WHO recommendation to initiate all HIV patients on antiretroviral therapy (ART) at diagnosis could potentially overextend health systems and crowd out sicker patients, mitigating the policy's impact. We evaluate whether South Africa's prior eligibility expansion from CD4 ≤ 200 to CD4 ≤ 350 cells/μl reduced ART uptake in the sickest patients.The 2015 HIV Treatment and Care Programme in KwaZulu‐Natal from April 2010 to June 2012 (n = 13 809), we assessed the impact of the August 2011 eligibility expansion on the number of patients seeking care, number initiating ART and time from HIV diagnosis to ART initiation among patients always eligible (CD4 0–200), newly eligible (CD4 201–350) and not yet eligible by CD4 count (>350). We used interrupted time series methods to control for long‐run trends and isolate the effect of the policy.Using data on all patients presenting to the Hlabisa ART eligibility led to an increased number of patients initiating ART per month . Newly eligible patients (CD4 201–350) initiated treatment 47% faster than before , while the sickest patients (CD4 ≤ 200) saw no decline in the monthly number of patients initiating treatment or the rate of treatment uptake.Expanding ART to patients with CD4 ≤ 350 cells/μl, while ensuring that the sickest patients did not experience delays in ART initiation. Treatment programmes must be vigilant to maintain quality of care for the sickest as countries move to treat all patients irrespective of CD4 count.The Hlabisa programme successfully extended  In September 2015, the WHO revised its antiretroviral therapy (ART) treatment guidelines, calling for a ‘test‐and‐treat’ strategy, extending treatment eligibility to all people diagnosed with HIV regardless of CD4 count. This recommendation reversed earlier guidelines that limited treatment to patients with lower CD4 counts or severe illness South Africa has the largest HIV‐infected population in the world, with 2015 estimates of 7 million people living with HIV and over 3.3 million receiving ART Several studies have found that earlier ART initiation for patients with CD4 between 200 and 350 decreases rates of death, disease progression and incident tuberculosis while increasing retention in care and virologic suppression, among newly eligible patients in both trial To evaluate the potential spillover effects of eligibility expansions, we assessed whether South Africa's expansion from CD4 ≤ 200 to CD4 ≤ 350 cells/μl led to changes in care‐seeking and ART uptake in three groups of patients: those who became eligible under the guideline change (CD4 201–350), the sickest who were eligible both before and after the guideline change (CD4 ≤ 200) and those who were not eligible by CD4 count either before or after the guideline change (CD4 > 350).We conducted an observational cohort study using data from the Hlabisa HIV Treatment and Care Programme located in KwaZulu‐Natal, South Africa. The Hlabisa programme was initiated in 2004 as part of a public sector roll‐out of HIV treatment in South Africa, implemented as a joint initiative by the Department of Health and the Africa Health Research Institute . This programme includes 17 primary healthcare clinics throughout the Hlabisa subdistrict that provide HIV rapid testing, counselling and free ART for anyone eligible under national treatment guidelines Any individual who attends a Hlabisa clinic and tests HIV‐positive has blood drawn for CD4 testing. That same day, the sample is transported to the district hospital laboratory for analysis, and the patient schedules a follow‐up visit at the local clinic for the following week to learn his or her CD4 results. ART eligibility, assessed according to the South African national guidelines, has changed over time: CD4 ≤ 200 cells/μl or WHO stage IV from 2004 Through linkage with the National Health Laboratory Service, the Hlabisa programme keeps electronic records for all patients from the time of first CD4 count (facility‐based HIV diagnosis) rather than from the time of ART initiation. Data on sex, age, visit dates, CD4 test results and date of transfer to another clinic  are recorded for all patients. Additional data are available for patients who initiate ART, including clinical information, pregnancy and tuberculosis status, and routine laboratory results.This secondary analysis of deidentified data was determined to be ‘not human subjects research’ by the Boston University Medical Campus Institutional Review Board (protocol H‐35385).We evaluated four outcomes to assess changes in clinic burden and treatment initiation in the period before compared to the period after the August 2011 ART eligibility expansion: (i) monthly number of new HIV diagnoses; (ii) monthly number of patients initiating ART; (iii) monthly proportion of new patients who initiate ART within 6 months; and (iv) days from first clinic visit to treatment initiation. Our analyses include all adults ≥16 years old who sought care in the public sector between 1 April 2010, when the previous guideline change was implemented, and 31 June 2012, 6 months prior to completion of data collection. Outcomes 1 and 2, the numbers of patients entering care and initiating ART, arise from an unobserved reference population of persons in need of HIV care residing in the Hlabisa catchment area. Any smooth secular trends identified by our time series models for these two outcomes likely reflect changes in this implicit denominator. Outcomes 3 and 4 were defined only for HIV‐diagnosed patients who had a CD4 blood sample drawn. Patients were included in these analyses regardless of ART eligibility. We excluded a small number of patients whose ART initiation date preceded their first reported visit to the Hlabisa clinics or who were missing results for their first CD4 test.All analyses were stratified by CD4 count at the time of facility‐based HIV diagnosis. We defined patients with CD4 ≤ 200 cells/μl as ‘always eligible’ (as they would have been eligible for ART initiation under the 2010 guidelines), patients with CD4 201–350 cells/μl as ‘newly CD4‐eligible’ (as they would not have been eligible until 2011 without another condition) and those with CD4 > 350 cells/μl as ‘never CD4‐eligible’ (as they would not have been eligible before or after the 2011 expansion without another condition). Because CD4 counts were not the sole determinant of ART eligibility, we would expect a slightly diminished effect of the August 2011 expansion among the ‘newly CD4‐eligible’ if any patients were previously eligible due to other conditions. This other eligibility criterion would not have affected the ‘always eligible’ population.vs. after the policy expansion. To estimate the impact of the reform on (i) numbers seeking care, (ii) numbers starting ART and (iii) the proportion of patients who initiated ART within 6 months, we performed linear regression on monthly values of these three outcomes as interrupted time series analyses controlling for first‐order temporal autocorrelation, using patient data from April 2010 through June 2012. For outcome To describe trends in new patient volume and new ART initiator volume, we report the mean monthly count of new HIV diagnoses and new initiators before To evaluate the impact of the guideline change on outcome Our study sample included 13 809 patients . A total of 8531 patients were included prior to the guidelines change as they had their first visit in the 16‐month period 1 April 2010 to 31 August 2011, while 5278 patients were included after eligibility expansion as they first presented in the 10‐month period 1 September 2011 to 30 June 2012. Patients were predominantly female (68%), with a median age of 31 years at first presentation  fell into the ‘always eligible’ CD4 category (≤200 cells/μl), 3610 (26%) were ‘newly CD4‐eligible’ (201–350 cells/μl), and 5149 (37%) were ‘never CD4‐eligible’ (>350 cells/μl). Overall, 4474 patients (32%) initiated ART within 6 months from first presentation, including patients not yet eligible for ART.While eligibility expansion increases the proportion of patients eligible for treatment, it might also impact the number of patients presenting for HIV testing if they believe they would be more likely to access treatment if positive. An average of 501.8 (SD = 77.8) patients diagnosed per month before the guideline change increased to 527.8 (SD = 65.6) after the guideline change, a crude change of +26.0  before the guideline change to 378.5 SD = 74.2) afterwards , who averaged 85.8 (SD = 19.1) initiators per month prior to the guideline change and 142.6 (SD = 142.6) afterwards, an adjusted increase of 73.0 patients per month [95% CI ] or 85% , there was no evidence of impeded transition to ART, with the proportion initiating within 6 months increasing slightly from 57.9% pre‐reform to 63.2% post‐reform [crude +5.3 percentage points ]. Similarly, the proportion of ‘never CD4‐eligible’ patients (CD4 > 350) who initiated within 6 months increased modestly from 2.9% to 4.3% [crude +1.4 percentage points ]  and rates of progression to ART initiation. The proportion of patients who started ART within 6 months of HIV diagnosis doubled in the ‘newly CD4‐eligible’ group from 24.3% to 49.9% [+25.6 ] when comparing April 2010 through February 2011 Moving from a binary treatment indicator to a continuous‐time survival analysis, we estimated adjusted Cox proportional hazards models. The overall speed of ART initiation increased following the guideline change . This increase was strongest among ‘newly CD4‐eligible’ patients , with possible modest increases among the ‘always eligible’  and ‘never eligible’ categories  for our outcome of interest, ART initiation within 6 months. Additionally, time series analyses are vulnerable to confounding by unpredictable (and unmodelled) secular trends. However, our exclusion of data that would be affected by earlier policy changes, our adjustment for changes in clinic operations during the holiday season and our control for gradual changes over time mitigate against such biases. Finally, we assessed the spillover effect of the eligibility expansion on entry into care and time to ART initiation among patients with lower (previously eligible) CD4 counts. However, additional dimensions of quality that were not observed in this study would be an important avenue for future research. For example, it has been documented that timely switching of ART to second‐line therapy based on viral load failure is suboptimal, possibly because of time pressure on clinic staff Our finding that the Hlabisa HIV Treatment and Care Programme successfully implemented ART eligibility scale‐up without incurring negative spillover effects on the sickest patients provides support for the feasibility of further programme expansion. This particular programme can serve as a model for scale‐up in other rural, resource‐limited settings and should be considered when evaluating the economic costs and implications of ART eligibility expansions. As South Africa has now extended treatment to all HIV‐infected patients, it will be important to continue to monitor the impact of these policies on all patients across CD4 levels and throughout the treatment cascade.


In 2015, this was updated to recommend cART initiation in all patients with HIV, regardless of CD4 count. Implementation of these guidelines in real‐world settings has not been evaluated in Latin America. To assess changes in time to cART initiation during routine care, we estimated trends in time from enrolment in care to cART initiation in HIV‐positive adults with high CD4 counts in the Caribbean, Central and South America network for HIV Epidemiology (CCASAnet) during 2003 to 2017.In 2013, the World Health Organization (WHO) recommended initiating combination ART (cART) in all adults with HIV and CD4+ lymphocyte counts (CD4) <500 cells/mm3 and without AIDS at enrolment at five CCASAnet sites  were included. Patients without information regarding AIDS‐defining events were excluded. We estimated unadjusted median time from enrolment to cART initiation by calendar year using Kaplan‐Meier methods and calculated adjusted hazard ratios (HR) and 95% confidence intervals (95% CI) for trends in cART initiation using Cox models and restricted cubic splines for continuous variables, accounting for age, sex, CD4 at enrolment, route of HIV transmission and clinic site.All cART‐naive individuals ≥18 years of age from 2003 to 2017 with CD4 ≥350 cells/mm3 at enrolment. Median time to cART initiation after 2013 was 6.21 weeks (interquartile range (IQR): 1.89, 23.21), and 4.71 weeks  after 2015. Among 763 (24%) patients who never initiated cART, 33 (4.3%) were reported as deceased, 481 (63%) were lost to follow‐up, and 249 (33%) were administratively censored before initiation. Adjusted probability of cART initiation greatly increased in recent years, in particular after 2013 and 2015 .Of the 3171 patients included, 1,650 (52%) had CD4 ≥500 cells/mmTime to cART initiation decreased substantially, roughly following changes in WHO guidelines in this real‐world setting in Latin America. However, a very high proportion of patients never started cART, compromising retention in care and survival, as shown by their higher proportion of LTFU and death, which reinforce the notion that earlier treatment implementation strategies are needed. Due to the undesirable side effects and toxicities of many older antiretroviral medications, cART initiation early in the epidemic was generally deferred among asymptomatic patients with CD4 counts >200 cells/mm3 counts and/or AIDS‐defining illness at initiation) is still high, mainly due to barriers for broader and universal HIV testing and cART initiation Although available evidence in Latin America buttresses local guidelines recommending universal cART initiation, its implementation remains uneven throughout the region 2http://ccasanet.vanderbilt.edu) has been described elsewhere https://www.iedea.org/) with the purpose of collecting HIV data from Central and South America and the Caribbean to describe unique characteristics of the HIV epidemic in this region. Five CCASAnet sites contributed data to this study: Instituto Nacional de Infectología Evandro Chagas, Fundacão Oswaldo Cruz, Rio de Janeiro, Brazil (Fiocruz‐Brazil); Fundación Arriarán, Santiago, Chile (FA‐Chile); Instituto Hondureño de Seguridad Social and Hospital Escuela Universitario, Tegucigalpa, Honduras (IHSS/HE‐Honduras); El Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México City, Mexico (INNSZ‐Mexico); and El Instituto de Medicina Tropical Alexander von Humboldt, Lima, Perú (IMTAvH‐Peru). CCASAnet sites that provided data only on cART‐treated patients were excluded.CCASAnet  at Vanderbilt University, Nashville, TN, USA. In each of the sites contributing data to this study, except IMTAvH‐Peru, ethical regulations and policies permit retrospective analysis of de‐identified clinical data without informed consent when research is approved by an Institutional Review Board or appropriately constituted ethics committee. At IMTAvH‐Peru, patients consent at time of enrolment to provide de‐identified clinical data for research studies.2.13 at enrolment were included in the study. Patients with history of an AIDS‐defining event or without information regarding AIDS‐defining events were excluded.All cART‐naive adults (≥18 years) who were enrolled in participating CCASAnet sites during 2003 to 2017 and had a CD4 count of ≥350 cells/mm2.2The primary outcome of this study was cART initiation. Individuals were followed from cohort enrolment until cART initiation, death, lost to follow‐up (LTFU) defined as a >12‐month gap between their last medical visit date and closure date for each participant site, or cohort closure date. We estimated the unadjusted median time from enrolment to cART initiation by calendar year periods using Kaplan‐Meier methods among all patients and censoring at the end of their follow‐up time for those who did not initiate cART, were LTFU or died. Additionally, among patients who initiated cART, we used a median regression model to examine median times to cART initiation; 95% confidence intervals (CI) were computed using a nonparametric bootstrap with 10,000 replications. Using a Cox regression model, we calculated hazard ratios (aHR) and 95% CI for cART initiation by year of enrolment, adjusting by sex, age, CD4 count at enrolment, probable route of HIV transmission, and site of enrolment. Restricted cubic splines were used for continuous variables  with three knots. The proportional hazards assumption was tested using Schoenfeld residuals; there was evidence that the hazards were not proportional, particularly with regards to the year of enrolment variable, although subsequent plots  and clinical characteristics  of patients who never initiated cART (non‐cART initiators) with those who did (cART initiators), using the Wilcoxon rank sum and the chi‐square tests as appropriate. Additionally, we reported the last status available in the dataset for non‐cART initiators, classified as death, LTFU or administrative censoring at time of study closure.All analyses were performed using RStudio Version 1.2.1335.33.13 and no AIDS defining event at enrolment. Of these, 2408 (75.9%) initiated cART during a median of 4.23 years of follow‐up. A description of the study population by clinical and sociodemographic characteristics is shown in Table 3 at enrolment.We included a total of 3171 patients with CD4 ≥350 cells/mmp = 0.56) were fairly similar between those starting and not starting cART. Among those who never started cART, 33 (4.3%) were reported as deceased, compared to 54 (2.2%) patients who started cART (p = 0.003). Among those who died, the median times to death was 3.1 years and 3.9 years for those not starting and starting cART respectively (p = 0.09). Among those who never started cART, 461 patients (60%) were LTFU, whereas in the group that started cART, 211 (8.7%) were LTFU (p < 0.001). The median time in care prior to LTFU was 4.27 (interquartile range (IQR): 2.05 to 7.63) years for those who never started cART and 3.91 (IQR: 1.74 to 6.05) years for those who started cART. A total of 47 patients were known to have transferred to another clinic, 27 (1.1%) among the group who started cART and 20 (2.6%) among those who never started (p < 0.01).Compared to non‐cART initiators, a higher proportion of cART initiators were female and a higher proportion had enrolled in recent years. The median CD4 at enrolment was lower among cART initiators than non‐cART initiators. Age and probable route of HIV transmission  compared to those in care at the end of follow‐up , p < 0.01. Median CD4 count at enrolment among deceased patients was similar to that among surviving patients , as was the median viral load at enrolment . The median time from ART to LTFU was 704 days (IQR: 206 to 1381) and patients who were not LTFU spent a median of 1120 days in care (IQR: 554 to 1894), p < 0.01.The groups of deceased and LTFU people had a higher proportion of females: 28% and 26% respectively compared to 20% among those still in care. Median CD4 count at enrolment among LTFU was slightly lower  compared to patients in care at end of follow‐up , 3.2Among all patients, median time to cART initiation between 2003 and 2008 was 169 weeks (95% CI: 156 to 180); time to cART initiation decreased to seven weeks (95% CI: 6.4 to 8) between 2015 and 2017  were associated with a lower hazard of starting cART. After adjusting for other factors, age was not strongly associated with starting cART (p = 0.065) , Honduras  and Mexico  had an increased hazard of starting cART when compared to those enrolled in Chile. Male sex  and higher CD4 counts at enrolment  lead to treatment delay and prioritizing cART initiation in patients with more advanced disease. For example, Chilean clinical sites took longer to adopt newer WHO recommendations for cART initiation when compared with other countries of the region Other factors, such as high CD4 counts at enrolment, male sex and study site, were also associated with lower hazards of cART initiation. Among patients with CD4 counts >350 cells/mmTemporal trends in time to cART initiation in Latin America in asymptomatic patients with high CD4 cell counts have not been evaluated previously, though several studies have explored time to cART initiation overall, also showing trends towards earlier cART initiation over time Also in our study, it is notable that males were less likely than females to initiate cART. This finding has been shown elsewhere, including by our group in Latin America In our study, the group of LTFU had a higher proportion of females, 26%, compared to 20% females among those still in care. However, in our study, as in a large study on gender and loss to follow‐up out of western Kenya (the AMPATH cohort) from 2001 to 2007, men with HIV infection were more likely to become lost to follow‐up than women, both before cART initiation and after. However, loss to follow‐up was more common before cART initiation than after in the AMPATH cohort Our study had some additional important limitations. We did not include socioeconomic status, or other factors such as travel distance to the care facilities and administrative barriers at each medical site, which might account for some of the patients not initiating cART. Our database does not include information on causes of death. Our adjusted models also did not directly evaluate changes in times until cART initiation relative to the time of local implementation of the WHO guidelines, which makes effects of WHO guidelines within different sites more difficult to evaluate. However, the number of patients and the diversity of sites included make this study a source of useful information for the real‐world clinical care of PLWHA in Latin America. The temporal trends towards reducing the time to cART initiation, even in patients with high CD4 counts, indirectly supports the feasibility of earlier, or even same‐day, cART initiation, among PLWHA in Latin America.5Our study shows that the time to cART initiation has substantially decreased over calendar year in the Latin American region, roughly coinciding with evolving recommendations from the WHO to start cART earlier. However, a very high proportion of patients never started cART, compromising retention in care and survival, as shown by their higher proportion of LTFU and death. These data reinforce the notion that earlier treatment implementation strategies in the region could be needed.None.BCR, YCV and AKP developed conceptualization and design of this study, contributed to interpretation of data, wrote the manuscript and had full access to all study data. YCV, PFR and BES conducted the data analysis, contributed to conception, design and interpretation of data and drafting the manuscript. YCV contributed to the data management. PFBZ, VV, CC, DP, EG, JSM and CM contributed to interpretation of data and revised the manuscript.


Liver enzymes abnormalities have been found to be common among patients on antiretroviral treatment (ART). Apart from the effects of ART on these changes, other factors that can potentially contribute to the abnormal levels of these enzymes have been found to vary in different geographical locations. This study investigated factors associated with liver enzymes abnormalities among human immunodeficiency virus (HIV) infected individuals on ART from the Lake Victoria zone, Tanzania. A cross-sectional study involving a total of 230 sera from HIV seropositive patients from different regions of the Lake Victoria zone was carried out in July 2017. All samples with required variables/parameters such as age, sex, ART regimen, and residence were serially included in the study. Hepatitis B virus (HBV) and Hepatitis C virus (HCV) detection and liver enzymes assays  and aspartate transaminase (ASAT)) were assessed following the standard procedures. Data were analyzed by using STATA version 13. The median age of the study participants was 38 (interquartile range [IQR]:30-48) years. The overall prevalence of abnormal liver enzymes was 43.04% . A total of 26.09% (60/230) had elevated ASAT while 23.9% (55/230) patients had elevated ALAT levels. ASAT levels were significantly high among patients with high HIV viral load (P= 0.002) while ALAT levels were significantly high among those coinfected with hepatitis C virus (P=0.017) and hepatitis B virus (P<0.001). A significant proportion of HIV seropositive individuals on ART have abnormal levels of liver enzymes, which is significantly associated with high HIV viral load and viral hepatitis. This calls for the need to emphasize screening of viral hepatitis and provision of appropriate management among HIV seropositive individuals in this setting. In the era of highly active antiretroviral therapy (HAART), liver diseases have become one of the commonest nonacquired immune deficiency syndrome (AIDS) related causes of death. It accounts for 14–18% of mortalities among human immunodeficiency virus (HIV) infected patients . Among hThis was a cross-sectional hospital based study which was conducted in July 2017 at the Bugando Medical Centre (BMC). BMC is a consultant and teaching hospital with about 900 bed capacity located in the Northwestern of Tanzania serving the lake zone regions, namely, Mwanza, Mara, Kagera, Shinyanga, Simiyu, and Kigoma with estimated population size of thirteen million people. BMC process samples for viral load for all CTCs in the lake zone and in each day samples from all centers are received.Sample size was estimated by using Kish Leslie formula using the prevalence of 16.4% ; the minSociodemographic and other relevant information such as age, sex, residence, ART regimen , reason for HIV viral load testing , and drug adherence  were extracted from laboratory request forms accompanying samples for viral load testing using a checklist. Blood specimens in vacutainer EDTA tubes  collected from different CTCs in different regions for viral load testing at BMC were used in this study.EDTA blood samples were centrifuged at 4000 revolutions per minute for 20 minutes to obtain plasma which was then used for viral load testing. Viral load testing was done using a COBAS TaqMan analyzer  following the manufacturer's instructions. Viral suppression was defined as viral load < 1000 copies/mL .The liver enzymes (ASAT and ALAT) were analyzed using the CIBA CORNING 252 calorimeter . Liver enzymes were considered normal when values range from 2-40 IU/mL for ASAT and 2-41IU/mL for ALAT. In addition, all samples were analyzed for the presence of HBV antigens and HCV antibodies using immunochromatographic tests  following the manufacturer's instructions.The standard operating procedures were strictly followed for the quality assurance. Control materials with known ALAT and ASAT results were used to calibrate the calorimeter as per assay kit instructions before processing the samples for ASAT and ALAT. HBV and HCV kits were quality checked using known HBsAg and anti-HCV antibody positive and negative sera controls.Every sample was given a unique identification number. All data were recorded in the log book, transferred to excel then transferred to STATA version 13  for cleaning and analysis. Results were presented into proportions for categorical variables and median (IQR) for continuous variables. Chi square test was used to test the association between liver enzymes abnormalities and other factors such as viral hepatitis and HIV viral load followed by multivariate logistic regression analysis to establish independent predictors. Wilcoxon Rank Sum Mann–Whitney test was used to compare median for various groups. A P value of < 0.05 at 95% confidence interval was considered statistically significant.Ethical clearance for using patient's samples was sought from the joint CUHAS/BMC research ethics and review committee with ethical clearance number CREC/381/2017. Permission to conduct the study was requested from hospital laboratory administration. All patient-related information was stored carefully and anonymously using codes.A total of 230 HIV seropositive individuals on ART with the median age of 33 (IQR: 30-48) years participated in this study. The slight majority of the participants 152 (66.1%) were females. A significant proportion of them were from Shinyanga (30.43%), Bunda (26.5%), and Butiama (21.3%). Other characteristics are shown in Overall, the prevalence of liver enzyme abnormalities was 43.04% . A total of 60 patients (26.09%) had elevated ASAT level while 55 patients (23.9%) had elevated ALAT levels . RegardiLiver enzyme abnormalities are common among human immunodeficiency virus (HIV) infected individuals and have been associated with multiple factors. However, the risk factors associated with these abnormalities tend to differ in different geographical locations. To the best of our knowledge, this is the first study to investigate factors associated with liver enzyme abnormalities in the Lake Victoria zone, Tanzania. The most salient finding in this study is high overall prevalence of liver enzyme abnormalities which was observed to be 43.09%. This was significantly high in comparison to previous studies in Cameroon and South Africa which observed the prevalence of (22%) and (23%), respectively , 14. FurIn this study, liver enzyme abnormalities were found to be significantly associated with viral hepatitis (HBV and HCV); this observation was similar to the previous studies , 16–19. Another observation in this study was significant association between high ALAT levels with young age. This could be explained by the fact that young aged individuals can mount strong immunity than old aged individuals; therefore, the elevated ALAT could be associated with immunopathology following viral infections .One of the major limitations of this study could be the sensitivity of the assays which might affect the results. In addition, other factors that can cause liver damage such as alcohol abuse and opportunistic infections were not investigated.This study observed high prevalence of liver enzyme abnormalities which was significantly associated with viral hepatitis and high HIV viral load among HIV infected patients in the Lake Victoria zone, Tanzania. Therefore, monitoring and management of liver enzymes abnormalities in HIV infected patients are essential in this setting.


The World Health Organization (WHO) recommends a method to estimate nationally representative pretreatment HIV drug resistance (PDR) in order to evaluate the effectiveness of first -line treatments. The objective of the present study was to determine the prevalence of PDR in Cuban adults infected with HIV-1.A cross-sectional study in Cuban adults infected with HIV-1 over 18 years was conducted. The probability proportional to size method for the selection of municipalities and patients without a prior history of antiretroviral treatment during the period from January 2017 to June 2017 was used. The plasma from 141 patients from 15 municipalities for the determination of viral subtype and HIV drug resistance was collected. Some clinical and epidemiological variables were evaluated.3 and the median viral load was 68000 copies / mL. The predominant genetic variants were subtype B (26.9%), CRF19_cpx (24.1%), CRF 20, 23, 24_BG (23.4%) and CRF18_cpx (12%). Overall, the prevalence of PDR was 29.8% . The prevalence was 12.8%  for any nucleoside reverse transcriptase inhibitor (NRTI), 23.4%  for any non-reverse transcriptase inhibitor (NNRTI) and 1.4%  for any protease inhibitor (PI). The most frequent mutations detected were K103N (12.9%), G190A (6.4%) and Y181C (4.8%).80. 9% of the patients corresponded to the male sex and 76.3% were men who have sex with other men (MSM). The median CD4 count was 371 cells / mmThe NNRTI prevalence above 10% in our study indicates that the first-line antiretroviral therapy in Cuba may be less effective and supports the need to look for new treatment options that contribute to therapeutic success and help the country achieve the global goals 90-90-90 set forth by UNAIDS. Highly active antiretroviral therapy (HAART) is one of the most significant advances in the control of the HIV / AIDS epidemic, because it has reduced morbidity and mortality in people living with HIV (PLHIV). However, because HAART is not capable of eradicating the virus from the organism, treatment must be for life . The emeThe HAART began in Cuba in 2001 with the employment in the first and second line of generic antiretroviral produced by the national biopharmaceutical industry, which has benefited to 83% of PLHIV (n = 18744) until December 2017 (MINSAP Computerized Registry). Several working groups have studied the situation of HIVDR in Cuba in untreated PLHIV at different times, which reported values of prevalence of HIVDR from 4% to 20.2% –9. HowevIn 2017, AIDS Research Laboratory and the National STI / HIV / AIDS Program of the Ministry of Public Health, with WHO advice, conducted a nationwide representative survey of Cuban patients with HIV-1 with the objective of estimating the prevalence of HIVDR in people who would start HAART.For the design of the national survey all patients diagnosed with HIV-1 infection, older than 18 years of age, and above who were initiating HAART and were antiretroviral therapy naive during the months January and June 2017, from the 168 municipalities of the country, were included. For sampling, the number of patients previously exposed to antiretroviral treatment and subsequent interruption for more than three months was unknown, so they were not included in the study design. Women with previous pregnancies were excluded from sampling.The 10% of the municipalities with the lowest number of patients that would start HAART were eliminated, which guaranteed a sampling frame that represented 90%. The "Probability Proportional to Proxy Size (PPPS)" sampling was used to select 165 patients from 15 municipalities , S1 Fig.The national survey was reviewed and approved by the Council of Researchs of AIDS Research Laboratory (CC-LISIDA-16-018). Ethical procedures were carried out in accordance with the requirements or standards of the Ministry of Public Health of the Republic of Cuba and the Ministry of Science, Technology and Environment which comply with the principles laid down in the Declaration of Helsinki for medical research in Human beings. This study was conducted with ethical clearance by the research on Human Subjects  Committee at the AIDS Research Laboratory, Cuba (CIE-LISIDA-16-04). Prior to sample collection, informed consent was obtained from each patient who participated in the study.TM DTCS Quickstar kit  on a CEQ TM 8800 genetic analyzer  and assembled using the Sequencher version 5.0 . The subtype of HIV-1 was determined by REGA HIV-1 subtypingtool v 3.0 (http://dbpartners.stanford.edu:8080/RegaSubtyping/stanford-hiv/typingtool/) and was confirmed by phylogenetic analysis.HIV RNA was extracted from 1 mL of plasma . The protease (PR) and reverse transcriptase (RT) regions were amplified by an “in house” method . Sequencwww.hiv.lanl.gov) and included in the alignments. For the determination of possible recombinants and breakpoints, bootscaning was performed and the points of similarity between sequences were determined using the Simplot v 3.5 and RDP4 programs. Additionally, phylogenetic tree was constructed using the neighbor joining method and the genetic distance was estimated according to the Kimura two parameters. Bootstrap values were calculated based on 1000 replicates. The tree was visualized using the program FigTree v 1.1.2 (http://tree.bio.ed.ac.uk/software/figtree/).Sequences were aligned using ClustalW in Mega v7. Reference sequences for different HIV subtypes were obtained at Los Alamos HIV Sequence Database (http://hivdb.stanford.edu/hivdb/by-mutations/). Any HIVDR was defined in sequences classified as low-, intermediate- or high-level resistance according to the Stanford HIVdb algorithm with respect to one or more antiretrovirals (ARVs). Drug resistance level was classified according to the Stanford Penalty Score as high (≥60), intermediate (30–59), or low (15–29). The surveillance mutations were defined per the 2009 WHO Surveillance Drug Resistance Mutations [Nucleotide sequences were analyzed using Stanford HIV database algorithm, available on the Stanford HIV database website (utations . The sequtations .http://pssm.cfenet.ubc.ca/who_qc) was used.To evaluate the quality control of the sequences, the WHO HIVDR tool .Statistical analyses were performed in GraphPad Prism 6 . Comparisons between groups were performed using Fisher’s exact or χThe data in 3 . The median viral load was 68,000 copies of RNA / mL and the CD4 + cell count was 371 cells / mm3 . 14.9% o3, 24_BG .The prevalence of PDR to any drugs classes was 29.8% . Drug resistance prevalence was 10.6% (95% CI 6.07–16.9) for any nucleoside reverse-transcriptase inhibitors (NRTIs), 23.4% (95% CI 16.7–31.3) for any non nucleoside reverse-transcriptase inhibitors (NNRTIs), 1.4% (95% CI 0.17–5.03) for any protease inhibitors (PIs). The most frequent mutations were K103N (12.1%); G190A (5.7%); Y181C (4.3%), which are associated with the high values of resistance to NNRTI described in the study .The phylogenetic analysis of the 41 sequences with resistance associated mutations did not detect any transmission cluster . In the p = 0.03) compared to those over 25 years of age . Women presented a higher prevalence of PDR , followed by MSM  and heterosexual men . No association was found between the prevalence of PDR to the different families and combinations of ARVs and the different geographic regions of Cuba involved in the study .CRF20, 23, 24_BG was the genetic variant with the highest prevalence of PDR , followed by CRF18_cpx , fundamentally to the NNRTI family.With respect to ARVs classes and therapeutic combinations, the detection of resistance to NNRTI in patients under 25 years of age was statistically significant , indicate that the treatment will not be effective in 29.7% of patients who start therapy with the lamivudine (3TC), zidovudine (AZT) and nevirapine (NVP) regimen. The therapeutic combination tenofovir (TDF), emtricitabine (FTC) and efavirenz (EFV), components of Atripla®, will not be effective in 27.6% of patients who initiate HAART .3, indicating the marked depression of the immune system. In this group of patients, the possible re-infection with genetic variants of HIV-1 different from the one causing the primary infection and presenting mutations associated to resistance to ARVs in their genome may be one of the causes of existing of pre-treatment resistance. Several studies have associated a higher prevalence of HIV-1 resistance mutations in subtype B than in non-B subtypes [The present work constituted the first study carried out in Cuba to know the prevalence of PDR of HIV-1 according to the methodology described by the WHO. The prevalence of PDR 29.8%) was higher than those described in previous studies conducted in Cuba during the 2007–2011 periods (12.5%) .8% was h. Other csubtypes , 22. In subtypes . In the One of the limitations presented by the study was the failure of the genotyping of a group of samples from the municipalities of the eastern region, Contramaestre and Palma Soriano, belonging to the Santiago de Cuba province. The loss of the cold chain during the process of transportation to AIDS Research Laboratory could be one of the causes of the decrease in plasma viral load at values below the limit of sensitivity of the genotypic assays for the determination of HIV drug resistance. The use of dried blood spots (DBS) would be a useful sample to avoid the loss of the cold chain during transportation to the genotyping laboratory. However, this type of sample was not used in the national survey, because at the time of the study, the test for the determination of HIV drug resistance from DBS was not validated in the AIDS Research Laboratory. The results of the national survey show that the combinations of drugs used in the first line of treatment will not be effective in 29.7% that start with 3TC + AZT + NVP and 27.6% of those that start with Atripla, so it was valued the change of treatment strategies in Cuba. WHO recommends not using NNRTIs in the first line of therapy if the PDR to this family of drugs is greater than 10% and, if this is not possible, consider introducing pre-treatment HIVDR testing . The nonIn the present study, an increase in pre-treatment resistance of HIV-1 to NNRTIs in Cuban patients who participated in the national survey was described, which evidenced the need to assess the change to more optimal and effective therapeutic strategies and strengthen the actions of prevention and surveillance of HIVDR.S1 Table(DOCX)Click here for additional data file.S1 Fig(TIF)Click here for additional data file.S2 FigThe samples are indicated by the symbol ● and the reference sequences of the subtypes and CRF were obtained from the Los Alamos database. The tree was constructed by the maximum likelihood method and the genetic distance was estimated according to the Kimura 2 parameter model. Numbers near the nodes represent bootstrap values .(TIF)Click here for additional data file.S3 FigNo clustering is observed among these samples. The letters PDR-2017 indicate the Cuban sequences.(TIF)Click here for additional data file.


People living with HIV (PLHIV) often face barriers in accessing quality and comprehensive HIV care, including stigma and discrimination, which results in poor retention and viral non-suppression. Peer-led interventions can help address these barriers. In Kenya, peer educators (PEs) are PLHIV who support other PLHIV to adhere to clinic schedules and antiretroviral medication uptake. In spite of their status as role models and their key role in supporting clients receiving HIV care and treatment, little is known about the characteristics and treatment outcomes of PEs themselves, specifically viral suppression.This is a retrospective descriptive analysis of program data on treatment outcomes of PEs engaged in active patient support activities between October 2010 and January 2017. All eligible PEs from 140 health facilities located in 23 counties of Kenya were included in the study. Data from 230 PEs were abstracted from the electronic medical records, patient files, and registers between June and August 2017. Study variables included key sociodemographic characteristics , duration on antiretroviral therapy (ART), WHO clinical staging, baseline CD4 count, current antiretroviral regimen and uptake of isoniazid preventive therapy (IPT). The outcome variable was viral suppression, defined as a viral load <1000 copies/ml.Overall, 173/230 (75%) of the PEs were female, 144/230 (63%) were married, and median age  was 38.5  years. The PEs had been on ART for a median  duration of 76.0  months. Six months IPT completion was high at 97%. Of the 222 (97%) PEs with an up-to-date viral load taken within the last one year, 211 (95%) were virally suppressed.Our study showed that peer educators actively engaged in patient support activities have achieved high viral suppression rates. In July 2016, the Kenyan Ministry of Health (MOH) rolled out the HIV Test and Treat guidelines, in line with the WHO recommendations . In KenyPLHIV often face barriers in accessing quality and comprehensive HIV care, including stigma and discrimination, which results in poor retention . Peer-leActive engagement of PLHIV as peer educators (PEs) responds to the need for a multidisciplinary approach. PEs utilize their life experiences to support prevention, adherence and retention among other PLHIV. In HIV programming, PEs are PLHIV who support other HIV-positive patients to adhere to medication and clinic schedules. Requirements of a PE in Kenya include: self-disclosure, ability to read and write, ART enrollment and participation in a psychosocial support group at one facility, demonstration of good adherence to ART, and acting as a good example for other PLHIV. Several studies in Kenya have evaluated the role of PEs in HIV service delivery. In one study, PEs were recruited to help improve HIV diagnosis, linkage to ART, and adherence and retention. In the first year, over 90% of eligible, in-patient clients were provided with pre-test counseling and referred for testing . In HomaWe conducted a retrospective descriptive analysis of program data on treatment outcomes of PLHIV who are engaged in active patient support activities. The PEs were drawn from 140 health facilities located in 23 counties where Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) supports HIV service delivery. Data were collected on all PEs in the 140 health facilities.For this study, we abstracted data on HIV-positive PEs who had been selected and engaged as PEs between October 2010 and January 2017. Data from 230 PEs were abstracted from the electronic medical records, patient files, and registers between June and August 2017. To be included in the study, the PEs had to be HIV-positive, enrolled on ART for more than six months, and providing psychosocial support to other PLHIV. In this study, we included all PEs who met the eligibility criteria and whose data were available.Patient level data were abstracted from the electronic medical records, patients’ files and registers using a standardized data abstraction tool. Predictor variables included key sociodemographic characteristics , duration on ART, WHO clinical staging, baseline CD4 count, current ART regimen and uptake of isoniazid preventive therapy (IPT). Advanced HIV disease was defined by CD4 count less than 200 cells/ml. One was considered to have received IPT if they completed 6 moths of IPT as recommended in the national guidelines. The primary outcome variable was viral suppression. We collected viral load results that were up-to-date at the time of data collection. Up-to-date viral load was defined as a viral load taken within the last twelve months with available results. We defined HIV viral suppression as the latest HIV RNA viral load value of less than 1,000 copies/ml as defined in the 2016 Kenyan MOH guidelines [Abbott RT-PCR   for HIV-RNA or Roche Amplicor RT-PCR . These platforms receive and process samples from the 140 health facilities included in the study. According to Kenyan ministry of health national guidelines, the first viral load is usually done after 6 months on ART followed by an annual viral load from the time of ART initiation. Viral suppression is defined as a viral load less than 1000 copies/ml.As part of routine program, viral load samples were collected as whole blood, dried blood spots or plasma and submitted to the processing laboratories which analyzed the viral load using either Continuous data were described through median and percentiles. Categorical data were described-through use of proportions. To assess differences in clinical and sociodemographic characteristics between men and women, a two-sample Z-test was used to estimate differences in sample proportions while the Mann-Whitney U test was used for continuous variables. All reported p-values were two-sided and a p-value <0.05 was considered statistically significant. Statistical analysis was conducted using the IBM SPSS software version 20.0 for Windows .The study protocol was reviewed and approved by the Kenyatta National Hospital Ethics Review committee in Kenya and the Chesapeake (Currently Advarra) IRB in the USA. A waiver of informed consent was received for this analysis.Of the 237 peer educators initially engaged in patient support in the 140 health facilities, three had dropped out of their job as peer educators and were not active in care in the three facilities where they had initially enrolled. Due to unavailability of their recent data within patient records, we excluded them from the study. At the time of study enrollment, four of the 234 PEs had been on ART for less than six months and were excluded from the study, as they were not yet eligible for the viral load test. The number of PEs included in the final analysis was 230 .Overall, 173/230 (75%) of the PEs were female and 144/230 (63%) were married . The ove11% of the men were unsuppressed compared to 3% of the women . We furtIn this study, we found that PEs had high rates of viral suppression. Of note is that this unique population has achieved the UNAIDS/WHO target of the third 90. To the best of our knowledge, limited studies have specifically evaluated viral suppression among PEs in Kenya and elsewhere as a specific patient population. We found the proportion of viral suppression reported within PEs to be higher than the overall viral suppression among adults living with HIV. Several studies in Kenya and our region report a viral suppression among general adult patient population ranging from 37% to 93% , 19–21.The role of peer-led interventions in health care is gaining more interest. In one study, there was improved ART adherence among HIV positive clients randomized to receive peer-led adherence intervention . Other dIn our study, more women were PEs compared to men. This is reflective of the proportions of patients accessing HIV care in our clinics where about 67% of these are women. Men are possibly still under-represented. Most of the patients in the study were still on first-line ART and yet were virally suppressed, despite being a mature cohort that had been on ART for a prolonged period of time. With good adherence within this unique patient group, viral suppression can be achieved even with prolonged duration on first-line ART.Similar to other studies in Kenya and elsewhere, female PEs were found to have higher suppression rates than males ,25. ThisWhile it is possible that involving PLHIV as peer educators may lead to worse outcomes among them due to the stress associated with work in addition to managing their own care, this was not noted in this study. Interesting, majority of the PEs had achieved viral suppression despite the fact that more than a quarter of them were enrolled on ART with advanced disease (CD4 < 200 or WHO stage 3 and 4). Several factors may have contributed to high viral suppression among PEs. PEs have the benefit of accessing patient literacy materials and working in an environment where adherence messages are being reinforced. They are also unlikely to miss appointments since they actually work in the facilities where they access their care and since they remind other patients of their appointment keeping, this may influence their own appointment keeping as role models. They are more likely to receive closer follow-up from the clinical team, and are more likely to have disclosed their status, which has likely led to better psychosocial support. Thus, when PLHIV are actively involved in their own care and that of other patients, this strengthens their adherence on ART and retention in care. Consequently, they will achieve viral suppression despite sociodemographic and clinical characteristics that generally predispose PLHIV to non-suppression.However, it is important to note that, there may be inherent factors  that make PEs good patients in the first place. It is possible that they were selected to be PEs by virtue of the fact that they are already good patients. Better viral suppression among PEs could therefore be explained by the fact that PEs may be a selected group (either self-selected or selected by the treatment programs) that are predisposed to have high adherence. Also, the act of being a PE may result in higher adherence. This study was not able to study this directly, but recognizes that these factors may have contributed to the findings. Qualitative studies would help researchers explore perspectives that make PEs more successful at achieving viral suppression.A limitation of this study is that study findings are not generalizable to other PLHIV who are not PEs. Generally, PEs have better psychosocial support, have less self-stigma, and were selected to be PEs based on existing desirable outcomes. Therefore, it is difficult to conclusively delineate whether their successful viral suppression reported in this study is correlated to their work as PEs specifically or not. Another limitation is that, since most participants were virally suppressed, the sample size became too small to analyze all the possible factors associated with viral suppression, given the small number of those not suppressed.Our study showed that PEs have high viral suppression rates. Longitudinal studies would help researchers and program implementers to understand further the reasons for better outcomes among PEs.S1 Peer Educator Dataset(CSV)Click here for additional data file.


Papua Province, Indonesia is experiencing an on-going epidemic of Human Immunodeficiency Virus (HIV) infection, with an estimated 9-fold greater prevalence than the overall national rate. This study reviewed the treatment outcomes of an HIV-infected cohort on Antiretroviral Therapy (ART) and the predictors in terms of immunological recovery and virological response.3) and immunological failure (CD4 <100 cells/ mm3) after at least 6 months on ART, using a longitudinal Generalized Estimating Equations multivariate model.ART-naïve individuals in a workplace HIV program in southern Papua were retrospectively analyzed. Patients were assessed at 6, 12 and 36 months after ART initiation for treatment outcomes, and risk factors for virological suppression  <1,000 copies/ml), poor immune response . Higher baseline CD4 was significantly correlated with better immunological outcomes, and lower likelihood of experiencing immunological failure (p <0.001).Assessment of 105 patients were included in the final analysis with a median age of 34 years, 88% male, median baseline CD4 236 cells/ mmVirological response at six months after beginning ART is the strongest predictor of viral suppression at 12 and 36 months, and may help in identifying patients needing additional adherence therapy support. Higher baseline CD4 positively affects the immunological outcomes of patients. The findings indicate HIV control programs should prioritize the availability of VL testing and begin ART regardless of CD4 counts in infected patients. Virological monitoring is the preferred method to monitor people living with HIV/ AIDS (PLWHA) on Antiretroviral Therapy (ART) . Viral lHome to the world’s fourth largest population of more than 260 million people ,8. PapuaWith good adherence, antiretroviral drugs (ARVs) improve the overall health status, survival and quality of life of PLWHA –17. BegiPT Freeport Indonesia (PTFI), an affiliate operation of an international gold and copper mining company, has operated in the Mimika District since the 1970s. Through its medical service provider, it began an HIV awareness campaign in the mid-1990s and an organized HIV treatment program in 2007, in parallel and partnership with the national HIV program at the district level. The company provides free-of-charge HIV testing and counseling, as well as care and treatment services, with the support of the national program and district health authorities for providing the ARV drug supplies. At the time of this study, all HIV-infected patients under the company’s clinical care were offered to start ART following the most current WHO recommendations [Studies have shown a large proportion of treatment failures attributed to patient non-adherence ,18,19. TCurrently, VL testing is not performed on a regular basis in the city of Timika , and is rarely accessible to the general public. However, PTFI health services routinely performs virologic monitoring amongst a sub-population (mine employees), in addition to the standard laboratory work-ups recommended in the 2014 guidelines.This study is designed to assess treatment outcomes and predictors among HIV positive adults initiating first-line ART under a workplace HIV treatment program. Until now, a detailed assessment of treatment outcomes in this particular group remained incomplete.We performed a retrospective cohort study of ART-naïve patients (employees and their immediate beneficiaries residing at site), ≥ 18 years-of-age, who began their first-line ART regimen at the mine-managed health care facilities between January 2008 and October 2015. Treatment outcomes were assessed at 6, 12, and 36-month time points, with repeated CD4 and VL level measurements. All patients were followed until their last visit, death, or end of the study period (36 months after beginning ART). Individuals without recorded baseline CD4 and VL measures, and at least one subsequent six-monthly CD4 and VL measures were excluded. Pregnant women at ART initiation or during the follow-up period were either excluded or censored, respectively. The reasoning behind removing pregnancy is that hemodilution, particularly during late stage pregnancy, might interfere with the interpretation of absolute CD4 cell counts . For pat3 or above were categorized as “poor immune responders”. Immunological failure was defined as persistently low CD4 count below 100 cells/ mm3.Treatment response was considered favorable in cases with viral suppression  after a minimum of 6 months on ART. Patients failing to achieve a CD4 cell count of 200 cells/mmRoutine data were accessed through the on-site electronic database medical record system. Data collected included basic demographic parameters such as age, sex, ethnicity, ART regimen, baseline CD4 counts and VL levels immediately prior to ART. Evaluations of VL level were based on a single measurement. To protect confidentiality, all patient identifiers were removed from the database before analysis.Patients were grouped according to their baseline CD4 count and VL level at the start of ART and other demographic variables. Categorical variables were summarized as frequencies and percentages while numerical variables with non-normal distributions were summarized as median and interquartile range (IQR).3, and experiencing immunological failure. Univariate analysis was conducted using chi-square (χ2) test. Predictors with a p-value <0.1, were placed in a longitudinal Generalized Estimating Equations (GEE) multivariate model to fit a repeated measures logistic regression. An independence correlation structure was used for the assumption that each repeated endpoint measurement is independent from one other. A 2-sided, p-value <0.05 was deemed statistically significant. All statistical calculations were conducted using STATA version 13.1 .We evaluated three endpoints: proportions of patients achieving viral suppression, failing to achieve a minimal CD4 count of 200 cells/mmThe Medical and Health Research Ethics Committee (MHREC), Faculty of Medicine, Gadjah Mada University, Indonesia granted ethical approval (KE/FK/1302/EC/2016), followed by final study approval from PTFI. This study used only secondary data; i.e., laboratory records and information from routine clinical records, therefore patients were not required to provide written consent for study participation.Between January 2008 and October 2015, 185 HIV positive patients initiated their first ART regimen at the participating health care centers. Of these, 76 patients were excluded, as they had one or more exclusion criteria. Four further patients were excluded due to inconsistent medical records where date of first ART initiation could not be determined .3 , and median baseline plasma VL level was 179,000 copies/ml .Baseline characteristics of the study population are provided in At the end of the observation period, with 36 months of follow-up after beginning ART, 4% of study subjects had died (n = 5), and 13% were no longer active in the system . Two patients (1.6%) had switched to the second-line regimen (n = 2). Laboratory findings following the exclusionary event were not included in the final analysis.3  at baseline, to 303 cells/ mm3  at the end of 36 months. The largest increment in CD4 count was seen in the ‘Low’ baseline CD4 group, compared to ‘Medium’ and ‘High’ groups, from a median of 46 cells/ mm3 , 236 cells/ mm3 , and 396 cells/ mm3  at baseline, to 266 , 325 , and 253 cells/ mm3  at 36 months, respectively , 28% (21 of 74), 32% (23 of 73) and 18% (7 of 39) showed poor immunological response marked by CD4 count below 200 cells/mmAt 6 months following ART initiation, 68% (n = 74) of the treated patients achieved viral suppression marked by VL level <1,000 copies/ml, increasing to 80% (n = 73) at 12 months, and 75% (n = 39) at 36 months. Median plasma VL declined from 175,000 copies/ml  at baseline to 22 copies/ml at 36 months, much lower than the defined limit of detection for suppression threshold criteria in LMIC .Univariate analyses revealed that neither sex nor baseline VL level affected treatment response. Multivariate analyses revealed that the single predictor of favorable virological outcome at 12 and 36 months was a one-log decrease in VL level at 6 months post-ART initiation . Patients of non-Papuan ethnicity have a higher likelihood  of achieving viral suppression at 6, 12, and 36-month time points, compared to those of Papuan ethnicity .Patients with higher baseline CD4 counts were significantly less likely to be poor immune responders; ‘medium’  and ‘high’ CD4 counts ; or experiencing immunological failure; ‘medium’  and ‘high’ CD4 counts ; at 6,12 and 36 month time points whilst on ART, than patients in the ‘low’ baseline CD4 group . AdditioEthnicity was also associated with immunological outcomes at 6, 12, and 36 months. Non-Papuan patients were less likely to be poor immune responders  and had a lower likelihood of experiencing immunological failure  whilst on ART, when compared to patients of Papuan descent.Our findings indicate that patients overall showed improvements in both virological and immunological response whilst on ART. Virological suppression was achieved in 80% of our study population at 12 months after ART initiation. This is within the range of 71–84% of patients showing viral suppression after 12 months of ART, reported by the TAHOD study and other HIV programs in LMIC settings ,27. It iIn our study, we found that the most significant predictor of achieving viral suppression at 12 and 36 months was a 1-log decrease in VL at six months after beginning ART. This finding is concordant with other studies reporting that a decrease in VL at an earlier stage showed a strong association with better virological outcomes at 12–24 months post- ART initiation –32. In o3 at 6 months post-ART initiation increases the risk of disease progression and death [In terms of immunological outcomes, the majority of patients showed improvements in CD4 count recovery over time. As there is no consensus on the definition of successful immunological recovery, we were interested in the minimal CD4 count before opportunistic infections typically become evident in poor immune responders. An absolute CD4 count of less than 200 cells/mmnd death ,33. A cond death . The pro3) count at baseline. However, despite showing the highest relative increase in CD4 recovery, patients in the ‘low’ group achieved lower CD4 peaks than those with higher baseline groups. Observation time, wherein an increase in CD4 depends on both the baseline value and amount of time on continuous treatment, might be one possible explanation for our findings [A low CD4 count at ART initiation was associated with higher likelihood of being a poor immune responder in our series. This is in concordance with other studies, which reported baseline CD4 counts were positively associated with immunological recovery ,33. ThisImmunological failure was significantly associated with lower initial CD4 counts and age. Other studies ,37,38 haOne important finding in our study was that ethnicity appeared to be a significant predictor of favorable treatment outcomes. Patients of non-Papuan origin  have a higher likelihood of achieving viral suppression, a lower likelihood of being a poor immune responder, and experiencing immunological failure, compared to patients belonging to the Papuan 7-tribes. There were no significant differences in ART response between the Papuan ethnic groups (7-tribes vs. others). The correlation between therapeutic response and ethnicity alone is not clear. Ethnicity  itself may not be a causal factor, but could influence immunological response for other reasons. However, we believe that social determinants such as prevailing cultural practice, educational level , as well as disease perceptions and treatment-seeking behavior may play an important role in a patient’s adherence to treatment and thus affecting treatment outcome. We could not find relevant treatment outcome studies in Papua or Papua New Guinea settings, published investigations were mostly related to the epidemiology, social experiences of PLWHA on ART as well as prevention initiatives –44. As PInterestingly, similar to longitudinal studies conducted in Ethiopia ,46, we oThere are several limitations in this retrospective study. VL level assessments were done based on single laboratory measurements, which might have affected the analysis by not ruling out random viral ‘blips’ (intermittent low-level viremia). The initial number of patients for inclusion was limited, and became smaller after invoking the study exclusion criteria. There was also a high percentage (~52%) of loss to follow-up patients by the end of the 36-month observation, especially in the ‘High’ CD4 group. This may have underestimated the outcome in the ‘High’ group. Health care providers should make a concerted effort to trace the LTFU. Additionally, since this study used secondary data derived from routine medical records, possible issues of data integrity may have had an impact on analyses and conclusions. To maximize the analytic precision, a longitudinal GEE multivariate model allowed use of all available data from each study subject. Advantages of this approach include accounting for correlations between response variables across time in the same individual and the flexibility to use non-normal distributed data without the need of complete datasets .Other points of interest such as patient HIV awareness and perceptions, actual daily adherence to treatment, education level, location of residence (onsite/ off-site), and disclosure of HIV-status to close acquaintances, were not available for analysis. The five deaths observed in our followed cohort had limited data for further analysis. Lastly, because employment at the mine is highly skewed towards male workers, females, in general, were under-represented in the analysis (12% of 105 patient records).Our findings demonstrate that VL testing plays a crucial role in predicting favorable virological outcome whilst on ARV treatment, and that baseline CD4 is the most significant predictor of subsequent immune recovery. National HIV control programs at the district level, should strongly consider implementing virological monitoring and provide VL testing for the public to enhance better treatment outcomes. To our knowledge, there are very few, if any, routine virological monitoring programs measuring treatment response outcomes in Indonesia. These findings from a workplace program should be a useful benchmark for other HIV programs in the country for considering virological monitoring of patient prognosis and treatment progress.S1 Table(DOCX)Click here for additional data file.


Managing and detecting antiretroviral treatment response is important to monitor the effectiveness of medication and possible drug switching for low immune reconstitution. There is less recovery of CD4+ T cells among human immunodeficiency virus patients infected with tuberculosis. Hence, we aimed to assess the effect of tuberculosis and other determinant factors of immunological response among human immunodeficiency virus patients on highly active antiretroviral therapy. A retrospective follow up study was conducted from October to July 2019. A total of 393 participants were enrolled. An interviewer based questionnaire was used for data collection. Patient charts were used to extract clinical data and follow up results of the CD4+ T cell. Current CD4+ T cell counts of patients were performed. STATA 13 software was used to analyze the data. A 3, poor treatment adherence and tuberculosis infection were significantly associated with the immunological failure.The mean age of study participants was 39.2 years (SD: + 12.2 years) with 8.32 mean years of follow up. The overall prevalence of immune reconstitution failure was 24.7% (97/393). Highest failure rate occurred within the first year of follow up time, 15.7 per 100 Person-year. Failure of CD4+ T cells reconstitution was higher among tuberculosis coinfected patients (48.8%) than mono-infected patients (13.7%). Living in an urban residence, baseline CD4+ T cell count ≤250 cells/mmThere was a high rate of CD4+ T cells reconstitution failure among our study participants. Tuberculosis infection increased the rate of failure. Factors like low CD4+ T cell baseline count, poor adherence and urban residence were associated with the immunological failure. There should be strict monitoring of CD4+ T cell counts among individuals with tuberculosis coinfection. Human Immunodeficiency Virus (HIV) infection is still a major public health problem in the globe. In countries of Sub-Sahara, there were about 23 million HIV infected people. Most of the infected Sub-Saharan patients had reported late to health facilities for treatment , 2. HIV Globally, by the year 2017, there were about 20.9 million HIV patients estimated to receive highly active antiretroviral therapy (HAART) . AntiretAmong HIV infected patients in developing countries, TB remains a major public health problem . MoreoveIn Ethiopia, access to HAART started massively in 2005 . The treA retrospective follow up study was employed to assess the effect of TB and other determinant factors of immune reconstitution among HIV patients on HAART in Adigrat General Hospital, Eastern Tigrai, Ethiopia from October to July 2019. Adigrat is a zonal administrative town of Eastern Tigrai, with an estimated population of 76,400 . The towAdigrat General Hospital is one of the governmental Hospitals located in Adigrat established for peoples from 6 weredas (districts). The Hospital is currently involved as teaching and referral services for more than 1,000,000 population with an average annual client flow of 131,125 people. The Hospital has about 120 beds with a total of 209 health care providers and 132 administrative staffs. There are about 10 health care providers in the HAART clinic of the Hospital and a total of 1582 HIV patients currently on HAART follow up.All HIV patients who were currently on HAART and screened for TB infection during or after initiation of the HAARTSimple random sampling technique was used to enroll the study participants from the sample frame of HIV patients list in the HAART clinic.Sample size was calculated using double population proportion and determined by Epi info version 7.1 software comparing the proportion of treatment response among TB exposed and non-exposed groups of the population and using 80% power.393 HIV patients were included with the ratio of 1:2 (123 exposed to TB and 270 non-exposed to TB).HIV patients complete charts and with at least 6 months of follow up of HAARTHIV patients who were transferredin with full previous data and initial baseline CD4+ countHIV patients who have provided written informed consent or assent to participate in the studyHIV patients who were lost to follow up to course of HAARTAn interviewer based semi structured questionnaire with some open and closed ended questions was used to collect socio-demographic data . Clinical data  and previous follow up results of CD4 + T cells  from patients’ medical records and charts.About 2 ml of venous blood was collected from each patient by trained laboratory professionals. Current CD4+ cell counts were performed using BD FACS Presto™ cartridge machine . We performed the CD4+ T cell counts using BD FACS Presto machine which is used to determine CD4+ T cells, CD4+ percentage and hemoglobin of the HIV patients on HAART. The cartridge of the BD FACS Presto contains dried fluorochrome-conjugated antibody reagents wherby bind with the CD4+ T cells. CD4+ T cell will be counted, when blood reacts with the dried fluorochrome-conjugated antibodies, the antibodies bind to the surface antigens on the T lymphocytes. After 18 min of incubation, the cells are analyzed on the BD FACS Presto™ near-patient CD4+ T cell counter.p <  0.20 in the bivariate logistic regression were transferred to multi-variate regression analysis to identify the factors that have statistical significance and significantly associated with the dependent variable. A p-value of ≤0.05 was considered as statistical significant.We used STATA version 13 software for data entry and analysis. Descriptive statistics were performed. Data were summarized and organized using figures and frequency tables. Bi-variate and multi-variate regression analysis were employed to measure the association between dependent and independent variables. Variables with Good adherence: When the average treatment adherence of HIV patients is greater than or equal to 95%.Average adherence: The average treatment adherence by the patients is from 85 to 94%.Weak adherence: The average treatment adherence by the patients is less than 85%.Taking HAART medications properly on a consistent basis over time and not missing doses of the prescribed therapeutic agents .Good adFailure in immune reconstitution: CD4+ T cell counts to baseline or below/CD4+ T cell counts below 100 cells/mm3 for consecutive tests during the course of HAART [of HAART .Success in immune reconstitution: CD4+ T cell counts greater than the baseline count after initiation of HAART [of HAART .The ability of the body to respond to HAART and recovery of CD4+ T cell countsA total of 393 HIV patients enrolled in HAART were included in our study. Out of the total, 262 (66.7%) were females. The mean age of the study participants was 39.2 years . The HIV patients were on follow up from 6 to 180 months with a median of 121 months. Most of the study participants were from urban residents, 249 (63.4%) . The mean baseline CD4+ T cell counts among HIV and HIV/TB infected individuals was 240 and 258 cells/μl. The HAART enrollment eligibility criteria for most of the study participants, 314 (79.9%) was due to clinical staging. One hundred twenty-three (31.3%) of the total study participants developed active TB within the 180 months of follow up with an incident of 4.04 per 100 PY. Most of the study participants, 350 (89.1%) were in WHO clinical stage I . About 62 (63.9%) of all the immune reconstitution failures of CD4+ T cell recovery had occurred within 1 year of HAART follow up. The rate of immune failure from our study participants on follow up was 15.78 per 100 PY at the end of 12 months, 8.27 per 100 PY at the end of 24 months, 6.11 per 100 PY at the end of 36 months, 4.32 per 100 PY at the end of 60 months and 2.47 per 100 PY at the end of 120 months.From this study, the prevalence of immunological failure among HIV/TB co-infected patients was 48.8% 60/123). However, the prevalence of immune reconstitution failure among HIV mono-infected patients was 13.7% (37/270). The Study participants were failed immunologically as they got infected with TB  were checked for each variable. Variables with a p-value less than 0.05 in the multivariate analysis were considered statistically significant at 95% confidence level. Finally, living in urban residence , having baseline CD4 count less than 250 , poor treatment adherence  and developing TB infection  were significantly associated with the immunological failure to HAART . This is similar to studies reported from Tanzania, 25%  and ChinIn this study, the rate of immunological failure was 2.966 per 100 PY. This is in line with previous reports from Latin America, 2.57 per 100 PY . HoweverTwo hundred eighty-five (72.5%) of our study participants had good adherence to treatment. Similar study reported from Southern Ethiopia, 81.8% , NorthweThe median baseline CD4+ T cell count of our study participants was 196 cells/μL. This is comparable with the studies reported in Southwestern Ethiopia, 191 cells/μL . Howeverp <  0.001). This report is supported by previous studies from Debremarkos, Ethiopia [p <  0.001). This is supported by a study conducted in Northwestern Ethiopia [Lower baseline CD4+ T cell count (baseline CD4+ T cell count less than 250 cells/μL) was statistically associated with immune reconstitution failure of HAART . This was similar to reports from Southern Ethiopia [This study revealed that, immune reconstitution failure was 11.5 times more likely to occur among TB co-infected individuals compared to TB non-infected individuals . A previous study conducted in Ethiopia [The other associated factor for experiencing low immune reconstitution was residence. Participants from an urban residence were 2.1 times more likely to have low CD4+ T cells recovery than rural residents (Ethiopia  has repoThe overall rate of immune reconstitution failure among HIV patients on HAART was high. TB co-infection has shown to contribute to the higher rate of low CD4+ T cells to HIV therapy. Other factors like low CD4+ T cell baseline count, poor adherence and urban residence were also associated with low immune recovery. HIV patients who are coinfected with TB should be monitored for evaluation of CD4+ T cell count determination strictly. Hence, there would be a good immune recovery of HAART. Moreover, a virological response shall be assessed to HIV patients on HAART to determine the recovery from viral antigen replications.


The sentence: “Patients eligible to enter MANET were established on 2 NRTIs plus a PI/b for ≥12 months and showed a CD4 count >200 cells/mm3 and a plasma HIV-1 RNA load.” should read: “Patients eligible to enter MANET were established on 2 NRTIs plus a PI/b for ≥12 weeks and showed a CD4 count >100 cells/mm3 and a plasma HIV-1 RNA load.” This has been updated in the original article.


Understanding the prevalence and evolution of HIV-1 drug resistance (DR) and associated mutation patterns is critical to implementing free antiretroviral therapy in Yunnan, the first antiretroviral treatment location in China. Here We provide a basis for understanding the occurrence and development of HIV-1 resistance in Yunnan and a theoretical foundational for strategy to delay HIV-1 drug resistance and achieve successful individualized treatment.Plasma samples from different cities/prefectures were collected at Yunnan Provincial Hospital of Infectious Disease from January 2010 to September 2016, and those from drug-resistant individuals were genotyped using in-house assays, 88 patients were selected for the study who had been on treatment for ≥6 months (and for whom drug resistance was then measured), and each patient had at least 3 genotype resistance tests and who were enrolled to analyze mutation and evolution of HIV resistance.264 Pol sequences of 88 patients were obtained. Drug resistance levels to eight drugs increased to varying degrees with prolonged treatment. Resistance to efavirenz (EFV) and etravirine (ETR) showed the highest change, comparisons of resistant changes to second and first and to third and second agents showed altered level of drug resistance were 25 and 20 cases, 28 and 18 cases, respectively. The smallest change was Lopinavir/Ritonavir (LPV/r) present 2 and 3 cases; Resistance to lamivudine (3TC) and lopinavir/ritonavir (LPV/r) was high among patients detected thrice, whereas other drugs were distributed in all resistance levels. M184 V/I (26.14%), T69S (11.36%), and T215Y/I (10.23%) mutations were the most common in nucleoside reverse transcriptase inhibitors (NRTIs), and K103 N/R/S (21.59%), V179D/E (20.45%) in Non-NRTIs (NNRTIs). Furthermore, L10 V/F/I (6.82%), A71V (4.55%), and I54V (4.55%) mutations were common in protease inhibitors (PIs).We found dynamic genotypic changes in HIV-1 drug-resistance in Yunnan, with prolonged treatment, and drug resistance was inevitable. However, resistance to different drugs occurred at varying times, and mutation site emergence was the main cause. These findings enhance our understanding of evolution and regulation, and are valuable for developing HIV-1 DR prevention strategies in Yunnan. It is estimated that at least 840,000 people are living with human immunodeficiency virus (HIV) in China. This epidemic is characterized by geographical disparities and a higher prevalence among certain subgroups of the population. The number of new cases is approximately 13,000 every month. The Yunnan province is the main area for smuggling illicit drugs into China. Therefore, the occurrence of the first HIV-1 epidemic (caused by subtype B (or B′) in 1989 among intravenous drug users (IDUs) in this province was not a surprise. Currently, the number of infected patients in this province is approximately 100,000, and HIV-1 genotypes B, C, CRF01_AE, CRF07_BC, and CRF08_BC are in circulation.The Chinese government implemented the National Free Antiretroviral Therapy (ART) Program in 2003, and highly active ARTs (HAARTs) were first provided in Yunnan in 2004. This strategy has markedly improved the morbidity and mortality associated with HIV-1 infection . FurtherThe effective prevention of the spread of HIV DR and the control of AIDS progression in already infected individuals is important. However, although numerous studies have investigated the prevalence of drug-resistant HIV variants, most were confined to specific areas or populations in Yunnan –13. FurtOur study aimed to conduct a province-wide survey to investigate the occurrence and development of DR to HIV-1 genotype, the extent of changes in drug sensitivity with prolonged treatment, and the appearance and evolution of HIV-1 DR mutant sites. These analyses were performed to understand the factors that may be associated with the onset and progression of DR and to propose ways of minimizing the impact of these factors on the clinical outcome.Blood samples were collected, three or more times, from 100 newly confirmed HIV-1-positive individuals between January 2011 and December 2016. The number of HIV/AIDS patients treated in Yunnan Province during the 6-year period was approximately 60,000, of which 15% (approximately 9000) were treatment failures and 4500 tested positive for DR. We expect that 100 individuals from 11 prefectures represent the larger patient population due to the systematic sampling method to select patients who tested positive for DR more than three times. The HIV-1 infection status was determined using an enzyme-linked immunosorbent assay  and confirmed using a western blot assay .9/L, (2) World Health Organization stage III/IV disease, or (3) willingness to receive ARTs regardless of criteria 1 and 2 [The study population consisted of patients with HIV/AIDS who received HAARTs for more than six months, were under the National Free Antiretroviral Treatment Program (NFATP), which provides lifelong free ARTs to people living with HIV; and met the national treatment criteria , 15. The 1 and 2 . Followi, marital status, route of transmission, baseline CD4+ count, sample area, and therapeutic regimen. For patients with DR, the treatment and drug replacement information were also recorded.Yunnan has AIDS treatment clinics in over 16 prefectures. The patients were regularly followed-up at each time point. At each follow-up, the doctor recorded the patient’s treatment information, including patient characteristics, and uploaded the information onto the province’s therapeutic website, we downloaded and recorded the demographic and epidemiological information of patients from the treatment system, collated the data which contained agePlasma was separated from whole blood, and viral RNA was extracted from 500 μL of plasma from HIV-1-positive patients using the Easy Q extraction system  according to the manufacturer’s instructions. For amplification of the Pol gene, the first-round amplification was performed using the One Step reverse transcription polymerase chain reaction  with primers for MAW26 (5′-TTGGAAATGTGGAAAGGAAGGAC-3′) and RT21 (5′-CTGTATTTCTGCTATTAAGTCTTTTGATGGG-3′) in a 25-μL reaction volume using 30 cycles. Nested Pol PCR was performed using primers for PRO-1 (5′-CAGAGCCAACAGCCCCACCA-3′) and RT20 (5′-CTGCCAGTTCTAGCTCTGCTTC-3′) for the second round. The cycling conditions used were as described by Li . Positivhttp://hiv-web.lanl.gov/content/sequence/BASIC_BLAST/basic_blast.html) to check for potential contaminations. A phylogenetic tree was constructed by the neighbor-joining method based on Kimura’s two-parameter distance matrix with 1000 bootstrap replicates using Mega 6.0. In the phylogenetic tree, we ensured that there was no cross-contamination. Drug-resistance mutation profiles and antiretroviral susceptibility were assessed using the World Health Organization-recommended list of mutations for DR surveillance.All the sequenced fragments were edited and assembled using Sequencher 6.0 DNA sequence analysis software . Clustal W Multiple alignments and manual editing were performed using Bio-Edit 7.0.9.1 software. The obtained sequences were compared to all known sequences in the HIV database using the Basic Local Alignment Search Tool  gene, were submitted to Stanford University [http://hivdb.stanford.edu/hivdb/by-mutations/). The levels of resistance to commonly used protease and RT inhibitors were analyzed using a genotypic resistance interpretation algorithm. The scores are the sum of each mutation penalty score for each drug. Scores less than 10 indicate susceptibility; scores between 10 and 14 indicate potential low-level resistance; scores between 15 and 29 indicate low-level resistance; scores between 30 and 59 indicate intermediate resistance. Scores of 60 or higher indicate high-level resistance.The nucleotide sequences of the iversity , 20  19.0 software . Categorical variables were compared using Fisher’s exact test or a Chi-square test. We determined that patient characteristics were considered statistically significant in the occurrence of DR when Between 2011 and 2016, 100 individuals of Yunnan province who had been accepted into the free ART program for more than six months and who had viral loads ≥1000 copies/mL, measured at least three times at a return interval of 1.5 years, were studied.On at least three separate occasions, genotype resistance tests were carried out on plasma samples from these subjects. After amplification, a genotype test was performed using an in-house method, and the raw sequences were assembled, aligned, and edited. As a result, 264 Pol sequences  were obtained. Samples from 12 individuals were not successfully amplified on one or more occasions as these individuals tested negative in all three tests performed to detect PCR products and the obtained sequences of HIV Pol genes. Therefore, we finally included 88 individuals for analysis.Pol gene are summarized in Table The BLAST search showed no evidence of sample contamination. The demographic characteristics of the participants with the 3  and 201–350 cells/mm3 . Comparatively, the incidence of DR in patients in the 351–500 cells/mm3 group was statistically significant.Based on the baseline CD4 lymphocyte count, the patients were mainly categorized into two groups: 0–200 cells/mmMost participants lived in Kunming, Lincang, and Honghe. In this study, we enumerated the treatment regimens for 88 individuals when the latest drug-resistance was detected. Patients who appeared to have nevirapine (NVP)-containing regimens had a higher DR incidence, those who had been switched to efavirenz (EFV)-containing regimens had lower rates of resistance, and those on protease inhibitor (PI)-containing regimens were almost completely non-resistant.DR variants were identified in 88 of the 100 subjects. The highest proportion of patients with DR detected at any time point was 61.4% (54/88), and the ratios of resistance for the first, second, and third detections were 61.4% (54/88), 59.1% (52/88), and 58.0% (51/88), respectively.Based on the treatment duration, the degree of resistance to eight antiviral drugs in Yunnan province increased to different extents; there was a high degree of resistance to Lamivudine (3TC) and lopinavir/ritonavir (LPV/r). The mean times at which resistance was assessed using the three DR tests in the 88 patients were 3.49 ± 2.73, 4.49 ± 2.85, and 5.97 ± 2.81 years. Increasing the treatment time also increased the number of DR subjects that received various drugs. Furthermore, the level of DR showed an upward trend, which is described in Table Next, we evaluated the changes in DR in the 88 treatment-failed individuals by comparing their second and first, and third and second results. The changes in DR among different patients are summarized in Table For the 88 HIV cases with Pol sequences, 61 were positive for the tested mutations. New mutations can emerge in the same patient as treatment progresses; however, early mutations can also disappear with drug administration.The most common NRTIs mutations were M184 V/I, T69S, and T215Y/I, with DR rates of 37.7, 16.39, and 14.75%, respectively. The mutation M184 V/I principally appeared in the first antiviral treatment failure, whereas the T215Y/I mutation was mainly associated with the second and third occasions.The most common NNRTIs mutations were K103 N/R/S, V179D/E, and G190A, with DR rates of 21.59, 20.45, and 18.18%, respectively. The NNRTI-related mutations mainly appeared in the first and second tests.The PI mutations most commonly found were L10 V/F/I, A71V, and I54V, with DR rates of 6.82, 4.55, and 4.55%, respectively. These latter sites were affected in the early stages of treatment. The mutations associated with DR in patients with ART failure are illustrated in Fig. In this study, we conducted a cohort analysis, using broad surveillance of HIV drug-resistance. One hundred HIV-1-positive individuals from 11 prefectures were enrolled in the study and 88 were subjected to DR analysis. Since all participants were from Yunnan, our data are not representative of the overall situation of drug-resistant variants. However, these data on the prevalence of drug-resistant variants will have important implications for clinical therapy, concerning genetic evolution.Since ART was made available free of cost across Yunnan, a significant number of individuals infected through sexual transmission accepted the free treatment . MoreoveOur study shows that ART duration positively correlated with an increased incidence of HIV-1 drug-resistant strains. In other words, the longer the duration of ART, the higher the probability of developing drug-resistance. Therefore, it is important to elucidate the occurrence and development of HIV DR as well as changes in mutations in Yunnan.Seven factors were taken into account in the DR and non-DR groups to determine the risk factors associated with HIV-1 DR. We inittially thought that the high prevalence of HIV DR among individuals infected through IDU was due to better adherence in individuals infected through sexual transmission, resulting in lower HIV DR –24. HoweInterestingly, when we analyzed the association between HIV DR and CD4+ counts, we found a statistical difference between the group with < 200 cells/μL and the group with 351–500 cells/μL, showing a close correlation between cell count and the development of drug-resistant strains, in addition to having a significant impact on the risk of mortality . This suZaccaerlli  comparedHowever, EFV was an exception to the trend as susceptibility in the third test was higher than that of the previous two tests. We surmise that the dose requirement of EFV in China is relatively high, resulting in a higher blood concentration, which slows the conversion of the virus into a resistant strain. For low-level and moderate DR, the resistance to the three types of drugs increased with the duration of treatment, but the opposite trend was observed for EFV. We highlight that the DR surveillance network at Stanford University is likely to use a mutation at a single locus to provide a definitive standard for interpreting EFV resistance results; this may have affected our results.The rates of high-level resistance were elevated for all the drugs assessed, which coincided with a decrease in the sensitivity rates. From the dynamic changes in drug susceptibility, we demonstrated that the extent changes of apparent DR were the highest for EFV, followed by NVP, and 3TC. As the duration of the therapy increased, the susceptibility to these three drugs decreased markedly, adherence in some patients was also reduced with prolonged treatment time, causing an increase in the number of resistant patients. However, the rise in drug susceptibility might be because ART medical professionals found, based on the initial DR reports, that the drugs were losing efficacy, and therefore, discontinued them, resulting in the disappearance of drug stress.Mutation at sites such as M184 V/I and K103 N are important because they cause resistance to several drugs, and thus, play a decisive role in the extent to which DR changes over time. Some patients who were initially susceptible transitioned to potentially drug-resistant at the second analysis. As time progressed, they developed low-level, moderate, or high-level resistance. This potential resistance should be treated as a red-flag warning of the need to improve adherence or switch to replacement drugs and must be swiftly acted upon to avoid the development of higher degrees of DR.The interaction between the host, drug, and virus contributes to DR in HIV because the virus develops strategies to escape drug pressure. For example, it mutates self-resistant gene sites to resist the therapeutic effect of ART drugs. Antiviral treatment failure in patients with HIV appears inevitable. Thus, timely detection of genotypic susceptibility to DR and an adjustment of the treatment regimen might improve ART success.Some of the most common nucleoside analog-associated mutations (NAMs) are the thymidine-associated mutations (TAMs). Two clusters were studied here; TAM-1 (M41 L and T215Y) and TAM-2 . The viruses that present TAM-1 s usually produce more cross-resistance to other NRTIs, whereas the cross-resistance of the viruses carrying TAM-2 is very low. The resistance rates of patients carrying the AZT and D4T mutations increased at all stages; this may be due to the long time that TAMs take to develop.M184 V/I was the most frequent NRTI mutation found during the first and second analyses. Another study showed that when 3TC was used as a single drug, M184 V/I resistant strains replaced wild strains in a few weeks and that when 3TC was used in combination treatments, M184 V/I DR strains always appeared first . This maWithin the three major classes of antiviral drugs, NNRTIs are the most complex, having many mutations. We observed that NNRTI mutations principally occurred in the first and second periods of treatment failure and were mainly K103 N/R/S, V179D/E, Y181C/I/V, G190A, Y188L/C. Because these mutations arose much earlier in the course of treatment, leading to high resistance to one or more NNRTIs, we deduce that mutation at these sites has an impact on the DR to all NNRTIs. Even though a NNRTI could replace another after failure, these mutations persisted.Previous studies have performed adaptive sequencing of subjects receiving NNRTIs, , 30 and As PIs are not widely used in patients with HIV/AIDS in and around our province, the frequencies of major or minor DR-related mutations were very low. L10 V/F/I had the highest rate (up to 6.82%). None of the major PI mutations emerged during the third monitoring. We believe that the occurrence of these mutations does not lead to real DR; the observed DR would likely be due to the transmitted strains.We acknowledge the limitations of this study. Most of these patients came from rural areas or towns and villages where the antiviral treatment and management could be improved, and the medical staff capacity is limited. Thus, it is possible that many of these patients were not switched to the second-line drugs when resistance to the first-line drugs occurred or did not completely follow the National Antiviral Treatment Manual Standards to replace the drugs. Therefore, we cannot accurately account for the drug replacement process for these 88 individuals. This is the major drawback of this study.The prevalence of HIV-1 DR in individuals with long-term ART-failure in Yunnan Province is likely the cause of the current hyper-endemic state. Based on our results, DR appears to be an inevitable outcome; however, we have found some evolutionary rules underlying its development and progression. Developing strategies to effectively optimize regimens in local regions and promote adherence to long-term medication will be an arduous task but will be important and of great significance to improve the control and prevention of AIDS in this area.