Anti-Retroviral Therapy (ART) is the recommended first line therapy for patients with HIV. Since 2004, Chinese government has provided free Chinese herbal medicine (CHM) for Chinese HIV/AIDS patients. Data of living patients with HIV from the NFTCMP database and Center for Disease Control (CDC) database during 2003–2016 in Guangxi province was obtained and compared. Patients were divided into 3 groups according to their recorded treatment regimens. A total of 2954 patients with their treatment recorded in the two databases were included for analysis, their median age was 46 years (IQR = 36–59), and 64.63% were male. CHM regimens users had baseline CD4 cell counts (380.11 ± 240.59 cell/μL), approximately 100 cell/μL significantly higher than patients receiving CHM combined with ART regimens or only ART regimens. There was no significant difference in mortality among groups. All three regimens improved patients’ CD4 cell counts. Compared to the sharp improvement in ART group during the first 6 months, CD4 cell counts of patients in CHM group and CHM combined with ART group showed a smooth and steady rise. CD4 cell counts of the combined group remained much lower than ART group in the first 3 years, but overtook ART group in the fourth year. Due to treatment, the global annual HIV-related all-cause mortality has continually decreased in recent years. By 2015 the number had reduced to 1.1 million [940 000–1.3 million]. According to the recent report of China Centers for Disease Control (CDC), on October 31, 2017, China’s population of people living with HIV was about 750,0002. HIV/AIDS remains one of the most important public health problems in China and no longer restricted to blood donors and drug users but increasingly spreading through the general population due to unsafe sex, especially among men who have had sex with men5.Human immunodeficiency virus (HIV) is a retrovirus that can destroy or impair the function of the immune system and which can later progress to Acquired Immune Deficiency Syndrome (AIDS), the most advanced stage of HIV infection. HIV/AIDS remains one of the most important public health problems in the world, particularly in low-income and middle-income countries. According to the World Health Organization (WHO) report6. In China, there are three main strategies for treating HIV, which include ART alone, CHM alone, and CHM combined with ART. A pilot project, the National Free CHM HIV/AIDS Treatment Program (NFCHMP), was initiated in 2004 and expanded rapidly. NFCHMP was supported by the State Administration of Traditional Chinese Medicine (SATCHM) and the Ministry of Finance, and the program has provided tens of thousands of HIV/AIDS patients with free Chinese medicine treatment.Chinese herbal medicine (CHM) was firstly used to treat patients living with HIV in 1987 when Chinese medicine practitioners from China provided medical assistance in Tanzania, Africa7 found CHM could significantly improve CD4 cell counts and symptoms . In Henan province, a retrospective cohort study based on the database of NFCHMP observed CHM could decrease the disease progression, reduce the mortality of PLHIV, and improve life expectancy. However, the major limitation was that they chose the world mortality rate over the same period as a comparison8. A 7-year observational study suggested long-term use of CHM could maintain or slow the pace of CD4 cell counts declining. However, this study did not address bias, potential confounders and the possibility that results may have occurred by chance9. CHM has also been reported to relieve HIV/AIDS patients’ clinical symptoms  and significantly decrease opportunistic infections in before and after studies12. Although there is some evidence to indicate there was an observable effect of CHM therapy on HIV, most studies had a small sample size and did not address confounding factors. To confirm the effect and safety of CHM, analysis of more longitudinal data is required to analyze the characteristics of the patients who receive CHM therapy, and statistically adjust for confounding factors. Obtaining longitudinal data is expensive, time-consuming, and the data is difficult to analyze, the advantage of longitudinal data is that the individual development of a certain outcome variable can be studied over time. However, when evaluating the effect of CHM for HIV/AIDS, most studies have ignored individual disease progression. With the development of statistical techniques, such as generalized estimating equations (GEE) and random coefficient analysis, it has become possible to analyze longitudinal relationships using all available longitudinal data, without summarizing the longitudinal development of each subject into one value13.A double-blind randomized controlled trial14. Therefore, this study aimed to utilize and explore longitudinal data from the registries established by SATCHM in Guangxi province to analyze the effect of CHM on patients with HIV.Guangxi, a province located in southwestern China that borders Myanmar, has the second highest HIV prevalence in the whole country due to its specific geographical location and cultural environmentThe Ethics Committee of Beijing University of Chinese medicine granted ethical approval for analyzing data from two registries (BZYYYDX-LL20160215). This study complied with the Declaration of Helsinki and Good Clinical Practice Guidelines in China. All participants provided their written informed consent and allowed their medical data to be used for researches. To protect participants’ privacy, we extracted all available data without names and other identifiers on HIV patients from two registries (CHM registry and CDC registry) in Ruikang Hospital, which is located in the Guangxi province of southern China. We excluded 29 records that only had an ID number and had no other information.CHM database collected data HIV/AIDS patients who participated in the NFCHMP and received CHM therapy. In this registered database, all participants were identified from 16 clinical centers across 14 cities. The CDC database in Nanning, the capital of Guangxi province, was also included to compare the effectiveness of CHM therapy and ART therapy. All patients in the two registries had been diagnosed with HIV infection via virus detection.In the 16 NFCHMP clinical centers, the patients diagnosed with HIV infection would have been informed that NFCHMP could provide free CHM. Patients who had a previous record of severe cerebrovascular disease, severe kidney and hematopoietic system disease, and mental disease were excluded. The NFCHMP participants would have been registered on the CHM registry and would have completed the pre-CHM treatment examination, which we defined as a baseline.Participants were provided with medication and assessed every three months via an interview and laboratory testing. Doctors identified the CHM therapy according to the infection stage of patients and used the Clinical practice proposal of Traditional Chinese medicine treatment for patients living with HIV/AIDS issued by SATCM. CHM therapy could include Chinese patent medicines such as Tangcao tablets, Shenling Fuzheng capsules, Qingdu capsules, Aifukang capsules, as well as other herbal recipes, depending on patients’ symptoms and according to TCM hospital clinical practice. Whether to take a combined treatment of CHM and ART were decided based on patients’ wishes and symptoms.According to the CHM registry, all patients took CHM. To compare the effectiveness of CHM with ART, we also accessed the CDC registry and extracted the data of HIV patients who took ART alone in Ruikang hospital.Demographic characteristics included participants’ gender and age were recorded in two registries. CHM registry recorded more demographic information, including marital status, educational levels, and possible route of infection. Mortality rate, CD4, CD8 cell counts, and white blood cell (WBC) counts were extracted to evaluate the effectiveness. We used the abnormal rate of liver and kidney function to evaluate safety. Alanine transaminase (ALT) and aspartate aminotransferase (AST) were used to evaluate liver function. Blood urea nitrogen (BUN) and creatinine (Cr) were used to evaluate kidney function.The data analyses were performed using SAS version 9.4. We divided participants into different groups by treatment. At baseline, descriptive statistics were used to examine the demographic and clinical characteristics of all participants and in different groups. Continuous variables were summarized as means, standard deviations, median, interquartile range (IQR), range . For categorical variables, the number and percentages of patients in each category were calculated and the proportions of participants who had dropped out, and the meantime of drop-out.13.This study provided longitudinal data, in which the outcome variables were repeatedly measured. We used analysis of covariance (ANCOVA) and GEE statistical methods to adjust confounding factorsOur first approach was an analysis of changes in outcomes between two points in time. Differences between groups were tested for statistical significance using chi-square and Wilcoxon-Mann-Whitney tests for categorical and continuous variables, respectively. Besides, differences between groups were estimated using a one-way analysis of variance (ANOVA) followed by the Student-Newman-Keuls (SNK) test for all pairwise comparisons. Results were considered statistically significant at 0.05 p-value.ANCOVA used to adjust confounding factors , furthermore, we used GEE to investigate the relationship between the outcome variable CD4 cell counts and the predictor variables , and in the model used in this study, we assumed a linear relationship with time.The Ethics Committee of Beijing University of Chinese medicine granted ethical approval for the study.Two thousand nine hundred fifty-four individuals recorded in two registries were extracted for analyses. Of these, 1374 individuals used CHM alone, 1198 individuals used CHM combined with ART, and 382 individuals used ART alone. Participants registered on the databases between 2003 and 2016, the highest proportion (25.84%) were in 2013.One hundred ten patients dropped out from CHM alone group with the mean drop-out time of 9.11 months. Reasons for dropping out were migrating from the area for work (n = 11), unwilling to take medications (n = 24), patients voluntarily withdrawing from the project (n = 39), travel issues (n = 4), other reasons including: lost touch, compulsory detoxification, being put in prison (n = 32).Sixty-seven patients dropped out from CHM combined with ART group, and the meantime of drop-out was 17.78 months. They dropped out for the following reasons: migrating from the area for work (n = 3), unwilling to take medications (n = 21), patients voluntarily withdrawing from the project (n = 23), travel issues (n = 4), other reasons including compulsory detoxification and lost-to-follow-up (n = 16).Of the participants who used CHM therapy and provided demographic characteristics, most participants were married (64.07%), 18.00% were single, 8.10% were divorced, and it is noted that 9.83% were widowed. Further analysis found that, for female patients, the proportion of the widowed (16.86%) was much higher than that of the single (7.58%). On the contrary, for males, the proportion of those who were single (21.24%) was much higher than that of widowed (8.75%). Most participants (40.45%) only received junior middle school education, and few (4.72%) had college or further college education. Most participants (84.38%) considered their possible HIV-infected route was sexual behavior, and drug taking (10.79%) was the second leading possible infection route , and 65.25% were male . Seven patients (0.51%) in the CHM group, eight patients (0.67%) in CHM combined with ART group, and five patients (1.31%) in the ART group, died.The baseline clinical characteristics of the whole cohort were stratified by therapy Table . At baseChanges in CD4 cell counts of the three cohorts were explored. As most participants had been registered in databases since 2011, four years of data were available. Figure We calculated the change of CD4 cell counts from baseline value during the 4-years follow-up period, ANCOVA was used to adjust major confounding factors  and compared the differences among groups Table .Table 3CTable Gender was significantly related to the development of outcome variable CD4 cell counts. The regression coefficient  for gender indicates that there was a greater increase in CD4 counts for females over time. For age, a negative association was found . The results also showed that there was a significant linear increase over time in CD4 cell counts . The change in CD4 over time was significantly different among groups.Table At baseline, comparing to participants used ART alone , participants in CHM group  and CHM combined with ART group  were more likely to have higher white blood cell (WBC) counts. After one year of treatment, there were no statistical differences in WBC counts among groups, and the mean and median WBC counts were all within normal limits.χ2 = 7.73, P = 0.02) higher than the ART group (13.61%). The abnormal rate of ALT had significant differences among groups. In the first three months of ART treatment, liver function abnormal rate significantly increased and significantly higher than the other two treatments. However, after more than three months of treatment, no significant difference was detected among groups. Regarding kidney function, BUN and Cr were not significantly different at baseline between the groups. For patients taking CHM and CHM combined with ART, and ART, the baseline BUN abnormal rate was 4.54%, 4.06%, and 4.56% respectively. There was no significant difference. During four years of treatment, only at 48 months was a significant difference detected between CHM combined with ART and ART alone. Three groups had similar Cr at baseline. During the treatment, the abnormal rate for the CHM group was significantly higher than for the CHM combined with ART at 3 months. Additionally, at 33 months, CHM had a significantly higher abnormal rate than ART.Figure 15. A study has suggested that the asymptomatic stage is the optimal time to take CHM, for it could help to maintain and enhance the immune function so as to delay the progression to the AIDS stage. For those patients who have a diagnosis of AIDS, CHM focuses on relieving symptoms of patients having AIDS-related opportunistic infection16. There was no statistical difference in the death rate among the three groups, and it may relate to the generally low death rate of patients with HIV.This preliminary analysis showed that CHM gradually and continuously improved CD4 cell counts of patients with a relatively better baseline CD4 status. Compared to patients who only took the ART regimen, the patients who combined CHM were more likely to have a steady and continuous growth in CD4 cell counts. This phenomenon indicated there might be some drug interactions between two therapies. We found that for the patients who had relatively higher CD4 cell counts (>350 cell/μL) and did not take ART before, CHM could steadily increase CD4 cell counts and improved immunity levels. Compared to using ART alone, the CD4 cell counts of participants using CHM combined with ART increased slower in the first three years. It may relate to the potential effect of CHM on promoting immune reconstitution and counteracting the adverse side effects of antiviral drugs17.In China, governments provide patients with free antiviral drug including nucleoside reverse transcriptase inhibitor (NRTI), non-nucleoside reverse transcriptase inhibitor (NNRTI), and protease inhibitor (PI), such as inhibitor didanosine (ddI), lamivudine (3TC), stavudine (d4T), zidovudine , nevirapine (NVP), and indinavir (IDV). Using a combination of d4T, 3TC and NVP are recommended as the first-line treatment for patients who had not received ART. For those patients who had accepted ART before, experts decide whether they need to change by considering their condition and personal willingnessAs a chronic disease, the safety of long-term medication is an important issue that both patients and doctors concerned with. In this study, long-term CHM alone or ART combined regimens seemed safety. After the first three months of treatment, only patients who used ART alone had a significant increase in the abnormal rate of liver function. While patients used CHM alone and CHM combined with ART had no significant change in liver function.The strength of our study was our use of both traditional statistical methods and GEE to analyze longitudinal data. This study has some limitations. The CHM database was based on the patients who had agreed to take part and who completed the full four years follow up and possibly did not reflect all those taking CHM. There may also have been some selection bias with those who accepted CHM as a treatment or as part of their treatment regimen. This was not a randomized controlled trial, and therefore, potential selection bias of whether or not to consent to the study may have influenced the results.Three therapies appeared to improve CD4 cell counts of patients in the first three years. After three years, CHM alone or combined with ART could still improve CD4 cell counts. There was no evidence to suggest CHM could decrease mortality. It is noteworthy that compared to patients who only took ART, patients taking CHM were more likely to have a steady rise in CD4 cell counts.


The Stanford Calibrated Population Resistance program v6.0 was used for Surveillance Drug Resistance Mutations (SDRMs).Disruption in HIV care provision may enhance the development and spread of drug resistance due to inadequate antiretroviral therapy. This study thus determined the prevalence of HIV-1 transmitted drug resistance (TDR) in settings of decentralized therapy and care in Senegal and, the Ebola outbreak in Guinea. Antiretroviral-naïve patients were enrolled following a modified WHO TDR Threshold Survey method, implemented in Senegal (January–March 2015) and Guinea (August–September 2015). Plasma and dried blood spots specimens, respectively from Senegalese (n = 69) and Guinean (n = 50) patients, were collected for direct sequencing of HIV-1 Genotyping was successful from 54/69 (78.2%) and 31/50 (62.0%) isolates. In Senegal, TDR prevalence was 0% (mean duration since HIV diagnosis 4.08 ± 3.53 years). In Guinea, two patients exhibited SDRMs M184V (NRTI), T215F (TAM) and, G190A (NNRTI), respectively. TDR prevalence at this second site, however, could not be ascertained because of low sample size. Phylogenetic inference confirmed CRF02_AG predominance in Senegal (62.96%) and Guinea (77.42%). TDR prevalence in Senegal remains extremely low suggesting improved control measures. Continuous surveillance in both settings is mandatory and, should be done closest to diagnosis/transmission time and with larger sample size. Genetic imprints of HIV-1 transmitted drug resistance (TDR) in therapy-naïve individuals may readily jeopardize the clinical benefits associated with antiretroviral therapy (ART). Currently this therapy is initiated in developing countries (DC) as a triple combination of two nucleosides reverse transcriptase inhibitors (NRTIs) and a non-NRTI (NNRTI) . TDR notSenegal and Guinea are two neighboring countries of West Africa which together with Central Africa (WCA) globally represents the second most affected region by HIV . In 2016TDR published estimates in Guinea date back to 2009 (8.6%) . This st3 for ART eligibility.The WHO threshold survey (TS) method  was slig3. At the RHS, a social assistant administers adherence counselling, which is mostly ensured by peers or support groups at respective ATCs that track care/treatment defaulters.HIV guidelines in Senegal , 12, 13 At the time of the study, recommended first-line therapies comprised two NRTIs  and one NNRTI (Nevirapine/Efavirenz). Confirmed cases of first-line failures  are switched to second-line therapies with two NRTIs and one protease inhibitor. For prevention-for-mother-to-child-transmission, both countries adopted option B+.On-site viral load tests are available/operational since 2013 (ATC/Dakar), 2014 (ATC/DNH), 2016–2018 (RHS) and, provided six-monthly. For ATC/Dakar, these tests were previously offered at the reference Laboratory of Bacteriology–Virology (LBV) of the Aristide Le Dantec UTH in Dakar. Unlike Dakar, resistance testing is lacking in Guinea and decentralized settings of Senegal.®; 903) before shipping to the LBV where all samples were genotyped. Dried blood spots (DBS) were also kept at − 80 °C until molecular analysis and, their preparation and shipping conditions have been described earlier [All patients in Senegal provided blood specimens (5 ml), collected in EDTA-tubes and centrifuged to harvest plasma that was stored at − 80 °C. In Guinea, blood was spotted (50 µl/spot) onto filter papers   and NucliSENS easyMag , respectively. cDNA Synthesis and PCR (nested-) were carried out in a one-tube reaction containing AMV-reverse transcriptase . HIV-1 pol gene encoding the protease (PR) and partial RT drug-targets was sequenced following the ANRS protocol [http://cpr.stanford.edu), WHO Surveillance Drug Resistance Mutations (SDRMs) [Viral RNA was extracted from plasma and DBS using the QIAmpprotocol . Using t (SDRMs)  were scr5 + I nucleotide substitution model. The Subtree-Pruning-Regrafting heuristic search was applied for optimal tree topology. Branch statistic was computed by the Shimodaira-Hasegawa-approximate likelihood ratio test (SH-aLRT) [Multiple sequence alignment was executed with Mafft v7.31  and, incSH-aLRT) . PatternPatients’ data were summarized as frequencies, means (± SD) and median  using Epi-info™ v.7.2.1.In total 69 ART-naïve patients were enrolled at the ATC/Dakar 68.11%) and RHS (31.88%). The median age of the study population was 37 years IQR 32–45) with females being mostly represented   and females constituted more than half of the study population  Table . Patient6–43 and The 0% TDR prevalence found in Senegal comforts previous studies from this site that reported no NNRTIs mutations and, a decline in NRTIs TDR (4.16–0%) between 1998 and 2006/2007 , 22. ThiCompared to the ATC/Dakar, viral load and resistance testing at the time of this investigation were hardly performed at the RHS. In a concurrent cross-sectional study conducted in these two facilities, we showed significant odds of VF and ADR to first-line ART, taken for ≥ 12 months, at the RHS (unpublished data). Despite the consistent rollout of antiretrovirals at decentralized sites since 2008, the 27.53% therapy-naïve cases at the RHS harbored no SDRM. This observation underscores the importance of preventing new infections in a context of inadequate therapy monitoring. Nonetheless, the magnitude of TDR at the RHS remains to be ascertained because of the few isolates screened. The restrictive criteria of WHO-TS to apply in antenatal settings of low HIV prevalence may explain this limitation . At Sain3; namely between 350 and 650 cells/mm3 with single measurements [3) may have implications for the WHO-TS in DC. Furthermore, this approach may defer treatment start, thereby increasing the likelihood of onward TDR [3) and MTSD (4.08 ± 3.53 years) in Senegalese patients may signify longer infections. This finding contradicts that seen in Guinean patients . In Tanzania, older patients (38.9 ± 10.1 years) presented a 19% TDR prevalence  [The underrepresented proportion of patients < 25 years old, especially in Senegal, might be perceived as an underestimation of TDR prevalence. This criterion and, primigravidity have shown limited sensitivities in identifying recent infections . The cururements . As suchward TDR . Scrutinward TDR  therefor3 years) . Hence, The WHO-TS strategy requires a minimum of 34–47 samples to report TDR in DC. Regardless of this criterion and, in spite of the Ebola crisis it could be argued that TDR rate in Guinea has not known any increase from 2009 when the last survey was conducted . FurtherSDRMs detected in Guinea may cause high-level resistance at initiation to Zidovudine (T215F), Lamivudine (M184V) and, Nevirapine/Efavirenz G190A/K103N). These resistant genotypes have been previously described in therapy-naïve patients at DNH 0A/K103N., 33. IbeMolecular phylogenetic confirmed CRF02_AG predominance in Western-Africa . RecombiThe prevalence of HIV-1 TDR in Senegal was extremely low but arguably moderate in Guinea, despite major challenges in the provision of HIV-related services. Further surveillance studies are needed especially in decentralized areas where treatment monitoring uptake is inadequate. Surveillance of TDR likewise should be enhanced in Guinea as disruption of health care due to the Ebola epidemic may have led to increased therapeutic failures.The sample size of this survey was not sufficiently informative of HIV-1 TDR dynamic at the decentralized and Ebola sites. Secondly, infections tended to be chronic in our sampling setting of Senegal, thus cautioning against extrapolation of the current 0% TDR. The use of conventional sequencing limits the detectability of resistant minority variants, which may have underestimated TDR prevalence.


The World Health Organisation recommended dolutegravir (DTG)-based antiretroviral therapy (ART) regimens are available but not reimbursed through the public reimbursement system in China. The objective of this analysis was to evaluate the cost-effectiveness of DTG (DTG + TDF/3TC) compared to efavirenz (EFV + TDF/3TC) in treatment-naive and ritonavir-boosted lopinavir (LPV/r + TDF/3TC) in first-line ART failure HIV-1-infected patients in China.A dynamic Markov model comprising of 5 response states and 6 CD4+ count-based health states was used. Efficacy, estimated as probability of virologic suppression (HIV RNA < 50 copies/mL) at 48 weeks, was obtained from a published network meta-analysis for ART-naive patients and from the DAWNING study for patients failing first-line ART. Baseline cohort characteristics were informed using DTG phase 3 studies and the DAWNING study data, respectively. Health state utilities were derived from DTG phase 3 studies. A 5-year cost-effectiveness analyses was conducted using the societal perspective. Outcomes were quality-adjusted-life-years (QALYs), life-years (LYs), incremental cost per QALYs (ICER).The viral suppression rates for DTG + TDF/3TC were higher than EFV + TDF/3TC (75.3% vs 64.0%) in treatment-naive and LPV/r + TDF/3TC (74.8% vs 58.4%) in first-line ART failure patients. This resulted in higher QALYs for DTG + TDF/3TC in treatment-naive (4.232 vs 4.227) and first-line failure settings (4.224 vs 4.221). Total discounted cost for DTG + TDF/3TC patients  were lower than comparators , thereby DTG dominated in both settings. Probabilistic sensitivity analyses indicated the probability of DTG + TDF/3TC being cost effective was 98.2% in treatment-naive setting and 100% in first-line failure setting at a willingness to pay threshold of RMB 100,000/QALY.With lower costs, higher response rates and higher QALYs, DTG + TDF/3TC can be considered as a cost-effective alternative for treatment naive and first-line failure patients in China. Dolutegravir is highly efficacious antiretroviral therapy recommended as first line treatment in patients living with HIV in most treatment guidelines but is not reimbursed on National Free IADS Antiretroviral Drug List in China.Our analyses show dolutegravir to be cost effective compared to efavirenz (EFV) in treatment naïve patients living with HIV (PLHIV) and compared to ritonavir boosted lopinavir (LPV/r) in first line failure PLHIV.This provides strong rationale for the adoption of WHO-recommended DTG into first- and second-line HIV treatment regimens in China and may help achieve 90-90-90 ambition set out by Chinese health ministry.The HIV epidemic in China is characterised by low national prevalence of 0.037% with some regions and some sub-populations reporting higher prevalence . The numPolicy makers in China have implemented 2015 World Health Organization (WHO) guidelines for HIV treatment which recommend ARTs for all PLHIV irrespective of their CD4 cell counts . The proDTG is a 2nd generation INSTI that received regulatory approval in China in 2015. DTG has demonstrated superiority to EFV and ritonavir-boosted darunavir (DRV/r) and, non-inferiority to raltegravir (RAL) in its phase 3 clinical program in treatment-naïve HIV-1 infected individuals –10. Two A previously published cost-effectiveness model was adapted to estimate the clinical outcomes and costs of DTG + 2NRTIs compared with EFV + 2NRTIs in treatment-naive and compared to LPV/r + 2NRTIs in first-line failure PLHIV. The model framework was a dynamic Markov model and has been described in detail previously . The anaIn summary, patients entering the model were distributed into one of the six CD4+ based health states depending on their baseline CD4+ level Fig. . Based oTwo separate cost effectiveness analyses were performed, one in treatment-naive patients and the other in individuals experiencing first-line treatment failure.In the treatment naive analyses, the baseline characteristics of patients entering the model were obtained from DTG phase 3 trials in treatment-naive HIV-1 infected patients –10 and fFor the analysis of first-line failures patients, the baseline patient characteristics were obtained from DAWNING study which compared DTG and LPV/r in combination with multiple backbones in HIV-1 patients failing first-line treatment . TreatmeSeveral assumptions and parameters were common to analyses in treatment-naive and first-line failure patients. The CD4+ changes beyond 48 weeks were based on pooled patient level data of all the DTG trials . FurtherPatients experiencing treatment-related adverse events (AE) were assumed to experience a QoL decrement and additional costs associated with that event. Those experiencing grade 2–4 AEs were assumed to switch to the next treatment. The likelihood of patients experiencing AEs was obtained from the pooled data of DTG phase 3 trials –10 in trHIV related comorbidities were assumed to impact utilities and costs. The risk of developing cardiovascular disease (CVD), a common comorbidity among HIV patients, was estimated in each model cycle based on published literature . The othMortality included death due to HIV, acute OIs, CVD or natural causes. HIV mortality was estimated based on CD4+ cell count and history of any OI . Acute OHealth state level utilities were derived from phase 3 studies of DTG trials and are displayed in Table ART costs were obtained from literature and are presented in Renminbi (RMB) . GenericHIV management costs included testing and switching costs , physiciCosts associated with management of frequent comorbidities such as cardiovascular disease also were included. These were estimated using the prevalence of CVD among HIV patients in China and their associated costs . All theIndirect costs comprising of productivity losses were included in the model. Productivity losses were estimated from literature  and costIn the base case, model time horizon was 5 years based on the mean duration of first-line ART in China . Both diThe incremental efficacy in quality adjusted life years (QALYs) and incremental costs of DTG + TDF/3TC was compared with EFV + TDF/3TC in treatment-naive patients and with LPV/r + TDF/3TC in first-line failure patients. The incremental cost effectiveness ratio (ICER) was reported as cost per responder and cost per QALY. Model robustness was assessed with multiple one-way deterministic sensitivity analyses by varying key parameters through plausible ranges of ± 20%. Parameters varied were CD4+ efficacy, AE prevalence, costs and utilities. Cost effectiveness estimates over model time horizons ranging from 1 year to patient lifetime were explored. Probabilistic sensitivity analysis (PSA) was used to estimate the impact of parameter uncertainties.The base case model predicted 75.3% patients on DTG + TDF/3TC and 64.0% patients on EFV + TDF/3TC to achieve and maintain virologic suppression. The mean duration of response per patient over 5 years was 41.7 months for DTG + TDF/3TC and 36.7 months for EFV + TDF/3TC. This resulted in 4.232 QALYs per patient on DTG + TDF/3TC and 4.227 QALYs per patient on EFV + TDF/3TC. The discounted and half-cycle corrected total costs of HIV treatment per patient over 5 years was RMB 219,259 for DTG + TDF/3TC and RMB 221,605 for EFV + TDF/3TC. The incremental cost effectiveness analyses showed DTG + TDF/3TC resulting in 0.006 incremental QALYs with cost savings of RMB 467 compared to EFV + TDF/3TC, thus dominating EFV based regimen  resulting in DTG based regimen dominating LPV/r based regimen. One-way sensitivity analyses identified utility estimate of the CD4 +>500 health state and prices of DTG + TDF/3TC and LPV/r + TDF/3TC as key drivers of the results. At a willingness to pay threshold of RMB 100,000, DTG + TDF/3TC had 100% probability of being cost-effective /3TC) and EFV + (TDF/emtricitabine (FTC))  as the SOur analyses resulted in ICERs that can be considered conservative. Due to the limited information available in the NMA , we attrOur analysis has limitations. We estimated ART efficacy from randomized clinical trials; it’s possible that real-world results, or those in China may differ. ART outcomes will also be affected by levels of adherence and persistence, prevalence of AEs and baseline CVD risk among HIV patients in clinical practice. In our analysis, we did not include these parameters due to lack availability of robust estimates specific to HIV patients in China. Some of the resource use estimates as well as clinical estimates such as risk of OIs were derived from older studies which may over or under estimate the current HIV resources in China. Incremental implementation costs or feasibility favouring either DTG or comparators were also not modelled.Recent 2018 WHO HIV treatment guidelines  recommenHIV-1 infected treatment naïve and first line failure patients achieved higher response rates and higher QALYs at lower costs, when treated with DTG + TDF/3TC compared to currently available ARV regimens. Inclusion of dolutegravir in the National Free AIDS Antiretroviral Drug List at an optimal price may offer healthcare professional and policy makers, an additional option in tackling the growing burden of HIV in China.


Differentiated antiretroviral therapy (ART) delivery models, in which patients are provided with care relevant to their current status  has become an essential part of patient-centered health systems. In 2015, the South African government implemented Chronic Disease Adherence Guidelines (AGLs), which involved five interventions: Fast Track Initiation Counseling for newly initiating patients, Enhanced Adherence Counseling for patients with an unsuppressed viral load, Early Tracing of patients who miss visits, and Adherence Clubs (ACs) and Decentralized Medication Delivery (DMD) for stable patients. We evaluated two of these interventions in 24 South African facilities: ACs, in which patients meet in groups outside usual clinic procedures and receive medication; and DMD, in which patients pick up their medication outside usual pharmacy queues.We compared those participating in ACs or receiving DMD at intervention sites to those eligible for ACs or DMD at control sites. Outcomes were retention and sustained viral suppression (<400 copies/mL) 12 months after AC or DMD enrollment (or comparable time for controls). 12 facilities were randomly allocated to intervention and 12 to control arms in four provinces . We calculated adjusted risk differences (aRDs) with cluster adjustment using generalized estimating equations (GEEs) using difference in differences (DiD) with patients eligible for ACs/DMD prior to implementation  for comparison. For DMD, randomization was not preserved, and the analysis was treated as observational. For ACs, 275 intervention and 294 control patients were enrolled; 72% of patients were female, 61% were aged 30–49 years, and median CD4 count at ART initiation was 268 cells/μL. AC patients had higher 1-year retention  and comparable sustained 1-year viral suppression (<400 copies/mL any time ≤ 18 months) . Retention associations were apparently stronger for men than women . For DMD, 232 intervention and 346 control patients were enrolled; 71% of patients were female, 65% were aged 30–49 years, and median CD4 count at ART initiation was 270 cells/μL. DMD patients had apparently lower retention  and comparable viral suppression versus standard of care , though in both cases, our findings were imprecise. We also noted apparently increased viral suppression among men . The main study limitations were missing data and lack of randomization in the DMD analysis.In this study, we found comparable DMD outcomes versus standard of care at facilities, a benefit for retention of patients in care with ACs, and apparent benefits in terms of retention (for AC patients) and sustained viral suppression (for DMD patients) among men. This suggests the importance of alternative service delivery models for men and of community-based strategies to decongest primary healthcare facilities. Because these strategies also reduce patient inconvenience and decongest clinics, comparable outcomes are a potential success. The cost of all five AGL interventions and possible effects on reducing clinic congestion should be investigated.NCT02536768. Matthew Fox and colleagues report on outcomes of two tailored service delivery models for HIV therapy in South Africa. Antiretroviral therapy (ART) has brought enormous benefits, enabling HIV patients to live longer and healthier lives. However, many patients struggle to adhere to this lifelong treatment, and their retention in care is suboptimal.To address this, South Africa’s National Department of Health has introduced National Adherence Guidelines for Chronic Diseases that recommend key interventions suitable for new patients, clinically stable patients, patients with advanced HIV disease or on a failing ART regimen, and lost-to-follow-up patients.The early implementation of these guidelines from 2015 was evaluated to understand the effectiveness of five interventions and learn about improvements for the guidelines’ rollout.This paper provides the results on adherence clubs and decentralized medication delivery, two interventions for efficient medication pick-up by clinically stable patients.We used a cluster-randomized evaluation design for adherence clubs and an observational study for decentralized medication delivery across 12 intervention and 12 control health facilities in 4 provinces.The 275 adherence club patients had improved retention in care at one year compared to the 294 controls, especially men, and comparable viral suppression within 18 months.The 232 patients receiving decentralized medication delivery had apparently lower retention in care than the 346 controls (possibly due to medication pick-up data not reaching clinics), and viral suppression was comparable overall, but men on decentralized medication delivery had apparently increased viral suppression.This programmatic evaluation with a comparison group provides the National Department of Health with many lessons for the national rollout of the guidelines and the effect one can expect from such alternative medication pick-up services.The control facilities were already offering some adherence and retention services, and the observed benefits of the guideline interventions are therefore additional.The comparable outcomes for decentralized medication delivery against standard of care, the retention benefit by adherence clubs, and the apparent increased effects among men suggest that these interventions can play an important role in South Africa’s ART program.Because the interventions also decentralize ART and reduce patients’ inconvenience, comparable outcomes are a potential success, and further work should investigate the cost–benefit relation and possible effects on decongesting clinics. The benefits of the rollout of antiretroviral therapy (ART) programs in resource-limited settings have been massive, including increased survival ,2, reducOne way to attempt to improve retention is by reducing the burden on the patient of seeking care. Differentiated ART delivery models, in which patients with different needs receive tailored care –18, has South Africa, which has the largest HIV treatment program in the world , has beeIn order to develop an evidence base behind differentiated ART delivery models and to inform improvement of the rollout of the interventions, South Africa’s NDOH piloted rollout of the interventions in 12 primary healthcare clinics (PHCs) from 2015. We evaluated five of the interventions and present here an evaluation of two strategies, ACs and DMD, for clinically stable patients designed to reduce patient burden, which would in turn help clinicians and staff to provide increased support to clients with advanced HIV disease and for those on a failing ART regimen. The evaluation design has been reported previously ,29.TIER.Net data; and 4) not participating in other adherence-related studies. Sites were matched on district, total on ART, proportion virally suppressed, setting , and location.The study used an unblinded cluster-randomized evaluation design for ACs and an observational study for DMD. For DMD, while the study was initially designed to have sites randomized to DMD roll out, changes in clinic mandates meant that some clinics began using DMD in control sites and not all intervention sites were able to begin implementing DMD. The full protocol can be seen in ACs comprise clinically stable ART patients who meet at facilities or community locations in groups of up to 30 every 2 to 3 months to receive group counseling, have a brief symptom screen, and receive prepacked medications. Clubs are managed by lay staff and nurses at the facility with support from community health workers. The goal is to keep patients engaged and adherent by providing social support and facilitating medication delivery and treatment monitoring while reducing patient burden at the clinic because these patients only require 6-monthly clinic visits and assessments for blood tests and rescripting. While each of the components of the ACs  are currently considered important parts of the intervention, to date, none of the components have been tested alone to determine which components are essential.DMD comprises prepacking and distribution of medications to PuPs, which are at locations other than the clinic pharmacy. Patients only need to come to the clinic on a 6-monthly basis for a clinical exam and rescripting. The goal is to reduce the time and resource burden on the patient while also decongesting clinics. DMD was established using three models: 1) facility-led prepackaging of medicines delivered to external sites; 2) Centralized Chronic Medicine Dispensing and Distribution (CCMDD), in which private partners prepackaged medicines and delivered them to the facility, which then distributed packs to dedicated PuPs (such as an AC) or delivered direct to a pharmacy or other dedicated PuP; and 3) chronic dispensing unit, in which the district pharmacist prepackaged medication and delivered to facilities, PuPs, or ACs. For clarity, we note that patients enrolled in the DMD analyses could not be in an AC.DOH staff at facilities started to be trained on these interventions in July 2015, and training continued until mid-2016. At the start of data collection, the intervention sites had been implementing these interventions for at least 1 month and at some sites up to 6 months. At intervention sites, clinically stable patients were supposed to be given a choice between any of the three repeat prescription collection strategies available: ACs, DMD, or spaced fast-lane appointments , though in some cases, facilities did decide which intervention a patient would be offered. Patients could also choose to switch between strategies, but this was monitored in our cohorts, and very few switches were recorded. It was not possible, however, for a patient to be enrolled in more than one approach at the same time.We included patients over 18 years old who were resident in the facility’s catchment area, had no documented plan to transfer facilities, and were neither pregnant nor eligible for prevention of mother-to-child transmission services. Patients had to be eligible for a repeat prescription collection strategy by 1) being on the same ART regimen for at least 12 months, 2) having had their most recent viral load in the past 3 months, and 3) having had two consecutive undetectable viral loads (<400 copies/mL).S1 CONSORT Checklist.As the study was designed to assess retention-based outcomes, we did not interact with patients because this could impact outcomes. Instead, we received a waiver of consent and reviewed medical records to identify eligible patients. Follow-up started when patients became eligible to receive the intervention: the date of prescription visits for ACs/DMD for intervention patients and, for control patients, the clinic visit that occurred closest to the date that the medical record was reviewed. Follow-up start dates were between March 2016 and March 2017. At intervention sites, we included patients identified as actually having received the intervention (AC or DMD) in a clinic register or patient files. When more patients than required could be identified, we took a random sample of those eligible . We then confirmed eligibility with clinic files. At control sites, we used clinic records to identify persons who would have been eligible for a repeat prescription strategy if they had been implemented at the facility and randomly allocated (using a computer) eligible patients to ACs or DMD to serve as controls . Again, we took a random sample of all those eligible. However, we note that because these participants were not offered the intervention, we could not identify which control subjects would have received the intervention if offered, and this could lead to some lack of comparability in our populations. Study flow figures for ACs and DMD are presented in Figs TIER.Net, and 3) the National Health Laboratory Service (NHLS) database of all viral loads done in South Africa’s public sector [We followed patients through routinely collected facility- and patient-level records. Follow-up data came from three sources: 1) clinic records , 2) a national electronic patients database called c sector ,30. PassTIER.Net, NHLS, or paper files. We did not specify a window around 12 months for suppression, so we defined this post hoc based on any suppressed viral load within 2 to 18 months after eligibility for ACs or DMD to allow time for viral loads to be recorded. If there were discordant results within the follow-up period , the outcome was classified as suppressed. We note that we consider this as continued viral suppression because everyone in the study had to have a suppressed viral load at entry, even though in some cases (N = 18 AC and N = 20 DMD), patients did have both an unsuppressed and suppressed viral load in that time period. We also report viral suppression among those patients who had a viral load for comparison to the results including all patients.Our first long-term outcome was sustained viral suppression (<400 copies/mL) at 12 months after eligibility for ACs or DMD, indicated by any suppressed viral load from TIER.Net and file review to measure 12-month outcomes. The database was locked on May 23, 2018.Our second outcome was retention in care at 12 months after eligibility for ACs or DMD defined as 100% − % attrition, with attrition as the sum of reported deaths, loss to follow-up, and transfers. Loss to follow-up was defined based on clinic definitions—failure to attend the clinic within 90 days of a scheduled appointment. For retention, we used We designed the study to have power = 80%, two-sided alpha = 0.05, and a coefficient of variation of 0.1 to account for clustering. We assumed 80% of patients would reach the primary outcome in the control arm. To detect a difference of 15%, we estimated we would need 24 subjects per clinic for each intervention .ij is a binary outcome for person i at site j, period is a dummy variable indicating the period , intervention is a dummy variable indicating randomization group , and β4 is the effect of the intervention . The model is further adjusted for a vector of covariates Xij  and for clustering by clinic using GEEs. We also conducted subgroup analyses by age and sex, but these were not prespecified subgroup analyses and, as such, should be considered hypothesis generating. We note further that the decision to add in the DiD analysis was not in our initial protocol but added prior to data analysis, once we determined full randomization could not be maintained and we could not identify all control patients who would have received the interventions if offered.We followed a similar analytic plan for each intervention and outcome. We compared arms on the proportion with the outcome and calculated crude risk differences and 95% CIs. Because we included those who actually received the intervention, our results should be considered as an “as treated” analysis. Next, we accounted for clustering using a linear regression generalized estimating equation (GEE) model of risk with an unstructured correlation matrix with site clustering. The model was then adjusted for differences in baseline covariates. Despite the cluster-randomized design, we anticipated differences between groups in the period prior to the intervention period. To account for this, we implemented a difference-in-differences (DiD) approach using data from a period prior to the intervention rollout . Our model isThe study was approved by the Human Research Ethics Committee (HREC) of the University of the Witwatersrand and the Boston University Institutional Review Board (IRB). Both approved use of routine clinic data for the evaluation and a waiver of consent. The trial is registered at clinicaltrials.gov (NCT02536768).3. Arms were well balanced with respect to baseline demographics, but we saw some small imbalance in CD4 count at ART initiation (median 278 versus 256), and those in the intervention arm had been on treatment for substantially longer than the control arm.About 84% of subjects had a repeat viral load within 18 months of club eligibility, but this did not differ by arm. Sustained viral suppression was high overall at about 80%, including those without a repeat viral load . This is expected given that those eligible for ACs are highly adherent already. In our crude analysis, ACs were associated with little change in sustained viral suppression  . We alsoRetention at 12 months was high in both arms (85%), as expected given the targeted population. ACs were associated with a crude 7.8 (95% CI: 2.1% to 13.6%) percentage-point increase in retention . Prior t3 at enrollment. Intervention and control arms were similar with respect to sex and age, but again, we found some small imbalances in CD4 (279 versus 256 cells/ml3) and log viral load at eligibility (log10 1.62 versus 2.09 copies/ml)  . As withWe found that sustained suppression rates were only about 75% overall, but this was largely because of patients without a repeat viral load. Among those with a repeat viral load, suppression was about 95%. Comparing DMD implementation sites to those not implementing DMD, sustained suppression was similar  . Prior tRetention was high overall (about 85%) with, apparently, somewhat lower retention in DMD than control sites . Prior to intervention, we found nearly identical retention  . AdjustiIn one of the first randomized trials of decentralized service delivery for HIV care, we found that AC patients had higher 1-year retention (89.5% versus 81.6%) and comparable sustained 1-year viral suppression (80.0% versus 79.6%) compared to those receiving standard of care. The retention association we observed was stronger for men than women . For DMD, we found that those in DMD had apparently lower retention (81.5% versus 87.2%) and comparable viral suppression compared to patients receiving standard of care (77.2% versus 74.3%), though our findings were imprecise. We also found apparently increased suppression among men . Thus, our findings demonstrate that such approaches can be implemented with potential for benefit and, at a minimum, no harm among patients who already have high rates of viral suppression and retention.South Africa’s National AGLs were developed to improve treatment outcomes and reduce the burden on clinically stable patients while allowing for provision of more intense care to individuals with advanced HIV disease. For repeat prescription strategies like DMD and for adherence approaches like ACs that also include repeat scripting, even if outcomes remain comparable to the control group, this could be seen as a benefit because these interventions are designed to make care easier for those clinically stable patients and help clinicians and staff to provide increased support to clients with advanced HIV disease and for those on a failing ART regimen, as well as freeing up capacity . In factWe did not look at short-term medication pick-up outcomes for DMD because data on pick-ups were kept by private providers and were not always fed back into patient records. Here, we looked at long-term outcomes, one of which  did not rely on data from outside service providers. DMD was more difficult to evaluate because not all sites that were supposed to implement DMD did so, and some that were not supposed to did. Still, we found no differences in sustained viral suppression between study arms . This could indicate a benefit of the intervention because it frees up clinic space. We did observe an increase in attrition associated with the intervention , but we suspect this is unlikely to reflect real differences given that retention was likely influenced by visit information not being returned to clinics files. Thus, the fact that we saw only small differences suggests retention is likely unchanged. Overall, DMD appears to be a useful intervention. Unlike ACs, which have been implemented in numerous settings, there is little evidence on DMD with which to compare our data.The evaluation was designed to evaluate the AGLs as implemented compared to standard of care. The use of a cluster-randomized evaluation helped increase validity, and use of routine data collection helped prevent the study influencing retention and suppression-based outcomes. At the same time, these choices also come with important limitations. First, it is critical when interpreting these results to understand that the control sites were not pure control groups because forms of the interventions were being implemented at many control sites. This would likely move estimates towards the null. Second, unlike individually randomized trials, our cluster-randomized design reduced power and increased the chances of confounding. Our DiD approach should help mitigate this, but some residual confounding may be left. Third, our use of routine data led to some missing data that we could not prevent. Fourth, not all those eligible for the intervention necessarily received it, and if those at intervention sites were a select group of patients, this could create bias. In addition, because subjects were not offered the interventions at control sites, we could not determine who would have received them if they had been offered. This could lead to some lack of comparability in our study populations at baseline. Fifth, while we did initially randomize clusters, this is not a fully randomized trial, both because for the DMD intervention, randomization was not maintained, but also because in the intervention sites, we only enrolled subjects who received the intervention, whereas in the control sites, we could only enroll a sample of those eligible for the interventions, even if they never would have received them if offered. The impact of this is not clear. Sixth, we note that those in the intervention arm had been on treatment for substantially longer than the control arm. We suspect this may be because providers prioritized targeting the interventions towards those who were on treatment far longer than the minimum required and had the longest track record of demonstrating stability on treatment. This could have the effect of making the interventions seem better than they are. Seventh, we conducted the study during the rollout, before sites had experience with the interventions, and as such, results under full implementation may differ. Eighth, DMD is largely run by parties outside the clinic so that data collection on the interventions was, during the study period, often controlled by third parties and did not always make it back into the data collection systems at the sites. This could have affected our long-term retention outcome. Ninth, we note that we did not a priori decide to stratify our analyses by sex, and therefore, sex-stratified results should be considered hypothesis generating and require confirmation. Finally, because these interventions were implemented at test sites, we do not know for sure that the results will generalize to all clinics in South Africa.In conclusion, we found that ACs and DMD, in agreement with other studies, are feasible, acceptable, and for ACs, had positive outcomes. We saw an overall retention benefit to ACs and comparable outcomes with DMD against standard of care, which should still prove to be a benefit to clinics as they are designed to decongest the clinic overall. ACs as a medication refill model worked especially for male patients, given the benefits seen in retention and sustained viral suppression. As the AGL intervention package is taken to scale, it will be important to track patient retention and sustained viral suppression and to quantify the cumulative cost benefit of the package of interventions across the HIV care cascade.S1 CONSORT Checklist(DOCX)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 TableAC, Adherence Club.(DOCX)Click here for additional data file.S3 TableAC, Adherence club; DiD, difference in differences.(DOCX)Click here for additional data file.S4 TableAC, Adherence Club.(DOCX)Click here for additional data file.S5 TableAC, Adherence Club; DiD, difference in differences.(DOCX)Click here for additional data file.S6 TableAC, Adherence Club.(DOCX)Click here for additional data file.S7 TableDMD, Decentralized Medication Delivery.(DOCX)Click here for additional data file.S8 TableDiD, difference in differences; DMD, Decentralized Medication Delivery.(DOCX)Click here for additional data file.S9 TableDMD, Decentralized Medication Delivery.(DOCX)Click here for additional data file.S10 TableDMD, Decentralized Medication Delivery.(DOCX)Click here for additional data file.S11 TableDiD, difference in differences; DMD, Decentralized Medication Delivery.(DOCX)Click here for additional data file.S12 TableDMD, Decentralized Medication Delivery.(DOCX)Click here for additional data file.S1 TextAGL, Adherence Guideline; NDOH, National Department of Health.(DOCX)Click here for additional data file.


Poor adherence to antiretroviral drugs and viral resistance are the main drivers of treatment failure in HIV-infected patients. In sub-Saharan Africa, avoidance of treatment failure on second-line protease inhibitor therapy is critical as treatment options are limited.In the prospective observational study of the Kilombero & Ulanga Antiretroviral Cohort in rural Tanzania, we assessed virologic failure  and drug resistance mutations in bio-banked plasma samples 6–12 months after initiation of a protease inhibitor-based treatment regimen. Additionally, viral load was measured before start of protease inhibitor, a second time between 1–5 years after start, and at suspected treatment failure in patients with available bio-banked samples. We performed resistance testing if viral load was ≥1000 copies/ml. Risk factors for virologic failure were analyzed using logistic regression.In total, 252 patients were included; of those 56% were female and 21% children. Virologic failure occurred 6–12 months after the start of a protease inhibitor in 26/199 (13.1%) of adults and 7/53 of children (13.2%). The prevalence of virologic failure did not change over time. Nucleoside reverse transcriptase inhibitors drug resistance mutation testing performed at 6–12 months showed a positive signal in only 9/16 adults. No cases of resistance mutations for protease inhibitors were seen at this time. In samples taken between 1–5 years protease inhibitor resistance was demonstrated in 2/7 adults. In adult samples before protease inhibitor start, resistance to nucleoside reverse transcriptase inhibitors was detected in 30/41, and to non-nucleoside reverse-transcriptase inhibitors in 35/41 patients. In 15/16 pediatric samples, resistance to both drug classes but not for protease inhibitors was present.Our study confirms high early failure rates in adults and children treated with protease inhibitors, even in the absence of protease inhibitors resistance mutations, suggesting an urgent need for adherence support in this setting. In Tanzania, as in many other sub-Saharan African (SSA) countries, there has been a tremendous increase in HIV care and treatment services over the past decade. This has reduced the prevalence of HIV infection to 4.6% . Since tSecond-line treatment in Tanzania consists of a boosted protease inhibitor (bPI) combined with two NRTI. Additionally, in young children, a bPI-based treatment is currently started as a first-line therapy . ChildreIn this study, we investigated the virologic outcome and development of DRM in HIV-1 infected adults and children on a bPI-containing regimen and identified risk factors for the development of treatment failure in a large rural HIV cohort in Tanzania.The Chronic Diseases Clinic at St. Francis Referral Hospital, Ifakara, Tanzania enrolls HIV-positive patients in a prospective cohort ). Written informed consent was obtained from the patient or, if younger than 18 years, the caregiver. Since its conception in 2005, KIULARCO enrolled more than 10,000 HIV-infected patients. Demographic, clinical, and treatment information is collected 4 times per year. Plasma is sampled twice yearly with storage in an onsite biobank. The cohort has been described in detail in other publications , 12. ForData on demographics, clinical progression and ART was extracted from the KIULARCO electronic medical records. We recorded risk factors for treatment failure at the start of bPI treatment; namely sex, age, VF on first-line ART defined as viral load (VL) ≥1,000 copies/mL, advanced HIV disease (CD4 cells <200/μL and/or WHO stage III/IV), BMI (only in adults), and self-reported non-adherence . VL was TM System (Thermofisher), with a detection limit of 100 viral RNA copies/mL; details have been reported elsewhere (dx.doi.org/10.17504/protocols.io.749hqz6) [http://hivdb.stanford.edu). All DRM conferring high-level resistance were considered. CD4 cell counts were determined by flow cytometry .Cell-free plasma was collected after centrifugation of EDTA blood at 1,900 rcf for 5 minutes and stored at -20°C until tested for VL, DRM or, after 2 weeks of being stored at -80°C. HIV RNA was extracted from 200 μL of plasma using the Pure Link Viral RNA/DNA Mini Kit , according to the manufacturer’s instructions. Viral RNA quantification was performed with a validated in-house protocol with the Taqman qPCR Master Mix (Thermofisher) using the StepOne749hqz6) . For all749hqz6) . HIV-1 dThe primary outcome was VF, defined as HIV-1 RNA levels ≥1000 copies/mL. The secondary outcome was the prevalence of drug resistance in patients with VF, as per the Major HIV-1 DRM list .Baseline was defined as the time point of starting a bPI ART or, if already on bPI ART, at inclusion into the cohort; variables and co-variates for risk factor analyses were considered up to 6 months before this date. Non-adherence was defined as missed at least one pill at any time during the past 6 months. VL results between 100–1000 copies/mL were defined as low-level viremia (LLV), whereas levels ≥1000 copies/mL where defined as VF. Advanced HIV disease was defined as CD4 cells <200/μL and/or a clinical WHO stage III/IV.The study was conducted according the current version of the World Medical Association Declaration of Helsinki. The KIULARCO study was approved by the Ifakara Health Institute institutional review board (IHI/IRB/No 16–2006), the Health Research Ethics Review Committee of the National Institute for Medical Research of Tanzania (NIMR/HQ/R.8a/Vol. IX/620), and the Ethical Review Board of the Canton of Basel, Switzerland.Demographic factors were summarized using frequencies and percentages for categorical data and medians and IQR for continuous data. Univariable and multivariable logistic regression models were used to estimate the association between risk factors and VF at 6–12 months. Non-linearity of the association with continuous variables was tested and modeled accordingly. Results are presented as odds ratios with 95% confidence intervals. Statistical analyses were performed using STATA 14 .Fig 1). Of these, 332 were not eligible for the following reasons: being on bPI for a duration of less than 6 months, being switched back to a non-bPI regimen before 6 months, or no sample available 6–12 months after bPI start. Characteristics at the start of bPI treatment of the eligible 252 patients (199 adults and 53 children) included in the final analysis are summarized in Table 1. Out of 199 adults, 121 (60.8%) were female (2 were pregnant), median age and BMI were 41 years (IQR 33–49), and 21.5 (IQR 19.1–23.5) respectively. An advanced WHO stage (III/IV) was recorded in 105 (52.8%) patients. The median CD4 cell count was 163/μL (IQR 71–276), and median time on ART before start of a bPI was 3.6 years (IQR 1.5–5.8). Out of 53 children, 20 (37.7%) were female, median age was 8 years (IQR 5–10), 39 (73.6%) were in WHO stage III/IV, and median CD4 cell count was 590/μL (IQR 250.0–940.5) with a median time on first-line ART of 3.3 years (IQR 2–5.2).Between 2005–2016, 584 participants of the KIULARCO cohort, received a bPI-based treatment , stavudine (42.9%) or tenofovir (32.9%). Due to reasons such as phasing out of certain regimens, adverse reactions, non-adherence, patient decision or stock-outs, many patients experienced several changes in their first-line treatment (median 2 (IQR 1–4)) before the start of a bPI-based treatment.Eleven out of 199 (5.5%) adults and 7/53 (13.2%) children had already been prescribed a bPI treatment at the time of enrolment into our clinic. In adults, this was due to previously suspected treatment failure. In contrast, children were started directly on a bPI regimen, which was based on new guidelines [Reasons for prescribing a bPI-based regimen were immunologic failure in 127 patients (50.4%), clinical failure in 20 patients (7.9%), or as VL testing was not routine in Tanzania at the time of the study, suspected VF (107 patients (42.5%)).Table 2). In 16/26 (61.5%) patients with VF, DRM testing was done and revealed NRTI DRM in 9/16 (56.3%), NNRTI DRM in 14/16 (87.5%) and no bPI DRM. In 129 available samples taken between 1–5 years after start of bPI (>12 months on bPI), VF was diagnosed in 15 (11.6%) and LLV was present in 12 of the 129 patients (9.3%) at a median of 753 days (IQR 573–1033). Prevalence of VF and LLV were stable over this time period . DRM testing from samples taken between 1–5 years after bPI therapy was only available in 7/15 (46.7%) patients, revealing NNRTI DRM in all seven, while 4 had additionally NRTI DRM, and 2 had, beside NRTI and NNRTI DRM, also bPI DRM (Table 2).VF was diagnosed after 6–12 months from initiation of bPI in 26/199 (13.1%) and LLV in 11/199 (5.5%) of adult patients  had confirmed VF and 14 (9.7%) had LLV. In the 41 sequences, available from samples before bPI start, 35 (85.4%) patients had NNRTI DRM and 30 patients (73.2%) had NRTI DRM. No bPI DRM was documented.While on bPI treatment, 45 patients developed clinical or immunologic failure and had an additional sample stored. Of these, we found VF in 11 (24.4%) patients. Among the 6 available sequences all harbored NNRTI DRM, 3 harbored NRTI DRM, but no bPI DRM was observed. In patients with sequential samples available, mostly NNRTI and NRTI DRM were detected during all time points. Median time from start of bPI to diagnosed failure was 224 days (IQR 115–381).At 6–12 months, 7/53 (13.2%) children experienced VF and 4 (7.5%) had LLV. Sequencing was successful in only 1 out of 7 and no DRM were detected. In 35 children, samples taken between 1–5 years after bPI therapy (>12 months on bPI), showed that 4 (11.4%) had VF and 3 (8.6%) had LLV after a median of 581 days (IQR 467–743). Sequencing was successful in 3 of those, yielding 1 patient with NRTI and NNRTI DRM, but no bPI DRM.In the 41 analyzed samples prior to therapy with bPI, 19 (46.3%) showed evidence of VF. After switching to bPI 16/19 re-suppressed, while 3 still had a VL >1000copies/mL. Two additional patients were suppressed before switch and experienced VF only in the 6–12 months sample. In the 16 pre-bPI samples with diagnosed VF, sequencing provided evidence of resistance with NRTI and NNRTI DRM in 15/16 (93.8%).At the time of suspected clinical/immunologic failure on bPI, 2/10 (20.0%) had a positive VL in the range of LLV, but none had a documented VF. Median time to diagnosed failure was 93.5 days (IQR 82–179) in children.In our study population (85 available sequences from 75 patients) subtype C was most prevalent , followed by subtype A  and subtype D . This correlates well with the previously reported subtype distribution for the region . RecombiM46I, L76V, V82A and I84IV. The second patient had L24I, M46I, I50L, I54A, and V82A.Overall, we found bPI DRM only in 2 adult patients. Both had been on a long-term bPI regimen  and both had accumulated multiple major bPI DRM. The first of these patients had the following mutations: K103NS, detected in 29 (51.8%) adults and 7 (36.8%) children. Additionally, Y181CIV was found in 15 (26.8%) and 4 (21.1%), E138KAQG in 10 (17.9%) and 4 (21.1%) and G190ASEQ in 12 (21.4%) and 5 (26.3%) adults and children, respectively.The most common NNRTI mutation was M184VI, which was found in 35 (62.5%) adults and 14 (73.7%) children. TAMs were found in 18 (32.1%) adults and 11 (57.9%) in children .For the NRTI, the most common non-TAM DRM was . Most common reasons for non-adherence were ‘having lost’ or ‘run out of’ medication, reported in 9/42 (21.4%) cases on first-line treatment and 11/28 (39.3%) on second-line treatment. One patient indicated depression as a reason for not taking pills during first-line treatment  and one on second-line . Reasons for poor adherence reported on first-line treatment only were ‘being too ill or too healthy’ , ‘being concerned about stigma’  and ‘problems with delivery or stock out’ .Prior to starting bPI, 27/199 (13.5%) adults and 15/53 (28.3%) children had reported episodes of non-adherence to ART intake. After 6–12 months on bPI, 19/199 (9.5%) adults and 9/53 (17.0%) children still reported non-adherence .For adults, the presence of advanced HIV disease (WHO stages III/IV or CD4<200) was the only significant factor associated with a positive VL at 6–12 months on bPI . For children, none of the investigated factors was significantly associated with a positive VL In this cohort from rural SSA we found a high rate of virologic failure on a bPI-based regimen despite a low emergence of resistance, which occurred exclusively after long-term drug exposure to protease inhibitors.At 13%, the failure rate in adults and children, occurring early on bPI-based therapy, was higher than observed in the same cohort for patients on a long term first-line treatment, where resistance remained stable over time . SimilarThe fact that HIV was suppressed on first-line treatment in about half of the patients with suspected treatment failure, supports the earlier notion that clinical deterioration or immunologic failure, based on the monitoring of CD4 cells and clinical condition alone, are poor predictors for VF , 22. PosSide effects of bPI, e.g. diarrhea, are likely to lead to poor adherence and consequent ongoing virus replication, especially in those failing patients who had not previously failed on NNRTIs. Furthermore, it is possible that patients were sensitized to adherence questions and subsequently not admit to any poor adherence.The high resistance rates for NNRTI in almost all virologically unsuppressed patients on first- or second-line treatment confirms that DRM do accumulate with time. This occurs when routine VL monitoring is not available and is a major concern with non-adherent patients, who are at risk of acquiring bPI DRM. The generally low bPI-related resistance rates can be attributed to the higher barrier to resistance development of this drug class  and the Our study confirms, in line with two other trials from SSA, that—even in the presence of NRTI resistance mutations—a triple drug regimen can retain efficacy with no obvious inferiority to other regimens , 25. At It remains to be elucidated, whether resistance testing followed by guided treatment switching is beneficial, cost saving, and will reduce second-line treatment failures. Results of the ongoing REVAMP study in South Africa are anticipated to address this question . ResistaIn our study, we measured LLV in 52 samples. In recent years, more literature on the significance of LLV is emerging , 28. A sThe only factor associated with VF at 6–12 months in adults was advanced HIV disease at the time of starting bPI. Factors such as an underlying untreated and progressing disease, associated weakness affecting the ability to travel and to attend clinical visits, drug intake, drug interactions, or side-effects of different medications leading to non-adherence could explain, why people with advanced illness more often had VF , 30.Currently, the knowledge about second-line failure in Tanzania is scarce. The strength of this study is an even age distribution among those enrolled due inclusion of both children and adults. Another strength is the long follow-up time with corresponding samples available from different time points. Furthermore, this study adds resistance information, which is not available in many settings.Our study has several limitations. The number of available samples of patients on bPI ART was relatively low. This was due to a significant variability in sample quality which led to inability to obtain sequencing results for every sample. This might have resulted in an underestimation of the true prevalence of viral drug resistance. Moreover, VL testing was done from bio-banked samples, and the definition of VF was based on a single VL, at the time neither confirmed by a second measurement nor followed by enhanced counseling, as recommended in the current national and WHO guidelines . Lastly,In conclusion, we demonstrate that VF can occur early after the start of bPI, remaining stable over time and is best explained by poor adherence and less well indicated by overt drug resistance mutations. High early failure rates with overall poor adherence are worrisome as they may pave the way to further and accelerated resistance, clinical failure and higher rates of viral transmission especially of drug-resistant HIV strains. Therefore, better monitoring tools to improve adherence are urgently needed in rural settings.S1 Figx-axis: years after start of bPI treatmenty-axis: % of patients*after start bPI.(TIF)Click here for additional data file.S1 Table*Non-Adherence: Reported frequency of missing of ≥ 1 pill(s).(DOCX)Click here for additional data file.S1 Dataset(XLSX)Click here for additional data file.


Three SAEs occurred: two were unrelated to the study product, and one was possibly related to ART interruption (ATI). ELISpot assays to detect T cell responses using peptides covering the HTI sequence showed no significant differences in immunogenicity between groups. There were no significant differences in viral load rebound dynamics after ATI between groups. The vaccine was safe and well tolerated. We were not able to demonstrate immunogenic effects of the vaccine.Therapeutic vaccinations aim to re-educate human immunodeficiency virus (HIV)-1-specific immune responses to achieve durable control of HIV-1 replication in virally suppressed infected individuals after antiretroviral therapy (ART) is interrupted. In a double blinded, placebo-controlled phase IIa multicenter study, we investigated the safety and immunogenicity of intranodal administration of the HIVACAT T cell Immunogen (HTI)-TriMix vaccine. It consists of naked mRNA based on cytotoxic T lymphocyte (CTL) targets of subdominant and conserved HIV-1 regions (HTI), in combination with mRNAs encoding constitutively active TLR4, the ligand for CD40 and CD70 as adjuvants (TriMix). We recruited HIV-1-infected individuals under stable ART. Study-arms HTI-TriMix, TriMix or Water for Injection were assigned in an 8:3:3 ratio. Participants received three vaccinations at weeks 0, 2, and 4 in an inguinal lymph node. Two weeks after the last vaccination, immunogenicity was evaluated using ELISpot assay. ART was interrupted at week 6 to study the effect of the vaccine on viral rebound. The vaccine was considered safe and well tolerated. Eighteen percent ( Despite the major successes of antiretroviral treatment (ART), the burden of treatment and costs drive the search for alternatives ,2. ThereHere, we explore the use of a new HIV immunogen, known as HIVACAT T cell Immunogen (HTI), in a phase IIa clinical trial, conducted by the iHIVARNA consortium see: . Its mRNIn preclinical mouse experiments, HTI-TriMix was found to be immunogenic ,11. NextInclusion started after approval  was randomly allocated and stratified per center. This ratio would allow sufficient study of HTI-TriMix compared to control groups TriMix and WFI, as is detailed below and in After screening, eligible patients were enrolled and randomized to one of the three study-arms, as seen in Safety assessments consisted of subject diary cards up to seven days following the vaccinations, outpatient clinic visits, and routine laboratory assessments, as seen in ®, Bonn, Germany) were used as positive controls. Results are expressed as mean number of spot forming cells (SFC)/106 PBMC from duplicate wells. Criteria for analysis were: PBMC viability > 80%, the media control <50 SFC/106 PBMC, positive responses against PHA-P >500 SFC/106 PBMC. ELISpot responses were considered positive in case of >50 SFC/106 PBMC and number of SFC/106 PBMC at least ≥2-fold over media control.Immunogenicity was assessed on cryopreserved PBMC at screening, baseline  and weeks 4, 6, 10, 18, and 30 of follow-up by the quantification of T cell responses by an interferon-gamma (IFN-γ) ELISpot assay in a single research laboratory, as described before . For patg for 1 h at 4 °C. Tubes were equilibrated with 50 mM Tris-Cl, pH 7.6; 150 mM NaCl to a final volume of 12 mL. After centrifugation, 11.2 mL of supernatant was aspirated and discarded. The pellet was thoroughly resuspended in the remaining 800 µL and tested for viral load with the Cobas® HIV-1 test on the Roche Cobas® 4800 system. To account for the concentration of the virus, the obtained result was multiplied by 0.08 (0.8/10).A total of 10 mL of EDTA plasma was ultracentrifuged at 170,000× 10 copies of total HIV DNA per million CD4 T cells measured by the housekeeping gene RPP30.To explore changes in the HIV reservoir size that could result from activation of HIV-1-specific latently-infected CD4 T cells, total HIV-DNA levels and cell-associated unspliced HIV-RNA (caRNA) ,12 expren (%) and median, interquartile range (IQR), unless stated otherwise. The primary safety endpoint is described by number and percentage of grade 3 or above AEs. The primary immunogenicity endpoint is described by the total magnitude of HTI specific IFN-γ T cell responses as the sum of SFC/106 input PBMC to all positive HTI peptide pools, and was calculated as log10(W6 responses)—log10(baseline responses) and log10(W18 responses)—log10(baseline responses). All analyses were performed two-sided at the 5% significance level, unless otherwise specified. Time until viral rebound, evolution of pVL, and viral reservoir were analyzed using a linear mixed effects model to compare the evolution over the study period. The moderate increase in T cell responses to peptides spanning the HTI sequence at week 8 of the phase I clinical trial [A full overview of the statistical analysis, sample size calculation, and interim analysis is available in al trial ,12 led tn = 16; TriMix n = 9; WFI n = 8). All but one participant were male, with a median age of 42 years, as seen in Flow chart and design of the study are shown in n = 37) were considered to be definitely related to the procedure or vaccine, but none of them were known grade 3 or above (three of unknown grade), as seen in n = 32) were short-lasting pain at the site of injection, localized numbness (<48 h) and vasovagal reactions. Twenty-seven percent of all AEs (n = 55) were considered to be possibly or probably related to the vaccine or vaccination procedure. This included mild, flu-like symptoms and headache, malaise, chills, and fatigue that lasted for a period <72 h. Four participants had an increase in creatinine kinase (CK), three of them were below grade 3. One of them had a CK increase of >10× upper limit of normal (grade 4) that was considered related to heavy exercise. None of them reported complaints and values normalized without intervention. No other laboratory abnormalities were classified as AE. After the third vaccination, an unrelated SAE was reported for one participant (HTI-TriMix). An acute obstructive cholangitis and associated pancreatitis was diagnosed, and the subject was admitted to a hospital.Overall, the procedure and the vaccine were well tolerated. From the total number of 206 AEs (entire study), 18% . None of the participants had symptoms suggestive of acute retroviral syndrome during the treatment interruption. All 32 participants that underwent ATI had a viral rebound ). First detectable viral load after treatment interruption was observed at a median of two weeks post stop-ART. Hazard ratios of time until viral rebound were not significantly different amongst groups . Ten participants restarted ART per protocol at week 18 (median HIV-RNA 4.80 log10 cp/mL IQR 0.58). One participant (WFI) stayed off-ART until week 22, because of a low plasma viremia at week 18 (236 cp/mL) (protocol deviation). At week 22, a SAE was reported for this participant; a worsening of previously known depression and anxiety, which was unlikely to be related to either the vaccine or low grade viremia. Following medical recommendation, ART was reinitiated. None of the participants reached a state of functional cure (pVL < 50cp/mL without ART) at the end of ATI, i.e., at week 18. Based on a locally estimated scatterplot smoothing (loess) graph of log10 pVL from treatment interruption until restart of ART, a piecewise linear model was fitted with a breakpoint at 35 days, with nested random effects for subject and site. We found no statistically significant associations for the HTI-TriMix group with pVL (p = 0.63).On advice of the treating physician, ART was restarted before week 18 in 20 participants  still had detectable pVL at the end of the study . All participants reached pVL < 50cp/mL thereafter, as confirmed by their treating physicians .One participant (HTI-TriMix) suffered from a diverticulitis that was complicated by a sigmoidal perforation eight weeks after restarting ART: it was considered a possible immune reconstitution inflammatory syndrome.10 SFC/106 PBMC; 95% CI: −0.35, 0.20; p = 0.14, shown for all three groups), as seen in At week 6 and compared to baseline, no significant increase in the total frequencies of IFNγ+ IN specific T cell responses in the HTI-TriMix group compared to the WFI group was observed  in magnitude of HIV-specific T cell responses at baseline and week 18, between HTI-TriMix group and control groups .Excluding early restarters, we found no statistically significant differences , compared to the control groups.We observed no changes in the size of the viral reservoir during vaccination, based on both total HIV DNA and caRNA measurements, as seen in The vaccine was shown to be safe and well tolerated as no serious unforeseen safety issues occurred and vaccine related side-effects were short-lived. Unfortunately, after completion of this clinical trial, a coding error was discovered in the plasmid DNA that had been used as template for the mRNA vaccine-construct see: . The plaThe vaccine was evaluated preclinically in mice and showed HIV-specific immunogenicity after immunization . Mice weThe study safety was not compromised, as is reflected by a similar distribution of (S)AEs between study groups. In particular, we observed no individual unforeseen AEs for the HTI-TriMix group during post hoc analysis. Additionally, pVL increased and, concomitantly, CD4 T cell counts declined as expected during a treatment interruption . From thAs recently published, there is consensus that ART interruption is the designated ,29,30 anIncreases in T cell responses were observed after treatment interruption (to both ‘IN’ and ‘OUT’ peptides), probably due to the rebounding virus antigenemia, stimulating the immune system. TriMix may have added to this effect, as we have observed both an earlier and higher increase in immune responses in the TriMix-containing arms versus the WFI arm. This would support the moderate immune responses observed at higher doses in the phase I trial ,12. It iPrematurely halting the trial for futility was based on the comparison of ‘IN’ responses from baseline to week 6 using an IFN-γ ELISpot assay during the double-blinded phase of the study. Additional immune assays later confirmed these findings: a CD8+ T cell mediated viral suppressive capacity assay  did not Still, the combination of subdominant, protective CTL regions, such HTI or other strategies, such as mosaic CTL vaccines aiming at more HIV-1 clades, is supported by several studies ,35,36.The erroneous study product made it impossible to draw conclusions on the induction of cellular immune responses against the HTI immunogen. This does not exclude the utility of targeting the more protective regions of the HIV-1 proteome, as more efficient immune responses were observed ,38. In vIn conclusion, the HTI-TriMix vaccine was safe and well tolerated. Future studies testing the correct HTI or other conserved HIV immunogens are still warranted and might eventually include additional targets to further enhance the antigen presentation process. An interim analysis for futility and careful participants’ monitoring proved to be of importance to ensure maximal participant safety in our study.