an independent factor significantly associated with all levels of response to HB vaccination in all models, following each dose. As previous studies in PWH ,22,33 an3 or lower was 49.5 IU/L, significantly lower than that in the other two groups. This provides strong evidence for using CD4 cell count cutoffs in clinical practice. After consideration of age and the CD4 cell count, the HIV-RNA viral load was another independent factor closely associated with the HB vaccination response. This result is at odds with that reported in previous studies [As in other studies, the baseline CD4 cell count following the second dose played a vital role in the HB vaccination response in our study ,33,36,37 studies ,24,38, w studies .We also observed that PWH with concomitant diseases tended to have a slightly lower seroconversion rate. Previous studies have shown similar results in the general adult population ,41,42, bThere are some limitations of our study. First, we evaluated the effectiveness of the standard HB vaccination schedule in HIV-positive adults without a healthy adult control group. However, the vaccine’s effectiveness among healthy people provides a good reference. Second, relatively few female participants were enrolled in this study, which is consistent with current trends in new HIV/AIDS cases. To our knowledge, females always respond more frequently than males due to sex hormone differences, specifically due to androgen and estrogen. Third, the lifetime vaccination history was investigated through in-person interviews and may have been influenced by memory bias. In our study, 7.4% of the patients responded strongly following their first dose of vaccination, showing that these participants were more likely to have received vaccinations in the past.The CD4 cell counts, HIV-RNA viral load, and age were associated with seroconversion. Taking different personal health conditions into account, the standard HB vaccination schedule remains highly effective among HIV-positive adults in China.


Background: The high effectiveness and safety of the two-drug (2DRs) strategy using dolutegravir (DTG) plus lamivudine (3TC) have led to international guidelines recommending their use for treatment-naive HIV patients. In virologically suppressed patients, de-escalating from 3DRs to DTG plus either rilpivirine (RPV) or 3TC has shown high rates of virological suppression. Objectives: This study aimed to compare the real-life data of two multicenter Spanish cohorts of PLWHIV treated with DTG plus 3TC (SPADE-3) or RPV (DORIPEX) as a switch strategy, not only in terms of virological suppression, safety, and durability but also in terms of immune restoration. The primary endpoint was the percentage of patients with virological suppression on DTG plus 3TC and DTG plus RPV at weeks 24 and 48. The secondary outcomes included the proportion of patients who experienced the protocol-defined loss of virological control by week 48; changes in immune status in terms of CD4+ and CD8+ T lymphocyte counts and the CD4+/CD8+ ratio; the rate, incidence, and reasons for discontinuation of treatment over the 48-week study period; and safety profiles at weeks 24 and 48. Methods: We conducted a retrospective, observational, multicenter study of 638 and 943 virologically suppressed HIV-1-infected patients in two cohorts who switched to 2DRs with DTG plus RPV or DTG plus 3TC. Results: The most frequent reasons for starting DTG-based 2DRs were treatment simplification/pill burden or drug decrease. The virological suppression rates were 96.9%, 97.4%, and 99.1% at weeks 24, 48, and 96, respectively. The proportion of patients with virological failure over the 48-week study period was 0.01%. Adverse drug reactions were uncommon. Patients treated with DTG+3TC increased CD4, CD8, and CD4/CD8 parameters at 24 and 48 weeks. Conclusions: We conclude that DTG-based 2DRs (combined with 3TC or RPV) in clinical practice were effective and safe as a switching strategy, with a low VF and high viral suppression rates. Both regimens were well tolerated, and ADR rates were low, including neurotoxicity and induced treatment discontinuations. International guidelines recommend the use of a three-drug 3DRs) combined antiretroviral therapy (cART) regimen as the standard of care for the treatment of most people living with HIV-1 (PLWHIV) ,3,4. ThiDRs combiLow CD4/CD8 ratios have been associated with T-cell activation, immune senescence, and higher morbidity and mortality, mainly related to the more frequent occurrence of non-AIDS events ,17. HoweAntiretroviral therapy suppresses HIV replication, allowing progressive CD4 T-cell recovery, the continuous normalization of CD8+ lymphocyte T-cells, and a higher CD4/CD8 ratio (>0.9) .Real-life data from cohorts are also available, and efficacy results in maintaining viral suppression were consistent with data from randomized clinical trials at week 48 and week 96. This study aimed to compare the real-life data of two multicenter Spanish cohorts of PLWHIV treated with DTG plus 3TC (SPADE-3) or RPV (DORIPEX) as a switch strategy, not only in terms of virological suppression, safety, and durability but also in terms of immune restoration. We conducted two retrospective, observational, multicenter studies of 638 and 943 virologically suppressed HIV-1-infected patients in two cohorts who switched to 2DRs with DTG plus RPV (from June 2018 to May 2019) or DTG plus 3TC (from August 2018 to August 2021). Thirteen Spanish hospitals integrated the DTG+3TV cohort, extending to 11 other hospitals in the DTG+RPV cohort. All patients fulfilled the following inclusion criteria: (a) treatment-experienced PLWHIV aged ≥ 18 years; (b) switching from 3DRs to DTG-based 2DRs, either with RPV or 3TC at least 48 weeks before the start of the study; and (c) HIV RNA viral load < 50 copies/mL in the previous 24 weeks before switching. Data were collected from medical records, anonymized, and entered into an online electronic database, REDCap  and 759.0  cells/μL in the DTG plus RPV and DTG plus 3TC groups. The rate of virological suppression at weeks 24, 48, and 96 is shown in p = 0.981). The proportion of patients with virological failure over the 48-week study period was 0.01%. Discontinuations per 100 patient-years were 11/940 (1.2%) of the patients in the 3TC group and 8/585 (1.4%) in the RPV group , toxicity (18.8%), suitability for future guidelines (8.5%), interaction with other drugs (6.6%), convenience (4.6%), and economic reasons (1.6%). Documented adverse drug reactions (ADRs) were uncommon at the end of the study. Only 1.2% of the patients developed a renal event, 1.0% a neuropsychological event, and 0.4% a digestive event. The DTG plus RPV regimen was found to have greater ADRs in all cases.p < 0.001) (< 0.001) .The results in The results of this real-world retrospective, observational, multicenter study support the use of DTG plus 3TC and DTG plus RPV as effective maintenance therapies in virologically suppressed treatment-experienced PLWHIV. DTG plus 3TC and DTG plus RPV provided durable virological suppression and were well tolerated. Despite the differences in baseline characteristics among both groups and a few cases of off-label use, these regimens achieved a rate of virological suppression close to 100% at 96 weeks.The virological results observed in our study are consistent with those reported in clinical trials. The TANGO study evaluated the efficacy and safety of switching to DTG/3TC from a TAF-based regimen  and the Moreover, our results for VF are comparable to the real-world VF reported for DTG-based triple therapy ,21,22. HThe results of this work also support those of previous meta-analyses evaluating both randomized controlled trials and real-world evidence studies, which report a high virological efficacy with DTG-based dual maintenance therapy and a low potential for drug–drug interactions and toxicity ,32. Overall, in terms of cases of loss of virological control in our study population, there were 43/1357 patients (3.1%) at 24 weeks, 30/1156 patients (2.6%) at 48 weeks, and 5/557 patients (0.9%) at 96 weeks. The resistance analysis showed no acquired resistance-associated mutations. Although sub-optimal adherence cannot be excluded, it is reassuring that the future treatment options for those participants were not compromised. Furthermore, these findings correlate with clinical and real-world trials ,30,31,33The 96-week probability of TF was 1.3% in the RPV group and 0.7% in the 3TC group, which was somehow lower than that expected, based on results of randomized trials ,34 and op = 0.877), the discontinuation rate is slightly lower in the investigational trials, 1−2% in GEMINI 1 and 2, 3% in TANGO [Both regimens were well tolerated, with 0.17% of the patients discontinuing treatment. Although we did not observe significant differences in the overall discontinuation rates between the two treatments  of diagnosed patients presented a positive surface antigen (HBs Ag) during the switch to DTG+3TC.Nine patients were newly diagnosed with HBV throughout the DTG/3TC cohort study period, but three were in the DTG/RPV group. These findings highlight the importance of immunizing patients against HBV at 2DR initiation.A significant increase in the overall mean CD4+ lymphocyte cell count was observed in the DTG/3TC group from baseline to 96 weeks. This increase was independent of sex, comorbidities, or pre-existing AIDS infection stage. In addition, a reduction in the absolute CD8+ value is also observed in the non-AIDS group. In the DTG/RPV group of patients, we observed a significant decrease in the CD8+ lymphocyte T count at week 24 and an increase in the CD4+ lymphocyte T count at week 48. However, we did not observe a change in the mean CD4+/CD8+ ratio in either treatment regimen. This ratio is a marker of immune activation, and a low value is a predictor of non-AIDS-related complications . SimilarThe limitations of this study include its retrospective nature, the use of a single-arm analysis which implies the lack of a control group, and publication bias. In addition, due to the retrospective and multicenter design, important data were missing for some of the variables included. Additional limitations of this analysis include those inherent to real-world studies, such as non-randomization, non-registered potential confounding factors in some patients, coding errors, and determination of causality. Likewise, 96 weeks may not be a long enough follow-up to capture some chronic comorbidities.The strengths of this study include its observational nature, the large sample size with a significant proportion of women, the substantial amount of data collected, the appropriate follow-up time, and, in particular, the diversity of populations, some of whom are typically excluded from RCTs but are, in fact, representative of a real-world setting. In this sense, our results could apply to clinical practice patients.Our findings indicate that DTG-based 2DRs (combined with 3TC or RPV) in clinical practice were effective and safe as a switching strategy, with a low VF and high viral suppression rates. Furthermore, the emergence of resistant mutations to DTG, RPV, or 3TC was uncommon, and 2DRs were associated with a favorable immunological recovery. Both regimens were well tolerated, and the ADR rates were low, including neurotoxicity and induced treatment discontinuations.Thus, a DTG-based 2DRs as a maintenance cART is an excellent option for clinicians to reduce AEs, drug–drug interactions, and costs while preserving antiviral efficacy and providing a high genetic barrier towards resistance development in the large majority of our patients.


There was a trend in higher mean levels of circulating 5-methyl-2′-deoxycytidine in carriers compared to CHB patients , as well as a trend in increasing 5-methyl-2′-deoxycytidine levels after treatment initiation in CHB patients compared to pre-treatment levels . Conclusions: Both circulating levels of cf-DNA and 5-methyl-2′-deoxycytidine might be useful biomarkers in order to monitor liver disease activity and response to antiviral treatment in HBeAg-negative chronic HBV patients, but further studies are essential in order to validate these intriguing findings.Background: Chronic hepatitis B virus (HBV) infection is a common chronic liver disease that is closely associated with increased morbidity and mortality. Circulating cell-free DNA (cf-DNA) and global DNA methylation, expressed as circulating levels of 5-methyl-2′-deoxycytidine, are increasingly used to monitor chronic inflammatory diseases of several etiologies. This study attempts to investigate the serum levels of circulating cf-DNA and 5-methyl-2′-deoxycytidine in HBeAg-negative patients with chronic infection (carriers) and chronic hepatitis B (CHB), as well as their changes after treatment initiation in CHB. Methods: Serum samples from a total of 61 HBeAg-negative patients (30 carriers and 31 CHB patients) were included in order to quantify the levels of circulating cf-DNA and 5-methyl-2′-deoxycytidine. In addition, serum samples from 17 CHB patients in complete virological and biochemical remission after initiation of treatment with a nucleos(t)ide analogue were included. Results: Circulating cf-DNA concentration was significantly increased after the initiation of treatment (15 vs. 10 ng/mL,  Chronic infection with hepatitis B virus (HBV) is a global public health issue, which can progressively lead to accumulating liver fibrosis, development of cirrhosis and eventually end-stage liver disease ,2. HBV aCell-free DNA (cf-DNA) is mostly released from cells that have sustained cell death and apoptosis, but also from other types of living cells, and it mainly consists of free-floating, double-stranded and highly fragmented DNA, with most fragments being approximately 150 bp in length ,9,10. CiAs a result, our study attempts to determine the levels in the serum of cf-DNA and 5-methyl-2′-deoxycytidine in HBeAg-negative patients with chronic HBV infection at different phases, as well as in CHB patients before and after treatment initiation.In total, 61 Caucasian adult HbeAg-negative subjects were included in our study. Of them, 30 were classified as cases of chronic infection (carriers) and 31 were classified as patients with CHB. All patients were closely followed at the outpatient liver clinic of the “Laiko” General Hospital of Athens for at least one year before a definite diagnosis of the phase of chronic HBV infection was made. In particular, our patients fulfilled the following inclusion criteria: (a) confirmed HbeAg-negative chronic HBV infection; (b) close follow-up for at least 12 months or until a definite diagnosis of CHB; (c) available stored serum samples; and (d) willingness to provide written informed consent to participate in the study.The criteria for exclusion were decompensated cirrhosis; HCC; coinfection(s) with hepatitis D, hepatitis C or human immunodeficiency virus; alcohol abuse; history of liver transplantation; and another potential cause of liver injury. In addition, HbeAg-negative patients who could not be clearly classified into the carrier or CHB phase were also excluded.Informed consent was acquired from all patients included in this study for the anonymous use of their data and biological material. This study was conducted according to the Declaration of Helsinki and was approved by the Ethics Committee of the General Hospital of Athens “Laiko” and of the Medical School of National and Kapodistrian University of Athens.The diagnosis of HbeAg-negative chronic HBV infection was based on positive HbsAg and negative HbeAg for ≥6 months. HbeAg-negative CHB was diagnosed in HbeAg-negative patients with elevated alanine aminotransferase (ALT) of at least twice the upper limit of normal (ULN), serum HBV DNA > 20,000 IU/mL or serum HBV DNA > 2000 IU/mL, and at least moderate liver necroinflammation and/or fibrosis. HBeAg-negative chronic HBV infection, which is also known as the “carrier” phase, was diagnosed in HBeAg-negative patients with undetectable or low (<2000 IU/mL) serum HBV DNA levels and persistently normal ALT levels according to the traditional cut-off values, during at least four 3-monthly determinations within 12 months. The diagnosis of cirrhosis  was validated with compatible histological, ultrasonographic and/or endoscopic findings.All subjects of our study were followed according to clinical practice based on local guidelines. Both physical examination and laboratory tests, including hematological and biochemical parameters, were obtained at least every 3–6 months, along with serum HBV DNA levels, which were determined every 6–12 months according to the phase of infection and the use of oral antiviral treatment. The surveillance of HCC was based on 6-monthly ultrasound imaging.No patient was receiving any type of antiviral at the onset of follow-up. Demographic data concerning age, gender, height, weight, smoking habits, alcohol use, chronic or occasional drug use and biochemical parameters, such as liver function tests , alkaline phosphatase (ALP), gamma-glutamyl transferase (GGT) and fasting glucose) and other patient characteristics were recorded at the baseline visit. Moreover, serum samples were collected at the baseline visit. Additionally, in 17 of the 31 CHB patients who started oral antiviral treatment, serum samples were also obtained at least 6 months or more after treatment initiation. All 17 patients achieved complete virological and biochemical remission under monotherapy with a nucleos(t)ide analogue (entecavir or tenofovir disoproxil fumarate) and all on-treatment serum samples were obtained after the induction of remission.g for 15 min whilst the serum layer was cautiously transferred to a fresh polypropylene tube and stored at −80 °C until analysis. After equilibration of the stored samples of serum initially at 4 °C and thereupon to room temperature (RT), further centrifugation of our samples was executed at 400× g for 2 min as a way to remove any potential remaining components of cells.All blood samples were centrifuged at 1500× ® Supermix (BIORAD cat no. 172-5124) was used to perform the qPCR reactions, while the human “TaqMan Control Genomic DNA”  was utilized in order to obtain the standard curve of the exact circulating cf-DNA concentrations of the measured samples , as well as from 16 of the 17 on-treatment serum samples of the 17 treated CHB patients.p = 0.559). On the other hand, it seemed that treatment for CHB had an impact on the serum abundance of circulating cf-DNA, as evaluated in 17 patients with serum available before and after CHB treatment initiation. Compared to baseline, circulating cf-DNA concentration was significantly increased after the initiation of treatment  (p = 0.173). Moreover, the stage of cirrhosis did not seem to affect any of these markers as there was no significant difference in the serum levels of cf-DNA between the 7 CHB patients with cirrhosis and the 24 non-cirrhotic CHB patients  (p = 0.336).No significant difference was observed in the circulating cf-DNA concentration between carriers and CHB subjects  a. No rem= 0.199) b, or in p = 0.089)   a, as wel= 0.079) b. Similap = 0.001) (p = 0.06), ALT , GGT  and ALP .No significant correlation between the levels of circulating cf-DNA or DNA methylation and the patients’ epidemiological or clinical characteristics, except from significantly higher levels of 5-methyl-2’-deoxycytidine in male patients compared to female patients (= 0.001) , was ideThis is the first study based on the liquid biopsy approach that attempts to evaluate the significance of circulating cf-DNA species in the two phases of HbeAg-negative chronic HBV infection, along with the changes in these biomarkers after treatment initiation in CHB patients ,29. In pΙt is well established that CHB is associated with increased HBV replication and viral load, elevated markers of hepatocyte injury (ALT/AST) and persistent necroinflammatory activity with accumulating fibrosis, while subjects with HbeAg-negative chronic infection (carriers) have low or no HBV replication, normal ALT/AST and an absence of ongoing necroinflammatory activity ,2. InflaCf-DNA consists of small nucleic acid fragments mostly deriving from apoptotic cells ,33. CellInterestingly, we found a trend in greater global DNA methylation, expressed as higher circulating levels of 5-methyl-2′-deoxycytidine, in our carriers compared to CHB patients. It has been already recorded that global DNA hypomethylation is associated with cellular senescence, whilst the hepatitis B virus X (HBx) protein seems to promote both specific regional hypermethylation and global hypomethylation ,37. ThesThe main outcome of this study was the significant increase in the levels of circulating cf-DNA during antiviral treatment in our CHB patients, compared to pre-treatment levels. Treatment with nucleos(t)ide analogues, which is the standard of care for CHB and was used in our patients, has been shown to generally affect DNA structural integrity, leading to stalled replication forks, chain termination and activation of checkpoint pathways, which halt cell-cycle progression . MoreoveThe circulating levels of 5-methyl-2′-deoxycytidine  were recorded to have a trend in increase after treatment with nucleos(t)ide analogue in our CHB subjects, compared to their pre-treatment levels. DNA methylation has been previously demonstrated to be related to transcriptional repression ,40, wherOur study has several limitations. Most significantly, this was a single-center study associated with a relatively limited number of patients that can neither provide strong positive findings or exclude type II errors of non-significant results. Given the limited number of patients and samples especially after treatment, the significance of cfDNA markers in subgroups of patients could not be reliably determined. Therefore, larger cohorts are required in order to further assess our findings and illuminate the potential role of these biomarkers.In conclusion, both circulating levels of cf-DNA and 5-methyl-2′-deoxycytidine might be useful biomarkers for monitoring liver disease activity and response to antiviral therapy in HBeAg-negative chronic HBV subjects. Our study represents a preliminary effort for the understanding of the significance of serum circulating cf-DNA biomarkers in the natural course of HBeAg-negative chronic HBV infection, as well as of their changes after treatment initiation in such CHB subjects, but more studies are required in order to corroborate our findings.


Median follow-up was 101 weeks (82–111). The virological success rate  was 100% (95%CI 95.8–100) and the strategy success rate (pVL < 50 copies/mL with no ART regimen change) was 92.9% (95%CI 85.3–97.4) at W48. Two VF occurred at W49 and W70, in 2 patients self-reporting poor compliance. No resistance mutation emerged at time of VF. Eight patients presented strategy discontinuation for adverse events. There was no significant change in the CD4 count, residual viraemia rate, neither body weight during follow-up, but a slight increase in CD4/CD8 ratio (p = 0.02). In conclusion, our findings suggest that B/F/TAF administered 5 or 4 days a week could maintain the control of HIV replication in virologically suppressed PLHIV while reducing cumulative exposition of ART.In this observational study, we aimed to evaluate whether bictegravir/emtricitabine/tenofovir alafenamide (B/F/TAF) administered 5 or 4 days a week is able to maintain viral suppression in people living with HIV (PLHIV). We enrolled 85 patients who initiated intermittent B/F/TAF between 28 November 2018 and 30 July 2020: median (IQR) age 52 years (46–59), duration of virological suppression 9 years (3–13), CD4 633/mm Although current antiretroviral treatments have improved in terms of efficacy, robustness, genetic barrier to resistance and tolerability, people living with HIV (PLHIV) have remained exposed to drug toxicity for several decades. Since the late 2000s, HIV physicians have been interested in intermittent strategies, i.e., ART administered 5 or 4 days a week, taking advantage of the drug half-life and the viral inertia of HIV to rebound. Several pilot studies, such as the FOTO trial  or the AIn France, intermittent ART has become very popular and common in several settings, since evidence of its effectiveness has been reported in international conferences and the literature. For illustrative purpose, 10.8%, 12.9% and 18.4% of ~4500 PLHIV followed in our centre  received intermittent ART at the end of 2019, 2020 and 2021, respectively. Here, we aimed to report our experience with intermittent B/F/TAF for maintaining the viral suppression in PLHIV with controlled HIV replication.This observational, non-interventional study included all adults living with HIV who switched to B/F/TAF administered 4 or 5 days a week, from 28 November 2018 to 30 July 2020, in the Infectious Diseases Departement of the Pitié Salpêtrière hospital, in Paris, France. This study was a retrospective analysis, and not a prospective clinical trial. ART prescriptions were made during routine follow-up by HIV physicians, and were not part of any protocol. These prescriptions were discussed with the patients at routine medical visits, as with any change in ART, and respected patient choice. The frequency of treatment was determined by the wording on the electronic prescription (“Biktarvy 1 pill a day 5 days of week” or “Biktarvy 1 pill a day 4 days of week”). Patients were asked to receive the treatment from Monday to Thursday/Friday and not to receive it from Friday/Saturday to Sunday . Compliance with this frequency was checked in the medical records.www.hivfrenchressistance.org) (accessed on 8 February 2023). We also reported antiretroviral plasma concentrations  when avpe HIV-1 .The primary outcome was the proportion of patients with virological success, defined as no virological failure  at W48. ART change was defined either as a switch to another 3-DR, or the resumption of a daily B/F/TAF regimen for any reason. Secondary outcomes included the proportion of patients with virological success at W96, calculated from data of patients having reached W96, therapeutic success (pVL ≤ 50 copies/mL without ART change) at W48 and W96; the proportion of patients with emergence of genotypic resistance and the plasma antiretroviral drug concentration in the event of VF; the change in CD4 count, CD4/CD8 ratio and weight over the study period, using Wilcoxon tests; the change in the proportion of participants with residual viremia , using a McNemar test.A total of 85 patients fulfilling all inclusion criteria switched to an intermittent B/F/TAF strategy, all having reached W48, and 51 having reached W96. Patient characteristics are detailed in Median (IQR) follow-up was 101 weeks (82–111). We observed no VFs up to W48, and two VF between W48 and W96, leading to a virological success rate of 100% (95%CI 95.8–100) at W48, and 97.6% (95%CI 91.8–99.7) at W96 .24h = 3524 and Ct = 187 ng/mL) and emtricitabine (C24h = 294 and Ct < 5 ng/mL), but low for tenofovir (both C24h and Ct < 5 ng/mL); resumption of B/F/TAF taken 4 days a week led to viral resupression; there was no acquired resistance mutation on genotypic testing. Eight patients presented a strategy discontinuation between D0 and W96 for adverse events , leading to a strategy success rate of 92.9% (95%CI 85.3–97.4) at W48, and 89.4% (95%CI 80.8–95.0) at W96.The two VFs occurred in patients who self-reported suboptimal adherence at time of VF. No genotypic data were available at baseline for both of them. The first VF occurred at W49, with pVL of 332 copies/mL; no antiretroviral plasma concentrations were available at this time, but resumption of daily B/F/TAF led to viral suppression; there was no acquired resistance mutation on HIV genotypic testing. The second VF occurred at W70, with pVL of 758 copies/mL; concomitant plasma concentrations were adequate for bictegravir , or in the rate of residual viremia: 44% at D0 to 30% at the end of follow-up , or in the body weight: +1.2 kg . There was a slight but significant increase in CD4/CD8 ratio: +0.06 .From D0 to the end of follow-up, there was no significant change in CD4 count: +7 cells/mm24h (24 h after the last drug intake) and Ct (at the end of the discontinuation window) were measured (24h were 1598 (1163–2281) ng/mL, 105 (48–305) and 10 (<5–20) ng/mL, respectively; and Ct were 114 (68–191), <5 (<5-<5) and <5 (<5-<5), respectively. Bictegravir Ct were below the protein-adjusted EC95 of 162 ng/mL in 22/38 patients (58%).Plasma antiretroviral concentrations were available for 38 patients, in whom Cmeasured . Median The ANRS QUATUOR randomised trial demonstrated the ability of INSTI-based 3-DR to maintain viral suppression in PLHIV with controlled HIV replication . HoweverIn this observational study, we reported a series of 85 patients under B/F/TAF administered 5 or 4 days a week, with high level of virological success (100% at W48 and 97.6% at W96). A majority of those patients were followed for more than two years, and we observed only two VFs, both having occurred in patients with poor adherence. There were no consequences in terms of emerging resistance, and the resumption of B/F/TAF leaded to viral resupression. These data are in line with those obtained in the ANRS QUATUOR trial, which demonstrated that no resistance emerged in case of VF under second generation INSTI-based ART, whether in the “daily arm” or in the “intermittent arm” [3) and a sustained viral suppression (~9 years), which could be a favourable profile for reducing treatment pressure. Due to the non-comparative nature of the study, we were not able to compare these immunological and virological parameters with those of PLHIV treated with daily 3-DR. However, it is interesting to note that half of the patients had a CD4 T-cell nadir < 250/mm3, and 20% of them had an AIDS-related event in their history.The patients presented here had a high CD4 T-cell count  ,16. ThisBoth TAF and INSTIs, including bictegravir, have been incriminated in body weight gain in PLHIV ,19,20. OThe manner in which ART was received by patients was checked at each medical visit by the clinician in charge of the patient, and reported in medical records. The intermittent received was mentioned on the electronic prescription, and in France, the delivery of ART in pharmacies is calculated on the basis of the prescription, so patients receiving intermittent treatment receive boxes of medicines less frequently than patients receiving daily treatment. Differences in plasma drug concentrations from samples collected at the end of rest periods and from samples collected during daily treatment confirmed compliance with the intermittent schedule.Our study has some limitations, as it is an observational study in a single centre, with a relatively small number of patients included for analysis. Due to the retrospective and observational nature of the study, we had to deal with missing data, which could limit certain analyses. The lack of a comparative arm clearly limits the significance of our findings. However, these original data add to the existing data and support the position of B/F/TAF as a robust antiretroviral combination that could be prescribed intermittently in order to optimize and deliver drug-reduced ART to PLHIV.


CYP2B6 polymorphisms and efavirenz drug resistance among women living with HIV who started on antiretroviral therapy during pregnancy and with high viremia during post-partum.We investigated the association between This was a cross-sectional study of women with viral loads greater than 1000 copies/ml who were at least 6 weeks postpartum. Sanger sequencing was used to detect resistant mutations, as well as host genotyping, and efavirenz resistance was compared among the metabolizer genotypes.Over the course of one year (July 2017-July 2018), 322 women were screened, with 110 (34.2%) having viral loads of 1000 copies/ml and 62 having whole blood available for genotyping. Fifty-nine of these women had both viral resistance and human host genotypic results. Efavirenz resistance according to metabolizer genotype was; 47% in slow, 34% in extensive and 28% in intermediate metabolizers, but the difference was not statistically significant due to the small sample size.There was no statistically significant difference in EFV resistance between EFV metabolizer genotypes in women who started antiretroviral therapy during pregnancy and had high viremia in the postpartum period. However, a numerical trend was discovered, which calls for confirmation in a large, well-designed, statistically powered study. Improved access to antiretroviral therapy (ART) by pregnant and post-partum women has significantly contributed to prevention of transmission of HIV infection to children, with 52% global reduction between 2010 and 2019 . HoweverEfavirenz is metabolized to 8-hydroxy-efavirenz by cytochrome P450 (CYP) monooxygenase system, predominantly by CYP2B6  while exAmong CYP2B6 polymorphisms, 516 and 983 causing slow metabolism are more frequent among individuals of African ancestry as compared to Caucasians . HoweverThis was a cross-sectional study nested in “Tracing non-rEtained HIV Positive pregnant Women enrolled in option B + and ascertaining their babIeS outcomes (sTEPWISe)” study conducted between July 2017 and July 2018 .The sTEPWISe study was conducted at HIV clinics of Kampala City Council Authority which are supported by the Infectious Diseases Institute (IDI) through CDC-PEPFAR. Study activities leveraged on routine services offered at the PMTCT clinics for newly diagnosed pregnant Women Living With HIV (WLHIV). The study aimed to trace pregnant WLHIV initiated on ART during pregnancy and disengaged from care, and were at least 6–12 weeks postpartum. Adherence to ART was self-reported and determined by clinicians as good, fair, or poor if participant reported missing < 2, 2–4, and ≥ 5 doses per month respectively. A participant was defined as disengaged from care if no clinic visit was recorded 90 days preceding database closure.A random sample of retained mothers with viralogical failure  was tested for presence of SNPs that influence plasma EFV concentration exposure and HIV resistance mutations to EFV. Seven participants were also randomly selected for EFV drug level measurement to confirm adherence status. A random sample of women disengaged from care were contacted by telephone and home visited to consent for blood draw for the aforementioned tests.Drug resistance testing was performed at the Infectious Diseases Institute Core Laboratory, Kampala, Uganda, which is accredited by the College of American Pathologists (CAP). Viral RNA was isolated from plasma samples using the Invitrogen Purelink viral RNA/DNA kit . HIV-1 genotyping was performed on extracted RNA using an in-house HIV-1 genotyping assay covering the protease (PR) and reverse transcriptase (RT) with subsequent sequencing using the BigDye Terminator v3.1 Cycle Sequencing Kit . Sequence analysis was performed using AB3730 capillary sequencer .rs3745274], 983 T → C [rs28399499], and 15582C → T [rs4803419]) were obtained from Life Technologies Ltd . Allelic discrimination plots and genotype assignments were performed using Opticon Monitor, version 3.1 (Bio-Rad Laboratories Inc.).Genotyping of the three CYP2B6 polymorphisms that predict increased EFV exposure was undertaken at the University of Liverpool. The E.Z.N.A. Blood DNA Mini Kit  was used to extract genomic DNA, which was then quantified using NanoDrop  and stored at − 20 °C until analysis. A real-time PCR allelic discrimination assay on a DNA Engine Chromo4 system was used for genotyping . The PCR protocol involved denaturation of DNA at 95 °C for 10 min, 40 cycles of amplification at 95 °C for 15 s and annealing at 60◦C for 1 min. TaqMan Genotyping Master Mix and assays for CYP2B6 (516G → T : 22-28), median weight was 60 kg , median CD4 T-cell count was 516 cells/mm3 (IQR: 324-640), median viral load was 25,562 copies/ml  and median duration between ART initiation and viral load testing was 10 months (IQR: 8-11).Over 90% (55/59) of participants were in their second or third trimester. Good adherence was reported at 90% by the retained women and 51% of the disengaged. Of the seven participants selected for EFV drug level measurement, none had detectable drug levels . All the 59 participants received EFV, tenofovir disproxil fumerate and lamivudine throughout the study period except one participant that received emtricitabine instead of lamivudine. The CYP2B6 population genotypic frequencies were; 30%, 50%, and 20% for slow, intermediate, and extensive phenotypes, respectively.Figure K103N conferring resistance to EFV and NVP was more common, occurring in 11/20 participants with resistance followed by E138A detected in two participants. M184V was the only clinically relevant mutation that renders resistance to NRTIs detected in the study.Table The prevalence of virological failure among Ugandan post-partum women initiated on ART during pregnancy was 34.2%. Overall EFV resistance was 34% with slow metabolizers (47%) having a higher frequency than extensive (31%) and intermediate (28%) women.Virological failure rates observed in this study were higher than observed in other studies in Africa –16. HowePrevalence of resistance to EFV reported in this study is similar to that reported from Malawi in women initiated on ART while pregnant, with 35% prevalence among patients with viral load ≥ 1000 copies/ml. However, a study undertaken in Tanzania reported higher rates of NNRTI resistance (57%) among pregnant women who started on nevirapine . The autThere was no statistically significant difference in EFV resistance among metabolizer genotypes. This contradicts the findings of a Botswana study, which found a link between EFV/NVP resistance and the CYP2B6 516G allele  . The afoThe study sample size was small to draw a statistically significant conclusion. This study did not assess whether viral resistance was primary or secondary, yet high frequencies of primary resistance could have greatly influenced study conclusions.We did not observe a statistically significant difference in EFV resistance between EFV metabolizer genotypes. However, a numeric trend was observed that warrantees confirmation in a large well designed statistically powered study.


Hospitalized people living with HIV (PLWH) with active viremia present a unique opportunity for addressing barriers to care (BTC) and optimizing 1-year outcomes. Large-scale interventions have had limited long-term success. We aimed to evaluate the role of pre-specified BTC to viral suppression at one year to guide local interventions.We performed a retrospective cohort study at a safety-net hospital in Los Angeles County evaluating encounters of adult PLWH admitted between 2015 - 2020. We collected demographics, clinical characteristics, and 1-year outcomes based off baseline virologic status.A total of 361 encounters involving 234 patients were reviewed. Patients viremic at baseline (n=70) were more often Black, cis-men, severely immunocompromised and 73% reported at least one BTC . At 1-year follow up, patients with baseline viremia or reporting multiple BTC regardless of baseline viral status were more likely to be viremic or lost to follow up .Population characteristics based off insurance status and baseline virologic statusData are n (%) or median (range). Categories may not add to 100% in cases of missing data. a – Based off first encounter; b - Encounters of patients with insurance though Department of Health Services or self-pay that have ability to follow up in the safety-net system included only; c – includes data for all patient encounters; d – other diagnoses include, but not limited to, chest pain, acute coronary syndrome, heart failure, diabetes with hyperglycemia, cerebrovascular event; c – excluding patients that died or discharged on hospice care; Suppressed – HIV-1 RNA < 200 copies, ART – antiretroviral therapy; dx - diagnosisOne Year Outcomes based off Baseline Viral Status in the Insurance Linked Populationa – Encounters of patients with insurance though Department of Health Services or self-pay that have ability to follow up in the safety-net system included only; b – Chi Square suppressed versus viremic baseline; LTFU – lost to follow up; Suppressed – HIV-1 RNA < 200 copies/mm3. Viremic – HIV-1 RNA > 200 copies/mm3Prevalence of barriers to care amongst PLWH suppressed or viremic at baselineHospitalized PLWH experiencing multiple barriers to care, regardless of baseline virologic control, are at higher risk for being viremic at 1-year and lost to follow up. These data can inform local interventions, i.e. enhanced post-discharge follow-up or social work involvement, and advocacy in this population.LTFU – lost to follow up; 1yr – 1-year; #V – cumulative number of prespecified barriers to care. Suppressed Baseline defined as HIV-1 RNA < 200 copies/mm3All Authors: No reported disclosures


Human Immunodeficiency Virus (HIV) infects over one million people annually. A major barrier to ending this pandemic is access to care. Prompt antiretroviral therapy (ART) initiation after diagnosis reduces time to viral suppression, decreases rates of opportunistic infections, and increases patient retention. At University of Kentucky HealthCare, there was a significant wait time from intake appointment to ART initiation with a provider. Beginning in November 2019, the HIV clinical pharmacist developed a program to initiate ART at intake appointments to curb this delay.This study was conducted to evaluate the impact of this initiative.We conducted a retrospective, quasi-experimental study assessing newly diagnosed HIV ART-naïve adult patients pre- and post-implementation of the pharmacist-driven ART initiation. Exclusion criteria included initial HIV-1 RNA < 40 copies/mL (undetectable) and patients transferring care. Those enrolled between November 2017 to October 2019 were included in the pre-group and those enrolled from November 2019 to November 2021 in the post-group. The primary outcome was time to undetectable from ART prescribing. Secondary outcomes included time to HIV-1 RNA < 200 copies/mL from ART prescribing, and time to undetectable from HIV-1 diagnosis.Overall, we included 185 patients (pre-group=104 and post group=81). Undetectable was achieved in 95.5% of patients. Demographics were similar between the groups (Table 1). Median days to undetectable  and HIV-1 RNA < 200 copies/mL  from ART prescribing were similar between the two groups. Median days to undetectable from diagnosis  and days to ART prescribing from initial visit  were significantly shorter in the post-group. Median days to initial visit from HIV-1 diagnosis were shorter in the pre-group . One-year retention was similar .Our study showed a significantly shorter time to undetectable from HIV-1 diagnosis with ART initiation by a clinical pharmacist at intake visits. Additionally, retention of care remained similar despite ART initiation prior to provider visit. This initiative improved timely access to care at our institution.All Authors: No reported disclosures


The Joint United Nations Programme on HIV/AIDS through the 95-95-95 target requires 95% of people living with HIV (PLHIV) on antiretroviral treatment (ART) to be virally suppressed. Viral Load (VL) non-suppression has been found to be associated with suboptimal ART adherence, and Intensive Adherence Counselling (IAC) has been shown to lead to VL re-suppression by over 70% in PLHIV on ART. Currently, there is data paucity on VL suppression after IAC in adult PLHIV in Uganda. This study aimed to evaluate the proportion of VL suppression after IAC and associated factors among adult PLHIV on ART at Kiswa Health Centre in Kampala, Uganda.Study was a retrospective cohort design and employed secondary data analysis to review routine program data. Medical records of adult PLHIV on ART for at least six months with VL non-suppression from January 2018 to June 2020 at Kiswa HIV clinic were examined in May 2021. Descriptive statistics were applied to determine sample characteristics and study outcome proportions. Multivariable modified Poisson regression analysis was employed to assess predictors of VL suppression after IAC.Analysis included 323 study participants of whom 204 (63.2%) were female, 137 (42.4%) were between the age of 30 and 39 years; and median age was 35 years (interquartile range [IQR] 29–42). Participant linkage to IAC was 100%. Participants who received the first IAC session within 30 days or less after unsuppressed VL result were 48.6% (157/323). Participants who received recommended three or more IAC sessions and achieved VL suppression were 66.4% (202/304). The percentage of participants who completed three IAC sessions in recommended 12 weeks was 34%. Receipt of three IAC sessions , having baseline VL of 1,000–4,999 copies/ml  and taking Dolutegravir containing ART regimen were factors significantly associated with VL suppression after IAC.VL suppression proportion of 66.4% after IAC in this population was comparable to 70%, the percentage over which adherence interventions have been shown to cause VL re-suppression. However, timely IAC intervention is needed from receipt of unsuppressed VL results to IAC process completion.The online version contains supplementary material available at 10.1186/s12981-023-00513-3. According to UNAIDS, 95% of PLHIV on ART should be virally suppressed as was ambitiously set through United Nations’ 95-95-95 target  fast traIAC assists individuals to develop a comprehensive ART adherence strategy by identifying and gaining insight of adherence barriers, explore practical ways to overcome the barriers and generate an ART adherence plan , 18.WHO endorses IAC provision for both children and adults who are found to have an unsuppressed VL, which adherence support has been shown to improve the VL suppression by up to 70% , 18. HIVThe Uganda Ministry of Health guidelines state that PLHIV on ART with un-suppressed VL should receive IAC, one counseling session monthly for three months, followed by repeat VL measurement a month after the third IAC session . VirallyAlthough Uganda has employed the IAC intervention program since 2015, scanty research data is available on HIV viral suppression after IAC. Central Uganda has higher HIV prevalence compared to other regions of the country; and urban areas have an even greater HIV burden than rural areas with urban areas HIV prevalence being 7.5% in comparison to 5.8% in rural areas . There iThis study aimed to evaluate the proportion of VL suppression after IAC and associated factors among adult PLHIV on ART at Kiswa Health Centre in Kampala, Uganda.A retrospective cohort study design that employed approaches of secondary data analysis of routinely available program data for PLHIV receiving ART at Kiswa Health Centre, a public HIV clinic in Kampala district was used. The proportion of PLHIV with VL greater or equal to (≥) 1000 copies/ml, on a test done between January 2018 and June 2020, who achieved VL suppression following IAC was determined; as well as the time to completion of the IAC sessions and the factors that were associated with VL suppression after IAC.The study was conducted in Kampala district at an HIV Clinic in Kiswa Health Centre situated within Nakawa Division. Located in the central region, Kampala, the capital city of Uganda is the second most populated district in Uganda with a population size of 1,507,080 people, 51.9% being females . KampalaAccording to a Uganda national survey conducted between August 2016 and March 2017, Kampala capital city had an HIV prevalence of 6.9% amongst people aged 15 to 64 years . Kiswa HAs of February 2020 under the guidance of the Uganda Ministry of Health, regimens containing Dolutegravir (DTG) were recommended for use as the preferred first and second-line treatment regimens for all HIV infected clients because of existence of great levels of HIV resistance to non-nucleoside reverse transcriptase inhibitors (NNRTI) containing firstline ART regimens and superior efficacy of DTG containing regimens compared to EFV based ART regimens . AdditioThe study population was all PLHIV aged 18 years or older, who had been on ART for at least six months with VL ≥ 1000 copies/ml, on a test done between January 2018 and June 2020. Data collection was completed in four weeks in May 2021.Anonymized client information was used for secondary analysis and each study participant received a unique identifier. Data on key variables of interest including age in years, sex, level of education, occupation, religion, marital status, WHO clinical stage for HIV infection, ART regimen at time of VL non-suppression, ART regimen initiation date, CD4 cell count at time of VL non-suppression, non-suppressed VL test result at beginning of IAC, number of IAC sessions received, dates IAC sessions were received and repeat VL test result following IAC was abstracted from the HIV clinic source records and captured into a Microsoft® Excel database. The primary sources of data were the HIV clinic’s health management information system, ART registers, VL registers, IAC registers and client treatment files/cards. Data was thoroughly reviewed to ensure quality.VL testing is done at the Central Public Health Laboratories and VL test results received from the national laboratory are recorded in VL registers and client cards by health facility staff and given to the clients at subsequent clinic visits. The CD4 counts are measured in the HIV clinic laboratory. The quality control (QC) procedure for flow cytometry is done every beginning of day before any samples are run. The QC report obtained is compared to expected value range and any measures obtained that are out of range are checked again through procedure re-run. CD4 testing is not performed if expected QC measures are not obtained. The QC review form log is completed for each QC procedure done and is reviewed by the QC supervisor or designee on a daily basis.As per the Uganda ministry of health consolidated guidelines for the prevention and treatment of HIV and AIDS, adequate IAC is considered as having a minimum of three consecutive IAC sessions following a non-suppressed viral load . TherefoAn individual was considered lost to follow up when he or she did not return to the HIV clinic for a visit in three or more consecutive months at any time point in their HIV care following ART initiation as per the Uganda Ministry of Health guidelines . ClientsThe primary study outcome was VL suppression after IAC. VL suppression was defined as a VL result of less than 1000 copies/ml , 18. A VP-values of less than 0.05 were considered statistically significant , 34. AllLocal ethical approval was provided by Mildmay Uganda Research Ethics Committee (1012–2020). Additionally, a waiver of consent was attained from the same IRB since retrospective study of de-identified data was to be done. Study administrative clearance was received from Kampala Capital City Authority and the In-Charge of Kiswa Health Centre III. The raw data will be retained for five years. Anonymized data and lack of access to participant files offered protection from risk of confidentiality breach.A total of 410 adult PLHIV at Kiswa Health Centre had an unsuppressed viral load ≥ 1000 copies/ml in the period from January 2018 to June 2020. The number of eligible study participants was 323 (79%) as 87 (21%) individuals were either lost to follow, transferred out, dead or had missing information and these were not included in analysis  were female. A considerable number of study participants; 137 (42.4%) were between the age of 30 and 39 years. The median age was 35 years (IQR: 29–42). Most participants (65.3%) were from Kampala district. The median time duration on ART at the time that the participant had a detectable VL was 4 years (IQR: 1–7), with the shortest time on ART being 6 months while the longest duration on ART was 16 years. The number of the study participants who were on an Efavirenz (EFV) based ART regimen was 143 (44.3%). Out of 143 participants who were on an EFV based regimen, 115 were taking Tenofovir Disoproxil Fumarate (TDF)/ Lamivudine (3TC)/ Efavirenz (EFV); 27 were taking Zidovudine (AZT) / Lamivudine (3TC)/ Efavirenz (EFV) while one participant was taking Abacavir (ABC)/ Lamivudine (3TC)/ Efavirenz (EFV). Additionally, majority of the participants were in WHO clinical stage 1; 253/266 (95.1%) and had been on ART for more than 5 years at time of VL detection; 153 (47.8%).All 323 study participants received at least one IAC session following the baseline unsuppressed VL result. The majority of participants; 208 (64.4%) received more than three IAC sessions while 99 (30.7%) participants received three IAC sessions. Participants who had one or two IAC sessions were 16.The time to IAC completion was determined as the time difference from the date of the baseline non-suppressed VL test result to the last documented offered IAC session as per the clients’ records prior to subsequent repeat evaluation of viral load. Only 34% of study participants completed the IAC intervention in 12 weeks while 46.7% of participants completed IAC between 13 and 24 weeks. The recommended time duration within which the three standard IAC sessions should be completed as per the Ministry of Health guidelines is 12 weeks [For this analysis, only study participants who received the recommended three IAC sessions or more (304) were included as these were considered to have completed the IAC intervention. Out of 323 participants, 16 had either one  or two  IAC sessOut of the 304 study participants with baseline viral non-suppression who received adequate IAC, 202 (66.4%) achieved VL suppression after the intensive adherence counseling intervention. (95% CI: 60.9-72.6%). At multivariable analysis, study participants who received three IAC sessions were 33% more likely to have VL suppression than those who received more than 3 IAC sessions , ARR: 1.33 (1.15–1.53), p < 0.001. Similarly, participants who had baseline VL of 1,000–4,999 copies/ml were 47% more likely to virally suppress compared to those with VL ≥ 10,000 copies/ml, ARR: 1.47(1.25–1.73), p < 0.001. Lastly, participants on DTG containing ART regimens were 61% more likely to have viral suppression when compared to those on EFV based ART regimen, ARR: 1.61 (1.37–1.88), p < 0.001.In this retrospective cohort study, the HIV VL suppression proportion was 66.4% following adequate IAC intervention for adult PLHIV at Kiswa Health Centre, who had been on ART for at least six months and had an unsuppressed VL in the period from January 2018 and June 2020. Linkage to IAC following the baseline unsuppressed VL was 100% in the study population. The percentage of study participants who were linked to the IAC intervention in less than a month from the time of non-suppressed VL result was 48.6%. The percentage of study participants who received three or more IAC sessions was 95% and only 34% completed the IAC intervention in the recommended 12 weeks.A retrospective cohort study in rural Uganda in 2017 found that 19% of 411 PLHIV with an unsuppressed VL did not receive IAC  while anThe study results on IAC linkage are comparable to findings from Ethiopia where all 235 PLHIV with unsuppressed VL involved in the retrospective cohort study received IAC , and finIn this study cohort, 77.4% of study participants received the first IAC session within 60 days or less from the time of the baseline non-suppressed VL result. This is an improvement by approximately 20 weeks in the aptness of IAC intervention provision in a public health facility setting when compared to earlier findings where the first IAC session was received up to 200 days following the unsuppressed VL result availability by 75% of study participants . HoweverOnly 34% of participants completed the recommended three IAC sessions in 12 weeks in the study, a proportion 12.8% smaller than the proportion of study participants who completed IAC in the recommended three months in a retrospective cohort study in Ethiopia [The percentage of study participants who completed the IAC intervention in 20 weeks was 75%, which was an improvement by 30 weeks in comparison to the findings of the same percentage (75%) of participants who finished the three IAC sessions after 50 weeks in an earlier retrospective cohort study conducted in Uganda .The VL suppression proportion of 66.4% for all participants who received the recommended three or more IAC sessions is higher than 9%, the VL suppression percentage after IAC documented by a prospective cohort study  and highThe study findings are contrary to those in a Swaziland study where EAC did not increase the likelihood of VL suppression .Multivariable modified Poisson regression analysis findings demonstrated significant associations between VL suppression after IAC and number of IAC sessions received, baseline non-suppressed VL result and ART regimen type. The participants who received three IAC sessions were 33% more likely to have VL suppression than those who received more than 3 IAC sessions , . Individuals received more than three sessions of IAC if their adherence level was less than 95% on pill count at three consecutive IAC sessions as per the Ministry of health guidelines . This inOn the contrary, number of intensified adherence counseling sessions received was found not to be independently associated with VL suppression in a retrospective cohort study in Zimbabwe . HoweverStudy findings support the current Uganda national guidelines that the recommended three IAC sessions are potent and by a larger proportion, in reversing HIV viral non-suppression among PLHIV who have been on ART for at least six months , as it iThe study participants whose VL was in the range 1,000–4,999 copies/ml were 47% more likely to suppress after IAC compared to their counterparts with VL ≥ 10,000 copies/ml . The study results are comparable to findings of a retrospective cohort study in Ethiopia where the baseline VL result was an important predictor of VL suppression after IAC . In EthiStudy strengths include the cohort design which inherently provided a temporal causal relationship between IAC and VL suppression , a largeIn conclusion, client linkage to IAC was 100% and VL suppression after adequate IAC was high (66.4%) and comparable to 70%, a percentage above which adherence support has been found to enhance VL suppression in PLHIV with a previously unsuppressed VL , 18. TheBelow is the link to the electronic supplementary material.Supplementary Material 1


As he remained poorly adherent to antiretroviral therapy (ART), B19V detection persisted. The second patient had sudden pancytopenia despite being on ART with an undetectable HIV viral load. He had historically low CD4+ counts, fully responded to IVIG, and had undiagnosed hereditary spherocytosis. The third individual was recently diagnosed with HIV and tuberculosis (TB). One month after ART initiation, he was hospitalized with anemia aggravation and cholestatic hepatitis. An analysis of his serum revealed B19V DNA and anti-B19V IgG, corroborating bone marrow findings and a persistent B19V infection. The symptoms resolved and B19V became undetectable. In all cases, real time PCR was essential for diagnosing B19V. Our findings showed that adherence to ART was crucial to B19V clearance in HIV-patients and highlighted the importance of the early recognition of B19V disease in unexplained cytopenias.Parvovirus B19 (B19V) infection varies clinically depending on the host’s immune status. Due to red blood cell precursors tropism, B19V can cause chronic anemia and transient aplastic crisis in patients with immunosuppression or chronic hemolysis. We report three rare cases of Brazilian adults living with human immunodeficiency virus (HIV) with B19V infection. All cases presented severe anemia and required red blood cell transfusions. The first patient had low CD4 Parvovirus B19 infection (B19V) is often asymptomatic or presents with mild disease. It can present as erythema infectiosum during childhood, a viral exanthem , hydrops fetalis in pregnant women, which can lead to miscarriages, or with less common symptoms that include painful or swollen joints (polyarthopathy syndrome). The infection is usually self-limited and resolves within one to two weeks. Due to red blood cell (RBC) precursors tropism, B19V might cause the temporary cessation of the bone marrow’s RBC production, leading to transient aplastic crisis (TAC), mainly in patients with chronic hemolysis, including hereditary spherocytosis (HS). The overlapping arrest of RBC production and excessive destruction can cause potentially life-threatening anemia, requiring urgent blood transfusions [Pure red cell aplasia (PRCA) has been described in patients living with HIV/AIDS (PLWHA), affecting up to 4.5% of patients ,3. ThereHerein, we report three rare cases of Brazilian PLWHA with B19V-mediated severe anemia. The HIV patients were treated at the Instituto Nacional de Infectologia Evandro Chagas (INI/Fiocruz) and manifested with different clinical presentations. We discuss B19V infection in PLWHA, clinical presentation, diagnostic challenges, and therapeutic responses. These cases highlight the importance of the early recognition of B19V disease in unexplained cytopenias settings.9/L, neutrophils 0.204 × 109/L, and platelets 354,000/mm3, with corrected reticulocytes 0%, aspartate aminotransferase 251 U/L, alanine aminotransferase 351 U/L, HIV viral load 40,305 copies/mL, and a CD4+ count of 6 cells/µL  and high HIV viral load . B19V DNA remained detectable (1.8 × 106 IU/mL), and IgM and IgG were indeterminate. As he was asymptomatic with normal blood cell counts, a new course of IVIG was not indicated.A 27-year-old Black male diagnosed with HIV months after birth in 1994 had a history of multiple infections, including pneumocystosis, tuberculosis (TB), and bacterial pneumonia. Due to poor adherence to antiretroviral therapy (ART), the patient had an extensively drug-resistant viral infection and was taking lamivudine (3TC), tenofovir (TDF), darunavir/ritonavir (DRV/r), dolutegravir (DTG), etravirine (ETR), and fostemsavir, and presented with anemia and mild leukopenia in November 2020. A bone marrow biopsy showed 70% cellularity, normoblastic erythroid series, reduced granulocytic series, and megakaryocytes with preserved morphology, absence of granulomas, and negative special stains for fungi and mycobacteria. Malignancies were ruled out. In April 2021, he complained of vertigo, headache, vomiting, and fever, and was admitted with a deterioration of the anemic condition, mild hepatitis, and no adenopathy. He exhibited hemoglobin (Hb) 1.7 g/dL, hematocrit (Ht) 6.5%, white blood cells (WBC) 2.33 × 10cells/µL . During cells/µL A, which tic tree . He receA phylogenetic tree of Parvovirus B19  in patients with HIV and anemia (red diamonds), defined as genotype 1a, inferred by using the Maximum Likelihood method and Tamura-Nei model . Evoluti+ counts below 200 cells/mm3. He sought medical consultation in August 2021 after four weeks of malaise, lethargy, and an acute incident of dizziness, diarrhea, and syncope. He had hypothyroidism and no history of hematologic disorders, but his mother suffered from chronic anemia. The patient was submitted to a full blood workup that showed pancytopenia , mildly elevated serum ferritin (611 μg/L), and anemic hemolytic features , and leukopenia (WBC 2510 cells/mm3) and average platelet counts. One month after ART initiation—on February 2022—the patient was hospitalized with anemia aggravation requiring RBC transfusion and cholestatic hepatitis, leading to a new suspension of tuberculostatic drugs. The HIV viral load decreased to 130 copies/mL, and CD4+ counts improved to 138 cells/mm3  [The relationship between anemia and B19V infection is well known ,10,11,12= 0.015) . A BraziAdherence to medication is one of the most critical factors for a successful ART. Poor medication adherence can lead to treatment failure and the development of drug-resistant strains of HIV. Several studies have shown that adherence to antiretroviral medication is associated with better health outcomes in HIV-positive individuals ,17. HemaSeveral case reports describe B19V infection in patients with HS, with patient’s findings usually including fever, fatigue, a family history of HS in most patients (59%), and in some cases liver dysfunction . B19V inHS is the most common RBC membrane disorder worldwide, and the most common hereditary hemolytic anemia in people with Northern European ancestry, with a prevalence of 1 in 1000 to 2500 . The abnBone marrow potentially suffers from the combined effects of HIV, inflammatory mediators released during infection, nutritional deficiency, and opportunistic pathogens . B19V shNevertheless, the diagnosis of B19V-induced anemia in PLWHA is rare, possibly due to underdiagnosing ,26. Mole+ counts, our patients did not experience a worse prognosis than immunocompetent individuals. The treatment of B19V infection depends on the clinical burden and the host’s immune response. Spontaneous resolution can occur if the immune system reconstitutes; no further treatment is needed in these cases. Still, IVIG is a fundamental source of neutralizing antibodies for persistently symptomatic individuals. Usually, only one course of IVIG is required for long-term remission [Despite the low CD4emission . The coremission . We hypoOur three cases descriptions highlight the importance of B19V diagnosis in PLWHA. Cytopenias are often multifactorial, and performing a comprehensive clinical evaluation is essential to prevent delayed diagnosis and morbidity. Persistent B19V infection in PLWHA is challenging to differentiate from other opportunistic infections or IRIS. Therefore, a high index of suspicion for B19V should be of concern for HIV patients with cytopenias and advanced immunosuppression. The decision to treat B19V should always be clinically guided. Although IVIG therapy is the primary treatment to clear viremia in PLWHA, ART compliance is essential to normalize blood cell counts and prevent B19V relapse.