Introduction: Resistance to antiretroviral drugs can complicate the management of HIV-1 infection and impair control of its spread. The aim of the current study was to investigate the prevalence and transmission of HIV-1 drug resistance among 106 antiretroviral therapy (ART)-naïve patients diagnosed in Iceland (1996–2012).Methods: HIV-1 polymerase sequences were analysed using the Calibrated Population Resistance tool. Domestic spread of transmitted drug resistance (TDR) was investigated through maximum likelihood and Bayesian approaches.Results: Among ART-naïve patients, the prevalence of TDR to any of the following classes  was 8.5% (95% CI: 4.5%- 15.4%): 6.6% to NRTIs, 0.9% to NNRTIs, and 1.9% to PIs. The most frequent NRTI mutation detected was T215C/D . The only NNRTI mutation detected was K103N . PI mutations detected were M46I  and L90M . Six patients harbouring T215C/D, were linked in a supported phylogenetic cluster. No significant association was found between TDR and demographic or risk groups. Trend analysis showed a decrease in the prevalence of TDR .Conclusions: TDR prevalence in Iceland was at a moderate level and decreased during 1996-2012. Screening for TDR is recommended to limit its local spread and to optimize HIV-1 therapy.Abbreviations: ART: Anti-retroviral therapy; ARV: antiretroviral; ATV/r: atazanavir/ritonavir; AZT: azidothymidine; BEAST: Bayesian evolutionary analysis by sampling trees; CI: confidence interval; CPR: calibrated population resistance; CRF: circulating recombinant form; d4T: stavudine; EFV: efavirenz; FET: Fishers’ exact test; FPV/r: fosamprenavir/ritonavir; HET: heterosexual; IDU: injection drug use; IDV/r: indinavir/ritonavir; LPV/r: lopinavir/ritonavir; MSM: men who have sex with men; M-W: Mann–Whitney U test; NFV: nelfinavir; NNRTIs: non-nucleoside reverse transcriptase inhibitors; NRTIs: nucleoside reverse transcriptase inhibitors; NVP: nevirapine; PIs: protease inhibitors; pol: polymerase gene; SDRM: surveillance drug resistance mutation; SQV/r: saquinavir/ritonavir; TDR: transmitted drug resistance HIV-1 was first reported in Iceland in 1985. By the end of 2012 a total of 300 patients had been diagnosed with HIV-1 infection in the country, of which 66 had developed AIDS and 39 passed away as a result of the disease.Successful management of HIV-1 infected patients is highly dependent on antiretroviral therapy (ART) that has been shown to reduce morbidity and mortality from the disease. ART alsoAntiretroviral (ARV) drug resistance mutation can arise as a result of direct transmission from a patient harbouring drug-resistant mutants  or due to selection of drug-resistant mutants within patients who are not successfully managed (secondary or acquired resistance). The rapid evolution of HIV-1 facilitated by its error-prone reverse transcriptase and selection pressure by the ARV drugs are the driving forces behind the emergence of ARV drug resistance.,10 ResisNo earlier studies have investigated the status of ARV drug resistance in Iceland. The objectives of the current study were to conduct an epidemiological surveillance on TDR among patients who were diagnosed with HIV-1 infection in Iceland between 1996 and 2012 and to describe the types of resistance to different classes of ARV drugs in the country, as well as to investigate the domestic transmission of TDR.Iceland is a Nordic country with a population of about 320,000 people as of the end of 2012.[The study was approved by Landspitali University Bioethics Committee in accordance with the declaration of Helsinki. Since many patients at the time of our study initiation were deceased or had moved outside Iceland, the Landspitali University Hospital Ethics Committee considered the use of the study material for the research in this study without the need of consent of the study participants since it would be impossible or impractical to obtain.pol) sequences that were utilized in our study were generated using the Sanger population sequencing method. The details of the sequencing approach were described previously.[pol sequences  were analysed using the calibrated population resistance (CPR) tool in the Stanford University HIV drug resistance database (http://cpr.stanford.edu/cpr.cgi).[The HIV-1 polymerase (eviously. The 106 cpr.cgi). The 2009cpr.cgi).n = 63) in GARLI v2.0 using the GTR+I + Γ nucleotide substitution model.[A maximum likelihood (ML) phylogenetic tree was constructed for the Icelandic subtype B sequences , and BEAST parameters showed high convergence with effective sample size (ESS) values ≥ 200 for all. The maximum clade credibility (MCC) tree was generated using TreeAnnotator v1.8.0 available in BEAST package.[PP) values equal to 1.0 were considered significant. The analysis was repeated after removal of resistance codon positions as described previously.The Icelandic clade B sequences were analysed using a Bayesian approach in BEAST v1.8.2. Analysis package. For branhttp://epitools.ausvet.com.au). P-values were calculated using the exact two-sided Fisher’s test (FET) through GraphPad Software, Inc., available online . Mann–Whitney U test (M-W) was done using the VassarStats website, available online (http://vassarstats.net/utest.html). For trend analysis, we used two-tailed linear-by-linear test for association through IBM SPSS Statistics 21.0.The binomial distribution  95% confidence interval of the prevalence was calculated using EpiTools epidemiological calculator available online . The median time between diagnosis and sampling was seven days (range: 0–154 days).Approximately 60% of the patients were males and 40% were females. The median age at the time of diagnosis was 34 years (range: 2–77 years). Males were found to be significantly older than females , MSM  and IDU . A high proportion of the patients  were born in Iceland, and approximately 50% of all patients reported to have been infected outside the country.Self-reported routes of HIV-1 infection were: HET  risk factor category, which was under-represented in our sample . To excln = 63; 59%) followed by CRF01_AE , subtype C , CRF02_AG  and sub-subtype A1 . The minor subtypes/CRFs included: subtype D (n = 2), CRF14_BG (n = 1), CRF16_A2D (n = 1), CRF40_BF (n = 1) and CRF45_cpx (n = 1). For subsequent analysis related to subtypes/CRFs, we have divided the samples into subtype B (n = 63) and non-B subtypes/CRFs (n = 43) groups.Subtype B was found to be the most common genetic variant in the study sample , non-nucleoside reverse transcriptase inhibitor (NNRTI) and protease inhibitor (PI), was found to be 8.5% (95% CI: 4.5%–15.4%). In the nine patients that harboured ARV drug resistance mutations, seven had at least one mutation suggestive of resistance to NRTIs, two patients had at least one mutation indicative of resistance to PIs and one patient had a mutation indicative of resistance to NNRTIs. A single patient had mutations suggestive of resistance to both NRTIs and PIs. None of the patients had a sequence with mutations to all three classes of ARV drugs.n = 7; 6%). The other NRTI mutation detected was M41L , which causes intermediate resistance to AZT and d4T. The only major NNRTI mutation detected was K103N , which causes high-level resistance to efavirenz (EFV) and nevirapine (NVP). The two major PI mutations found were M46I , which causes low-level resistance to nelfinavir (NFV) and L90M , which causes high-level resistance to NFV, intermediate resistance to indinavir/ritonavir (IDV/r) and saquinavir/ritonavir (SQV/r) and low-level resistance to atazanavir/ritonavir (ATV/r), fosamprenavir/ritonavir (FPV/r) and lopinavir/ritonavir (LPV/r).[Thymidine analogue 215 revertant mutants (T215C/D), that cause low-level resistance to azidothymidine (AZT) and stavudine (d4T), dominated the NRTI mutations detected ( (LPV/r).The prevalence of TDR was higher in patients who were born in Iceland (12.3% vs. 2.5%), and in patients who reported infection in Iceland (10.2% vs. 2%); however, the difference was not statistically significant. Stratified by risk factor, TDR was found to have a higher prevalence in HET (11.1%) and MSM (10.3%) in comparison to IDU (3.8%) but without statistical significance. TDR was also more prevalent among patients infected with subtype B compared to all non-B subtypes/CRFs (12.7% vs. 2.3%) but also without statistical significance .Table 3.PP value of 1.0 in the MCC tree . The patients within this cluster harboured T215C/D and were diagnosed between 1997 and 2008. Three patients were males, two of whom reported MSM and one reported HET as risk factors for HIV acquisition. Three patients were females who reported HET as a risk factor for HIV acquisition. An identical cluster was found in the ML tree constructed after removal of resistance mutation codon sites. This excludes the possibility of incorrect clustering due to convergent evolution. The same transmission cluster was also identified through Bayesian analysis before and after removal of resistance mutation codon sites, with a MCC tree . The timn = 40) to those with dates of diagnosis after mid-2004 (n = 66), we found a significant higher likelihood of harbouring drug resistance mutations in the earlier time interval .When we compared patients diagnosed before mid-2004 . No statistical difference was found upon tracking the temporal changes in subtype B vs. non-B subtypes/CRFs over the study period .To investigate the trend of TDR prevalence and subtype distribution over time, we divided the study period into quarters, each of which represented 4.25 years. The proportion of patients with TDR was 26.0, 5.9, 4.0 and 2.4% for the four quarters, respectively. A significant decline of TDR prevalence was noted during 1996–2012 . This result is slightly higher compared to other Nordic countries.,23 NeverThe results of our study have also shown an evidence of decreasing TDR prevalence in Iceland during 1996–2012. This can be attributed to the continued improvements in treatment strategies that successfully suppress viral load and contribute to lower likelihood of transmission. As we haDespite lacking statistical significance, the finding that TDR was more prevalent among patients who were born in Iceland and reported infection in the country might be the consequence of the fact that access to widespread ART was established early in Iceland, similar to other European and North American countries. The same reason could explain the higher prevalence of TDR among patients infected with subtype B compared to other HIV-1 genetic variants that dominate in countries where widespread ART was introduced later in the course of HIV-1 epidemic.,31An interesting finding of our study was that a majority of thymidine analogue 215 revertant mutants circulated among MSM and HET in Iceland between 1997 and 2008 with an estimated median time to the most recent common ancestor of this cluster dating back to 1989. The domestic nature of the TDR cluster was confirmed previously using phylogenetic analysis with similar reference GenBank sequences obtained through BLAST. The likeSince the accurate times of infection in all patients were unknown, we considered the Icelandic samples to represent a sero-prevalent cohort. This is an inevitable caveat in most clinical settings since patients are diagnosed at various stages of infection. Another limitation is that the HIV-1 sequences analysed were generated based on the Sanger population sequencing method, and thus minor virus populations might have escaped detection.In conclusion, we conducted our investigation on the basis of WHO recommendations for ARV drug resistance surveillance. These results can be valuable in contributing to successful management of HIV-1 infected patients. The results of our study also give useful insights about the effectiveness of the past measures of control and management of these infections. Our findings highlight the importance of continuously monitoring the emergence of ARV resistant mutants in a systematic, prospective manner, to prevent or limit the spread of such mutants which can hinder effective management of HIV-1. Thus, routine baseline HIV-1 genotypic resistance testing in newly diagnosed HIV-infected individuals in the country is recommended to disclose TDR at an early stage which can help to optimize the management of the patients.Click here for additional data file.


Four weeks later he was admitted to the intensive care unit with severe sepsis. The diagnostic pathway identified progressive multifocal leukoencephalopathy, digestive Kaposi sarcoma, and P. aeruginosa bacteraemia. Five weeks after starting ART, TCD4+ cell count was 259 cells/mm3 (15%) and HIV RNA = 3500 copies/mL (4 log). He developed respiratory failure and progressed to septic shock and death. Those complications might justify the outcome but its autopsy opened Pandora's box: cerebral and cardiac toxoplasmosis was identified, as well as hemophagocytic syndrome, systemic candidiasis, and Mycobacterium avium complex infection. IRIS remains a concern and eventually a barrier to ART. Male gender, young age, low TCD4 cell count, and high viral load are risk factors. The high prevalence of subclinical opportunistic diseases highlights the need for new strategies to reduce IRIS incidence.One of the purposes of antiretroviral therapy (ART) is to restore the immune system. However, it can sometimes lead to an aberrant inflammatory response and paradoxical clinical worsening known as the immune reconstitution inflammatory syndrome (IRIS). We describe a 23-year-old male, HIV1 infected with a rapid progression phenotype, who started ART with TCD4+ of 53 cells/mm Antiretroviral therapy (ART) led to a dramatic change in the clinical picture and prognosis of the Human Immunodeficiency Virus (HIV) infection. However, some patients develop a paradoxical worsening of their clinical status after starting therapy. HIV-associated immune reconstitution inflammatory syndrome (IRIS) has emerged as an important early complication of ART introduction, particularly in patients with severe immunosuppression. The diagnosis is based on an unexpected clinical worsening, days to months after the ART introduction, an abrupt rise of TCD4+ cell count, and a decrease >1 log in HIV RNA load in the presence of pathological antigens  reaching3 (15%) with a HIV RNA of 88500 copies/mL. HBV, HCV, syphilis, Mycobacterium tuberculosis, CMV, and Toxoplasma screenings were negative and chest X-ray, abdominal ultrasound, and colonoscopy were unremarkable. During the follow-up, although presenting with a stable TCD4+ cell count, he kept high viral load and a serodiscordant sexual partner, those being reasons for initiating ART, which he refused. In February 2012 secondary syphilis was diagnosed with a TCD4+ count of 264 cells/mm3  and a HIV RNA load of 339000 copies/mL . Three months later, with 53 TCD4+ cells/mm3 (3.3%) and a viral load of 890000 copies/mm3 (6 log) he was started on TDF + FTC + EFV.A 23-year-old male was diagnosed with HIV infection in July 2011, having a negative HIV serology 6 months earlier. By September 2011, his TCD4+ cell count was 563 cells/mm3 (15%)] and a 2 log drop in the HIV viral load [3500 copies/mm3 (4 log)]. Initial thoracic, abdominal, and pelvic CT scan were unremarkable. Bronchial aspirate and bronchoalveolar lavage (BAL) were sterile for fungi and fast growing bacteria. PCR assays to identify Chlamydophila, Legionella, Mycoplasma, CMV, HSV, and Mycobacterium tuberculosis were negative. The patient remained febrile, and due to severe pancytopenia, hepatosplenomegaly, and an elevated ferritin, hemophagocytic syndrome was suspected, not being confirmed on the bone marrow aspirate though. By the 9th hospitalization day he presented with seizures and the MRI scan showed bilateral and multifocal white matter with high signal intensity on T2-weighted and FLAIR images. This, associated with the presence of JC virus in CSF, led to the diagnosis of progressive multifocal leukoencephalopathy (PML). Diarrhea persisted but due to clinical instability and severe anemia and thrombocytopenia, endoscopic studies were only performed on the 24th hospitalization day. Upper and lower endoscopy revealed multiple polypoid lesions with a cherry-red appearance in the stomach and colon, compatible with Kaposi sarcoma ( Pseudomonas aeruginosa bacteraemia, the clinical state deteriorated and the patient died.Four weeks later he was admitted to the emergency department with fever, oral candidiasis, diarrhea, hypotension, and pancytopenia. Gastrointestinal sepsis was suspected and he was started on ciprofloxacin and fluconazole. He developed shock and respiratory failure in the next 48 h and was admitted to the intensive care unit. Antibiotic regimen was changed to imipenem, metronidazole, and fluconazole. Faeces microbiological and parasitological tests were negative, blood and urine cultures were sterile, and CMV plasma antigen was negative. Five weeks after starting ART there was an increase in TCD4+ cell count [259 cells/mm sarcoma . He was  Candida species was found in the anal canal, colon ( Mycobacterium avium complex culture from the bronchial aspirate became positive after death. A. baumannii grew from the right atrium blood culture and aspects of anal condyloma and intraepithelial low-grade neoplasm were also identified, as well as several aspects consistent with systemic shock.The clinical course and the documented complications, some of them defining AIDS, would be sufficient to explain the poor outcome but the autopsy opened an unexpected underworld: Kaposi sarcoma was confirmed in the stomach and colon but also in the esophagus and mediastinal lymph nodes ; Candidal, colon , and lunl, colon . As prevl, colon ; brain hl, colon ; multipll, colon  and hearl, colon  configurChronic HIV infection is a disease of coinfections with immunosuppression allowing reactivation of dormant pathogens or increasing susceptibility to exogenous ones. The vast majority of HIV-infected patients have one or more coinfections at some point during the disease course, which play an important role in chronic immune activation. The higher the antigen burden, the higher the risk for IRIS. This case presents multiple unmasking-IRIS with systemic Kaposi sarcoma, systemic candidiasis, and PML, coupled with several more or less quiescent defining AIDS diseases.3 in the first year of seroconversion seems to identify a rare group of individuals at high risk for faster disease progression [A meta-analysis with 13103 HIV-infected patients showed that IRIS occurred in 16.1% of the cases after starting ART . This nugression . The pat3 but only 1% when the initial TCD4+ cell count was ≥500 cells/mm3 [3 for tuberculosis and isosporiasis infections and less than 100 cells/mm3 for candidiasis, PCP, CMV infection, and MAC infection [3 leading to a profound immunosuppressed state, which dramatically increased the risk for several OI in a short period of time.Several factors are independently associated with occurrence of OI such as African American/Black race or Hispanic/Latino ethnicity, intravenous drug users, heterosexual HIV transmission, lower TCD4+ cell count, and higher viral load . Sixteennfection . In this Mycobacterium tuberculosis and Cryptococcus neoformans; cerebral toxoplasmosis is rare. Twelve to 22% of AIDS patients had endomyocardial involvement by T. gondii at autopsy; in the highly active ART era the prevalence of cardiac toxoplasmosis confirmed postmortem has been reported to be less than 10% [ M. avium complex infection related to IRIS, in the presence of TCD4+ <100 cells/mm3, is 3.5% [Along with depression of immune system, OI presentation becomes blurred and the diagnosis is difficult. Our patient, despite his profound immunosuppression, was asymptomatic until the start of ART. KS is the most common HIV-associated malignancy and disease exacerbation or presentation after starting ART can be as high as 29% . Centralthan 10% . The incEarly HIV infection detection and treatment are crucial to a better prognosis. Recent changes in the treatment guidelines are expected to reduce IRIS incidence, particularly by reducing the duration and degree of immunosuppression. Nevertheless, systematic screening for OI before starting ART is still a key element to prevent this phenomenon. The risk of paradoxical IRIS could also be substantially altered by deferral of ART initiation, particularly in central nervous system IRIS. This approach is postulated to ensure adequate treatment of OI, reduce the antigen burden before starting ART in HIV-infected patients with severe immune deficiency, and promote immune recovery.Despite the lack of standardized treatment protocol for IRIS, ART should not be interrupted and there may be a need for corticosteroid therapy. As such, treatment of these patients is a huge challenge and further research regarding the immunopathogenesis, diagnosis, and its management should be pursued.


Based on data from clinical practice, we evaluated the effectiveness and safety of switching to abacavir/lamivudine plus rilpivirine (ABC/3TC+RPV) treatment in virologically suppressed HIV-1-infected patients.We performed a multicenter, non-controlled, retrospective study of HIV-1-infected patients who switched treatment to ABC/3TC+RPV. Patients had an HIV-RNA <50 copies/mL for at least 24 weeks prior to changing treatments. The primary objective was HIV-1 RNA <50 copies/mL at week 48. Effectiveness was analyzed by intention-to-treat (ITT), missing = failure and on-treatment (OT) analyses. The secondary objectives analyzed were adverse effects changes in renal, hepatic or lipid profiles, changes in CD4+ cell count and treatment discontinuations.P<0.001. Thirty-eight adverse events (AE) were detected in 32 patients. Of these, 25 had no clear association with treatment. Three patients interrupted therapy due to AE. We observed a decrease in all lipid parameters, P<0.001, and a slight improvement in the glomerular filtration rate, P<0.01. Therapy was considered to have failed in 18 patients owing to virological failure (5 [2.4%]), toxicity/poor tolerability (4 [2%]), clinical decision (3 [1.5%]), loss to follow-up (3 [1.5%]), death (1 [0.5%]), and no clinical data (2 [1%]).Of the 205 patients included, 75.6% were men and the median age was 49. At baseline, before switching to ABC/3TC+RPV, median time since HIV diagnosis was 13.1 years, median time with undetectable HIV-1 RNA was 6.2 years and median time of previous antiretroviral regimen was 3.1 years (48.3% patients were taking efavirenz and ABC/3TC was the most frequent backbone coformulation in 69.7% of patients). The main reasons for switching were drug toxicity/poor tolerability (60.5%) and simplification (20%). At week 48, the primary objective was achieved by 187 out of 205 (91.2%) patients by ITT analysis, and 187 out of 192 (97.4%) patients by OT analysis. The CD4+ lymphocyte count and CD4+ percentage increased significantly from baseline to week 48 by a median of 48 cells/μL (−50 to 189) and 1.2% (−1.3% to 4.1%), respectively, The results of this study confirms that ABC/3TC+RPV is an effective, safe, and cost-effective option for the treatment of patients with virologically stable HIV-1 infection. First-line combined antiretroviral therapies (cART) are currently highly effective –2. HowevTherapy regimens are sometimes switched to improve or maintain the patient’s quality of life and, in a few cases, to reduce treatment costs . StrategThe combination of abacavir/lamivudine (ABC/3TC) is widely used in both clinical trials and real-world practice, especially when clinicians wish to avoid the toxicity of older nucleoside/nucleotide analogues, such as zidovudine, didanosine, stavudine and tenofovir (TDF) –9.Based on the ECHO and THRIVE clinical trials –14 the sThe combination ABC/3TC+RPV might simultaneously address the issues of effectiveness, tolerability and ease of administration as an alternate therapy in routine clinical practice.Given the lack of evidence on switching to ABC/3TC+RPV, it is important to test the feasibility of this strategy. We carried out a study to explore the effectiveness and safety of switching to a regimen comprised of a fixed-dose ABC/3TC and RPV in virologically suppressed HIV-1-infected patients.This was a multicenter, non-controlled and retrospective study of HIV-1-infected patients switching to ABC/3TC+RPV conducted in 13 hospitals in Spain. All included patients had to fulfill the following criteria: i) age ≥18 years, ii) documented HIV-1 infection, iii) switch from another therapy regimen to coformulated ABC/3TC (600/300 mg fixed-dose combination) and RPV (25 mg) once daily for any reason from March 2013 to March 2014 and iv) serum HIV RNA <50 copies/mL for at least 24 weeks before switching to ABC/3TC+RPV. Analysis was carried out in 2015, to ensure that the final patient included in 2014 had at least 48 weeks of follow up. Patients tested negative for HLA*B5701 before initiating ABC/3TC+RPV.(every 12 to 24 weeks), reasons for treatment discontinuation in patients who stopped or changed therapy, and results of genotypic resistance testing after virological failure, when available.Eligible individuals were identified by a systematic search of the databases of each center. Data for the study was collected retrospectively from patient´s medical records, anonymized and entered into an electronic database. The information collected included: baseline demographic and HIV-related data, comorbidities, adverse events and laboratory results , at baseline and thereafter according to the routine clinical protocols in each hospital The study protocol was approved by the Hospital Universitario Gregorio Marañón Ethics Committee with code SEI-RIL-2014-02, in accordance with the principles of the Declaration of Helsinki 2008. The study required local approval of several other Clinical Research Ethics Committees: Hospital Universitario Vall d´Hebrón Ethics Committee, Hospital de Mataró-Consorcio Sanitario del Maresme Ethics Committee, Hospital Universitario de Bellvitge Ethics Committee, Hospital Clínico Universitario de Valencia Ethics Committee and Ethics Committee of the province of Huelva.Analysis with a view to scientific publication was based on anonymized routine clinical data, thus obviating the need for written informed consent.The primary objective was the percentage of patients who maintained virological suppression (HIV-1 RNA <50 copies/mL) after 48 weeks of treatment. This outcome was analyzed using intention to treat (ITT), missing = failure and on treatment (OT) analyses. Treatment was considered to have failed when any of the following events occurred: virological failure (VF), defined as two consecutive HIV RNA measurements >50 copies/mL or a single measurement of >50 copies/mL if treatment was changed afterwards; treatment interruption by patient; change of treatment regimen due to non-VF reasons and incomplete data. Viral load was evaluated 3 or 4 times during the 48-week period of the study to ascertain virologic control, according to the routine clinical protocols in each hospital. The secondary objectives were adverse events, changes in CD4 count, lipid, hepatic or renal profile changes, treatment discontinuations and reasons for discontinuations.All analyses were carried out using IBM SPSS Statistics for Windows®, Version 21.0 .t test  and the Wilcoxon test . Normality of the variables was tested with the Kolmogorov-Smirnov-Lilliefords test. The association between qualitative variables was assessed using the χ2 test when the sample was sufficiently large or Fisher's exact test when it was not. The 95% confidence intervals were calculated based on the Newcombe-Wilson hybrid score.We analyzed the variables available at baseline and at 48 weeks. Variables that did not follow a normal distribution were described using the median and interquartile range (IQR). Nominal variables were described as numbers and percentages. Paired samples were compared using the For the primary outcome , we included all registered patients (incomplete or missing patients were defined as failures). We also performed an analysis excluding patients whose treatment was discontinued for non-virological reasons .The study population comprised 205 patients. Baseline patient characteristics are summarized in At baseline, before switching to ABC/3TC+RPV, median time from HIV diagnosis was 13.1 years, median time from first antiretroviral treatment was 9.6 years, median time of previous antiretroviral regimen was 3.1 years and median time with undetectable HIV-1 RNA was 6.2 years.Prior to switching, 63 patients (30.7%) were taking a ritonavir-boosted protease inhibitor (bPI) and 122 patients (59.4%) a NNRTI . TDF was part of the previous backbone in 53 patients (25.8%) and ABC in 144 (70.2%). Of note, ABC/3TC was the most frequent nucleoside reverse transcriptase inhibitor (NRTI) backbone coformulation before switching (69.7%). The main reasons for switching were drug toxicity/tolerability in 124 cases (60.5%) and regimen simplification in 41 (20%). In the toxicity/tolerability group of patients, 82 (65.3%) were on EFV-based regimens and 25 (20.2%) on bPI-based regimens. Regimen simplification (doses per day or number of pills) resulted primarily from bPI and etravirine-based regimens .The primary objective was observed in 187 out of 205 patients  by ITT analysis. When patients who had discontinued therapy for non-virological reasons were excluded, 187 out of 192 patients  reached the primary outcome per protocol  . TherapyP<0.001. In patients with a previous AIDS diagnosis (CDC stage C3), the CD4+ lymphocyte count and CD4+ percentage also increased significantly by a median of 50 cells/μL (−19 to 182.5) and 1.7% (−0.5% to 4.3%), respectively, P<0.001.The median CD4+ lymphocyte count and median CD4+ percentage increased significantly from baseline to week 48 by a median of 48 cells/μL (−50 to 189) and 1.2% (-1.3% to 4.1%), respectively, In this study cohort, 38 adverse events (AEs) were registered among 32 patients (15.6%) . ClinicaP<0.001 for all differences. There was no significant difference in lipid profiles in patients previously on a bPI-based regimen, but patients previously on an EFV-based regimen presented changes in T-chol, −15.4% , LDL-chol -14.6% , HDL-chol, −9.8%  and TG −20.3% .Median changes in lipid, hepatic, and renal profiles were analyzed at week 48 . In thisP<0.01.No changes were observed in liver profiles  at week 48, except for a slight decrease in gamma-glutamyl transpeptidase and alkaline phosphatase levels. This decrease was especially significant in the group of patients previously on an EFV-based regimen, median gamma-glutamyl transpeptidase of −18.5 IU/L (−41.7 to −7 IU/L) and a median alkaline phosphatase of −16.4 IU/L (−35 to −5 IU/L), 2 (−4.8 to 10) by week 48, P<0.01. Most of the patients who attained an increase in eGFR were taking TDF before switching (n = 55) and these patients had a median increase in eGFR of 7 mL/min/1.73 m2 (−5.8 to 13.1) at the end of follow-up, P<0.04. There were no significant changes in eGFR in patients previously on EFV or bIP-based regimens.The estimated glomerular filtration rate  increased by a median (IQR) of 1.1 mL/min/1.73 mTo our knowledge, there is little data showing that switching to ABC/3TC+RPV is effective, safe, and well tolerated in virologically suppressed HIV-1-infected patients. Previous studies have demonstrated that when switched from EFV+FTC/TDF, RPV+FTC/TDF is not inferior in terms of efficacy, has a better tolerability profile (resolving neuropsychiatric toxicity), and patients have a high adherence to this regimen , 18. In Of the 205 patients included, 18 experienced treatment failure, although only five experienced protocol-defined virological failure during the 48 weeks of the study period. Interestingly, two of those patients presenting as virological failures had two consecutive HIV-1 RNA values between 50 and 200 copies/mL and later achieved and maintained HIV-1 RNA <50 copies/mL without having to modify their treatment. Resistance testing performed on samples from the other three patients who experienced virological failure revealed mutations that may have compromised the efficacy of the regimen in two cases. A high proportion of patients maintained an undetectable viral load at week 48 after the switch, probably because of the excellent tolerability profile of ABC/3TC+RPV and the good adherence motivated by the low pill burden and once-daily regimen.We documented a median increase of 48 cells/μL (7.2%) in the CD4+ lymphocyte count but only a 1.2% increase in the percentage of CD4+ cells. Immune function was largely unchanged given the small and clinically insignificant change in CD4%. The absolute CD4 change may have been driven by increases in white blood cells or total lymphocyte count. Further follow-up would be needed in order to observe potential clinically significant changes.The frequency of adverse events was low (15.6%). The attending physicians considered most events to be unrelated to the study medication, and most AES resolved. Only three patients discontinued the regimen owing to adverse events. The low number of discontinuations due to poor tolerability indicates that the regimen was well tolerated.A small irrelevant decrease was observed in the serum concentrations of all fasting lipids. This observation was more evident in the group of patients with a previous EFV-based regimen, comprising nearly half of the patients who switched to RPV+ABC/3TC. This finding is similar to findings described in other studies with EFV, in naïve or treated patients , 22. No Additionally, serum biochemistry analysis revealed a small but statistically significant decrease in alkaline phosphatase and gamma-glutamyl transpeptidase levels, especially among the group of patients with a previous EFV-based regimen. EFV is known to produce enzyme induction in the liver through CYP3A4 and has been described in the EFV data sheet in 7% of the patients who receive 600 mg of this drug .2, no clinical relevance could be established. This increase is much more striking in the subgroup of patients who switched to ABC/3TC+RPV from a regimen containing TDF with a median increase in the eGFR of 7 mL/min/1.73 m2. This finding may reflect either a decrease in the inhibition of the tubular secretion of creatinine or an improvement in renal function after removing TDF from the regimen [Despite a significant median increase in eGFR of 1.1 mL/min/1.73 m regimen , 26. Fut regimen .Our study has several limitations. First, it was a retrospective study. Second, there were differences in clinical protocols and visit timetables between the study centers. It also lacked a comparative arm.Nevertheless, our findings are relevant, because ABC/3TC+RPV proved to be highly effective in virologically suppressed HIV-1-infected patients. Therefore, this combination could potentially form the basis for a switching strategy, especially when TDF cannot be taken because of toxicity issues, resistance, or clinical reasons. Safety is yet another key advantage of ABC/3TC+RPV. For example, adverse events are infrequent and a regimen free of TDF has potential long-term benefits for the kidneys and bones.In addition, this switching strategy could be cheaper than the most common antiretroviral regimens that include protease and integrase inhibitors. These savings can have a significant economic impact on the hospital drug expenses.In summary, the results of the SIMRIKI study support the use of ABC/3TC+RPV as an effective, safe, well-tolerated and cost-effective switching strategy in patients with virologically stable HIV-1 infection.


Despite vigorous studies, effective nonnucleoside inhibitors of HIV-1 reverse transcriptase (NNRTIs) are still in demand, not only due to toxicity and detrimental side effects of currently used drugs but also because of the emergence of multidrug-resistant viral strains. In this contribution, we present results of docking of 47 inhibitors to 107 allosteric centers of HIV-1 reverse transcriptase. Based on the average binding scores, we have constructed QSAR equations to elucidate directions of further developments in the inhibitor design that come from this structural data.The online version of this article (10.1007/s00894-017-3489-3) contains supplementary material, which is available to authorized users. According to the latest estimates from The Joint United Nations Programme on HIV and AIDS, there were 36.7 million people living with HIV in 2015, up from 33.3 million in 2010. Among them, 1.1 million died from AIDS-related illnesses . Althoug-1 mutant and wild-type (wt) HIV-1 strains at low nanomolar concentrations. However, etravirine must be given twice daily and is not recommended for initial treatment of HIV infection because of insufficient data in treatment-naive individuals whilst rilpivirine has suboptimal efficacy in patients with viral loads greater than 100,000 copies/ml or CD4 cell counts below 200 copies/ml at baseline because of higher virologic failure rate. Moreover, their use in some settings is limited by hypersensitivity reactions or other adverse effects. In addition, although these drugs have higher genetic barriers to resistance than first-generation NNRTIs, drug resistance still emerges, and K103N and E138K are the most common mutations selected by ETV and RPV. Importantly, when resistance to RPV is selected after virologic failure, cross-resistance to all nonnucleoside reverse transcriptase inhibitors is commonly observed  as implemented in SCIGRESS Suite software [In the first approach, based on classical descriptors, several models were created using the software . In the software  was basesoftware , 30. Thesoftware  was empl3). Lack of systematic difference between binding to wt and mutated enzyme seems thus to indicate that activity against mutants is connected with the structural features of the ligand rather than their binding energy. Interactions within the allosteric site are mostly associated with van der Waals forces and to a lesser extend to hydrogen bonding [All 47 ligands present in the PDB that are bound in the allosteric cavity have been docked to all 107 structures and averaged scores for a given ligand were obtained separately for wild-type (wt) and for mutated enzyme  indicate relative importance of each descriptor – the larger the value the more important is the descriptor. Topological results are illustrated by Fig. Several models gave acceptable correlation coefficient, while when only easily interpretable descriptors were used the following equation turned out to be statistically the best:double bond count from 4 to 14, (80.156) - SCIGRESS treats aromatic systems as having alternating double and single bonds,sec-amine count from 0 to 3 (51.719),cyano count from 0 to 2 (21.880),(nonpolar area)2 from 113,241 to 483,701 Å2 (121.969).The ranges of values for the descriptors in the training set and obtained corresponding partial-F values (in parenthesis) were:Since the objective is to have compounds with the lowest (most negative) FlexX score, the model given by Eq.  suggestsThe second attempt aimed at creating QSAR using fragment contribution approach using common substructures present in the training set using ADMEWORKS ModelBuilder. Due to size of the training set, the set of six descriptors was chosen. As illustrated by Fig.  r2 of less than 70% does not encourage its use for direct prediction of unknown compounds. However, the sign of the linear regression equation’s weight vector coefficients is a measure of the influence of a given substructure contribution to activity. In particular, negative values indicate improvement in binding, while positive values suggest that the corresponding substructures should be eliminated or their presence minimized. The obtained results are summarized in Table The model cross-validationAs can be seen, the interpretation of results of the fragment-based QSAR leads to similar conclusions, as the interpretation of the topological QSAR – the presence of sec-amino and cyano groups is improving activity, while parts of purely hydrocarbon-nature should be avoided.−5 per nucleotide addition [HIV-1 reverse transcriptase (RT) has relatively low fidelity – its error rate is evaluated to be in the range of 10addition , 34. A hThe interpretation of results of fragment-based QSAR leads to similar conclusions as interpretation of the topological QSAR: the presence of sec-amino and cyano groups is improving binding, while hydrocarbon fragments should be avoided.Two main conclusions are drawn from the research presented in this study:ESM 1(XLSX 342 kb)


We describe the accumulation of HIV-1 drug resistance and its effect on the activity of next-line components in patients with virological failure (HIV-1 RNA >1000 copies/mL) after 1 year (t1) of first-line antiretroviral therapy (ART) not switching to second-line drugs for one additional year (t2) in low-middle income countries (LMIC).p = 0.012 and OR 0.28, 95% CI 0.06–1.29, p = 0.103, respectively). Overall thymidine analogue mutations (TAMs) accumulation rate was 0.32/year, 0.50/year in the subgroup with HIV RNA >10,000 copies/mL; NNRTI RAM accumulation rate was 0.15/year, 0.40/year in the subgroup with HIV RNA >10,000 copies/mL.We selected 48 patients from the DREAM cohort ; their median pre-ART CD4+ cell count was 165 cells/μl. At t1 patients were receiving ART since a median of 12.2 months (mainly zidovudine/lamivudine/nevirapine), their median HIV RNA was 3.8 log10 copies/mL, 43 (89.6%) presented at least one resistance-associated mutation (RAM), most frequently for lamivudine/emtricitabine, nevirapine and efavirenz. Resistance to tenofovir, was 10% at 1 year and higher than 20% at 2 years, while projection at 3 years was >30%. At t2, 42 (89.4%) had a predicted low-level or higher resistance to at least 1 s-line drug. At t1, the frequency of RAM in patients with a lower adherence to pharmacy appointments (<95%) was significantly lower  than in those with a better adherence  (OR 0.12, 95% CI 0.02–0.63, While the activity of NNRTIs is compromised early during failure, tenofovir and zidovudine activity are reduced more frequently after 1 year of documented virological failure of thymidine analogue-based first-line ART, with RAMs accumulating faster in patients with higher viral loads. The present observation may help informing decisions on when to switch to a second line ART in patients on virological failure in LMIC. As of December 2016, 19,5 million people were receiving antiretroviral therapy (ART) word-wide. As antiretroviral treatment is rapidly being scaled up, HIV drug resistance is emerging and increasing at the global level. WHO recently reported that levels of pre-treatment drug resistance (PDR) to nevirapine and efavirenz, the two most affordable non-nucleoside reverse transcriptase inhibitors (NNRTIs) used in the first-line ART in resource-limited settings, was 10% or above in 6 of 11 countries performing nationally representative HIV drug resistance (DR) surveys, 3 out of 4 in Africa . WHO cont1) and after 2 years (t2) of ART without switching to a second-line regimen and c) had a stored plasma sample at t1 and t2. We also considered: t2^: 2 years after ART initiation  considering historical genotype; t3*: 3 years after ART initiation , projected results assuming a continuous linear accumulation of resistance mutations and historical genotype at year 2 (cumulating resistance of t1 + t2). Genotyping of reverse transcriptase (RT) and protease was performed at t1 and t2 by the Trugene HIV-1 genotyping method . Proportion of subjects with major resistance associated mutations (RAM)  to NRTIs, thymidine analogue mutations (TAMs) and NNRTI RAM and with resistance to individual drugs as interpreted by Stanford’s HIVdb 7.0 system  was calculated. Adherence was measured by per cent on time pharmacy appointment keeping, allowing a delay tolerability of 10 days. The protocol was approved by the National Ethics Committee from Mozambique .A retrospective longitudinal cohort study was performed with parameters extracted from the Drug Resource Enhancement against AIDS and Malnutrition (DREAM) database for HIV-infected patients. DREAM is a program of care for people with HIV designed and managed by the Community of Sant’Egidio , which is now working in ten African countries including Mozambique , 10. TheBaseline characteristics of study patients were described using standard descriptive statistics. Associations between socio-demographic and HIV-related variables were assessed using the Chi-square test for categorical variables and Student’s t-test or the Mann – Whitney test for continuous variables, as required. Association between adherence to pharmacy appointments and resistance mutations was analyzed by logistic regression. Data were analyzed using SPSS software package .10 copies/ml. Most of the patients (95.8%) were infected with HIV-1 subtype C. At t1, patients were receiving ART for a median of 12.2 months and the most frequently employed regimen was zidovudine/lamivudine/nevirapine , followed by stavudine/lamivudine/nevirapine , stavudine/lamivudine/efavirenz , zidovudine/lamivudine/abacavir  and zidovudine/lamivudine/efavirenz . Between t1 and t2, NRTI components were substituted in 2 cases from zidovudine/lamivudine to stavudine/lamivudine, in 2 cases from stavudine/lamivudine to zidovudine/lamivudine and in 2 cases from stavudine/lamivudine to tenofovir/lamivudine. Table There were 48 eligible patients enrolled in the study: 24 (50%) were males. At baseline  the median patients’s age was 35 years , the median CD4+ cell count was 165 cells/μl, and the mean viral load was 4.69 logp = 0.012). The mean yearly TAMs accumulation rate was 0.32; which rose to 0.49 in patients with pharmacy appointment adherence >90%. In patients with HIV-1 RNA > 10,000 copies/mL TAMs showed a mean yearly accumulation rate of 0.50. Probability of NNRTI resistance was also lower in less adherent patients at t1 . Mean NNRTI RAMs accumulation rate was 0.15/year. In subjects with pharmacy appointment adherence >90% the mean accumulation rate was 0.17/year. In patients with HIV-1 RNA > 10,000 copies/mL the mean yearly accumulation rate of NNRTI RAMs was 0.40.At t1, the probability of RAM in patients on virological failure differed based on levels of adherence to pharmacy appointments. In particular, frequency of NRTI RAM in patients with a lower adherence to pharmacy appointments (<95%) was significantly lower  than in those with a better adherence  (OR 0.12, 95% CI 0.02–0.63, Mozambique, a sub-Saharan country with HIV prevalence of 10.6% provides antiretroviral therapy based on a public health approach , 11, 12.While the activity of NNRTIs is compromised early during failure, tenofovir and zidovudine activity begin to be reduced more frequently after 1 year of documented virological failure of thymidine analogue-based first-line ART. Higher viral load at failure is associated with a faster rate of resistance accumulation. The present observation may inform decisions on when to switch to a second line therapy in patients on virological failure in LMIC settings.


Men had higher mortality rates compared to women, 6.7 per 100 person-years (p-y), (95% CI: 5.8–7.8) vs. 4.4 per 100 p-y, (95% CI: 3.8–5.0); mortality rate ratio: 1.54, (95% CI: 1.27–1.87), p <0.001. Age-standardised mortality rate was 7.9 per 100 p-y (95% CI: 4.1–11.7) for men and 5.7 per 100 p-y (95% CI: 2.7 to 8.6) for women ). Mean CD4+ cell count increases post-ART initiation were lower in men at all follow-up time points. Men presented later in the course of their HIV disease for ART initiation with more advanced disease and experienced a higher mortality rate compared to women.In attaining UNAIDS targets of 90-90-90 to achieve epidemic control, understanding who the current utilizers of HIV treatment services are will inform efforts aimed at reaching those not being reached. A retrospective chart review of CAPRISA AIDS Treatment Program (CAT) patients between 2004 and 2013 was undertaken. Of the 4043 HIV-infected patients initiated on ART, 2586 (64.0%) were women. At ART initiation, men, compared to women, had significantly lower median CD4+ cell counts (113 vs 131 cells/mm In South Africa, an estimated 6.2 million people are currently living with HIV infection . South AIn order to achieve the UNAIDS 90-90-90 goals for epidemic control and enhance individual and population level impact of public access anti-retroviral therapy (ART), detailed understanding of gaps in access to treatment services and factors that contribute to poor HIV treatment outcomes including ongoing mortality, is imperative. Data from other countries are inconsistent and contradictory, with some studies demonstrating gender imbalances in access to HIV treatment services and in clinical outcomes among patients on ART ,5, and oNotwithstanding the higher burden in women and 5–7 year earlier acquisition of HIV infection in adolescent girls and young women between the ages of 15–24 years , men areA South African study assessing the sustainability of task shifting in a rural primary care clinic demonstrated that 68.8% of those accessing ART services between 2004 and 2010 (p < 0.05) were women , and thoIn a country with the largest ART rollout program, it is important to understand who the current utilizers of HIV treatment services are, as this will help inform efforts aimed at reaching those currently not being reached. This study sought to investigate whether there were gender and age differences in those accessing HIV care services and clinical outcomes in those initiated on ART among urban and rural patients utilizing a free HIV treatment program in KwaZulu-Natal, South Africa.We undertook a retrospective chart review of ambulant HIV infected, ART naïve adult patients enrolled into the PEPFAR-funded CAPRISA AIDS Treatment Programme (CAT) between June 2004 and August 2013. Patients were enrolled from two different catchment populations in KwaZulu-Natal; a TB clinic in the urban eThekwini district and a rural primary health care clinic in Vulindlela, rural KwaZulu-Natal. ART eligibility criteria, and definitions of immunologic and virological response to ART, defined as <400 copies/ml was as per current South African Government HIV/AIDS treatment guidelines . FollowiRoutine demographic and clinical data were recorded at baseline and at follow-up visits. Laboratory safety assessments and CD4+ cell counts and viral loads were conducted at baseline and every 6 months or as clinically indicated. Patients were regarded as lost to follow-up if they missed 3 consecutive scheduled visits and if all attempts to track them telephonically and physically had failed. No lost to follow-up patients re-engaged in care. Patients provided written informed consent for participation in the CAT programme and for the use of their medical records. Approval for data collection and analysis was obtained from the University of KwaZulu-Natal, Biomedical Research Ethics Committee (Ref: E248/05).We used unpaired t-test, and Wilcoxon rank sum test for continuous data and Fisher’s exact test for categorical data to compare demographics and clinical characteristics between men and women. Data was censored at 72 months of follow-up. Kaplan-Meier was used to construct survival curves and compare them using the log-rank test. Poisson approximations and F-tests were used to construct 95% confidence intervals (CI) for mortality rate, TB incidence rate and rate ratios, respectively. We calculated age-standardised mortality rates using 5-year age band. The province of KwaZulu-Natal was used as a standard population. Predictors of mortality were assessed through both univariate and multivariate proportional hazards regression. Proportionality was assessed by fitting time dependent covariates in a model created by interacting baseline variables with survival time.The association between gender and CD4+ cell count was determined through linear mixed models. All models were adjusted for baseline covariates such as clinic site, age, tuberculosis status at baseline, past history of TB, WHO stage, CD4+ cell count and viral load. We conducted sensitivity analysis evaluating the impact of ART programme maturity on the effect of gender on mortality during ART initiation periods of 2004–2008 and 2009–2013.We calculated attributable risk in order to assess the relative contribution and impact of specific covariates on mortality. The effect of loss to follow-up on mortality was determined through sensitivity analysis. P values less than 0.05 were considered statistically significant. All analyses were conducted using SAS, version 9.4  and R version 3.2.2.The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.3), p <0.001, a lower median body mass index (BMI) (21.0 vs 24.2 kg/m2), p<0.001 and higher mean log viral loads (5.0 vs 4.9 copies/ml), p<0.001  men and 2586 women (64%), 14 years and older, were initiated on ART between June 2004 and August 2013. Baseline clinical characteristics are presented in  p<0.001 . The ove p<0.001 .Deaths occurred among 173 men and 239 women, over 8033.71 person-years of follow-up, (median of 16.3 months ), . Overall3, p = 0.098; 5.4 (95% CI 4.3–6.7) and 3.8 (95% CI 3.2–4.6) for baseline CD4+ cell counts of 50–200 cells/mm3, p = 0.012 and 5.2 (95% CI 2.8–8.9) and 2.1 (95% CI 1.2–3.3). Mortality rate ratio stratified by baseline CD4+ cell count comparing men and women was 1.31 (95% CI 0.95–1.8) for baseline CD4+ cell counts < 50 cells/mm3, p = 0.098; 1.42 (95% CI 1.08–1.87) for baseline CD4+ cell counts of 50–200 cells/mm3, p = 0.012 and 2.1 (95% CI 1.22–5.26) for baseline CD4+ cell counts of > 200 cells/mm3  vs 3.9 per 100 p-y (95% CI: 2.4–5.9) in women of the same age, mortality rate ratio: 3.06 (95% CI: 1.45–6.46), p = 0.003 . Among tells/mm3 .3 and 556.6 cells/mm3, p = 0.001 among men and women respectively , p<0.0001, and a two-fold higher risk of death among patients with a baseline CD4+ cell count between 50–200 cells/mm3, , p = 0.001, : 1.29, 95% CI: 1.05–1.58, p = 0.016 . Risk of= 0.001, .In addition, patients presenting with no TB at ART initiation or a higher mean log viral load or WHO stage 4 disease had significantly higher risk of death .We found that the attributable risk of death among patients initiating ART was 24.3% (95% CI 17.3–30.5) for patients with a low baseline CD4+ cell count and 10.2% (95% CI 2.7–16.9) for male patients .Of note, sensitivity analysis evaluating the impact of ART programme maturity on the effect of gender on mortality showed that mortality rates between men and women was consistently two-fold higher and significantly different at all follow-up time-points between 2009–2013. This finding did not hold for the period 2004–2008 during the period of ART initiation .We provide evidence of gender disparities between HIV infected men and women in access and response to antiretroviral therapy. Clinical outcomes differed by gender; with men demonstrating higher overall mortality rates and suboptimal immunologic recovery.The bulk of deaths in both men and women occurred in the first 24 months of follow-up concurring with findings from other studies ,19. DespAfter removing the confounding effect of age, mortality rates observed in men and women in our study was lower than the age-standardised mortality rates. Interestingly, mortality rates among men and women in the study population closely approximated age-standardised mortality when we assumed that patients who were loss to follow-up within 6 months of ART initiation died.In contrast to the epidemiological data of the evolving epidemic in southern Africa wherein HIV acquisition does not occur in men until their late twenties ,21 and wConversely, studies from developed countries show differing results, finding no gender differences in clinical, virological and immunological outcomes among HIV infected men and women initiating ART ,23. A muPoor prognostic markers of ART response were apparent in men at baseline, who were older, had lower CD4+ cell counts and higher viral loads compared to women. This finding concurs with published South African literature demonstrating that compared to men, women were more likely to access HIV testing, and among those testing HIV positive, women were younger with higher CD4+ cell counts than their male counterparts .This study also showed that the late presentation of men was associated with poor immunological response to ART with higher risk of morbidity and mortality . Our fin3 in comparison with those patients that presented with baseline CD4+ cell counts of less than 50 cells/mm3. Furthermore, we found that the mortality risk among patients initiating ART was attributable to both low baseline CD4+ cell count and male gender, corroborating published literature showing that baseline CD4+ cell count is an important factor impacting CD4+ cell count increase and recovery on treatment [We show that during follow up overall mortality rate halved among men and women with baseline CD4+ cell counts of 50–200 cells/mmreatment . In settOur findings demonstrate that the absence of a diagnosis of prevalent TB increased risk of mortality. Published literature has cited that undiagnosed TB is higher among patients accessing ART than in the general population; with the majority of incident TB diagnosed in the early weeks of ART initiation being TB prevalent but missed at baseline screening ,31,32. IMen had higher lost to follow-up rates in our cohort in keeping with reports from published literature ,34. AdveAs this was a secondary analysis of routinely collected programme data, missing data limited our ability to comment on various correlations e.g. the impact of socio-economic and demographic variables on clinical outcomes. Treatment adherence was not measured and its impact on outcomes could be underestimated. We have not investigated other biological and behavioural factors that may have contributed to poor ART outcomes in men. While the vast majority of patients enrolled into this cohort were women, we had very few pregnancies and are therefore unable to comment on the impact of pregnancy in women on mortality in this cohort. Additional studies that explore potential barriers that South African men experience when seeking HIV care, and optimal strategies to link and engage men in ART services, is warranted.While heterosexual transmission is the primary mode of HIV transmission in sub Saharan Africa, the impact of free ART provision on access and clinical outcomes in men and women is unequal. Men presented late for ART initiation with more advanced disease and a higher mortality rate compared to women in this six-year ART program. The increased feminization of the HIV epidemic in sub Saharan Africa has rightfully demanded that greater focus be given to women with respect to HIV prevention, transmission, treatment and care. However, in a predominantly heterosexual epidemic, greater programmatic effort should be directed toward encouraging men to test early and frequently. As we prepare to scale-up “Test and Treat” in all HIV infected patients, innovative strategies are needed to ensure that men and women that test HIV positive have access to effective linkage to care for early ART initiation to achieve the goal of reducing mortality and increasing AIDS free survival.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.


Routine laboratory monitoring is part of the basic care package offered to people living with the Human Immunodeficiency Virus (PLHIV). This paper aims to identify the proportion of PLHIVs with clinical and immunological failure who are virologically suppressed and risk being misclassified as treatment failures.A retrospective analysis of patient viral load data collected between January 2013 and June 2014 was conducted. Of the patients classified as experiencing either clinical or immunological failure, we evaluated the proportion of true  failure, and estimated the sensitivity and specificity of the immunological and clinical criteria in diagnosing true treatment failure.n = 1859) were suspected of treatment failure and their viral loads analysed. 40% (n = 737) demonstrated viral suppression (VL < 1000 copies/ml). The median viral load (VL) was 3317 copies/ml . Among the 799 (2.9%) PLHIVs on ART classified as having clinical failure, 41.1% (n = 328) of them had confirmed viral suppression. Of the 463 (1.7%) classified as having immunological failure, 36.9% (n = 171) had confirmed viral suppression. The sensitivity of the clinical criteria in diagnosing true failure was 61% (CI 58%–65%) while that of the immunological criteria 38% (CI 35%–42%). The specificity of the clinical criteria was 34% (CI 30%–39%) while that of the immunological criteria 66% (61%–70%). Age below 20 years was associated with a high viral load (p < .001). Sex and ART regimen were not associated with the viral load.Of the 27,418 PLHIVs aged 2–80 years on ART in the study period, 6.8% (Clinical and immunological criteria alone are not sufficient to identify true treatment failure. There is need for accurate treatment failure diagnosis through viral load testing to avoid incorrect early or delayed switching of patients to second-line regimens. This study recommends increased viral load testing in line with the Kenya’s ART guidelines. In 2015, an estimated 1.5 million Kenyans were living with HIV, with 897,000 of them on antiretroviral therapy (ART) , 4, 5–21PLUS KAMILI is one such project, supporting HIV service delivery in Eastern and Central Kenya, a catchment area of 11 counties and over nine million inhabitants. The project supports 46,264 PLHIVs, of whom 34,648 are on ART. Integrated service delivery focuses on HIV testing services (HTS), care and treatment, prevention of mother-to-child transmission (PMTCT), orphaned and vulnerable children (OVC) services, and reproductive health activities. A critical project component is laboratory networking to ensure timely collection and transport of viral load samples and a rapid turn-around time for results.Many organizations work jointly with the MOH in addressing the HIV epidemic in Kenya. The USAID-funded APHIA3 after 12 months on ART [In Kenya, routine laboratory monitoring is part of the basic care package offered to people living with HIV (PLHIV), and includes tests to monitor the efficacy of ART on viral suppression . Clinical failure is defined as occurrence of a new or recurrent WHO stage 3 or 4 disease after at least six months on ART Table , while is on ART . VirologIn this paper, we analyse viral load data collected from patients with suspected treatment failure based on clinical and immunological criteria between January 2013 and June 2014 from 11 APHIAPLUS KAMILI counties. We aim to demonstrate that a proportion of patients with clinical and immunological failure are virologically suppressed and yet may be misclassified as treatment failure.This was a retrospective cross sectional analysis of secondary de-identified data collected for programmatic purposes as part of routine patient care.PLUS KAMILI project, which supports HIV care and treatment in 142 MOH and faith-based organizations health facilities.The study was conducted in eight counties covered by the APHIADe-identified electronic medical records data was collected from PLHIVs who had been on ART for more than 6 months. This data was retrieved from the national electronic archive on viral load testing. Patients on second-line ART regimen and those with incomplete socio-demographic and viral load data (597) were excluded from data analysis.From January 2013 to June 2014, samples from 1859 patients with suspected treatment failure were collected and submitted to the laboratory for viral load testing.Abbott® RT-PCR   for HIV-RNA and Roche Amplicor RT-PCR . Blood samples taken included dried blood spots (DBS) and plasma, and were sent to the Kenya Medical Research Institute (KEMRI) and National HIV Reference Laboratory (NHRL) for processing.During program implementation, all PLHIVs suspected of treatment failure had blood drawn for viral load testing as part of their routine laboratory monitoring while on ART. Assays used for the viral load were 3 after 12 months of ART, and viral suppression as VL < 1000 copies/ml.The variables of interest included age, sex, duration on ART, ART regimen and justification for the viral load test. The primary outcome was the patient’s viral suppression. Virological failure was defined as VL > 1000 copies/ml, immunological failure as a CD4 fall by >30% from peak or failure of CD4 count to rise to >100 cells/mmp-value <0.05 was considered statistically significant.Statistical analysis was conducted using the software SPSS v20 for Windows. Data was checked for consistency and extreme outliers as part of initial data cleaning. Cross-tabulations, histograms and box plots were used to examine the data. Mean, median and standard deviation were used to describe continuous data while frequencies were used for categorical data. Association between variables was assessed through bivariate and multivariate methods. A Viral load data from 1859 patients in eight of the eleven counties supported by the project were analysed Table . Three cThe most common indication by clinicians for requesting viral load testing was clinical failure (59%), followed by immunological failure (34%), and others (7%).The proportion of patients with viral suppression was 39.5%, with 60.5% experiencing virological failure. There was no significant difference between the proportion of male patients who were virally suppressed (43.1%) and that of female patients (43.6%). Viral suppression was highest among patients aged above 61 years (55.4%) and lowest in those aged below 20 (23.9%) years.n = 328) had confirmed viral suppression. Of the 463 patients reported as having immunological failure, 36.9% (n = 171) had confirmed viral suppression . The sensitivity of clinical criteria in diagnosing true failure was 61% (CI 58%–65%) while immunological criteria had a low sensitivity of 38% (CI 35%–42%). The specificity of the clinical criteria was 34% (CI 30%–39%) while that of the immunological criteria was 66% (61%–70%) .Our study presents data on discrepancies in classification of treatment failure based on clinical, immunological and virological criteria. Consequently, we demonstrate that the use of clinical and immunological criteria alone may result in misclassification of patients with viral suppression as treatment failure leading to unnecessary, untimely, and incorrect switching to second line regimens.Our study adds to the literature from studies done elsewhere which also evaluated misclassification of treatment failure in patients on ART. In a prospective cohort study in Uganda, immunological criteria failed to identify all the genuine treatment failures and had a low sensitivity . StudiesIn the course of treatment of PLHIVs, virological failure occurs early, followed by immunological and clinical failure. Therefore, there is need for timely and accurate treatment failure diagnosis based on viral load testing in order to avoid early or delayed switching of patients to second-line ART regimen. Switching early to second-line regimen increases the cost burden of HIV treatment and minimizes options for subsequent regimens, should they be required . On the In this study, the age of the patient was associated with virological failure. Majority of patients who had virological failure fell within the age range of 20–40 years. This data is similar to that of a study conducted in Kenya by Hassan (2014) where young age was a significant predictor for virological failure and drug resistance . Young HPatient viral load must necessarily be interpreted with caution - viral load is affected by inter-patient variation, laboratory errors, opportunistic infections, pre-ART viral load and the ART regimen , 19. TheAn important study limitation is that the dataset analysed was based on patients with suspected treatment failure only and hence the findings cannot be generalized to the general population of PLHIVs in care. A further limitation is that this study investigated over-diagnosis of treatment failure in the absence of viral load testing. In the absence of viral load monitoring, this study cannot investigate the full scale of true treatment failure. Finally, incomplete documentation of viral load data was a notable challenge. This could possibly be due to clinicians failing to update all the patient details at the time of requesting for the viral load test. This limitation can be overcome through mentorship sessions and on-job training.A key strength of this study is the availability of a large sample size, making it possible to analyze variables at bivariate and multivariate levels. Data quality was high and obtained entirely from the online viral load monitoring system in Kenya.The findings from this study add to the body of knowledge on clinical and laboratory challenges of managing HIV-infected patients in low-resource settings, and build the case for the need for viral load monitoring of patients on ART.Clinical and immunological criteria when applied without viral load testing are not sufficient to definitively identify treatment failure in a timely manner. There is need for accurate treatment failure diagnosis based on viral load to avoid early or delayed switching of patients to second-line ART, and the subsequent consequences of that untimely switching. This study recommends universal viral load testing for all HIV-infected individuals in line with Kenya’s ART guidelines. Findings from this study further strengthen policy and guidelines on viral load testing as the standard reliable test to be conducted prior to switching patients from first to second line ART regimens. A viral suppression survey with genotypic resistance is needed in the future to shed more light on treatment failure.


Crack cocaine use is known to contribute to poor adherence to antiretroviral medications; however, little is known about facilitators of or barriers to effective HIV treatment use among HIV-infected crack cocaine users. We sought to identify correlates of optimal pharmacy refill adherence for antiretroviral medications and plasma HIV RNA viral load (pVL) suppression among this population.Data from a prospective cohort of HIV-positive people who use illicit drugs in Vancouver, Canada, were linked to comprehensive HIV clinical monitoring and pharmacy dispensation records. We used multivariable generalized linear mixed-effects modelling to longitudinally identify factors associated with ≥95 % adherence to pharmacy refills for antiretroviral medications and pVL <50 copies/mL among crack cocaine users exposed to highly-active antiretroviral therapy (HAART).p < 0.05). The results for pVL non-detectability were consistent with those of medication adherence, except that longer history of HAART (AOR: 1.06), receiving a single tablet-per-day regimen (AOR: 3.02) and participation in opioid substitution therapies was independently associated with pVL non-detectability (AOR: 1.55) .Among 438 HAART-exposed crack cocaine users between 2005 and 2013, 240 (54.8 %) had ≥95 % pharmacy refill adherence in the previous 6 months at baseline. In multivariable analyses, homelessness (adjusted odds ratio [AOR]: 0.58), ≥daily crack cocaine smoking (AOR: 0.64), and ≥ daily heroin use (AOR: 0.43) were independently associated with optimal pharmacy refill adherence (all Homelessness, and daily crack cocaine and/or heroin use were independently and negatively associated with optimal HAART-related outcomes. With the exception of opioid substitution therapies, no addiction treatment modalities assessed appeared to facilitate medication adherence or viral suppression. Evidence-based treatment options for crack cocaine use that also confer benefits to HAART need to be developed. Highly-active antiretroviral therapy (HAART) has substantially improved the life expectancy of people living with HIV  and has In 2014, the Treatment-as-Prevention (TasP) approach, which aims to expand access and adherence to HAART among people living with HIV and thereby prevent HIV transmission, was incorporated into the global HIV/AIDS response strategies by the Joint United Nations Programme on HIV/AIDS . This isDespite many reports of poor adherence to HAART among HIV-infected crack cocaine users –15, to dData for this analysis were derived from the AIDS Care Cohort to evaluate Exposure to Survival Services (ACCESS), a prospective cohort study of HIV-positive people who use illicit drugs in Vancouver, Canada. Recruitment and data collection procedures have been described in detail elsewhere . In brieAt baseline and semi-annually thereafter, participants completed an interviewer-administered questionnaire soliciting demographic data, information on drug use patterns, as well as other characteristics and exposures. At each visit, individuals also underwent an examination by a study nurse and provided blood samples for serologic analyses. Through a confidential linkage with the provincial Drug Treatment Program (DTP), a complete clinical profile of all CD4 T-cell counts, pVL observations, exposure to specific antiretroviral agents, and treatment outcomes for each participant were obtained. In British Columbia, all provision of HIV treatment is centralized through a province-wide dispensation program, where treatment and related care are provided free of charge. Data collection by the DTP has been described previously , 18. TheParticipants were eligible for the present analysis if they were recruited by ACCESS between December 1, 2005 and November 30, 2013, reported having smoked crack cocaine in the six months prior to the baseline assessment, and had initiated HAART prior to enrolment in ACCESS. As well, at least one observation of CD4 cell count and pVL had to be completed within ±180 days of the day they entered the study. For a sub-analysis focusing on dual crack cocaine and opioid users, the sample was further restricted to those who had a history of any opioid use or participation in methadone maintenance therapy at baseline.The primary outcomes of interest were optimal adherence to pharmacy refills for antiretroviral medications and pVL non-detectability in the previous six months. We measured pharmacy refill adherence in each 6-month period as the number of days for which medications were dispensed over the number of days since the initiation of HAART, which was capped at 180 days. We defined optimal pharmacy refill adherence as equal to or greater than 95 %. We have previously demonstrated the clinical validity of this pharmacy refill data and shown that it reliably predicts virologic suppression , 20 and vs. female), ethnicity (Caucasian vs. other), and education level (<secondary education vs. ≥secondary education). Substance-using behaviours included: crack cocaine smoking (≥daily vs. <daily), heroin use (≥daily vs. <daily), crystal methamphetamine use (≥daily vs. <daily), and heavy alcohol use (≥5 drinks per day vs. <5 drinks per day). Other behavioural variables included: homelessness, engagement in sex work or drug dealing, incarceration, participation in inpatient addiction treatment , participation in outpatient detoxification services, seeing drug counsellors or participation in addiction-related peer support meetings , and participation in opioid substitution therapies  . The use of opioid substitution therapies was considered in the sub-analysis focusing on dual crack cocaine and opioid users only. Clinical variables included: CD4 cell count (per 100-cells/mm3 increase); antiretroviral tablet regimen (single tablet vs. 2-3 tablets vs. >3 tablets per day); years since HAART initiation (per year increase); physician experience on HIV care at the time of antiretroviral therapy initiation (having ever treated <6 patients vs. ≥6 patients). All variables except for the demographic characteristics referred to the previous six months unless otherwise indicated.We considered a range of explanatory variables that might be associated with optimal pharmacy refill adherence and/or pVL non-detectability. Demographic characteristics included: age (per 10-year older), gender  in the six months prior to the baseline assessment. Categorical variables were analysed using Pearson’s χ2 test  and continuous variables were analysed using the Wilcoxon rank-sum test. Next, we used generalized linear mixed-effects modelling (GLMM) with the logit link to longitudinally identify factors associated with optimal pharmacy refill adherence and pVL non-detectability, respectively. This form of regression modelling accounts for the correlation between repeated observations gathered over time from the same individual, and estimates the effect of the explanatory variables on the likelihood of optimal pharmacy refill adherence and pVL non-detectability in each individual.First, we examined baseline characteristics of the sample, stratified by medication adherence  and Type III p-values to construct multivariable GLMM logistic regression models. This procedure balances model selection on finding the best explanatory model with best model fit, as described previously : 35.0 – 75.9). At baseline, 240 (54.8 %) exhibited optimal pharmacy refill adherence in the previous six months, and a total of 390 (89.0 %) individuals attained optimal adherence at some point during the study period.Table p < 0.05). Additionally, among a sub-sample of dual crack cocaine and opioid users, those who accessed opioid substitution therapies were more likely to have exhibited optimal pharmacy refill adherence (p = 0.005). Table p = 0.008).Compared to those who had suboptimal pharmacy refill adherence in the previous six months, individuals who had optimal pharmacy refill adherence were older, more likely to be male, self-report Caucasian ancestry, possess a high school diploma, have higher CD4 cell count and a shorter length of exposure to HAART, and have seen drug counsellors or participated in addiction-related peer support groups in the previous six months, while they were less likely to be homeless, smoke crack cocaine or use heroin at least daily, engage in sex work or drug dealing in the previous six months  and higher CD4 count  remained independently and positively associated with optimal pharmacy refill adherence, while homelessness , at least daily crack cocaine smoking , and at least daily heroin use  remained independently and negatively associated with optimal pharmacy refill adherence. When the sample was restricted to dual crack cocaine and opioid users, the same set of variables remained significantly associated with optimal pharmacy refill adherence. Participation in opioid substitution therapies was not independently associated with optimal pharmacy refill adherence .Table Among our sample of HAART-exposed crack cocaine users, we found that homelessness, and high-intensity crack cocaine and heroin use were independently and negatively associated with optimal pharmacy refill adherence and pVL non-detectability. Except for opioid substitution therapies, none of the addiction treatment modalities assessed, including inpatient treatment, outpatient detoxification services, drug counselling, and participation in peer support groups such as Narcotics Anonymous, were significantly associated with optimal pharmacy refill adherence or pVL non-detectability. Specifically among a sub-sample of dual crack cocaine and opioid users, enrolment in opioid substitution therapies was independently associated with pVL non-detectability but not with optimal pharmacy refill adherence.We found an independent association between at least daily use of crack cocaine and poor medication adherence and having a detectable viral load. This is consistent with previous reports that crack cocaine users are less likely to enjoy gains from HAART –15. In aThe finding that none of the addiction treatment modalities except for opioid substitution therapies were associated with optimal pharmacy refill adherence or viral suppression serves to underscore previous calls for identifying more evidence-based addiction treatment approaches that also confer benefits on HIV disease management among HIV-positive crack cocaine users , 14, 25.In contrast, we found that dual crack cocaine and opioid users who were enrolled in opioid substitution therapies were more likely to achieve virological success, and the positive effect of opioid substitution therapies remained significant even after the adjustment for the high-intensity use of crack cocaine and heroin. This adds important evidence to a body of research indicating the effectiveness of these therapies for the improvement of HIV treatment adherence and outcomes . PreviouSimilarly to our previous investigation that indicated that homelessness posed a barrier to antiretroviral therapy among HIV-infected people who use illicit drugs generally , we founOur study has several limitations. First, as the study sample was not randomly selected, our findings may not be generalizable to other populations of crack cocaine users. Second, the self-reported data may be affected by reporting biases, including recall bias and socially desirable responding. However, we note that this type of data has been commonly utilized in observational studies involving people who use drugs and found to be valid . Also, aIn sum, among our sample of HAART-exposed crack cocaine users, those who were homeless and those who engaged in high-intensity crack cocaine or heroin use were more likely to have suboptimal adherence to antiretroviral medications and fail to achieve viral suppression. Further, none of the addiction treatment modalities assessed appeared to facilitate medication adherence or viral suppression, except for opioid substitution therapies. These findings suggest an urgent need to develop evidence-based treatment options for crack cocaine use that also confer benefits to HAART-related outcomes.ACCESS, the AIDS Care Cohort to evaluate Exposure to Survival Services; AIC, Akaike information criterion; AOR, adjusted odds ratio; GLMM, generalized linear mixed-effects modelling; HAART, Highly-active antiretroviral therapy; IQR, interquartile range; OR, odds ratio; pVL, plasma HIV RNA viral load; TasP, Treatment as Prevention