Introduction of antiretroviral therapy (ART) in sub-Saharan Africa was a hot debate due to many concerns about adherence, logistics and resistance. Currently, it has been significantly scaled up. However as the WHO clinico-immunological approaches for initiation and monitoring of ART in the region lacks viral load determination and drug resistance monitoring, HIV infected adults and children may be at risk for “unrecognized” virologic failure and the subsequent development of antiretroviral drug resistance. This study evaluates the virological efficacy and immunological recovery of HIV/AIDS patients under ART.+ T cell recovery were determined using standard virological and immunological methods.Consecutive HIV-1 infected adults (N = 100) and children (N = 100) who have been receiving ART for up to 6 years at Gondar University Hospital, Ethiopia were enrolled following the WHO protocol for assessment of acquired drug resistance. Magnitude of viral suppression, genotypic drug resistance mutations and patterns of CD4+ T cell count has increased from baseline 124 to 266 (IQR: 203–306) and 345 (IQR: 17–1435) to 998 (IQR: 678–2205) cells/mm3 in adults and children respectively after 12 months of ART. Nevertheless, small but significant number of clinically asymptomatic adults (16%) and children (13%) had low level viraemia (HIV-1 RNA 41–1000 copies/ml).Virological suppression (HIV RNA < 40 copies/ml) was observed in 82 and 87% of adults and children on a median time of 24 months on ART, respectively. Mutation K103N conferring resistance to non nucleoside reverse transcriptase inhibitors and thymidine analogue mutations  were found only in one adult and child patient, respectively. Median CD4Majority of both adults (82%) and children (87%) who received ART showed high viral suppression and immunological recovery. This indicates that despite limited resources in the setting virological efficacy can be sustained for a substantial length of time and also enhance immunological recovery irrespective of age. However, the presence of drug resistance mutations and low level viraemia among clinically asymptomatic patients highlights the need for virological monitoring. Conces of ART,17 and aring ART-20. Thisring ART.http://www.etharc.org/). Access to optimal laboratory monitoring with viral load testing is not available. Hence, ART initiation and monitoring is based on the WHO clinico-immunological approach. However, as this approach lacks viral load determination and drug resistance monitoring by sequencing of reverse transcriptase gene segments HIV infected adults and children may be at risk for “unrecognized” virologic failure and the subsequent development of antiretroviral drug resistance. The aim of this study was to evaluate the virological efficacy and CD4+ T cell recovery among HIV/AIDS adults and children patients who were on ART for up to 6 years.In Ethiopia HIV prevalence is estimated to be 1.5% among the general population with an estimate of about 800, 000 people living with HIV (78% adults and 22% children <14 years). By the end of 2012, there were 249,174 adults and 16,000 children on treatment, of whom 135 children and 865 adults were receiving second line drugs. However, in some regions 40% of patients who were enrolled to ART dropped out from treatment. The over all current ART coverage for adult populations is high (86% of estimated eligible). Conversely, the coverage of ART for children is low (only 20% of estimated eligible) , Northwest Ethiopia. GUH is a referral and teaching hospital responsible for the treatment of more than 8, 000 HIV infected adults and 400 children. Adult patients with WHO clinical stage 4 irrespective of CD4 for ART. HIV-inf for ART. Howevercells/mm3. Similarcells/mm3. ART in cells/mm3,22. OtheThis longitudinal study follows the WHO protocol for assessment of acquired drug resistance for adults. Consecu+ T cell count was done at baseline and at 6 months interval using the FACSCount flow cytometer  following the manufacturer’s protocol. The laboratory is accredited by the American Society of Clinical Pathologists and participated in external quality control and assurance program.Minimal socio-demographic data and relevant clinical features of the patients were retrieved from medical records. About 10 ml venous blood was collected in a tube containing ethylene diamine tetra-acetic acid (EDTA). After centrifugation (956 rcf for 5 minutes) plasma was separated and stored at -40°C until further used. CD4m2000sp automated sample preparation system  according to manufacturer’s instructions. Plasma viral load was measured using Quantitative RealTime HIV-1 assay by the Abbott m2000rt instrument with a lower detection limit of 40 copies/ml.RNA was extracted from 0.6 ml of plasma with the Abbott pol gene were amplified using an in house assay. In brief, Phusion Hot Start High-Fidelity DNA polymerase  was used in nested PCR with the outer primers HIVpcrFor1 (5′TGATGACAGCATGTCAGGGAGTGG3′) and HIVpcrRev1 (5′GGCTCTTGATAAATTTGATATGTCCATTG3′) yielding a 1757 bp amplicon, and subsequently by the inner primers HIVpcrFor2 (5′AGCCAACAGCCCCACCAG3′) and HIVpcrRev2 (5′CTGTATTTCTGCTATTAAGTCTTTTG 3′) yielding a 1389 bp amplicon. Initial denaturation was done at 98°C for 2 minutes followed by 40 cycles consisting of 10 seconds of denaturation at 98°C and 25 seconds of annealing at 64°C for the first round outer primers (HIVpcrFor1 and HIVpcrRev1) PCR and at 53°C for the nested inner primers (HIVpcrFor2 and HIVpcrRev2) PCR with a 40 seconds extension at 72°C for both and final extension for 5 min at 72°C. Purified PCR products were subjected to direct sequencing of both the sense and antisense strands using Big Dye Terminator Cycle Sequencing Ready Reaction kit . For each sample, six separate sequencing reactions were done using the two inner PCR primers and four additional internal primers: HIVseq1 (5′GTTAAACAATGGCCATTGACAGA3′), HIVseq2 (5′TGGAAAGGATCACCAGCAATATT3′), HIVseq3 (5′GGGCCATCCATTCCTGGCT3′) and HIVseq4 (5′2CCATCCCTGTGGAAGCACATT3′) which allowed a double coverage of the pol region. All primers positions are matched to HIV-1HXB2 (GenBank accession number K03455). Both forward and reverse overlapping sequences were manually edited with the Geneious Basic software version 5.4[http://hivdb.stanford.edu/).Viral RNA was reverse transcribed using AMV reverse transcriptase  and the outer primer HIVrt (5′TGTTTTACATCATTAGTGTG 3′). The entire protease (PR) and partial (76%) reverse transcriptase (RT) regions of the + T cell response: patients who failed to achieve an absolute increase in CD4+ T cell count from baseline by at least 50 cell/mm3 at 12 months were defined as immunological non responders. Those patients who achieved an absolute CD4+ T cell count of 200 cells/mm3 at the 12 months visit were defined as immunological responders. Absolute response in CD4+ T cell count was calculated at every 6 months intervals and categorized into 2 phases: Phase I from base line to 12 months, Phase II from 13–48 months. Duration of ART was rounded to the nearest half or full year. Univariate analysis was performed for sex, age, WHO clinical stages, ART regimen at baseline, duration of ART, haematocrit value and CD4+ T cell count. Logistic regression was used to study associations between baseline characteristics and outcomes. A p-value of less than 0.05 was considered statistically significant. The statistical analyses were carried out using SPSS statistical software version 17.The main outcomes of interest were virological suppression (HIV RNA < 40 copies/ml), drug resistance mutation/s and immunological recovery. Virological suppression was defined as HIV viral load <40 copies/ml. Immunological recovery was evaluated based on CD4The work meets relevant ethical guidelines. Institutional ethical clearance was obtained from the University of Gondar Ethics Review Committee. Written and/or verbal informed consent was also obtained from study subjects and/or families and/or guardians.+ T cell count for adults and children was 144 cells/mm3 (Inter quartile range (IQR) 91.25-181.75) and 345 (IQR 17–1435). The median duration with ART was 24 months (IQR: 18.00-29.25) for both adults and children. The proportions of patients with CD4+ T cell strata, WHO clinical stages, the duration of time on ART, the main therapeutic regimen are summarized in Table A total of 200 HIV-infected patients (100 adults and 100 children) were included in the present study with the mean ± standard deviation age of 34.2 ± 8.4 and 5.3 ± 1.2 years, respectively. At baseline the median CD4+ T cell counts of 50–99 cells/ml , 100–199 cell/mm3  or with baseline CD4+ T cell counts of >200 cells/mm3  who achieved a viral load of <40 copies/ ml as compared with those with a baseline CD4+ T count of < 50 cells/mm3. Samples with plasma viral load of >400 copies/ml were amplified and genotyping was successful in 4 patients and all were found to be HIV-1 subtype C. Mutation K103N conferring resistance to the NNRTIs NVP, delavirdine (DLV), EFV and etravirine (ETR) was found in one patient. Polymorphic accessory mutation to the protease inhibitor class of ARVs at codon 74 (T74S) was observed in 2 patients. In 3 patients, naturally occurring polymorphisms that may or may not have an impact on levels of drug resistance were found   was observed in children in a median time of 24 months on ART. One HIV-1 subtype C isolate with thymidine analogue mutations  was detected. Low level viraemia (HIV-1 RNA in the range of 41–1000 copies/ml) was observed in a single sample of 13 clinically asymptomatic children.+ T cell counts <100 cells/mm3 was 31% at baseline. This proportion had decreased to 6% by month 12 of the treatment. The median CD4+ T cell count increased nearly two-fold from baseline, reaching 266 cells/mm3 after 12 months on ART . Thus, the pattern of CD4+ T cell count increase on average in 6 months time, and in the next 7–12 months was 75.64 cells/mm3 and 58.8 cell/mm3, respectively, with statistically significant mean difference (P = 0.023). However, the further increase in the ensuing 12 months of ART was slower with a mean of 47.33 cells/mm3 at 13–18 months and 3 cells/mm3 at 19–24 months and did not reach at statistical significance level. Accordingly, the rate of CD4+ T cell count increase was divided into 2 phases: a rapid phase , and a slower phase   to 998 (IQR 678–2205) in a median time of 12 months on ART. The CD4+ T cell counts after a median time of 24 months on ART were similar between viraemic (n = 13) and aviraemic (n = 87) children (median (IQR) 996 (730–1524) versus 946 (472–1102) (P = 0.10) cell/mm3.In a similar trend, the median absolute CD4+ T cell count (i.e. < 50 cells/mm3) at the initiation of ART required more time to recover compared to those patients with a higher baseline CD4+ T cell count  did not reach the lower threshold of 350 cells/mm3 up to 42 months on ART, though there was a remarkable increase to an average of 276 cells/mm3 , the CD4+ T cell count increased by >50 cells/mm3 in 16 (16.7%) patients. Of these, the viral load was suppressed below LLD- lower limit of detection (<40 copies/ml) in 13 patients in a median time of 24 months on ART. Among patients with baseline CD4+ T cell counts of <50, 50–99, 100–199 and ≥ 200 cells/mm3, the proportions of patients who were immunological non-responders were 1, 1, 10 and 4,  respectively. Failure to attain 200 cells/mm3 was not significantly associated . The recovery of CD4+ T cell count follows similar pattern independent of the antiretroviral drug regimen up to 24 months in both adults and children. However, patients with ART regimen 1c and 1d showed a slight increment in CD4+ T count between 24 and 42 months of ART. During the study period, there was a treatment switching in 15 patients due to peripheral neuropathy secondary to d4T associated toxicity (n = 7), AZT induced anaemia (n = 2) and d4T related lipoathrophy (n = 1). The incidence of tuberculosis during the first 6 months on ART was 7% and hence NVP was substituted by EFV in those patients.Adult patients with low baseline CD4 Figure . In the The 82% suppression rates and the low level of HIV drug resistance in adults with a median time of 24 months on first line ART in the present study from Ethiopia demonstrates a high level of effectiveness of the antiretroviral agents in the setting. The result is in agreement with data from Europe and North America and with+ or CD8+ T-cell counts or the risk of subsequent virological failure. Natural variation, assay effects and adherence might all have a role.The high rate of virological suppression may have an impact on HIV prevention and reducing the overall risk of transmission at a population level. It has been suggested that scaling up of ART results in a level of virological suppression at the population level that will reduce HIV transmission-32. To rThe sustained virological efficacy on 6 years ART in the present study might be attributed to free provision of ART and care for HIV infected patients as it has been previously shown to improve treatment efficacy and the + T cell count starts rising and continues so for at least 3–5 years[+ T cell count in the first 6 months and in the following 7–12 months by 12.2 cells/mm3/month and 9.6 cell/mm3/month, respectively, followed by almost linear rise in the subsequent two years. This is in agreement with a report that shows the rapid initial increase in CD4+ T cell count in the first 6 months[+ T cells trapped in the lymphoid tissue. However, the relative slow increase rate of CD4+ T cell after 12 months of ART  and the gradual annual changes in CD4+ T cell count thereafter suggests that the number of CD4+ T cell may reach a plateau level sometime in the future. In this case the naïve CD4+ T-lymphocytes from the thymus, as well as memory CD4+ T-lymphocytes, contribute to the reconstitution of the immune system[+ T cell count of <50 cells/mm3 had similar rate of increase in the first 6 months and the consecutive months compared with higher baseline CD4+ T cell count. In most HIV-1 infected individuals treated with ART, CD4+ T cell recover to levels above 500 cells/mm3, at which HIV-1 related clinical complications are rare[+ T cell counts in adult Ethiopians irrespective of HIV infection[+ T cell counts and optimal CD4+ T cell recovery among children in the current study is parallel with the data that shows the predominance of naive CD4+ T cell phenotype at birth which is comparable to Caucasians[It has been documented in European patients that, after the initiation of ART, peripheral CD4–5 years. Our dat6 months which ree system. The datare rare. None ofnfection,39 and lnfection. The relucasians.After a median time of 24 months on ART, high viral suppression rates in adults (82%) and children (87%) were observed in Gondar hospital, Northwest Ethiopia where patients usually present late in the course of infection. This suggests that antiretroviral drugs in the setting can sustain virological efficacy for a substantial length of time and enhance immunological recovery irrespective of age. However, the presence of drug resistance mutations and low level viraemia among clinically asymptomatic patients highlights the need for regular virological monitoring in order to optimise treatment success and preserve future treatment options.The authors have no competing interests to declare.AM: study design, data collection, analysis and interpretation and draft the manuscript; UGL: study design, data interpretation and revising the manuscript; MM: study design, data analysis and interpretation and revising the manuscript. All authors have approved this final version for submission.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/14/28/prepub


Information concerning lipid disturbances in HIV-infected women on antiretroviral therapy (ART) is scarce. The objective of the study is to describe the lipid profile in a large cohort of HIV-infected women on contemporary ART and analyse differences between regimes and patient's characteristics.Observational, multicentre, cross-sectional study from the Spanish VACH Cohort. 922 women on stable ART without lipid-lowering treatment were included.Median age was 42 years, median CD4 lymphocyte count was 544 cells/mm3, and 85.6% presented undetectable HIV-1 viral load. Median total cholesterol (TC) was 189 mg/dL , HDL cholesterol 53 mg/dL , LDL cholesterol 108 mg/dL , and triglycerides 116 mg/dL . Mean accumulated time on ART was 116 months; 47.4% were on NNRTI-based regimes, 44.7% on PI, and 6.7% on only-NRTI therapy. 43.8% were also hepatitis C (HCV) coinfected. Patients on PI treatment presented higher TC/HDL ratio than those on NNRTI (p < 0.001). Significantly higher HDL values were observed in NNRTI-treated patients. HCV-coinfected patients presented lower TC/HDL ratio than the non HCV-coinfected. In multivariate analysis, factors independently associated with TC/HDL ratio were age, triglyceride levels and HCV co-infection. PI treatment presented a non-significant association with higher TC/HDL ratio.In HIV-infected women, the NNRTI-based ART is associated with a better lipid profile than the PI-based. Factors unrelated to ART selection may also exert an independent, significant influence on lipids; in particular, age, and triglyceride levels are associated with an increased TC/HDL ratio while HCV co-infection is associated with a reduced TC/HDL ratio. The increase in cardiovascular risk (CVR) observed in HIV-infected patients is a cause for concern. Most clinical studies have detected a relationship between cardiovascular disease and traditional risk factors, among which age, male gender, smoking, hypertension and diabetes are the most important. There is far less information concerning CVR in HIV-infected female patients. For years, some inequalities in female participation in clinical studies have been observed. In HIV infection, women have been under-represented as participants as trial participants in for all types of clinical interventions . This isThere is concern about the potential cardiovascular complications of antiretroviral therapy (ART) in women because of their characteristics and the limitations of published studies. Physiological ageing and also menopause increases CVR. Factors potentially involved in determining sex differences in pharmacological effects that may be involved in CVR include differences in body weight and composition, pharmacokinetic issues related to drug metabolism and other, such as nutritional factors, concomitant treatments as well as hormonal and reproductive status .Lipid disturbances are frequently observed in HIV infection, and they include elevations in triglycerides (TG) and total cholesterol (TC), and reduced levels of high-density lipoprotein cholesterol (HDL). They may be related to ART and also to the direct effect of HIV. Low TG and high HDL levels have been described in HIV infected women in comparison to men , but HIVThis is a multicentre, cross-sectional study, designed to describe the lipid profile, CVR factors and HIV-related variables in a cohort of HIV-infected women on ART without lipid-lowering treatment®, Betek 43 SL, Huelva, Spain). All patients gave their written informed consent prior to the inclusion in the study.Patients were included in the Spanish VACH cohort. Characteristics of this cohort have been described elsewhere . In summFemale subjects aged 18 years or more at the time of enrolment with documented HIV-1 infection, attending VACH cohort outpatient HIV-1 treatment centres for routine, scheduled, clinical appointments, were eligible for this study. In order to be eligible, subjects must have been on at least three antiretroviral drugs, at the time of the study visit. Only those patients with more than three months on the current treatment were included in the study, and no upper limit of treatment length was set. Being on any lipid-lowering treatment was an exclusion criterion. Antiretroviral (ARV) naïve subjects or ARV experienced, but currently untreated subjects or those currently treated with NRTI bi- or mono therapy were not eligible for this study. Informed consent was obtained from the patients at study entry data collection in the VACH Cohort.®, an application specifically developed for the management of the cohort data. On enrolment, standardised data collection electronic forms were completed at the sites providing information from physical examination, patient interview and patient case notes, concerning family history of coronary heart disease, patient prior history of CVD and diabetes, cigarette smoking, blood pressure, diabetes mellitus and anti-hypertensive therapy and fasting serum lipid levels. Physical examination included anthropometric determinations such as weight, height, waist and hip diameters. All laboratory measurements were obtained in at least 8 hours of fasting state at each site. Lipid variables analysed included TC, TG and HDL; analysis were determined by enzymatical methods using standardised commercial kits; LDL was calculated by Friedewald's formula, except in patients with levels of cholesterol over 400 mg/dL (LDL = TC - ([TG/5] + HDL). The main variable analysed was TC/HDL ratio. This was selected because of its proven value in predicting cardiovascular outcomes in both genders [Data were prospectively collected according to standardised criteria and are electronically stored in the ACyHAdditionally, all cumulative data characterising the patient's underlying HIV-1 infection since inclusion in any of the individual cohorts were collected, including information on demography, antiretroviral therapy, CD4 cell counts and HIV-1 viral load. Dates of diagnosis of all AIDS-defining diseases were recorded using the 1993 clinical definition of AIDS from the Centres for Disease Control and Prevention.Most patients (98.8%) were on at least two nucleoside reverse transcriptase inhibitors (NRTI) therapy. 48.6% were also receiving non-nucleoside NRTI (NNRTI) and 45.9% protease inhibitors (PI). No information regarding specific drugs was available for analysis; in most cases, PI were low-dose ritonavir-boosted. Four groups of different treatments were identified: group 1, 2 NRTI + 1 PI (47.4% of the study population), group 2, 2 NRTI + 1 NNRTI (44.7%); group 3, 3 NRTI (6.7%) and group 4, NNRTI + PI combination therapy (1.2%). This information is also presented in Table 25-P75). The t-student test was used to compare quantitative variables between two independent groups. The analysis of variance (ANOVA) or the non-parametric Kruskal-Wallis test was used to compare the metabolic parameters between the four treatment groups. If a significant difference was found in ANOVA or Kruskal-Wallis test, it was further evaluated by using a Bonferroni-corrected α level of 0.05/6 = 0.0083.The quantitative variables were summarized by their mean and standard deviation (SD) or median and interquartile range . Statistical analyses were performed using the SPSS 15.0 statistical package.922 patients were included in the study. Their clinical characteristics are described in Table The figures Regarding TG levels, in the NRTI, PI, NNRTI and NNRTI + PI groups median values and IQR were as follows (mg/dL): 126.5 (88.5-173.2), 128.5 (94.2-183.0), 103.0 (77.0-145.7) and 141.0 (104.0-201.0), respectively. Using Kruskall-Wallis test, statistically significant differences were found between the four treatment groups . Using Bonferroni test for multiple comparisons, statistical differences were detected between PI and NNRTI groups (p < 0.001).Table Pearson's and Spearman's correlation coefficients were calculated to evaluate the linear relationship between TC/HDL ratio and quantitative independent factors. TC/HDL ratio showed a positive significant correlation with LDL  and TG levels . Significant but weaker correlations were also found with age  and BMI . These positive correlations indicate that any increase in these values is associated with higher levels of TC/HDL ratio, and therefore with impaired metabolic status. To the contrary, TC/HDL ratio showed a significant negative correlation coefficient with the eGFR .In order to evaluate the role of the different independent factors in the TC/HDL ratio, a multiple linear regression analysis was performed. All the independent factors that showed a significant relationship with the TC/HDL ratio in the univariate analysis  were included in the regression analyses. Of those factors, only HCV coinfection, age and TG levels remained significantly and independently associated with the TC/HDL ratio on multivariate analysis. PI-treatment and BMI reached borderline statistical significance table .The interaction between the PI treatment group and the TG levels with the TC/HDL ratio was studied and an interaction term was included in the linear regression model. The quantitative TG variable was dichotomized in two groups (TG > 200 mg/dl). The β coefficients, adjusted for all the variables in the model described previously, for the relationships between PI treatment and the TC/HDL ratio in the TG ≤ 200 mg/dl and TG > 200 groups were 0.21  and 0.45 , respectively. The interaction term did not reach statistical significance (p = 0.252), showing that the relationships between variables TC/HDL ratio and PI treatment group were not modified as a function of the TG level.In this study we present the lipid profile of a large cohort of HIV-infected women on contemporary ART, without lipid-lowering treatment. Most of the patients had low-risk lipid profile. The main findings include the importance of age, trygliceride levels, HCV coinfection, type of treatment (PI vs NNRTI) and BMI on plasma lipids.Major guidelines for lipid management are based in LDL concentrations , althougAlthough there are no differences related to gender with regard to the efficacy of ART, an increased proportion of ART-associated adverse events have been described in women. Some drug-related complications such as lactic acidosis, anaemia, liver toxicity or nevirapine-related rash are more common in women. In the recently published darunavir/ritonavir-based Grace trial , which wInformation about dyslipidaemia in HIV-infected women on ART is scarce. This may be due to the reduced number of women included in clinical studies or to the fact that they have not assessed gender as an independent variable. A small observational study published in 2001 described that metabolic adverse effects during ART were more pronounced in women than in men . To the It is well known that increased age is related to a pro-atherogenic lipidic profile. In fact, several cross-sectional population studies have demonstrated that TC and LDL levels increase after the onset of puberty until 50 years of age, and then plateau until 70 years of age . In addiOur data on the effect of HCV infection on lipid metabolism are consistent with previous studies, which describe lower lipoprotein levels  in HCV mono-infected patients in comparison with control subjects . HCV infIt has long been known that ART has a significant effect on plasma lipids . NormaliThe use of thymidine-NRTI therapy (d4T or AZT) has been displaced from the first line of treatment for most of the HIV-treatment guidelines because of side effects. The prolonged use of these drugs has been convincingly associated with alterations in body fat distribution and metabolic derangements, such as insulin resistance or hypertriglyceridaemia. In naive patients, comparing stavudine to tenofovir (TDF) (plus lamivudine and efavirenz in both arms), stavudine led to significantly greater increases in TG and TC at 96 weeks than TDF . Also, iOur study has several limitations: no information is available regarding HCV viral load or specific HCV treatment. The selection of patients without lipid lowering treatment may bias our study population to a lipid-disturbances protected group of patients. We considered that the inclusion of patients with lipid lowering treatment while on ART adds confusion when interpreting lipid profile. Pharmacologic interactions between statins or fibrates with ARV drugs and different dosages of drugs may render heterogeneous results on lipids that are difficult to analyse. Absence of detailed information about specific drugs is also a limitation of the study. On the other hand, it has the strength to have a high number of patients studied.In summary, we have shown that in HIV infected women, NNRTI-based ART is associated with a better lipid profile than the PI-based. The beneficial effect on lipids of NNRTI should make their use advisable in patients with increased cardiovascular risk, such as older women. Age and TG levels are independent factors significantly associated with increased TC/HDL ratio and HCV coinfection is independently associated with a reduced TC/HDL ratio. These factors must be taken into account when analysing the effect on lipid profile of different types of ART.The authors declare that they have no competing interests.VE and ISL had the original idea. VE wrote the article. MFF did the statistical analysis. All authors contributed in the recruitment, reviewed the final document and made suggestions. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6874/11/36/prepub


Background. Universal access to antiretroviral therapy (ARVT) started in Mexico in 2001; no evaluation of the features of ARVT prescriptions over time has been conducted. The aim of the study is to document trends in the quality of ARVT-prescription before and after universal access. Methods. We describe ARVT prescriptions before and after 2001 in three health facilities from the following subsystems: the Mexican Social Security (IMSS), the Ministry of Health (SSA), and National Institutes of Health (INS). Combinations of drugs and reasons for change were classified according to current Mexican guidelines and state-of-the-art therapy. Comparisons were made using χ2tests. Results. Before 2001, 29% of patients starting ARVT received HAART; after 2001 it increased to 90%. The proportion of adequate prescriptions decreased within the two periods of study in all facilities . The INS and SSA were more likely to be prescribed adequately  compared to IMSS. The distribution of reasons for change was not significantly different during this time for all facilities . Conclusions. Universal ARVT access in Mexico was associated with changes in ARVT-prescription patterns over time. Health providers' performance improved, but not homogeneously. Training of personnel and guidelines updating is essential to improve prescription. The use of highly active antiretroviral therapy (HAART) has shown a dramatic impact in terms of decreasing morbidity and mortality among HIV/AIDS patients . HoweverIn Mexico between 1997 and 2001, ARVT was only provided to subjects that were affiliated with the Instituto Mexicano del Seguro Social (IMSS), Mexican social security medical institutions, which only covers individuals who are employed in the formal sector and their dependents. Universal access to ARVT for the rest of the population (approximately 50%) was incorporated in 2001 by the Mexican government, although the policy was only fully implemented in 2003. Before this, access to ARVT for non-IMSS affiliated patients was limited and not sustained, which significantly impaired optimal adherence to ARVT and made it difficult if not impossible for physicians to comply with national treatment guidelines, and thus a large proportion of HIV patients undergoing treatment were exposed to suboptimal antiretroviral therapies [Along with the large investment made by the government to improve access, an enormous effort was made to elaborate and update national guidelines for antiretroviral prescriptions, the first of which were published in 1997. However, at the individual level, prescriptions were not necessarily based on those guidelines but were influenced by other factors such as shortages, health provider expertise, and the impact of marketing pressure on prescribing physicians. While there is no evidence of these types of impacts in Mexico, they have been documented in other high- and middle-income countries , 7.A previous study during the initial period of the universal access program in Mexico showed a widespread pattern of inadequate antiretroviral prescriptions in a convenience sample of facilities in the three subsystems . To our nth depending on the sample size in each facility.The study that this paper is based on was a pilot study funded by the University of California Institute for Mexico and the United States (UC MEXUS) in 2005. The objective of this pilot study was to provide data to inform both decision-making and a future NIH grant as a proof of concept project. In particular, one specific objective of the project was to assess “the variability of compliance by care providers with national treatment guidelines.” The sample size determined for the original study protocol was 625, which represented 90% of the total number of patients eligible to receive HAART in the sampled facilities in 2002, proportionally distributed across facilities. The selection of 643 patients was random in order to ensure representativeness. Study subjects were selected from a list of “active” patients in each facility in 2002. We ordered this list in an Excel spreadsheet and then selected every other 4th, 5th, or Information was collected retrospectively from the medical records of the 643 randomly selected HIV-infected patients at four healthcare facilities between 2001 and 2005. Patients from each center were stratified as follows: 75% of patients on ARVT, 10% deceased patients, and 15% not eligible for treatment. For the purpose of the study, only subjects who initiated antiretroviral therapy within the first 3 months after beginning care were included in the analysis. The facilities included in this study were selected for convenience to represent the spectrum of care provided in Mexico and included (1) a second-level hospital of the Mexican Social Security System (IMSS), where patients were treated by a single internist, and antiretrovirals were available for the entire period of the study; (2) a second-level hospital of the Ministry of Health System (SSA), Hospital General de Cuernavaca (HGC), which offers care for the uninsured population, and where patients were treated by a general practitioner, and (3) two third-level, academic hospitals that are part of the National Institutes of Health , Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán (INCMNSZ), and Instituto Nacional de Cancerología (INCAN), which are specialized institutes catering to the general population and the two oldest AIDS clinics in Mexico, where patients were treated by infectious disease specialists.Data extracted from the records included date of treatment initiation, history of drugs prescribed, CD4 counts, and VL tests performed over time. Our data covers retrospective information starting from 1990 for INCAN and INCMNSZ, 1993 for the IMSS, and 1999 for the SSA, the dates when HIV/AIDS clinics were formally initiated in each institution, and continuing through mid-2005 in all cases.adequate because they were explicitly recommended in the national guidelines that were current in the year of use or indicated according to the current state of the art,inadequate because the combination of drugs was explicitly contraindicated, was a toxic one, increased the risk of adverse reactions, was antagonistic, and was not recommended due to demonstrated lower efficacy in clinical trials or because no clinical trial had documented the efficacy of the regimen.All ARV treatment changes were classified according to the reason for change, which was evaluated by the authors according to information from patient records, into one of the following categories: presumed viral failure, assumed when the new regimen included two new drugs, one of which was of a different class, even though this was not always documented by a detectable VL ,toxicity, assumed when one drug from a group was substituted for another of the same group in a patient with suppressed viral load,optimizing a previous suboptimal regimen, that is, when mono- or bitherapy was changed to a 3-or-more drug regimen or when a less valid regimen was changed to a valid regimen according to prevailing recommendations at the time,deemed inadequate by existing guidelines, that is, when the new combination was more toxic or antagonistic or when no study had been published using this combination. The proportion of regimens in each facility falling into either adequate or inadequate antiretroviral combination categories and into categories describing the four different reasons for changing regimen was evaluated over the indicated periods of time. The first three categories of reasons for change were considered adequate and the last was inadequate.Antiretroviral prescriptions were assessed in terms of their adherence to national guidelines by two of the authors, (PV-YC), an infectious disease specialist with 20 years of experience in HIV care and the principal author, who were blinded to the patient affiliation. All antiretroviral combinations ever prescribed to our sample of patients were classified in one of the following categories:Antiretroviral prescription adherence to prevailing guidelines or norms was evaluated before and after 2001 and classified as described above. The official guidelines or norms selected as references had to have been published at least 3 months before the evaluated prescription.Before universal access, until 2000, we used the official norm NOM 003-SSA2-1993 [After universal access, since 2001, we used “the guide for care of patients with HIV/AIDS in outpatient services and hospitals, second edition” published in June 2000 [SA2-1993  and “theSA2-1993 . After uune 2000 . Bitheraune 2000 ” was pubχ2 test. To compare the distribution of combination drugs prescribed in each facility by period, we used a χ2 test. To estimate the probability of prescribing appropriately, we used a logit model controlling for period and facility. We compared the proportions of changes by reason between facilities using a χ2 test. A type I error probability of 0.05 was used as the threshold for statistical significance. Statistical analyses were performed using STATA version 10.Differences between facilities in the type of therapy initiated during the studied time period were estimated using a P = 0.48), sexual preference (P = 0.36), first CD4 count (P = 0.78), and gender (P = 0.79), but there were significant differences in the facility they attended  and the period of analysis   were not included in the analysis for one of the following three reasons: 47% of their records did not have information on antiretroviral drugs, 22% died within three months of beginning care, and 32% were lost to followup (LTFU) within three months of beginning care. Patients not included and patients included in the analysis had similar distributions in age at initiation of care ( = 0.00) .P value < 0.01).The analytical sample was 501 patients, 78% of the original sample: 209 (41%) from the IMSS, 105 (21%) from the SSA, and 187 (37%) from the INS. The mean follow-up time from treatment initiation for the 501 included patients was 3.69 years (SD: 3.34) with a median of 2.69 years (IQR: 1.00–5.40). By subsystem, we found a mean of 3.47 years  and a median of 3.0 years (IQR: 1.23–5.40) for the IMSS; a mean of 1.7 years  and a median of 1.28 years (IQR: 0.59–2.62) for the SSA; and a mean of 5.06  and a median of 3.28 years (IQR: 1.49–9.05) for the INS. Follow-up times were significantly different between health subsystems  was observed in all facilities . The firn = 62) starting ARVT before 2001 were treated with monotherapy, compared to 3.6% (n = 12) after 2001. The drug used in most of the cases was AZT (70%), followed by DDI (16%). Twenty-nine percent of patients who started antiretroviral therapy before 2001 and 90% after 2001 used a regimen with 3 or more drugs. Before 2001, there were differences between the percentages of patients using HAART in each subsystem: IMSS versus INS , SSA versus INS  and IMSS versus SSA . After 2001, no significant differences were found between the SSA and the IMSS , nor between the IMSS and the INS  and the SSA and the INS .Numbers and percentages of patients by type of antiretroviral therapy  facility and period are shown in P value < 0.001). The percentage also decreased from 100% to 72%  in the SSA and from 94% to 79% in the INS  .The percentage of adequate antiretroviral regimen combinations that were started decreased between the two periods of study in each facility. In the IMSS, 75% of prescriptions were adequate until 2000 versus 38% after 2001 ( = 0.02) . SignifiP value < 0.01), and all facilities had a higher probability of an adequate prescription before universal access   .P values = 0.05 and 0.001, resp.).P value = 0.22). After 2001, the percentages were 44.5%, 54%, and 44.4%, respectively . Differences between subsystems were found in the category of changes for presumed viral failure after 2001  but not in the period up to 2000 . Changes for toxicity started early in facilities with more experienced physicians; the INS reported that 21% of changes were for this reason up to 2000, which was higher than the percentages in the IMSS (12.8%) and the SSA (16.7%). Differences were significant between the IMSS and the INS . After 2001, the percentage of changes for toxicity between all facilities were more similar . A significant difference was found when inadequate changes were compared between IMSS and INS facilities in each period; it was significantly higher in the IMSS than the INS in both periods . After 2001, the differences in changes for unknown reasons that were categorized as inadequate between the three subsystems were significant .Optimizing a previous suboptimal regimen was the first cause for change in both periods and equaled 40% of the total changes until 2000 and 46% after 2001. Until 2000, 45% of the changes occurred for this reason in the IMSS, 16.7% in the SSA, and 39.1% in the INS  or in the SSA , but it was marginally significant in the INS , where the percentage of changes for toxicity decreased after 2001 (21% versus 14.8%) and changes for optimizing increased (39.1% versus 44.4%). By facility between periods, no differences for presumed viral failure were found . The percentages of inadequate changes in each facility (IMSS and INS) were similar between periods  (The percentages of changes for each reason were not significantly different during the studied time in the IMSS ( = 0.65) .Boosting PI with ritonavir was not considered a change of regimen, but it was found in 88 patients (49%), 12 before 2001 and 76 (24%) in the second period. The medical facility with the highest percentage of boosting was the INS, with 92% before 2001 and 51% for the second period.In this study, we documented a heterogeneous pattern of adequacy in ARVT prescriptions in the health facilities included. Our results showed a significant increase in the use of HAART after 2001, with a higher percentage in the IMSS compared to the INS and the SSA during the first period but with a similar distribution between facilities after 2001. A higher probability of an adequate initial prescription was observed in the INS and the SSA compared to the IMSS in both periods, especially before 2001. The distribution of reasons for changes to prescriptions was not significantly different during the study period in the IMSS or the SSA, but it was marginally significant in the INS, where the percentage of changes for toxicity decreased after 2001 and changes to optimize ARVT increased. A significant difference was found when inadequate changes were compared between facilities; it was significantly higher in the IMSS than the INS in both periods, but percentages in each facility (IMSS and INS) were similar between periods.After the first local guidelines for antiretroviral drug prescriptions were published in 1997  and afteAccess to antiretroviral therapy in Mexico has been a stepwise process depending on the health subsystem. Each subsystem has different antiretroviral drug availability conditions that have had an impact on the ability of physicians to prescribe them. For social security workers, it became possible to receive a triple HAART regimen in 1997, even though only 30% of IMSS patients began receiving HAART before 2001. However, for the other hospitals included in this study, universal access started as a progressive process after 2001, when HAART was included in the Seguro Popular , 17, andAlthough guidelines were published for antiretroviral use –14, theyPrescriptions before 2001  were not necessarily the best possible ones due mainly to limited access to antiretrovirals. Of concern is that, before 2001 in the IMSS, all antiretroviral drugs were available free of charge, but the prescription patterns were similar to other facilities that did not have free access to antiretroviral drugs or monitoring tests during this period, and over time the impact on prescriptions after 2001 was similar to other institutions. This is a difficult phenomenon to explain, as we would expect that with full antiretroviral availability the prescriptions would be written according to guidelines. However, a decrease in the percentage of adequate combinations is plausible as it may be related to an insufficient supply of ART compared to an increasing demand explained by the expansion of universal access. Physicians may have prescribed older and outdated combinations because they were available in stocks. New combinations may have taken time to be widely available in the country. Another potential explanation is the lack of training to introduce physicians to the new guidelines. ARV shortages could cause the delivery of incorrect prescriptions , but we Our results show that patients had been exposed to a great extent to suboptimal therapy in the studied facilities before 2001. On average, 62% received monotherapy or bitherapy with nucleoside analogues during this period, even when international guidelines did not recommended monotherapy or bitherapy beginning in 1998 , 14, whiMexican guidelines were written in the year 2000 with concepts that were far behind the state-of-the-art knowledge of antiretroviral therapy, which resulted in larger use of suboptimal 2 nucleoside regimens with the consequent selection of drug resistance and possible transmission in the community. A recent study of HIV transmitted drug resistance (TDR) for the period of 2005–2009 in Mexico showed a 7.4% prevalence of TDR HIV, which was higher than that predicted by WHO TDR surveillance. The prevalence of nucleoside reverse transcriptase inhibitors (NRTIs) in this representative cohort was 4.2%, the highest of all antiretroviral drugs, and, of these, 70% had thymidine analogue mutations (TAMs), and up to 20% had 2 or more TAMs .Because mechanisms to update guidelines to reflect fast-changing current evidence do not exist in Mexico, the guidelines usually become obsolete rapidly, as reported in this study, with significant public health consequences. In contrast, we can argue that scientific knowledge is rapidly socialized and that the speed of socialization has been increasing for several decades and particularly in the last decade. However, physicians face different situations in their practice. They may have knowledge from different sources regarding what will be the best regimen for a patient to be prescribed. Also if the patient must pay for antiretrovirals out of their own pocket and does not have the economic resources to pay for triple therapy, then the physician had to assess this particular situation and make a decision. This was the situation for the INS and the SSA until 2001 when universal access was announced. However, again, this was a gradual process; every patient had to fulfill certain administrative requirements to be a candidate and beneficiary for universal ARV access.This study shows that prescriptions that are written by physicians without experience in HIV medicine and who follow the guidelines strictly or are compelled to do so by authorities may have negative consequences. In the current environment, training medical doctors in nonspecialized facilities and improving access to laboratory resources (VL and genotype tests) are important for improving ARVT prescriptions. We envision two ways to improve prescriptions in our health system: (1) monitoring and supervision by peers of ARVT prescribed in facilities where physicians are less trained or less experienced and (2) restricting options for first line regimes for nonspecialized physicians.The main limitation of our study is that it evaluates ARVT prescription patterns in only four facilities in the country, and although we cannot claim that the study sample represents the whole country, these four facilities are referral centers  for HIV-patient care in each of the health subsystems. In addition although the facilities were selected for convenience, all the subsystems were represented. As explained before, the data were collected in 2005, which explains why we do not have information for subsequent years. The relevance of these results stems from the fact that we described the prescribing patterns before and after the introduction of a universal access, policy in a middle-income country with a fragmented health system, a wide heterogeneity in the prescribing physicians' clinical capacities and with fewer alternatives for prescriptions than there are currently. In the context of a significant global push for universal access to health care in general and to antiretrovirals in particular, significant lessons can be drawn from the experience in Mexico in the early 2000s.Our work has other limitations common to retrospective studies; in addition to having a nonrepresentative sample of all clinics treating HIV patients in the country, we have no data regarding the supply of antiretroviral drugs during this time for each facility nor do we have data concerning the patients' adherence to antiretroviral regimens. All this would allow us to extrapolate our results to other Mexican facilities and to explain how patterns of prescriptions are affected by other circumstances besides physician expertise. Although this study does not measure patient outcomes, we were able to evaluate the adequacy of prescriptions according to the guidelines in place. Universal access did improve the appropriateness of prescriptions in facilities where patients paid out-of-pocket for their antiretrovirals before universal access, but it had no impact in the one facility where there had been full access since 1997 (IMSS).The scaling-up of ARVT poses enormous challenges, aside from the economic burden of providing drugs and the high cost of laboratory exams; the success of this huge effort of governments and agencies may be hindered if the prescriptions for these regimes are inadequate. National guidelines should be updated according to the pace of knowledge and should always leave open the possibility of tailoring HIV prescriptions for special cases through peer review. The clinical care of people with advanced HIV disease, with opportunistic infections, malignancies, and/or viral failure, could be very complex and thus requires the knowledge of experienced physicians to reach better clinical outcomes, to manage drug interactions, to promote adherence, and to avoid resistance transmission .This study evaluates ARVT prescription patterns over time in four facilities of three different Mexican health subsystems. The results contribute to the identification of trends and the quality of antiretroviral prescriptions before and after the first years of universal access in Mexico, discuss possible explanations for the observed prescription patterns, and propose ways to improve prescriptions. The expected benefits to patient survival and quality of life with novel therapies require, in addition to sustained drug access, good prescription practices by physicians. Medical doctors with a high level of training and experience are as important as access to drugs and laboratory exams to monitor therapy responses –28.


Contrary to what has been described elsewhere, there was no specific effect of protease inhibitors on herpes zoster incidence. The present study is the first to suggest that crack cocaine is associated with an increased incidence of herpes zoster. The neurological or immunological effects of crack are discussed.A retrospective cohort study was conducted on 1541 HIV-infected patients to determine variables associated with the incidence of herpes zoster. A single failure Cox model showed that herpes zoster incidence increased following the first 6 months of antiretroviral treatment adjusted hazard ratio (AHR)=5 (95%CI=2.6-9.2), P<0.001; in the >60 years age group AHR=2 (95%CI=1-4), P=0.04; in patients in the top CD8 quartile AHR=2.1 (95%CI=1.3-3.6), P<0.001; and in patients previously reported to use crack cocaine AHR=5.9, (95%CI=1.4-25), P=0.02. Herpes zoster incidence increased in patients with CD4 counts<500 per mm Similar to other herpes viruses, the varicella-zoster virus (VZV) causes both acute illness and lifelong latency. During the primary infection, VZV enters the cutaneous endings of sensory nerves and migrates up to the sensory nerve ganglia. The virus incorporates nucleoprotein within ganglionic cells and establishes latency which is maintained through cellular immunity . With adIn acute VZV infection, varicella, primarily affects children in temperate areas. Thus most HIV-infected patients born in the United States and Europe have already had varicella or have been vaccinated, and therefore are not susceptible to primary infection. However, in tropical areas children often escape primary infection . The objFrench Guiana is the French territory where the HIV prevalence is highest. The epidemic is driven by transactional sex and perhaps by crack cocaine. Over seventy percent of the patients are foreign . The health system is the French system. All patients residing for over 3 months on the territory are eligible to receive health insurance and residence permits. The latest antiretrovirals, genotyping, viral load and other biological tests are free of charge.All HIV-positive patients followed in Cayenne, Kourou, and Saint Laurent du Maroni Hospitals between 1 January 1992 and 31 October 2008 were enrolled in the French Hospital Database for HIV (FHDH). Time-independent variables such as sex, nationality, mode of acquisition of HIV, and time-dependent variables such as age, CD4 cell counts, CD8 counts, HIV-1 viral loads, antiretroviral treatments, and clinical events are routinely entered by trained clinical studies technicians. Diagnoses are coded according to the 10th International Classification of Diseases. Specific details such as the location of herpes zoster could not be obtained from the database. Patients included in the FHDH give written informed consent for the use of their records’ data. Their identity is encrypted before the data are sent to the Ministry of Health and the Institut National de la Recherche Médicale, which centralizes data from Regional coordination committees for the fight against HIV/AIDS (COREVIH) throughout France. This data collection is approved by the Commission Nationale Informatique et Libertés. The study was a retrospective cohort study, using a single failure Cox proportional hazards model to evaluate the adjusted relationship between failure and explanatory variables. The failure event was the incidence of a first episode of herpes zoster. The main explanatory variables were age categorized <30, 30-39, 40/59, >60), sex, nationality, reported addictions, CD4 cell count at the time of the visit , CD8 cell count categorized in 4 quartiles , HIV1 viral load, the presence or absence of HAART, the time since treatment started , and the period . The proportionality of the hazard functions was determined using Schoenfeld and scaled Schoenfeld residuals and the global proportional hazards test. Age, CD4 and CD8 cell count category at the time of HIV diagnosis, and follow-up duration were transformed into dummy variables to compare different groups with a reference group. In order to test the eventual influence of protease inhibitors, 2 approaches were used: first, an interaction term between the 6 month period following treatment initiation and protease inhibitors was created and added to the Cox model.; second, a nested case control study was conducted with 4 random controls sampled for each case of herpes zoster, at the time of herpes zoster. The data were analysed using STATA 12.0 . A total of 1541 subjects with 34310 observations were included, representing a total of 7159 person-years of follow-up. A total of 181 first clinical episodes of herpes zoster were recorded. There were 2 reported cases of meningeal herpes zoster, and 7 cases of disseminated herpes zoster. P=0.4. After adjusting for potential confounders, such as antiretroviral treatment, CD4 counts, age and gender, this association remained significant. The interaction term testing a specific effect of protease inhibitors on the incidence of herpes zoster was not significant, thus removed from the final model. Similarly, the nested case control study did not find any specific association between protease inhibitors and herpes zoster (adjusted odds ratio=0.8 (95% CI=0.4-1.4), nd and 4th quartiles had an increased incidence of herpes zoster. The CD4 decline was rapidly associated with an increased incidence of herpes zoster (<500 CD4 per mm3), but further immunosuppression only marginally increased the incidence of herpes zoster. Patients with CD8 counts in the 2Patients aged 60 and over had an increased risk of herpes zoster.3 (inter quartile range=241)) and non users (163/mm3 (SD=253)), P=0.56. CD8 counts at the same time were significantly lower among crack users (516/mm3 (inter quartile range=590)) than non users (763/mm3 (inter quartile range=668)), P=0.005. After controlling for CD4 count, crack users (failure event in this model) were less likely to be on ARV treatment than non crack users adjusted hazard ratio=0.17 (0.08-0.36), P<0.001. Finally, the Analysis of the proportion of crack users by period showed that there was a gradual increase in the proportion of crack users 1.1% in 1992-1996, 1.8% in 1997-2002, and 5.8 in 2002-2008 (P<0.001).Although there were few patients concerned (n=58), there was an association between crack cocaine use and herpes zoster (incidence rate 4.4 per 100 person-years when crack use was reported versus 2.2 per 100 person years when crack use was not reported. 3 but more advanced immunosuppression did not seem to further increase incidence. It has been reported that protease inhibitor initiation specifically increased incidence of herpes zoster, possibly through a CD8 boosting mechanism[Although French Guiana is in the tropics where the proportion of persons infected by VSV is lower, the repThe observation that crack cocaine was associated with an increase in the incidence of herpes zoster was a novel finding. Cocaine, a sigma1 agonist neurotropic drug, has an effect on the homeostatic balance between TH1 pro-inflammatory versus TH2 anti-inflammatory balance and skews the cytokine response towards anti-inflammatory cytokines. Thus, a


Recent papers have suggested that expanded combination antiretroviral treatment (cART) through lower viral load may be a strategy to reduce HIV transmission at a population level. We assessed calendar trends in detectable viral load in patients recruited to the Australian HIV Observational Database who were receiving cART.Patients were included in analyses if they had started cART  and had at least one viral load assessment after 1 January 1997. We analyzed detectable viral load (>400 copies/ml) in the first and second six months of each calendar year while receiving cART. Repeated measures logistic regression methods were used to account for within and between patient variability. Rates of detectable viral load were predicted allowing for patients lost to follow up.Analyses were based on 2439 patients and 31,339 viral load assessments between 1 January 1997 and 31 March 2009. Observed detectable viral load in patients receiving cART declined to 5.3% in the first half of 2009. Predicted detectable viral load based on multivariate models, allowing for patient loss to follow up, also declined over time, but at higher levels, to 13.8% in 2009.Predicted detectable viral load in Australian HIV Observational Database patients receiving cART declined over calendar time, albeit at higher levels than observed. However, over this period, HIV diagnoses and estimated HIV incidence increased in Australia. There has been much interest recently in the role that combination antiretroviral treatment (cART) might have in decreasing HIV transmission at a population level. A reduced HIV viral load as a consequence of cART appears to reduce the risk of heterosexual HIV transmission -3. At a Despite biological plausibility and the observational results, mathematical modelling studies have had inconsistent conclusions. Some studies have suggested that early HIV diagnosis and widespread cART could reduce HIV transmission at a population level ,8, whileThe objective of this paper is to estimate the proportions of patients with detectable HIV viral load by calendar year in patients receiving cART in the Australian HIV Observational Database (AHOD), allowing for patient covariates and differential follow-up patterns.Analyses were based on patients recruited to AHOD. Detailed methods have been described previously , but briEthics approval was obtained from the University of New South Wales Human Research Ethics Committee and all other relevant institutional review boards, and written informed consent was obtained from all patients.Patients were included in this analysis if they had started cART , and had at least one viral load assessment after 1 January 1997. Using an intention-to-treat approach, patients were considered to remain on cART if they reverted to mono or double therapy. No account was taken of changes to the antiretrovirals received. Complete treatment interruptions of more than 14 days were excluded from analyses. Any viral load tests prior to cART were also excluded. A second sensitivity analysis was limited to patient prospective follow up.The endpoint analyzed was detectable viral load (defined as >400 copies/ml) in the first and second six months of each calendar year while receiving cART. Detectable viral load was defined as >400 copies/ml as follow up included periods when more sensitive viral load assays were not available. If a patient had multiple viral loads in a six-month period, then the viral load closest to the middle of the period was selected.3, missing); viral load in previous six-month period, including viral loads while not receiving antiretrovirals - if a viral load was missing, then the previous viral load was carried forward ; current CD4 count, including CD4 counts while not receiving ARVs - if a CD4 was missing, then the previous CD4 was carried forward ; year first received cART ; year first HIV diagnosis ; and time since first cART .The following covariates were considered: age at baseline ; sex; HIV exposure ; AIDS prior to first cART; mono or duo antiretroviral treatment prior to first cART; HCV antibody ; HBV surface antigen ; viral load prior to first cART ; CD4 count prior to first cART  covariates. Covariates were also excluded if there appeared to be collinearity problems .The statistical models were used to make three sets of predictions for each six-month calendar period, and predictions compared with observed rates of detectable viral load. The probability of detectable viral load was predicted for the following three scenarios:1. All patients included in the predictions, including all patients who were lost to follow up, who had missing values, or who died. This estimates the proportions of patients with detectable viral load if they had all survived and remained on cART to the appropriate time point2. All patients included in the predictions, but excluding patients who died from the time of death3. Limiting predictions to patients who had a viral load test result, so predictions fitted to the analyzed data.Scenarios 1 and 3 can be thought of as likely upper and lower limits on estimates of the proportions of detectable viral load. Scenario 1, which includes all patients who are lost to follow up, who cease cART or who die, would be an upper limit. Scenario 3, which predicts based only on the analyses data, would be a lower limit as these are patients who remain in follow up and so would generally have a better outcome. Scenario 2 was expected to lie within these two limits.A total of 2439 patients were eligible for inclusion in the analysis. The median number of viral loads analyzed for each patient was 13 (interquartile range 7 to 19). A total of 654 patients (4.7 per 100 person years) were lost to follow up (defined as more than 12 months without a clinic visit) and 194 patients died (1.4 per 100 person years). Patient characteristics at first cART are summarized by year of first cART in Table The final fitted multivariate model is summarized in Table Observed proportions of detectable viral load in patients receiving cART, by six-month calendar year periods, together with model-fitted predicted proportions, are shown for all patients combined in Figure Observed and predicted proportions of detectable viral load by period of first cART are shown in Figure Sensitivity analyses were also performed based on patient prospective data only. These analyses found the same covariates to be included in multivariate models, and gave similar trends in observed and predicted proportions of detectable viral loads (data not presented).The proportion of patients in AHOD with detectable viral load while receiving cART has been observed to be decreasing, to around 6% in 2009. These analyses, which adjust for patient covariates and differential follow up, suggest that the true proportions of patients in AHOD receiving cART with detectable viral load in more recent calendar time periods are higher than the simple observed proportions. The higher estimated proportion of patients with detectable viral load in adjusted analyses is mostly due to the inclusion of patients who were lost to follow up, and observed proportions should be used with caution because of this bias.Under scenario 2 , but censors patients who have died, the predicted proportion of patients with detectable viral load in 2009 was 13.8% compared with an observed proportion of 6.3%. Although predicted proportions of detectable viral load were higher than observed proportions, a consistent finding of our analyses was that there was no evidence of increasing proportions of patients with detectable viral load, both overall and by time of first cART. This is reassuring as it suggests that there is as yet no evidence of cohorts of HIV-infected patients running out of effective treatment options.Our analyses specifically looked at detectable viral load by calendar time. We performed this analysis, as opposed to looking at detectable viral load from time of first cART, because of the recent interest in levels of community viral load in HIV-infected patients receiving viral load tests by calendar time, and how this might impact on HIV transmission at a population level -6. In AuCombination ART is publicly funded and freely available to all HIV-infected patients in Australia. The HIV epidemic remains very largely (85%) transmitted through male homosexual sex , a well-Finally, the analyses presented here suggest that in HIV-infected men receiving cART, HIV viral load has continued to decrease through the 2000s, albeit at slower rates than observed data suggest. This set of circumstances in Australia would appear to offer the best hope for cART to have an effect on reducing HIV transmission at a population level. However, over this period, total HIV diagnoses have increased in Australia, from a low of 718 new diagnoses in 1999 to around 1000 new diagnoses annually in 2006-2008 .Mathematical models and back-projections analyses have both suggested that this reflects a real increase in HIV incidence in homosexual men ,18. If tMathematical modelling has been used to investigate trends in HIV incidence in Australia. Early models did suggest a decrease in HIV incidence among homosexual men during 1996 to 1998 due to the introduction of widespread cART, but that this was followed in 1998 to 2001 by a slow increase in incidence due to increasing rates of unprotected anal intercourse with casual partners while use of cART remained fairly stable . More reA key limitation of our analyses is the extent to which trends in AHOD are representative of all HIV-infected people in Australia. AHOD is an observational cohort study of HIV-infected people attending clinics for their care, and recruited more patients in the late 1990s and early 2000s than in recent years. Hence trends in undetectable viral load may not reflect all HIV-infected patients receiving cART. We did stratify trends by different periods of first cART to try to assess this. AHOD represents 15-20% of HIV-infected patients receiving cART, and in terms of key epidemiological characteristics, seems reasonably representative of the wider HIV epidemic in Australia . HoweverA further limitation is that AHOD, as with all observational cohorts, has missing data and some patients were lost to follow up. While we predicted trends in detectable viral load adjusted for important covariates using statistical models that allow for patients lost to follow up, there may be unmeasured and unmeasurable confounders that would affect our results. In particular, it may be that the apparent continuing decline in detectable viral load in patients receiving cART, albeit at higher levels than observed declines, is better interpreted as a plateau over the period from the mid-2000s.Our analyses suggest that in AHOD, true calendar trends in detectable viral in HIV-infected patients receiving cART are higher than observed trends when adjusted for confounding covariates and patients lost to follow up. Whether these predictions reflect true continuing decreases, or actually something more of a plateau, we feel is open to interpretation. It is reassuring that under all models, there was no suggestion of increasing detectable viral load, either observed or predicted. The fact that these decreasing trends in detectable viral load in patients receiving cART in AHOD have been accompanied by increases in HIV diagnoses and estimated HIV incidence suggests that, at least in Australia, the likely decrease in the risk of transmission from people receiving cART as a result of reduced HIV viral load is being counterbalanced by increasing risk of transmission due to behaviour changes.MGL has received research grants, consultancy and/or travel grants from: Boehringer Ingelheim; Bristol-Myers Squibb; Gilead; GlaxoSmithKline; Janssen-Cilag; Johnson & Johnson; Merck Sharp & Dohme; Pfizer; Roche; and CSL Ltd. IW has received research grants, consultancy payments, clinical support funds or honoraria from: Bristol-Myers Squibb: Gilead; Merck; and Abbott. All other authors have no competing interests to declare.All authors contributed to the development of the hypothesis and analysis plan. MGL and HM performed the statistical analysis. MGL wrote the first draft of the manuscript. All authors commented on drafts and approved the final version of the manuscript.


Mortality in patients starting antiretroviral therapy (ART) is higher in Malawi and Zambia than in South Africa. We examined whether different monitoring of ART  could explain this mortality difference.Mathematical modelling study based on data from ART programmes.We used a stochastic simulation model to study the effect of VL monitoring on mortality over 5 years. In baseline scenario A all parameters were identical between strategies except for more timely and complete detection of treatment failure with VL monitoring. Additional scenarios introduced delays in switching to second-line ART (scenario B) or higher virologic failure rates (due to worse adherence) when monitoring was based on CD4 counts only (scenario C). Results are presented as relative risks (RR) with 95% prediction intervals and percent of observed mortality difference explained.RRs comparing VL with CD4 cell count monitoring were 0.94 (0.74–1.03) in scenario A, 0.94 (0.77–1.02) with delayed switching (scenario B) and 0.80 (0.44–1.07) when assuming a 3-times higher rate of failure (scenario C). The observed mortality at 3 years was 10.9% in Malawi and Zambia and 8.6% in South Africa (absolute difference 2.3%). The percentage of the mortality difference explained by VL monitoring ranged from 4% (scenario A) to 32% . Eleven percent was explained by non-HIV related mortality.VL monitoring reduces mortality moderately when assuming improved adherence and decreased failure rates. Since 2003 the number of people receiving antiretroviral therapy (ART) worldwide has increased 16-fold, with 6.6 million people on treatment at the end of 2010 Studies of the effect of routine VL monitoring on mortality have produced conflicting results. Two randomized trials VL monitoring should lead to more timely detection of treatment failure, more effective, targeted adherence counselling and more appropriate switching to second-line ART, thus reducing exposure to a failing regimen and improving survival. In the present study we used a mathematical model to examine the extent to which the mortality differences observed in patients starting ART in the different settings in Southern Africa Our study had two components: first we adapted a previous mathematical model The International epidemiologic Databases to Evaluate AIDS in Southern Africa (IeDEA-SA) is a regional collaboration of ART programmes, which is part of a large international network First-line ART was defined as a regimen of two nucleoside reverse transcriptase inhibitors (NRTIs) and one nonnucleoside reverse transcriptase inhibitor (NNRTI). A switch to a second-line regimen was defined as a change from the initial NNRTI-based regimen to a protease inhibitor-based regimen after at least 6 months of follow-up. Virologic treatment failure was defined as a plasma viral load ≥1000 copies/ml. Immunologic failure was defined according to the WHO, as either a CD4 cell count <100 cells/µl, below baseline or a decrease of at least 50% from the on-treatment peak value Appendix S1.We adapted a previously developed individual-based mathematical model to simulate outcomes after ART initiation in a cohort of 1000 HIV-infected adult patients Appendix S1. The model parameters and their sources are shown in The model was parameterized using data from the Khayelitsha In the first analysis, we simulated cohorts with identical baseline characteristics to compare 5-year mortality between VL monitoring and CD4 monitoring. Three scenarios were compared: In baseline scenario A, we assumed that patients switch to second-line ART according to the guidelines, i.e. immediately after meeting the relevant failure criteria. All other parameters including non-HIV related background mortality were also assumed to be identical between the two strategies. Any difference in mortality would thus be due to the ability to detect treatment failure more accurately when using routine VL compared to CD4 monitoring, leading to more timely switching to second-line ART.In scenario B we investigated the effect of reluctance to switch by introducing a delay from meeting the failure criteria to switching. Sites without access to VL monitoring tend to have lower switching rates than sites with regular VL measurements Lower virologic failure rates as a consequence of better adherence in sites with routine VL monitoring could also reduce mortality Appendix S1 for details).In all three scenarios baseline characteristics were identical across strategies and age- and sex-specific background mortality rates were for Africans living in the Western Cape in 2007 In the second analysis, we aimed to determine to what extent VL monitoring could explain the observed difference in mortality between VL (South Africa) and CD4  sites The low accuracy of the WHO immunologic failure criteria meant that only 8% of virologic failures could be detected by CD4 monitoring within one year Table 1.The proportion of patients who switched within one year of meeting relevant failure criteria was 53% in programmes with routine VL monitoring and 6% among patients with CD count monitoring Table 1.Assuming a higher rate of virologic failure in the CD4 monitoring cohort had a more substantial impact  to 10.1% . The Kaplan-Meier estimate of mortality at 3 years in the CD4 monitoring only cohorts was 10.9% Figure 1The absolute difference in observed mortality between Malawi and Zambia and South Africa was 2.3% (10.9%–8.6%). Approximately 4% of the observed difference in mortality could be explained by more complete detection of virologic failure with VL monitoring Figure 2We used a mathematical model to estimate the causal effect of VL monitoring, compared to CD4 count monitoring, on mortality in ART programmes and to examine to what extent the higher mortality among patients starting ART in Zambia and Malawi, compared to South Africa et al found that viral load monitoring increased the average survival time in the first 5 years of ART from 4.09 to 4.14 The results of previous modelling studies of the VL monitoring and mortality have been heterogeneous. Phillips Despite the fact that poor adherence is a major predictor of virologic failure The effect of VL monitoring on mortality and other outcomes should ideally be examined in adequately powered randomized controlled trials. For ethical reasons the protocols of randomized trials will tend to resemble scenario A in our modelling study, where trial participants are monitored closely for adherence and clinical symptoms and thorough adherence counselling is implemented in all groups. Indeed, in the only trial comparing VL with CD4 count monitoring published so far, all patients were visited weekly by a trained lay person using a standardized symptoms questionnaire. Patients were weighed each month and drugs were replaced weekly using pre-packed storage containers A non-inferiority trial in rural district hospitals in Cameroon The beneficial effect of VL monitoring on adherence may thus be masked in randomized trials due to intensive counselling and clinical monitoring in all arms. Furthermore, patients who participate in clinical trials can generally be expected to be more adherent than patients treated in routine ART programmes. Although there are at least two ongoing trials that compare routine VL to CD4 monitoring Our study had several limitations. First, the probability of HIV-related outcomes in our simulations depended on only two patient-level factors – virologic and immunologic treatment response. We thus ignored factors such as age and gender of the patient, adherence to treatment, resistance mutations, baseline CD4 and VL values, opportunistic illnesses and co-infections. Although some of these factors were recorded, we decided to keep the structure of the model simple. We stress that our results reflect the situation of the ART programmes included in this study, and may not apply to other settings. Nevertheless, these cohorts are typical for adult ART programmes in Southern Africa, with the majority of patients being women and most patients starting ART with low CD4 cell counts. Second, we assumed a constant rate of immunologic failure following virologic failure: we did not have sufficient data to estimate the progression to immunologic failure more precisely. Third, we assumed that the hazard of death after virologic failure increased over time whereas the hazard after immunologic failure remained constant, in line with previous studies We restricted our simulations to two strategies and five years of follow-up, and did not include costs or the effect on HIV transmission. Additional strategies could include CD4 monitoring with targeted VL monitoring (i.e. in patients experiencing immunologic failure), CD4 or VL monitoring with different measurement frequencies, or VL monitoring with different failure thresholds. A recent study confirmed the key role of targeted VL monitoring to prevent unnecessary switching and to reduce costs In conclusion, we have shown that routine VL monitoring can reduce mortality over the first five years of ART. The magnitude of this benefit depends on the ability of VL monitoring to improve adherence and therefore decrease rates of virologic failure. As point-of-care VL testing will be introduced in programmes in resource-limited settings in the near future, more research is urgently needed to improve our understanding of how VL monitoring impacts on disease progression, the development of drug resistance and HIV transmission at the individual and population level.Figure S1Schematic representation of disease progression on ART in the mathematical model.(DOCX)Click here for additional data file.Figure S2Comparison of the main outcomes between the mathematical model and the source data.(DOCX)Click here for additional data file.Table S1Patient characteristics at start of antiretroviral therapy in the dataset that was used to parameterise the mathematical model.(DOCX)Click here for additional data file.Appendix S1Description of the mathematical model and data sources.(DOCX)Click here for additional data file.


Adverse outcomes occurring early after antiretroviral therapy (ART) initiation are common in sub-Saharan Africa, despite reports of high levels of ART adherence in this setting. We sought to determine the relationship between very early ART adherence and early adverse outcomes in HIV-infected adults in Botswana.This prospective cohort study of 402 ART-naïve, HIV-infected adults initiating ART at a public HIV clinic in Gaborone, Botswana evaluated the relationship between suboptimal early ART adherence and HIV treatment outcomes in the initial months after ART initiation. Early adherence during the interval between initial ART dispensation and first ART refill was calculated using pill counts. In the primary analysis patients not returning to refill and those with adherence <0.95 were considered to have suboptimal early adherence. The primary outcome was death or loss to follow-up during the first 6 months of ART; a secondary composite outcome included the primary outcome plus incident opportunistic illness (OIs) and virologic failure. We also calculated the percent of early adverse outcomes theoretically attributable to suboptimal early adherence using the population attributable risk percent (PAR%).Suboptimal early adherence was independently associated with loss to follow-up and death  and with the secondary composite outcome including incident OIs and virologic failure . However, of those with early adverse outcomes, less than one-third had suboptimal adherence and approximately two-thirds achieved virologic suppression. The PAR% relating suboptimal early adherence and primary and secondary outcomes were 14.7% and 17.7%, respectively.Suboptimal early adherence was associated with poor outcomes, but most early adverse outcomes occurred in patients with optimal early adherence. Clinical care and research efforts should focus on understanding early adverse outcomes that occur despite optimal adherence. Death in the initial months after initiating combination antiretroviral therapy (ART), often termed “early mortality,” accounts for the majority of all first-year deaths in adult HIV treatment programs in resource-limited settings More broadly, adherence as well as virologic and immunologic responses to ART among patients who suffer early mortality after ART initiation remains largely uncharacterized, in part because many events occur before these measures can be obtained. Nonetheless, understanding response to ART in these individuals is important for the design of interventions aimed at reducing early mortality. For example, patients may have difficulty tolerating medications early during therapy, leading to failure to respond virologically and immunologically and subsequent disease progression Adherence is strongly related to clinical outcomes and is the first step in responding to ART In previous studies in Botswana we have documented that the vast majority of deaths in the first year after starting ART occur in the initial months of treatment and that the median adherence level measured approximately 6 months after ART initiation is high (91%) 3 or a qualifying opportunistic illness (OI) were provided with free ART This prospective observational cohort study evaluated the relationship between early suboptimal adherence and early adverse outcomes among ART-naïve, HIV-infected adults aged 18 years and older initiating free ART at the Infectious Disease Care Center (IDCC) at Princess Marina Hospital (PMH) in Gaborone, Botswana. The IDCC at PMH is a large public HIV clinic where HIV-infected individuals with CD4 counts <200 cells/mmEarly adherence was determined using pill counts performed by study staff at the time of initiation and first ART refill, given data indicating that pharmacy adherence measures such as pill counts consistently predict outcomes and are more accurate than self-report Loss to follow-up or death after ART initiation were considered together as the primary composite outcome given a strong documented relationship between loss to follow-up and death in this specific setting as well as several others Study staff approached patients during clinic visits. Patients providing written informed consent in English or Setswana were assessed prior to ART initiation and then monthly thereafter until approximately 6 months after ART initiation. Practically, patient follow-up was considered complete when individuals had completed the baseline visit plus 5 monthly follow-up visits scheduled after ART initiation. Data on viral loads, CD4+ T cell (CD4 cell) counts and clinical diagnoses were abstracted from paper or electronic medical records using study-specific forms. ART medication names, doses, number of pills dispensed and returned and dates of dispensation were obtained from the IDCC pharmacy. The date of loss to follow-up was the date of the patient's last contact with the clinic, laboratory or pharmacy. Greater than 90% of patients provided a cell phone number and home address where they could be reached, and patients were actively traced via phone if they missed a clinic visit. If patients were unable to be reached by phone on three separate days, the study team performed a home visit in an effort to locate the patient. Deaths and dates of death were confirmed by the patients' medical records or by patient contact report. Records of patients with incident OIs were reviewed by study staff blinded to patient adherence status to ascertain if the OI was under evaluation prior to ART initiation. If this blinded review suggested that the OI was present at baseline but undiagnosed , it was categorized as prevalent. Diagnoses of TB and other OIs were not always confirmed microbiologically. Data were entered into a Microsoft Access database using double data entry.Patients were included in the analyses if they had non-missing baseline initial ART regimen data of start date, pills dispensed, drug names and doses. The vast majority of deaths in the first year after ART initiation occur in the first several months after treatment is begun, and mortality rates among those who survive this initial early treatment period decrease substantially thereafter A challenge inherent in determining the relationship between early adherence and early outcomes is that some patients initiate ART and never return, in which case their adherence is unknown. Requiring patients to return for at least one ART refill in order to be included in the study would eliminate such patients from the analysis but could introduce potentially severe selection bias due to the relationship between loss to follow-up and death exp(RR−1)]/[Pexp(RR−1)+1]} * 100 where Pexp = prevalence of suboptimal adherence in the population, and RR = unadjusted relative risk of early adverse outcomes among patients with suboptimal adherence Most studies relating adherence to outcomes have expressed this relationship in terms of odds ratios, relative risks or relative hazards Analyses were done using SAS 9.1 (SAS Institute Inc.), Cary, North Carolina, USA. The research ethics boards of the Botswana Ministry of Health, the PMH and the University of Pennsylvania approved this research protocol.3 (IQR 73–180). Forty of 45 patients (89%) being treated for active TB at baseline, and 288 of 321 patients (90%) who were not being treated for active TB and who had a baseline CD4 count <200 cells/mm3 were on trimethoprim-sulfamethoxazole at the time of ART initiation. Furthermore, 94 of 275 patients (34%) who were not being treated for active TB and who did not have a prior history of isoniazid preventive therapy (n = 84) were given isoniazid at baseline. Among 367 patients (91%) with non-missing baseline hemoglobin values, the median hemoglobin level was 11.5 gm/dL (IQR 10.0–13.1).Between May 31, 2005 and November 19, 2007, 474 patients were enrolled. Of these, 40 (8%) were later found to be ineligible because they were not ART naïve, 28 (6%) had missing initial ART regimen data and 2 (<1%) withdrew, leaving 402 (85%) for analysis. The median date of enrollment was December 31, 2006 and the median follow-up time was 256 days (interquartile range (IQR) 180 to 344 days), reflecting the observed variability in actual time to completing 5 follow-up visits in the study. Baseline characteristics of the cohort are shown in Overall, 37 of 402 patients died  or were lost to follow-up , and the median time-to-event among patients who died was approximately 3 months . Using death or loss to follow-up as the outcome, the unadjusted RR for suboptimal early adherence and this outcome of 2.09, and the prevalence of suboptimal early adherence of 0.19, the PAR% for early death or loss to follow-up from suboptimal early adherence was 14.7%. For the composite outcome including OIs and virologic failure, the PAR% was 17.7%.Approximately two-thirds of patients who experienced early outcomes had early adherence ≥95% , and the high levels of adherence, even in those with early outcomes, were reflected in high rates of virologic response. Overall, 355 of 402 (88%) achieved at least one viral load ≤400 copies/mL. Among the 56 patients who had initial adverse clinical outcomes that were not virologic failure, 24 (43%) achieved one or more viral loads ≤400 copies/mL prior to or on the day of their initial adverse outcome, 10 (18%) achieved this degree of virologic response after the initial outcome and 22 (39%) did not have a documented viral load at or below this level. Of these 22, only 1 patient had documented virologic failure, while the remaining 21 did not have follow-up viral load measurements. According to initial event type, 68% (23 of 34) of those whose initial event was an incident OI, 57% (8 of 14) of those whose initial and only recorded event was death, and 61% (34 of 56) of those with any initial non-virological adverse outcome had one or more documented viral loads ≤400 copies/mL. The median time between the closest viral load ≤400 copies/mL and the initial adverse outcome among those who had non-virologic initial adverse outcomes and measured viral loads was 3 days (IQR 68 days before to 39 days after).This study, based on prospectively collected data from routine clinical practice in Botswana, provides evidence that suboptimal early ART adherence as measured by pharmacy refill data and pill counts increases the risk of early adverse outcomes. In the primary analysis, patients who had suboptimal early adherence during approximately the first 21 days of ART had twice the risk of early adverse outcomes as compared to patients whose adherence was ≥95%. However, the proportion of early adverse outcomes theoretically attributable to suboptimal early adherence in this population, estimated as the PAR%, was relatively low (<20%), and most early outcomes observed occurred in patients with high levels of adherence and virologic suppression around the time of their event. These results do not challenge the fact that adherence is critically important in HIV care. However, they do indicate that in many individuals living in similar settings with similarly advanced HIV disease, even high levels of initial ART adherence may not be enough to prevent emergent OIs, AIDS progression, and death. The findings provide further data supporting the revised WHO guidelines stressing the need to start ART at earlier stages of HIV Our finding of increased risk of events in patients with suboptimal adherence are consistent with a similar study from Kenya which found an increased risk of death and loss to follow-up in patients with lower adherence measured at 2 months post-ART initiation We did not prospectively grade drug toxicity, but many ART drugs including zidovudine and nevirapine, which were initiated by most and nearly half of the patients in this study, respectively, have potentially fatal toxicities that could cause early mortality despite and perhaps even due to high levels of adherence Strengths of this study include a novel focus on early adherence data using prospective prescription information, careful ascertainment of data on incident OIs, active patient tracing to determine outcomes, the sub-Saharan African setting and the availability of routinely-collected viral load results, which enhanced our evaluation. Inclusion of patients who initiated but never returned for an ART refill in the primary analysis is another strength of the study. Given that risk of early mortality after ART initiation in resource-limited settings is highest very early after starting ART Our study also has several limitations. For example, the generalizability of our findings of relative risk and the low PAR% could be limited if the patients agreeing to participate in this study were more adherent compared to those being treated in other settings. The overall rate of documented virologic response in the cohort (88%) was slightly higher than pooled estimates from sub-Saharan Africa (76%), suggesting that the study sample demonstrated adherence that was relatively high but certainly not outside of observed ranges In conclusion we found that suboptimal early adherence, while associated with adverse outcomes, is a relatively uncommon finding in patients experiencing early adverse outcomes. Given the high contribution of early outcomes to morbidity and mortality in ART treatment efforts in resource-limited settings, further research to understand, identify, treat and prevent these outcomes is needed.