Little information is available on the efficacy and safety of the dual combination of ripivirine plus dolutegravir. This work aims at beginning to fill this gap.All HIV-1 infected subjects treated with ripivirine plus dolutegravir between October 2014 and September 2015 in eight Italian centres were included in an observational cohort. Data were collected at baseline and at weeks 4, 12, 24 and 48.One hundred and thirty-two subjects were followed for a median of 24 months, mean 33 months. One subject discontinued the study drug at week 24 for headache, one for drug interaction and one died after week 24 of illicit drug abuse. The mean age was 51.8, females 31.7% and non-caucasians 10%. Fifty-seven (43.2%) had at least one failure in their treatment history. Reasons for switching were simplification (53.0%), toxicity (34.8%), drug interactions (n = 7), persistent low-level viremia (n = 4), non-adherence (n = 3) and viral failure (n = 2). Sixty patients (45.5%) had reverse transcriptase (RT) mutations and 69  had protease (PR) mutations. Sixteen had baseline viral replication, 27 had < 50 HIV-1 RNA copies/mL and in 89 (67.4%) no virus was detected . At w4, 114 (86.4%) had NVD, 15 had 1 to 49 HIV-1 RNA copies/mL and 3 had 50 to 57 copies/mL. At week 24 one subject had viral rebound without mutations due to missed drug refill, 19 had 1 to 49 copies/mL, and 112 had NVD. All 132 subjects were tested at weeks 4 and 24. Of the 50 subjects who had a 48-week follow-up, one had a treatment interruption, four had 1 to 49 copies/mL and 45 had NVD. Among the entire population, one subject had low-level, one intermediate and 4 high-level resistance to rilpivirine: none failed by week 48. Mean serum creatinine increased by +0.1 mg/dL. During the follow-up one patient reported headache and insomnia.Ripivirine plus dolutegravir proved safe and effective in this cohort of non-naïve HIV-1 infected subjects. Each study enrolled approximately 500 patients from 13 countries, focusing on women and subjects over 50 years of age. The primary endpoint of such studies is the proportion of patients with plasma HIV-1 RNA <50 copies/mL at week 48. Secondary endpoints include evaluation of the development of viral resistance, measurements of safety and tolerability, and changes in renal, bone and cardiovascular biomarkers. A third trial, named DORISS, by the University of Nantes, was withdrawn prior to enrolment [HIV-1-infected subjects on antiretroviral therapy are now facing the perspective of an improved life expectancy . A partinrolment . Also, anrolment .max in 16 healthy male and female adults [in vitro study showing not only synergy between the two compounds, but also the ability to fully suppress viral replication over 90 days of culture in MT-2 cells at concentrations exceeding the EC50 by four folds and to allow viral replication without selecting resistance at lower concentrations [A phase 1, open-label, crossover study showed a modest increase in DTG and RPV AUC and Ce adults , who rec2. The aim of this study is to provide an initial set of data about the clinical use and safety of this combination in a cohort of unselected patients.Despite this, published data on the clinical use of this combination is limited to the experience in 11 subjects described by Camelia Gubavu et al. within a group of 31 patients on various DTG-based dual regimens . Separatglomerular filtration rate (e-GFR) was estimated at baseline and at follow-up according to the Chronic Kidney Disease–Epidemiology Collaboration (CKD-EPI) equation [All subjects who started DTG plus RPV between October, 1, 2014 and September, 30, 2015 were included in an observational multicenter cohort named TivEdO . After approval by Ethics Committees, no further enrolment was allowed to discourage undue influence on clinical practice . Only clinical events, demographic data, CD4 cell counts, HIV-1 RNA, serum creatinine and urinary proteins were deemed relevant for this study. The equation . For the✓Comitato Etico Interaziendale Milano Area A.✓Comitato Etico delle Aziende Sanitarie dell’Umbria, Perugia.✓Comitato Etico Arnas Garibaldi, Catania.✓Comitato Etico Regionale Regione Liguria.✓Comitato Etico Sperimentazione Clinica Azienda Ospedaliera-Universitaria Careggi, Firenze.✓Comitato Etico dell'Università Cattolica del Sacro Cuore—Policlinico Universitario Agostino Gemelli, Roma✓Comitato Etico IRCCS Policlinico San Matteo, Pavia✓Comitato Etico della Asl to/2 di TorinoThe study has been conducted according to the Good Clinical Practice (GCP) Guidelines.The patients were controlled (visit and blood work) about 4 weeks after simplification to the study regimen, and subsequently at months 3, 6 and 12. For homogeneity no data were collected after week 48. For the toxicity analysis the Common Terminology Criteria for Adverse Events  was considered [The statistical analysis of this study is limited to median values and ranges for the immunologic aspect. No statistical significance was assessed given the non homogeneity of the population.One hundred and thirty-two subjects were enrolled in this cohort and followed for a median of 24 months, mean 33 months. The median age was 51.8 (range 29–77), females were 42 (31.7%), non-caucasians 13 (10%), and risks factors were balanced . Fifty-seven (43.2%) had had at least one failure with a previous antiretroviral regimen. The main reason for the switch was simplification , followed by toxicity , drug-drug interactions with anti-HCV therapy , persistent low-level viremia , non-adherence  and viral failure . The complexity of the former regimen and the frequency of resistance mutations at baseline are reported in One patient discontinued study drug at week 24 for headache, one for drug interaction and one died after week 24 from illicit drug abuse.Sixty patients (45.5%) had reverse transcriptase (RT) mutations–of which 46 to NRTIs alone, one to NNRTIs alone and 13 to both, including six to RPV, 69  had protease (PR) mutations; one had full INSTI resistance but is, nevertheless, taking DTG twice daily, having no other choice due to drug interaction and resistance. Eight subjects (6.1%) never had a genotype for historical reasons.The virologic baseline condition and outcomes are described in The population who had viral load >50 copies/mL narrowed from baseline (n = 16), to week 4 (n = 3). At week 24 only one subject had viral rebound without mutations due to missed drug refill (11030 copies/mL). Of the 50 patients who had a 48-week follow-up, the above mentioned subject had another treatment interruption, with 14770 copies/mL, four had 1–49 copies/mL and 45 had NVD. The patient who had frequently interrupted therapy after baseline accumulated RT mutations 138Q and 181C, while the integrase gene was unaffected.CD4+ T-cells absolute count and proportion increased over time both in the entire cohort and in the week 48 subgroup, as shown in One subject had low-level resistance to rilpivirine, one intermediate and 4 high-level resistance , but none failed, all having a 48-week follow-up.Therefore, in this population no viral failures were observed in the short term, while the proportion of subjects with any detectable viremia decreased by 50%.trough performed in 9 subjects revealed suboptimal concentrations of rilpivirine in 4 subjects and low concentrations in general(<20–38 ng/mL), while dolutegravir median level was 445 ng/mL (range 334–1112).The median variation in serum creatinine was +0.1  and the median eGFR decline was 10.3 ml/min (from 87.4 to 77.1). One subject had mild proteinuria at baseline that resolved spontaneously by week 24. Over the follow-up period, only one patient reported headache and insomnia, which lead to treatment discontinuation. Finally, the pharmacokinetic analysis of both drugs’ CFurthermore, comparing the cost of the former treatment line with the study regimen, there is no additional economic burden, rather the dual therapy saves € 3.90 per day per patient (22.69 vs 26.59 €/day).We describe the experience of several Italian physicians who switched their patients to RPV plus DTG exclusively for clinical reasons.Apart from the perspective of future long-acting parenteral therapies combining INSTIs with RPV , this coThe TivEdO observational study showed that dual regimen therapy with DTG plus RPV was safe and effective, confirming what was described by Gubavu et al  and by SAlso, the particularly small pill size was very appreciated by the patients.The regimen was overall well tolerated and just one subject discontinued it at week 24 for headache. Our experience did not reveal low tolerability of DTG as recently described by a group of Dutch colleagues . Our popThe drug-drug interaction that led to discontinuation was between RPV and proton pump inhibitors, irreplaceable in a subject affected by gastro-esophageal reflux.The switch did not increase the cost of therapy, although this was not a driver towards it.Clearly, this observational study has many limitations: first of all, the only two inclusion criteria were being HIV-1 antibody positive and having started DTG plus RPV; second, the population was rather heterogeneous in . Finally, we only took a small group of parameters of safety into consideration, besides attainment and maintenance of virologic suppression.In this setting no cases of virological failure were observed in patients who adhered to the regimen DTV plus RPV; indeed, the only patient who had virological failure, accumulating also mutations to NNRTIs, was frequently off therapy due to problems with drug refill. The combination was well tolerated, with only one drop-out due to tolerability issues. Randomized clinical trials will make the potential of this attractive regimen more evident.S1 Appendix(PPT)Click here for additional data file.S2 Appendix(PPT)Click here for additional data file.S3 Appendix(XLSX)Click here for additional data file.S4 Appendix(PDF)Click here for additional data file.


Twenty-eight patients were treated for keratoconus. The mean Kmax was 56.18 ± 7.90. The thinnest point, as assessed by optical coherence tomography (OCT), was 443.18 ± 39.75 μm. Accelerated transepithelial CXL was performed, and corrected distance visual acuity (CDVA), corneal topography, and OCT were recorded at 1 week postoperatively as well as at 1, 3, 6, and 12 months. The surgery was uneventful in all eyes. Postoperative epithelial edema was observed and faded in 3 days. The postoperative Kmax was 54.56 ± 8.81, 55.78 ± 8.11, 56.37 ± 8.71, 55.80 ± 7.92, and 55.47 ± 8.24 at 1 week, 1 month, 3 months, 6 months, and 12 months, respectively . The thinnest postoperative corneal point, 439.04 ± 44.99 μm, was observed at 12 months (P = 0.109). The epithelial thickness decreased during the first postoperative week then showed a gradual recovery. Postoperative pachymetry thickness showed no significant changes for up to 12 months. Postoperative epithelial thickness decreased temporarily, then stabilized at month 12. Accelerated transepithelial CXL was shown to be effective and safe for the treatment of keratoconus.The thickness of corneal pachymetry and the epithelium after accelerated (45 mW/cm Keratoconus (KC) is a degenerative, bilateral, asymmetrical, non-inflammatory disease that induces biomechanical corneal weakening due to aberrant changes in organization and the structure of stromal corneal collagen fibers1Corneal collagen cross-linking (CXL) is used to treat keratoconus and keratectasia by strengthening corneal tissue through an interaction using a riboflavin photosensitizer and ultraviolet (UV) light. This treatment is based on an increase in covalent bonds within or between corneal collagen molecules that increases the biomechanical strength of the cornea5491011132) transepithelial CXL on the changes in epithelial and corneal thickness in patients with progressive keratoconus by using spectral-domain anterior segment optical coherence tomography (OCT) to investigate the regeneration progress of the epithelium as well as the impact on different corneal sectors. We also compared the topographic and refractive results for validity and examined the endothelial cell density to evaluate safety.CXL is a surgical treatment that aims to stabilize the keratoconus, and transepithelial CXL offers the prospect of the presence of epithelium in visual rehabilitation. Early studies of this treatment showed that transepithelial CXL has the potential to offer patients both rehabilitation in visual acuity and corneal stabilityPatients diagnosed with progressive keratoconus were enrolled in a prospective case series study approved by the Ethics Committee of the Eye and ENT Hospital of Fudan University. The study adhered to the tenets of the Declaration of Helsinki and included 28 patients (28 eyes) treated for progressive keratoconus since December 2013. The mean age of the enrolled patients, which included 21 males and 7 females, was 23.61 ± 5.05 years ( ± SD) . WrittenThe inclusion criteria included axial corneal topography patterns consistent with keratoconus, elevated posterior surface elevation on topography mapping, an increase in central corneal astigmatism of at least 1.00D, an increase in the maximum cone apex curvature of at least 1.00D, a reduction of at least 10 μm in the thinnest point during the observation period, and biomicroscopic signs . Exclusion criteria included patients with a history of corneal surgery or chemical injury, corneal pachymetry less than 400 mm measured with a Pentacam , delayed epithelial healing, or pregnancy or lactation during the course of the study2 for a surface dose of 7.2 J. The ultraviolet treatment procedure lasted for 5 min and 20 s  containing 0.25% riboflavin-5-phosphate, hydroxypropyl methylcellulose, sodium edetate, trometamol, benzalkonium chloride, and NaCl in the corneal epithelial trephine  was used to completely cover the cornea for a total of 4 min. The cornea was then rinsed completely with VibeX Xtra (Avedro) containing 0.25% riboflavin-5-phosphate and NaCl, and sufficient VibeX Xtra was used in the corneal epithelial trephine for a total of 6 min. After using the epithelial trephine, the cornea was rinsed completely with balanced salt solution (BSS). Ultraviolet treatment was conducted using the KXL System (Avedro). The treatment protocol involved pulsed illumination for 1 s using 45 mW/cmand 20 s . The corIn the preoperative and postoperative examinations, the following parameters were assessed: corrected distance visual acuity (CDVA) (logMAR), intraocular pressure, manifest refraction, slit-lamp examination, corneal topography , endothelial cell density, and spectral-domain OCT . The study participants were followed-up postoperatively at 1 week, and at 1, 3, 6, and 12 months.t test was used to compare the postoperative changes from the preoperative values. Statistical analyses were performed using SPSS software, PASW 18.0 . Statistical significance was defined as a p-value < 0.05.Results from the statistical analyses were expressed as the mean  ±  SD. For the missing data on a particular visit, the last observation carried forward (LOCF) method was used. A student’s All surgical procedures progressed successfully, and no intraoperative or postoperative complications occurred. No patients received additional surgery, such as penetrating keratoplasty (PKP), for any reason, and no haze or infection was observed. Among the 28 patients, nine received accelerated transepithelial CXL in both eyes, five received PKP in fellow eyes, seven lack follow-up data, and the other seven patients received no ophthalmic surgery in the fellow eyes. .The mean maximum apical keratometry value (Kmax) was 56.18 ± 7.90 preoperatively, and 54.56 ± 8.81, 55.78 ± 8.11, 56.37 ± 8.71, 55.80 ± 7.92, and 55.47 ± 8.24 postoperatively at 1 week, and at 1, 3, 6, and 12 months, respectively (P > 0.05). Corneal astigmatism was 2.64 ± 1.90 preoperatively and 2.74 ± 2.02 postoperatively at 12 months (P = 0.829). The CCT showed an increasing trend at postoperative 1 week and then returned to preoperative levels at postoperative 12 months. No significant changes were observed in the corneal posterior surface elevation .The mean epithelial sector thicknesses before and after treatment are listed in The changes in the thickness of each corneal pachymetry sector are listed in At baseline, the uncorrected distance visual acuity (logMAR) was 1.02 ± 0.55, and significantly improved to 0.58 ± 0.34 at postoperative 12 months (P = 0.023). Preoperative CDVA (logMAR) was 0.31 ± 0.35 and postoperative CDVA at 12 months was 0.15 ± 0.19 (P = 0.056) .No statistically significant difference was found in the spherical equivalent (D) using subjective refraction at the postoperative follow-ups compared to preoperative values . The spherical equivalent at baseline was −6.23 ± 3.81 D, and the spherical equivalents at postoperative 1 week, and at 1, 3, 6, and 12 months were −5.33 ± 3.36 D, −4.75 ± 2.60 D, −5.04 ± 2.97 D, −4.83 ± 2.9 D, and −5.35 ± 3.41 D, respectively. IOP was 12.29 ± 3.16 and 10.68 ± 3.72 mm Hg at baseline and postoperative 12 months, respectively, whereas endothelial cell density was 3264.67 ± 382.09 and 3303.92 ± 309.67, respectively, with no significant difference detected .et al.17Treatments for ectatic corneal disorders, such as keratoconus, pellucid marginal degeneration, and iatrogenic corneal ectasia have changed dramatically in the past few decades. Previously, rigid contact lenses were the primary therapy. For eyes with contact lens intolerance, penetrating keratoplasty and implanting intrastromal corneal ring segments might be the next step in the treatment. A new treatment called corneal collagen cross-linking evolved and changed the perspective on corneal ectasia managementPrevious clinical and experimental studies have supported the efficacy and safety of the traditional CXL procedure for treatment of keratoconus910112) transepithelial CXL, which reduced the cross-linking time by increasing the UVA power, preserving the epithelium layer, and requiring significantly less time compared with traditional CXL as well as stabilizing the corneal thickness. This procedure facilitates use of CXL for patients with thin corneas or for less cooperative patients as well as increasing vision during the initial postoperative period and having fewer requirements for a sterile environment. To the best of our knowledge, this is one of the first studies describing the outcomes of accelerated (45 mW/cm2) transepithelial CXL as well as the postoperative corneal and epithelial thickness outcomes measured by OCT after accelerated transepithelial CXL using a pulsed UVA dose of 7.2 J/cm2 (intensity of 45 mW/cm2 lasts for 5 min and 20 s) to treat keratoconus.In our study, patients underwent accelerated , and corneal astigmatism changed from 2.64 ± 1.90D to 2.74 ± 2.02D (P = 0.829). The Pentacam and RTVue anterior segment OCT showed a decrease in the thinnest point of the cornea at the end of the follow-up period of 4.14 μm and 4.68 μm, respectively, which were not statistically significant compared to preoperative levels .et al. included mean values for preoperative and postoperative maximum K values  that showed a significant decrease over time with improved efficiency in treating progressive keratoconus and long-term stabilization of the cornea. Removing the corneal epithelium has been associated with high risks, such as infection2226The traditional CXL procedure is shown to stabilize structurally weak corneas, halt keratoconus progression, and improve the visual acuity of affected patients20Using OCT preoperatively and postoperatively to determine corneal epithelial thickness, we found that due to the riboflavin invasive procedure, corneal epithelial thickness in surgical fields significantly declined at postoperative 1 week. All sectors of the corneal epithelium were restored to preoperative levels at 1 month postoperative, which was consistent with the corneal epithelial regeneration period. Recent studies reported that postoperative corneal thickness initially decreased then returned to baseline values at 3–6 months after the “epithelium-off” accelerated CXL procedure28At postoperative 12 months, all epithelial sector points showed no significant changes compared to the baseline (P > 0.05). Regarding corneal thickness, we found significant decreases at postoperative 1 week in the paracenteral-superior and mid-peripheral-inferior temporal sectors as well as an increase in the paracenteral-inferior sector compared to baseline levels. We also found stable measurement results in all sectors at postoperative 12 months, except for the paracenteral-inferior and mid-peripheral-inferior temporal sectors, which indicates that the corneal epithelium and corneal thickness were stable in patients with progressive keratoconus who underwent accelerated transepithelial cross-linking. This outcome was consistent with the OCT findings and the patients’ descriptions. The mechanisms of corneal regeneration are unknown and should be addressed in future studies.In our study, a corneal epithelial trephine was applied to increase epithelial permeability. Several options have been tried to improve the physicochemical results of CXL. Investigators reported that the significantly weaker biomechanical effect of “epithelium-on” CXL was possibly the result of insufficient and non-homogeneous transepithelial riboflavin diffusion into the corneal stroma303113et al. found a reduction in Kmax to only 1.4D compared with 1.78D at 1 year, and 2.2D at 2 years36Keratoconus progression, as well as stability, generally does not follow a linear trend over time. Various studies have reported continuous flattening of the corneal curvature ranging from 0.72 to 2.2D for the first yearA limitation of our study involves the relatively low number of patients and lack of a control group undergoing standard CXL, which may increase the risk of bias. Additional trials  are needed to better assess the impact of our procedure on keratoconus stabilization, especially for younger patients.2) transepithelial CXL support is a safe and effective treatment of progressive keratoconus. After this treatment, postoperative epithelial thickness and pachymetry thickness initially decreased then returned to baseline levels at postoperative 3 months and achieved stabilization at postoperative 12 months. The stabilities of the corneal pachymetry and epithelial thickness can therefore be regarded as a parameter of clinical effectiveness. However, further clinical studies with longer follow-ups are necessary to fully assess the long-term efficacy of accelerated transepithelial CXL.In conclusion, our results indicate accelerated  Transepithelial Corneal Collagen Cross-linking for Keratoconus Patients. Sci. Rep.6, 32692; doi: 10.1038/srep32692 (2016).


Viral load (VL) assessment is the preferred method for diagnosing and confirming virologic failure for patients on antiretroviral therapy (ART). We conducted a retrospective cross-sectional study to evaluate the virologic suppression rate among patients on ART for ≥6 months in five hospitals around Port-au-Prince, Haiti.Plasma VL was measured and patients with VL <1,000 copies/mL were defined as virologically suppressed. A second VL test was performed within at least six months of the first test. Factors associated with virologic suppression were analyzed using logistic regression models accounting for site-level clustering using complex survey procedures.3 and 200 cells/mm3 or lower , poor adherence (aOR: 0.69 [0.59–0.81]), and TB co-infection (aOR: 0.73 [0.55–0.97]).Data were analyzed for 2,313 patients on ART for six months or longer between July 2013 and February 2015. Among them, 1,563 (67.6%) achieved virologic suppression at the first VL test. A second VL test was performed within at least six months for 718 (31.0%) of the patients. Of the 459 patients with an initial HIV-1 RNA <1,000 copies/mL who had a second VL performed, 394 (85.8%) maintained virologic suppression. Virologic suppression was negatively associated with male gender , 23 to 35 months on ART (aOR:0.72[0.54–0.96]), baseline CD4 counts of 201–500 cells/mmThis study showed that over two-thirds of the patients in this evaluation achieved virologic suppression after ≥ six months on ART and the majority of them remained suppressed. These results reinforce the importance of expanding access to HIV-1 viral load testing in Haiti for monitoring ART outcomes. Routine HIV-1 viral load monitoring is essential for ensuring optimal treatment outcomes of patients on antiretroviral therapy (ART) and preventing the emergence and transmission of HIV drug resistance (HIVDR). While there has been a major expansion of ART in most resource-limited settings, access to routine virologic monitoring remains limited . DespiteRoutine VL monitoring for HIV patients on ART is a standard practice in resource-rich countries –13. ManyThis is a retrospective cross-sectional study design. The facilities included in this evaluation were: Hôpital de l’Université d’État d’Haïti, Hôpital Isaïe Jeanty-Léon Audain, Hôpital Universitaire La Paix, Grace Children’s Hospital, and Hôpital Saint Damien-Nos Petits Frères et Soeurs. These are five major hospitals in the Port-au-Prince metropolitan area that provide care to approximately 10% of all active patients on ART in the country.HIV-positive patients received care according to the Haiti national HIV care and treatment guidelines . The fir7 copies/mL when 0.2 mL plasma volumes are used for testing ). Finally, WHO stage II presentation was associated with 1.47 times the odds of virologic suppression when compared to those presenting with WHO Stage I (95% CI: 1.03–2.10); there was no significant difference in odds of virologic suppression for those patients with WHO stages III or IV when compared to stage I  and 2.07 times (95% CI: 1.70–2.51) the odds of virologic suppression when compared to those aged 22–40 years. Male gender was associated with a 20% decrease in odds of virologic suppression compared to females . Those with TB co-infection had 27% decreased odds of virologic suppression (aOR: 0.73 [0.55–0.97]) and those with poor adherence had 31% decreased odds of virologic suppression (aOR: 0.69 [0.59–0.81]). Those with decreased CD4 counts had lower odds of virologic suppression when compared to those with CD4 counts of 500 cells/mm stage I .Implementation of routine VL monitoring for patients on ART has been the main focus in most resource-limited countries since the publication of the WHO 2013 consolidated ARV guidelines [In the current evaluation, we found that about 68% of the participants on ART for ≥6 months achieved virologic suppression. These results are similar to those reported in other resource-limited countries –28. A prStudies have indicated that many demographic and clinical parameters may impact treatment outcomes for ART patients , 29–32. WHO now recommends treating all PLHIV regardless of CD4 T cell count and the Ministry of Health of Haiti has recently adopted the ‘test and start’ strategy . In lighThe findings of this evaluation should be interpreted with caution in light of the limitations. First, the cross-sectional design and the lack of geographic representativeness of the study warrant caution in the interpretation and generalization of the findings. Second, healthcare providers might have prioritized patients with suspected treatment failure since this was the first time that VL testing was offered to patients at these health facilities, which may have led to a selection bias towards a higher rate of virologic failure. Third, while missing at random was assumed, these data may be missing in a pattern correlated to virologic suppression and may have introduced bias into the study. Finally, the WHO guidelines recommend a second VL test be performed after 3 months of intensive adherence counseling, in this study however, the second VL test was performed within at least six months after the initial VL test, which makes it difficult to accurately evaluate the impact of adherence on virologic suppression.This is the first multicenter evaluation on virologic outcome of patients receiving ART in Haiti. The results provide important information about the rate of virologic suppression, showing that a high proportion of patients maintain virologic suppression and underscoring the importance of intensive adherence counseling. Our findings will be important to inform the current scaling up of routine viral load monitoring in Haiti and the revision of the National HIV treatment guidelines.


Interindividual heterogeneity in the disease progression of HIV-1-infected patients receiving long-term antiretroviral therapy suggests that some host-related factors may have limited treatment efficacy. To understand the nature of factors contributing to treatment failure, we performed a retrospective cohort study of 45 chronically HIV-1-infected individuals sharing a similar demographics and route of infection, compared the differences between virologically suppressed (VS) and treatment failure (TF) patients with respect to clinical, immunological and virological characteristics. We found that the baseline diversity of HIV-1 env quasispecies was the major difference between VS and TF group, and higher baseline diversity in TF patients. We further predicted TF-related env mutations using a selection pressure-based approach, followed by an analysis of these mutations based on the available three-dimensional structures of gp120/gp41 or their complexes with neutralizing antibodies. Notably, almost all of the identified residues could be mapped to the epitopes of known HIV-1 neutralizing antibodies, especially the epitopes of broadly neutralizing antibodies, and these mutations tended to compromise antibody-antigen interactions. These results indicate that the escape of HIV-1 from host humoral immunity may play a direct role in TF in long-term antiretroviral-experienced patients and that based on env gene sequence of the viruses in the patients. With the advent of highly active antiretroviral therapy (ART), a combination of three or more potent antiretroviral drugs, profound suppression of viral replication has been achieved, and HIV-1-associated mortality has been dramatically reduced3. Nonetheless, considerable variation of the virus is observed among patients in response to treatment, with a substantial proportion of individuals experiencing treatment failure, including virologic failure, i.e., inability to achieve or maintain suppression of viral replication; immunologic failure, i.e., failure of CD4 count to increase; and subsequent clinical failure5. This interindividual heterogeneity in disease progression suggests that some host-related factors may have affected the effectiveness of ART. An understanding of such contributing factors associated with treatment failure is critical to developing an effective long-term HIV treatment strategy.Rapid replication dynamics and high mutation rate of human immunodeficiency virus type 1 (HIV-1) allows the virus to evolve continuously and quickly during the course of infection6. Some HIV-1-infected individuals are able to develop heavily mutated, broadly neutralizing antibodies (bnAbs) capable of neutralizing a broad spectrum of HIV-1 isolates10. These bnAbs only appear after several years of HIV-1 infection, suggesting the continuous viral escape and selection by autologous neutralizing antibodies12. It is also intriguing to observe that a small group of HIV-1-infected individuals (<1%), termed elite controllers, spontaneously maintain undetectable levels of viral replication in the absence of antiretroviral therapy by mounting robust immune responses directed at HIV-114. Moreover, the escape mutants in the envelope glycoprotein (Env) during early HIV-1 infection primarily involved changes in N-linked glycosylation that could sterically inhibit the accessibility of neutralizing epitopes15. All these findings suggest a critical role of selective pressure exerted by host humoral immune response in driving HIV-1 evolution. However, in ART-treated patients, the selective pressure is predominantly governed by antiretroviral drugs, and the effects of HIV-1 evolution and escape from host immune selective pressure on disease progression under long-term ART are largely unknown.Host immune response elicited by HIV-1 contributes to the repression of viral replication, but it varies greatly in different individualsenv quasispecies was found to be the major difference between the two groups. More specifically, compared to those in individuals in the VS group, both gp120 and gp41 gene quasispecies of HIV-1 in the TF patients showed higher baseline diversity. Treatment failure-related adaptive mutations were further predicted by using a selection pressure-based analysis of single-genome amplification (SGA)-derived full-length HIV-1 env. Notably, most of the identified mutations could be mapped to epitopes of known HIV-1 neutralizing antibodies, especially epitopes of bnAbs. These results demonstrate that the escape of HIV-1 from host humoral immunity contributes to disease progression in patients on long-term ART.Therefore, to identify host and viral factors associated with differing clinical outcomes in HIV-1-infected patients receiving long-term antiretroviral treatment, we performed a retrospective cohort study of 45 chronically HIV-1-infected individuals sharing a similar demographic and ethnic background. All these patients were infected with HIV-1 subtype B’ through a similar route of infection, and they were enrolled in the National Free Antiretroviral Treatment Program in Anhui and Henan provinces, China. These patients were categorized into two groups: virologically suppressed  and treatment failure , according to disease outcome. The differences between the two groups with respect to clinical, immunological and virological characteristics were then compared. Interestingly, diversity of HIV-1 All 45 enrolled patients, who participated in a multicenter AIDS Cohort Study in Anhui and Henan provinces in China from 2004 to 2011, shared a common ethnic background and a similar route of infection, namely plasma donation. Similarity of immunological and viral genetic backgrounds provided a unique opportunity to explore the relationship between viral evolution and disease progression in different individuals.+ cell count differed between the two groups before treatment. Similar to the TF group, drug-resistant mutations in the pol region of the VS group were rarely found . Although there is a significant difference in switching regimens among the treatment failure cases, it occurred after the “treatment failure”.Patients were divided into two groups according to disease outcome. The virologic suppression (VS) group was defined as viral load persistently <400 copies/ml after ART for 6 months. The treatment failure (TF) group was defined as repeated viral load >400 copies/ml after 6 months. By the close of the study period, 20 patients were classified as TF, and 25 patients were classified as VS. Baseline demographic and clinical features of all patients are shown in Table + cells after 6 months of ART  to amplify the full-length env genes as previously reported16, whereby PCR products were derived from a single template molecule. Plasma collected at baseline and during ART was used to evaluate env clonal genotypes. A total of 1,021 single-genome full-length gp160 amplicons were obtained for cross-sectional and longitudinal analysis by SGA. Among these, 638 sequences derived from plasma of VS (n = 352) and TF (n = 286) at baseline were used for cross-sectional analysis. Analysis of gp160 nucleotide sequences at baseline showed that all sequences clustered phylogenetically with subtype B’ reference sequences  and during ART. Sequence diversity was calculated using the Kimura 2-parameter model option in MEGA 5. The number of sequences of 12 patients included in the analysis was shown in Table A total of 552 single-genome full-length gp160 amplicons, including 169 sequences from baseline, derived from plasma of 12 TF patients, who had never switched regimens and had good adherence until the last follow-up point, were used for longitudinal analysis Fig. . TF patienv quasispecies. Quasispecies heterogeneity was quantitated by the mean genetic distance (d) of the sequences in each group. As shown in Fig. Demographic characteristics and baseline drug-resistant mutations were the same between the VS and TF groups; therefore, we sought to investigate the difference between the two groups based on the diversity of HIV-1 env diversity between baseline (T0) and during ART. Following baseline, two time points were selected based on viral load level: 1) when viral load reached a level >400 copies/ml (T1) and 2) maximum value of viral load (T2). A total of 536 gp160 sequences derived from 12 TF patients were analyzed and displayed no significant difference between baseline, T1 and T2 in gp160, or its subregion diversity  of HIV-1 ps Table . Althoug17. Thus, we also compared the V3 loops of the VS and TF groups. As shown in Fig. The gp120 V3 loop has been suggested as a major viral determinant for co-receptor preference+ T cell count, viral load, gp160 diversity, drug-resistant mutations and co-receptor usage, were all pooled for analysis. Interestingly, gp160 diversity was the only variable that remained significant in the final model, and it was the best single variable for predicting TF for 75.6% individuals in this cohort  and synonymous (Ks) nucleotide substitutions were calculated, as described in the Methods section, and used as an indicator of selective pressure acting on Env-coding genes. Treatment failure-related adaptive mutations were screened by the Ka/Ks ratio of individual residues as follows: (a) Ka/Ks > 1 and sequence frequency > 0.01 in the TF group, while Ka/Ks < 1, or Ka/Ks > 1, but LOD < 2, in the VS group; (b) sequence frequency of TF group higher than that of VS group (p < 0.05), while the corresponding population frequency of the TF group was over 0.15.To gain more insight into the difference in 18.In total, 36 and 10 putative adaptive mutations related to treatment failure from gp120 and gp41 regions were obtained, respectively Table  and 5 cr19, we also measured the relative replication fitness of several treatment failure-related Env adaptive mutations, including G145N, I371V, A607N, E662K and N677K mutant viruses. Although the 1 + s fitness values of A607N and N677K increased slightly, the 1 + s fitness values of G145N, I371V and E662K viruses were not significantly different from those of the wild-type, suggesting that the change in viral fitness of these variants may not be a major determinant of treatment outcome 31, CH10332, b12 and F10533, NIH45-4634, 12a2135, and 3bnc11736. The surface area where residues 392, 396, 397, 402, 405 and 407 are located can be accessed by some glycan-dependent bnAbs. For example, bnAb PGT135 recognizes the glycosylation site Asn39237. Residue 419 also interacts with some neutralizing antibodies, including b12, 17b37 and X538.To better understand the mutations identified by bioinformatic prediction, we mapped these residues on the high-resolution structures of HIV-1 gp120 (PDB ID 4TVP) and gp41 (PDB ID 2PV6). To our surprise, almost all of these residues (28 of 31 in gp120 exterior Env and 2 of 3 in the outer membrane part of gp41) appear to be involved with possible epitopes of previously reported neutralizing antibodies  region in the outer membrane part of gp41. Residue 662 can directly interact with bnAbs 2F5 and m6643, three relatively high-frequency mutations, including I371V in gp120 CD4-binding loop within the epitope of VRC01; Q170K in gp120 V2 loop within the epitope of CH59; and T240K in gp120 seven-stranded sheets within the epitope of 35O22, were evaluated to determine how extensively these mutations could affect antibody-gp120 binding. For the docked VRC01/gp120 binding36, a Z-rank was obtained with a top pose score of −120.767 for VRC01-binding to wild-type gp120, in contrast to the score of −112.569 for binding to mutant gp120 I371V, indicating that the binding of VRC01/gp120 encounters a more energetically favorable docking compared to the binding of VRC01/gp120-I371V. In detail, VRC01 VH moved closer to the gp120 CD4-binding loop by ~1 Å shift in response to the I371 to V371 mutation . Notably, the strong H-bond of Q170gp120 NE2-N31CH59 OD1, which exists at the CH59/gp120 interface with a distance of 2.1 Å and is the major non-bonding interaction for associating CH59 and gp120 V2 peptide, was found to be broken in the CH59/gp120-Q170K complex . Based on the docked structural analysis of these three treatment failure-related mutations in Env proteins, antibody binding ability was compromised, irrespective of epitope location.We next employed molecular docking to investigate if the treatment failure-related adaptive mutations of HIV-1 Env would compromise the binding capability of bnAbs. By using the Z-DOCK programion Fig. , resultilex Fig. . For thelix Fig. . Such ch50 of the bnAb VRC01 against the mutant viruses (I371V) was assessed and compared with that against the wide-type viruses (AT1). Indeed, we found that the I371V mutant virus gained 4.9 times enhancement of resistance to VRC01 . This result suggests that some mutant viruses in the treatment-failure patients may have acquired resistance to some bnAbs.The neutralization assay was performed to determine whether the adaptive mutation would affect the sensitivity of mutant-viruses to the bnAbs. The IC45. HIV-1 has been reported to escape neutralizing antibodies during early infection via a “glycan shield” mechanism whereby escape mutations in the Env become involved in N-linked glycosylation; such mutations were very sparse and, generally, did not map to known neutralization epitopes11. Humoral responses also evolve in response to these Env escape mutations, but the kinetics of evolution does not correlate with the rate of disease progression6. Recently identified broadly neutralizing antibodies (bnAbs) against some conserved epitopes have rekindled interest in exploring antibody-virus co-evolution pathways in vivo, but these antibodies only naturally arise in a fraction of individuals after years of HIV-1 infection. Thus, despite intensive research, important gaps remain in our understanding of humoral immune responses relative to HIV-1 disease progression. In particular, considering that selection pressure exerted on viruses has been largely replaced by antiretroviral drugs in ART-treated patients, it is important to ascertain whether and how humoral immune responses affect disease progression under this circumstance.A thorough understanding of humoral immune responses to HIV-1 has been a major research focus in recent yearsenv gene. A study population was very carefully selected for homogeneity in terms of demographics, ethnic makeup, treatment modality and, importantly, route of infection (infected with the same HIV-1 subtype B’ via former plasma donation). This unique feature enabled a comparative study across subpopulations that exhibited different treatment outcomes. Interestingly, although different baseline variables of the TF and VS groups were compared, including, for example, CD4+ T cell count, viral load, drug-resistant mutations, and co-receptor usage, the only variable that showed a significant difference between the two groups was gp160 diversity. The gp120/gp41 diversity did not increase or decrease in these TF patients during long-term ART, suggesting that the viruses may have evolved to escape host immune responses before the initiation of ART via quasispecies diversification. This also suggests that the level of gp160 diversity may be used as an indicator to predict disease prognosis under certain circumstances.In the present study, gene sequencing and selection pressure-based analysis were employed to uncover the underlying relationships between treatment failure and putative adaptive mutations occurring in the HIV-1 The residues that underwent positive selection pressures were determined by calculation of Ka/Ks ratio for individual amino acids in gp120 or gp41. Based on the crystal structures of gp120 and gp41 proteins, we mapped these residues onto the structures of Env. In contrast to the untreated patients in which Env escape mutations were sparse and could not be mapped to known neutralization epitopes, we found that most of these mutation sites overlapped with the neutralization epitopes of different kinds of bnAbs: R419K and I371V locating in the epitope of CD4bs antibody b12 and VRC01; R166Q and Q170K in the epitope of V1/V2 targeting antibodies PG9, PG16, and CH59; T232R, T240K, V242I, E267K, E269G in the epitope of gp120/gp41 interface antibody 35O22; E662K and N677K in the epitope of MPER antibody 2F5 and 4E10  are just located on the Env surfaces and could be a dominant epitope by a number of Abs, but we only found one bnAb, PGT122, that mostly recognizes V3 but also has some interactions with the 134–138 loop. We believe that further studies, e.g., by using B cells from the patients described in this study, could lead to the isolation of Abs targeting this loop.To elucidate the mechanism that governs the development of these treatment failure-related adaptive mutations, we selected three bnAbs  that have available crystal structures in complex with gp120/gp160 for computational modeling analysis to evaluate whether Env adaptive mutations have an impact on antibody binding. The docking results suggest that these mutations tend to compromise antibody-antigen interactions. While the accumulation of HIV-1 escape mutations is a very complex process, this finding suggests that escape of antibody binding could be one of the routes via which the viruses escape from host humoral immunity in long-term antiretroviral-experienced patients. In a proof-of-concept study, we generated a mutant HIV-1 virus with a single I371V mutation, and compared side-by-side the neutralization activity of VRC01, the most advanced clinically developed HIV-1 bnAbs, against the wild-type and the mutant virus. The HIV-1 I371V mutant gained 4.9 times enhancement of resistance to VRC01, suggesting that some viruses from TF patients may have acquired resistance to some bnAbs. Nevertheless, further study is warranted to investigate how the emergences of these HIV-1 mutants cause the ART failure. For instance, we will isolate these viral mutants and test their sensitivity to the antiretroviral drugs used by the TF patients, even though these drugs are not expected to target the HIV-1 Env, because we cannot exclude the possibility that the mutations of viral Env may cause the change of viral replication kinetics and viral sensitivity to some of the antiretroviral drugs.5. Of note, advances in antibody-based therapeutics are coming at an ever-increasing pace, and, as a result HIV-1 bnAbs, hold promise in the ongoing effort to eradicate HIV49. In the present study, it was shown that host humoral immunity may play a role in treatment failure in long-term ART-treated patients. Some mutations in HIV-1 gp120/41 may have resulted in escape from some neutralizing antibodies and thus contributed to disease progression. This implies that a combination of conventional antiretroviral drugs with potent bnAbs, especially a cocktail of bnAbs targeting different epitopes, could be beneficial in patients who have shown poor response to ART. Moreover, given that there is no mutation in the HIV-1 gp41 NHR region, the target of HIV-1 fusion inhibitors, the combination of T20 with antiretroviral drugs may be provided to the patients immediately after their viruses are identified to carry the mutations in the sites overlapped with the neutralization epitopes of bnAbs, to avoid the treatment failure.These findings have considerable importance for developing an effective long-term antiviral strategy against HIV-1. Although highly-active ART (HAART) is very effective in suppressing viral replication, it can result in toxicity with unpredictable effects and resistance to therapy, especially with long-term use, resulting in treatment failure in a substantial proportion of individualsenv mutations identified by SGA sequencing and selection pressure-based analysis may provide an immunological basis for understanding the co-evolution of viruses and bnAbs in a particular patient. Based on env gene information of the viruses in the patients, we may be able to predict the treatment outcome, based on which individualized therapeutic regimen, such as the combinations of antiretroviral drugs with HIV-1 entry inhibitors targeting the coreceptor  or gp41 , rather than gp120 where the mutations are located, may be designed in advance for the patients with TF potential.In conclusion, our study provides evidence that escape from host humoral immunity may play a role in treatment failure in long-term antiretroviral-experienced patients. Treatment failure-related This study was approved by the Institutional Research Ethics Community of the Chinese Center for Disease Control and Prevention, and all subjects signed informed consent to participate in the research study prior to blood and data collection. All experiments were performed in accordance with relevant guidelines and regulations.+ T cell count and drug-resistance mutations. Plasma viral loads were determined with real-time Nucleic Acid Sequence Based Amplification (NASBA)  according to the manufacturer’s instructions. CD4+ T cells in whole blood were quantitated by flow cytometry using Tritest CD3/CD4/CD45 TruCount Tubes . For detection of drug-resistance mutations, viral RNA was first extracted from plasma using the QIAamp® Viral RNA Mini Kit  according to the manufacturer’s protocol and then used to synthesize first-strand cDNA using the SuperScript™ III First-Strand Synthesis System (Invitrogen). The HIV-1 pol gene was amplified with specific primers that annealed to conserved regions of the pol region, and sequences of the pol gene were compared to the consensus B reference sequence using HIVdb software  to detect the drug-resistance mutations.The study population consisted of 45 chronically HIV-infected patients on a stable ART regimen who participated in a multicenter AIDS Cohort Study in Anhui and Henan provinces in China from 2004 to 2011. Patients who initially received therapy with a first-line regimen of lamivudine (3TC), stavudine (d4T), or zidovudine (AZT) and nevirapine (NVP) or efavirenz (EFV) were selected. Patients in this study met the following inclusion criteria: be naïve-ART before enrollment and be 18–65 years old with uninterrupted HAART for more than 12 months. 3 patients in TF group and 2 patients in VS group who were lost to follow-up at the last sampling point were excluded. Blood samples collected at each follow-up point were analyzed for viral load, CD450. For SGA, according to a Poisson distribution, a positive reaction rate of 30% or lower, or cDNA diluted to ensure fewer than 29 PCRs yielded from a total of 96 independent PCRs thus ensuring that amplicons were derived from a single template. Sequences of the env region were amplified by a nested polymerase chain reaction using Premix Ex Taq version 2.0 . PCR products derived from cDNA dilutions yielding less than 30% PCR positivity were sequenced by an ABI 3730XL Sequencer using BigDye terminators . The chromatogram data were cleaned and assembled using Sequencher v4.9 .HIV-1 RNA extraction, cDNA synthesis, and SGA were performed as previously reportedhttp://www.hiv.lanl.gov/content/sequence/GENE_CUTTER/cutter.html) and then adjusted manually with BioEdit software (version 7.1.3). Phylogenetic analysis was performed using the Kimura-2 model of substitution within neighbor-joining method in MEGA 5 at the nucleotide level, and the reliability of the branching orders was tested by bootstrap analysis of 1,000 replicates51. HIV-1 co-receptor usage (CCR5 and CXCR4) was predicted using WEBPSSM (http://indra.mullins.microbiol.washington.edu/webpssm/). Sequence diversity was calculated using the Kimura 2-parameter model option in MEGA 5. The number and location of potential N-linked glycosylation sites (PNGSs) for each sequence were estimated using the N-GLYCOSITE web tool from the Los Alamos HIV database (http://www.hiv.lanl.gov/content/sequence/GLYCOSITE/glycosite.html).Multiple nucleotide sequence alignments of gene sequences encoding for the Env CDS, V1V2, V3, V4 and V5 of HIV-1 from each subject were conducted using Clustal W, input in Gene Cutter tool from the Los Alamos HIV sequence database  were analyzed to screen treatment failure in relation to adaptive mutation by a selection pressure-based analysis. The Ka/Ks ratio could be used as an indicator of selective pressure acting on a protein-coding gene. The computation of Ka/Ks for an individual site or specific amino acid was based on the model of Chen et al.52. A Ka/Ks value of 1, >1 or <1 indicated a neutral selection, a positive selection or a negative selection, respectively. Log odds (LOD) confidence score was used to measure the significance of selection pressure, and LOD > 2 indicated a significance of the positive selection. Ka/Ks and LOD were calculated by the CorMut R package53. When performing the computation, HXB2 served as a reference.A total of 638 54. The Bayesian network was constructed by the bnlearn R package, and the results were revised by the nonparametric bootstrap method. More than 65% of bootstrap support was considered robust, while 35–65% was considered thin55. The mutations having direct connection with treatment failure with bootstrap value over 65% were identified.Bayesian network was applied to further analyze the correlation between predicted mutations and treatment outcome. Generally, the Bayesian network is a graphical model that encodes a joint probability distribution of a set of random variables, where nodes represent random variables, and arrows represent probabilistic dependencies between them50 of viruses with adaptive mutations was quantitated to detect viral infection ability. Mutant virus and wild-type virus AT2 co-infected PM1 cells with equal P24 antigen levels. Cells were collected from 3 to 6 days post-infection. Cells were stained by anti-Thy1.1 antibody and anti-Thy1.2 antibody, respectively, and subsequently both antibodies. The ratio of the two viruses was detected by FACS. Relative fitness was calculated using the online tool VFitness (http://bis.urmc.rochester.edu/VFitness/FitnessTwo.aspx).A multiple-cycle recombinant virus growth competition assay was applied to determine the impact of quasispecies variation on viral fitness. Mutations were introduced to the wild-type plasmid pAT1 by PCR to construct the mutant plasmids which contained the critical adaptive mutation sites. Then HEK-293T cells were transfected with mutant plasmids to rescue the viruses with adaptive mutations. TCID43 implanted in the Accelrys Discovery Studio (http://accelrys.com) was used to fit bnAbs VRC01, CH59 and 35O22 onto gp120. The output Z-scores for the top poses was used to determine the effects of treatment failure-related residues of Env proteins on antibody binding. The three-dimensional structures for these Fab and HIV Env were extracted from the resolved crystal structure of VRC01/gp120 (PDB ID 4LST)36, CH59/gp120 (PDB ID 4HPY)44, and 35O22/gp160 complexes (PDB ID 4TVP)27. For calculation convenience, the constant regions of Fab were removed with only consideration of the V regions (VH-VL). Env mutants, including I371V for VRC01, Q170K for CH59, T240K for 35O22, were modeled by the PyMOL molecular graphics system  without atomic clashes.The Z-DOCK program56 with a cutoff of 0.9; 3) loop regions were rebuilt according to SEQRES57 data; and 4) cysteine bridges in these proteins were defined as blocked regions. Then Z-DOCK performed a systematic search of a uniform sample of docked protein poses and used an internal scoring algorithm to predict optimal interactions. A total of 54000 docked poses were initially produced, which were further filtered and re-ranked to obtain the top 200 poses based on Z-Rank score using electrostatic and desolvation energy and non-deterministic FFT optimization. These 200 poses were then visually scrutinized and judged by Z-Score. The most reasonable poses were chosen as the models for the VH-VL-Env complexes by combined consideration of general features of antibody-antigen interaction, such as hydrogen bonds, salt bridges, hydrophobic packing and other interactions at the interface, without any highly unusual features and steric clashes. The Z-scores for VH-VL docking into wild-type and mutant Envs were evaluated and compared.Before docking, the structures of bnAbs and Env were processed as follows. 1) water molecules were deleted and hydrogen atoms were added at pH7.4 and an ionic strength of 0.145 and in a dielectric environment of 10; 2) energy was minimized based on CHARMM58. Briefly, the bnAb was at serial dilution was incubated with the mutant virus (200 TCID50) for 1 h at 37 °C. The virus with wild Env sequence (AT1) was included as control. TZM-bl cells (1 × 104) with DEAE-dextran (15 μg/ml) were added to each well. After 48 h incubation, The RLUs were determined using the luciferase reporter gene assay system  and the luminometer (PerkinElmer Life Sciences), as described previously58. Mock infected cells were used to determine background luminescence. IC50 (the concentration of an inhibitor causing 50% inhibition of infection) value was then calculated59.A sensitive HIV-1 neutralization assay was performed to test the neutralizing activities of the bnAb VRC01 against HIV-1 carrying Env with I371V mutation as previously described+ T cell count, viral load, gp160 diversity, drug-resistant mutations and co-receptor usage, were included for logistic analysis. The statistical analyses were performed using the SPSS software package (version 17.0).Comparisons of differences between VS and TF groups were calculated using Mann-Whitney, Chi-Square or Fisher’s exact test. The relative fitness comparison between mutant viruses and wild-type viruses was done using the Wilcoxon rank sum test. Statistical significance was set at P value < 0.05 and for two-sided tests. Logistic regression and receiver operating characteristic (ROC) analysis were performed to develop a predictive model. Covariates, including CD4Supplementary Tables


HIV‐infected patients in non‐clinical trial settings in Asian countries.Although substitutions of antiretroviral regimen are generally safe, most data on substitutions are based on results from clinical trials. The objective of this study was to evaluate the treatment outcomes of substituting antiretroviral regimen in virologically suppressed HIV‐infected patients enrolled in the TREAT Asia HIV Observational Database (TAHOD). Individuals were included in this analysis if they started combination antiretroviral treatment (cART) after 2002, were being treated at a centre that documented a median rate of viral load monitoring ≥0.8 tests/patient/year among TAHOD enrolees, and experienced a minor or major treatment substitution while on virally suppressive cART. The primary endpoint to evaluate outcomes was clinical or virological failure (VF), followed by an ART class change. Clinical failure was defined as death or an AIDS diagnosis. VF was defined as confirmed viral load measurements ≥400 copies/mL followed by an ART class change within six months. Minor regimen substitutions were defined as within‐class changes and major regimen substitutions were defined as changes to a drug class. The patterns of substitutions and rate of clinical or VF after substitutions were analyzed.The study population consisted of ART after 2002, 3119 (78.1%) had at least one period of virological suppression. Among these, 1170 (37.5%) underwent a minor regimen substitution, and 296 (9.5%) underwent a major regimen substitution during suppression. The rates of clinical or VF were 1.48/100 person years (95% CI 1.14 to 1.91) in the minor substitution group, 2.85/100 person years (95% CI 1.88 to 4.33) in the major substitution group and 2.53/100 person years (95% CI 2.20 to 2.92) among patients that did not undergo a treatment substitution.Of 3994 adults who started The rate of clinical or VF was low in both major and minor substitution groups, showing that regimen substitution is generally effective in non‐clinical trial settings in Asian countries. Therefore, the objective of this study was to evaluate the treatment outcomes of substituting antiretroviral regimen in virologically suppressed HIV‐infected patients in non‐clinical trial settings in Asian countries.22.1The study population consisted of HIV‐infected patients enrolled in the TAHOD before March 30, 2016. This cohort contributes to the International Epidemiology Databases to Evaluate AIDS (IeDEA) global consortium and has been described previously 2.2Two analyses were conducted to evaluate minor and major treatment substitutions separately. Viral suppression was defined as having had two viral load measurements <400 copies/mL between 90 to 390 days apart. Periods of viral suppression were considered to begin from the date of the second viral load <400 copies/mL. Minor regimen substitutions were defined as within‐class changes  and major regimen substitutions were defined as changes to a drug class . Baseline time in both analyses (minor switches and major switches) was defined as the date of first ART substitution after achieving viral suppression. Patients who had never received mono/dual therapy prior to baseline were excluded. For an approximate reference point, we also evaluated rates of VF among patients who never underwent an ART switch. The baseline date used to calculate follow‐up time for the non‐switch group was the date of viral suppression. The primary endpoint to evaluate outcomes was clinical or virological failure (VF), followed by an ART class change. Clinical failure was defined as death or an AIDS diagnosis. VF was defined as confirmed viral load measurements ≥400 copies/mL followed by an ART class change within six months The reason for treatment substitution was categorized as adverse event (AE)‐associated when a patient had any documentation of an adverse event‐associated treatment substitution (as determined by the treating physician) between the date of viral suppression and baseline. Patients were considered hepatitis B (HBV) co‐infected if they had any record of a positive HBV surface antigen test, and hepatitis C (HCV) co‐infected if they had any record of a positive HCV antibody test. The window period for baseline CD4 cell count testing was between three months before baseline to three months after baseline. Where multiple test results were available within this period, the measurement closest to the time of treatment substitution was used. Nadir CD4 cell count was defined as the lowest documented CD4 cell count prior to baseline. Peak HIV‐1 RNA level  was defined as the highest documented VL prior to baseline. Country income status was defined according to World Bank categorizations 2.3The rates of virological failure after treatment substitutions were calculated. Competing risk regression was used to determine factors associated with VF after treatment substitution. Loss to follow up and major treatment substitution after baseline were considered competing risks. Type of treatment substitution, reason for treatment substitution (adverse event or other), baseline age, sex, HIV exposure category, HBV surface antigen/HCV antibody positivity, AIDS diagnosis prior to baseline, nadir CD4 count, peak viral load, period of treatment substitution and country income status were evaluated as fixed covariates. Co‐trimoxazole use, CD4 cell count and ART adherence were evaluated as time‐updated covariates. The final models included type of ART substitution, baseline age, sex, CD4 cell count, ART adherence, period of treatment substitution and country income status. Any other variables found to be significant after adjusting for these core variables were also included. Patients with missing data were included in all analyses but hazard ratios for missing categories are not reported. Stata  version 14.1 was used for all statistical analysis.3Of the 3994 adults who started ART after 2002, 3119 (78.1%) had at least one period of virological suppression. Among these, 296 (9.5%) underwent a major regimen substitution during suppression, and 1170 (37.5%) underwent a minor regimen substitution during suppression. A total of 17 patients in the minor switch, six in the major switch and 69 in the non‐switch group were confirmed with two consecutive viral load measurements ≥400 copies/mL. Patients confirmed with a single viral load ≥400 copies/mL were 13, 3 and 28 in the minor, major and non‐switch group respectively. AIDS diagnosis was confirmed in 14, 7 and 65 patients in the minor, major and non‐switch group respectively. Death was confirmed in 15, 6 and 31 patients in the minor, major and non‐switch group respectively.3 in the minor switch group, and 490 cells/mm3 (338 to 643) in the major switch group. 618 (52.8%) and 158 (53.4%) switches were associated with an adverse events in the minor and major switch groups respectively.The baseline characteristics of the study participants are described in Table Table The rates of VF were 2.85 per 100 person years (95% CI 1.88 to 4.33) in the major substitution group and 1.48 per 100 person years (95% CI 1.14 to 1.91) in the minor substitution group. The rate of VF among patients that did not undergo any treatment substitution during suppression (n = 1756) was 2.53 per 100 person years (95% CI 2.20 to 2.92). The median (IQR) duration of follow‐up was 3.1 (1.3 to 5.1) years in the minor switch analysis and 1.8 (0.9 to 3.7) years in the major switch analysis. Rates of loss to follow up were 1.7 per 100 patient years (95% CI 1.3 to 2.1) and 1.7 per 100 patient years (95% CI 1.0 to 2.9) respectively. Tables 4The objective of this study was to analyse, in real‐world settings, the rate of VF when substituting ART in virologically suppressed HIV‐infected patients. In our study, the rate of VF during virological suppression was low in patients who had undergone both minor and major ART switches. These results are consistent with prior studies that ART substitution in virologically suppressed HIV‐infected patients is generally effective Prior studies in clinical trials have proven that switching EFV, for intolerance or toxicity, to NVP or rilpivirine (RPV) is generally safe and efficacious p = 0.05). In one study with 3447 HIV‐infected patients, protective factors for VF were older age, higher CD4 cell count and medication adherence et al. considering patients receiving PI‐based therapy, low baseline CD4 cell count and high viral load were both independent predictors of both virological and clinical failure. Neither the type of PI or previous ART taken was associated with risk of clinical progression 3 in the minor and major substitution group respectively. The reason for the difference in results may be explained by the smaller number of patients in this study compared to the Grabar et al. study, which included 975 patients.Although the rate of VF were generally low in both major and minor substitution groups, patients who had a history of prior AIDS diagnosis in our major substitution analysis had a slightly higher risk of VF compared to those without a history of AIDS (2.37; 95% CI 1.01 to 5.58, There are several limitations to this study. First, TAHOD participating sites are generally urban referral centres, and each site recruits patients who are considered by local clinicians to have a reasonably good prospect of long‐term follow‐up. This limits the generalizeability of the results, as viral suppression may have been overestimated relative to the background population. Second, the number of patients, especially those patients with major substitutions limited the statistical power of this study. Third, the reasons for changing regimens for each individual were not clearly identifiable from our observational database; thus, we could not draw inferences about whether certain ART switch situations were riskier than others. Finally, patients that did not switch do not have a comparable baseline date as they do not have a date of ART switch. The difference in baseline makes comparison between the three groups difficult.In a real‐world multisite Asian cohort of cohorts, we found rates of clinical or VF to be low in patients who had undergone both minor and major switches in ART medications. This supports the finding that ART regimen substitution in virologically suppressed patients is effective in non‐clinical trial settings in Asian countries.


The U.S. Centers for Disease Control and Prevention (CDC) recommended a new regimen for treatment of latent tuberculosis (three months of weekly isoniazid and rifapentine) in late 2011. While completion rates of this regimen were reported to be higher than nine months of isoniazid, little is known about the completion rates of three months of isoniazid and rifapentine compared to nine months of isoniazid or four months of rifampin in actual use scenarios.We conducted a retrospective cohort study comparing treatment completion for latent tuberculosis (TB) infection in patients treated with nine months of isoniazid, three months of isoniazid and rifapentine or four months of rifampin in outpatient clinics and a public health TB clinic in Seattle, Washington. The primary outcome of treatment completion was defined as 270 doses of isoniazid within 12 months, 120 doses of rifampin within six months and 12 doses of isoniazid and rifapentine within four months.p < 0.001). These associations remained statistically significant even after adjusting for clinic location and type of monitoring. Monitoring type (weekly versus monthly versus less often than monthly) had less impact on treatment completion than the type of treatment offered.Three hundred ninety-three patients were included in the study. Patients were equally likely to complete three months of weekly isoniazid and rifapentine or four months of rifampin (85% completion rate of both regimens), as compared to 52% in the nine months of isoniazid group , and is less expensive compared to combination therapy with isoniazid and rifapentine, and thus can be the optimal treatment regimen to achieve the maximal efficacy in a community setting. Treating latent TB infection (LTBI) in high-risk individuals is one of the eight Millennium Development goals of the United Nations . In the With the availability of novel treatment regimens for LTBI, medical providers now face the challenge of choosing which regimen is best suited for an individual patient. Historically, the regimen of choice for LTBI was nine-months of daily isoniazid . Nine moIn 2011, the CDC recommended a three-month directly observed, weekly dosed therapy of isoniazid and rifapentine as an “equal alternative” to the nine month isoniazid regimen  in healtThere has been significant excitement about three months of isoniazid and rifapentine as an expedited treatment option, but many features of this treatment make it less than ideal for certain patients and clinical settings. While the isoniazid and rifapentine regimen offers the promise of higher completion rates, likely due to less cumbersome dosing and shorter duration, this therapy is also significantly more expensive likely driven by the recommended use of DOT –19, whicDaily rifampin for four months has long been seen as an alternative regimen  for peopTo date, there have been no studies directly comparing completion rates of isoniazid only, rifampin only, and isoniazid and rifapentine regimens. Data on “actual use” in the outpatient setting would be helpful to health care providers to guide choice of therapy for individual patients. The aim of this study is to compare the rates of completion of the three LTBI therapies across heterogeneous populations in various outpatient settings, including primary care clinics, subspecialty clinics, and a public health TB clinic.We conducted a retrospective cohort study of all patients who initiated treatment for LTBI with nine months of isoniazid, rifampin only, or isoniazid and rifapentine dispensed at a hospital affiliated pharmacy or TB clinic during 2009 or between July 1, 2013 and June 30, 2014. Five hospital-affiliated clinics in Seattle, Washington participated in this study: four outpatient clinics affiliated with an urban academic tertiary care medical center, and one county TB clinic. The outpatient clinics include a hospital employee health clinic, a primary care clinic focused on care of immigrants and refugees, a primary care clinic focused on the care of homeless individuals, and a sub-specialty infectious diseases clinic. Given that this was a retrospective chart review and patient identifiers were removed before entry into the secure database, subject consent to participate was waived by the Institutional Review Board (IRB) per standard practices at our institution. The IRB at the University of Washington Human Subjects Division approved this study (#43613).Patients were identified for inclusion in the study if they were 18 years old or older. For patients treated in the hospital-affiliated outpatient clinics, pharmacy records were used to identify patients who were given a prescription for isoniazid without ethambutol or rifampin, rifampin alone, or isoniazid with rifapentine. For isoniazid monotherapy patients, records were queried for those who initiated treatment in 2009, well before the nation-wide isoniazid shortage and 9 months of isoniazid was standard of care. Records were queried again for those who initiated treatment between July 1, 2013 and June 30, 2014 for all three regimens. Medical records for the TB clinic were held separately and LTBI cases treated with the regimens of interest were identified in a TB Control Program database. Diagnosis of LTBI was made by either tuberculin skin test (TST) or interferon gamma release assay (IGRA) in combination with chest x-ray. Screening for active and latent TB was standard practice for patients in the international clinic, homeless clinic and employee health due to the high risk of exposure in those populations. The infectious diseases clinic treated patients planning to undergo treatment of another disease process with immunosuppressive therapies. Patients from the Public Health Clinic, were screened as contacts of active cases being treated by Public Health. The sample size we had was determined by the number of patients seen in our clinics during our study period and so we did not calculate power. The 95% confidence intervals we present in Table Patients were evaluated for LTBI treatment and monitored for adverse effects during follow up visits. When evaluating for side effects, specific side effects such as liver function test (LFT) abnormalities, lab abnormalities, and other known or common medication side effects were marked as present or absent, whereas patient side effects were classified as “other” if the patient reported a subjective side effect which was not a known side effect of the medication regimens  Choice of treatment regimen, frequency of follow-up visits, and frequency of laboratory monitoring were selected by the treating physician at his or her discretion based on patients’ other comorbidities, medications, length of therapy and cost. Patients on the nine-month isoniazid and four-month rifampin daily regimens were typically seen monthly in the public health clinics, and monthly or less often in the outpatient clinics. Patients monitored less than monthly were monitored this way because of poor attendance in clinic. When present in clinic, regular monitoring was completed as it would have been in a monthly monitoring scenario. Patients on isoniazid and rifapentine were seen weekly for DOT by either a nurse or an outreach worker. A small number of the patients on isoniazid and rifapentine received weekly phone calls or met virtually with an outreach worker via webcam, rather than in-person contact. The public health TB clinic used a standard set of questions to check for specific side effects, whereas in all other clinics, patients were asked a targeted review of systems at the provider’s discretion to assess for side effects to the regimens. Interpreters were used for non-English-speaking patients.The primary outcome was treatment completion. This outcome was determined based on pharmacy records of prescription fulfillment. Patients were considered to have completed therapy if they filled prescriptions consecutively to correspond to 270 doses of isoniazid within 12 months [p-values in lieu of logistic regression since our outcome was common. We identified potential confounders a priori based on their relationship between the hypothesized factor and completion of treatment. Confounders evaluated were specific to each exposure of interest and included demographic  and treatment characteristics  and were modeled as categorized in Table We calculated counts, proportions, and means for demographic, treatment, and health characteristics for all participants combined and by treatment type. We estimated counts and row proportions for treatment, clinic, and monitoring type. We hypothesized these three factors would be associated with completion of treatment. We used Poisson regression models with a log link and robust error variance to estimate unadjusted and adjusted relative risks (RR) along with 95% confidence intervals (CI) and A total of 393 participants were included in the study: 87 patients received three months of isoniazid and rifapentine, 82 received four months of rifampin and 224 received nine months of isoniazid Table . There wPatients treated with four months of rifampin were as likely to complete therapy as those on three months of isoniazid and rifapentine. Patients on nine months of isoniazid were less likely to complete treatment than patients on four months of rifampin or three months of isoniazid and rifapentine with adjusted relative risk of 0.66  and 0.59 , respectively Table . These ap-values ≤0.01). Patients treated in the homeless clinic or infectious diseases clinic appeared to be less likely to complete treatment than patients in the public health TB clinic, although the differences were not statistically significant with adjusted RR of 0.65  and RR of 0.74 , respectively  and 0.64  respectively  and RR of 0.60 . However, these associations were no longer apparent after adjusting for clinic location and treatment type with RR of 1.12  and RR of 1.21 , respectively  in any material way . We did not adjust for these factors in our analysis since they did not confound our associations. Additionally, we compared our reported results for all adjusted associations in Table We evaluated race/ethnicity, foreign born status and English-speaking for all adjusted associations presented in Table a priori that those patients with three or more medical problems would complete therapy less often. However, after adjusting for the clinic type and insurance, there was no significant difference in completion rates between patients with more medical problems compared to patients with fewer medical problems with RR of 1.08   Table . We hypo3) Table .This retrospective cohort study demonstrated comparable completion rates between the novel three months of isoniazid and rifapentine and the less often used four months of rifampin. Both regimens had superior rates of completion compared to nine months of isoniazid. Currently, four months of rifampin is considered a secondary alternative, rather than a comparable choice with nine months of isoniazid or 12 weeks of rifapentine with isoniazid, which are the current standard. Given the lower cost to patients and health care settings of four months of rifampin compared to three months of isoniazid and rifapentine, we suggest that providers consider four months of rifampin as an alternative first-line option for LTBI treatment among the appropriate populations. Use of rifampin would offer significant cost savings to patients and health care systems in the United States and abroad. Additionally, improved rates of treatment completion would help reduce incidence of active cases in the United States and around the world.With the publication in 2011 of non-inferiority of three months of isoniazid and rifapentine  to nine New and exciting treatments may not always be the best choice . RifamycThe results of this study have important practical implications for providers, patients, and health care systems. The two regimens likely have similar side effect profiles , 26, buta priori hypothesis in which we anticipated DOT regimens would be superior due to the nature of DOT. No significant difference was found in completion rates between DOT and the rifampin-based self-administered regimen. In other words, non-adherence to the recommended follow-up was not associated with treatment non-completion. Our data represent real-life scenarios that are often missing from research settings, which can make research findings challenging to apply to the imperfect clinical setting. These findings suggest that self-administered four months of rifampin may be able achieve high compliance rates similar to the rates of three months of isoniazid and rifapentine, without the costs of DOT to both patients and health care systems. These findings underscore the utility of four months of rifampin for providers who do not have the resources available for DOT in the outpatient setting.Our data show that the type of treatment offered was a strong predictor of treatment completion whereas monitoring type was not. This is contrary to our We also found significantly higher completion rates at the public health TB clinic compared to primary care clinics. The comparative success of the TB clinic may be the result of having staff that have been trained to focus on engagement of patients in LTBI treatment, whereas primary care visits often attempt to address multiple issues in a 15-min visit without dedicated staff to address LTBI treatment. Alternatively, the relative success of the public health TB clinic may be due in part to patient motivation to complete therapy because personal experience through close contact to active TB cases.While a homeless incentive program was used in this study, we did not see a higher rate of completion in the homeless clinic compared to other sites. This is in line with recent findings that incentive programs may have short term effects on clinic attendance, but do not seem to reliably increase the number of people completing treatment for LTBI .Our study has limitations. First, given that our study was retrospective and not randomized, the design limits the strength of the conclusions regarding the true equivalence of the regimens. Provider discretion should still guide the choices between rifampin only regimens versus INH-rifapentine, which may still be of greater utility in patient populations with historically low adherence, such as homeless patients and those actively using alcohol or other substances. Second, all participating clinics are located in one US city. Though we include a representative mix of foreign-born and homeless persons (see Table In conclusion, this outpatient-based comparison of four months of rifampin, three months of isoniazid and rifapentine, and nine months of isoniazid demonstrates comparable completion rates between four months of rifampin and three months of isoniazid and rifapentine while taking into consideration the monitoring frequency. Given the similar side effect profile but significant cost savings with four months of rifampin, we suggest that four months of rifampin be considered exchangeable with three months of isoniazid and rifapentine and nine months of isoniazid for treatment of latent tuberculosis infection.


The patients on the tenofovir-based HAART and female sex however appeared to be associated with more multiple ADREs.Tenofovir-based highly active antiretroviral therapy (HAART) is one of the preferred first-line therapies in the management of HIV 1 infection. Ghana has since 2014 adopted this recommendation; however there is paucity of scientific data that reflects the safety and efficacy of the tenofovir-based therapy compared to zidovudine in the Ghanaian health system. This study sought to assess the comparative immune reconstitution potential between tenofovir and zidovudine-based HAART regimens, which includes lamivudine and efavirenz in combination therapy. It also aimed to investigate the adverse drug reactions/events (ADREs) associated with pharmacotherapy with these agents in a total of 106 HAART naïve HIV patients. The study included 80 patients in the tenofovir cohort while 26 patients were on the zidovudine regimen. The occurrence of HIV comorbidities profile was assessed at diagnosis and throughout the study period. The baseline CD4 T cells count of the participants was also assessed at diagnosis and repeated at a median period of five months (range 4–6 months), after commencing treatment with either tenofovir- or zidovudine-based HAART. After five months of the HAART, the tenofovir cohort recorded higher CD4 T cell count change from baseline compared to the zidovudine cohort ( The main physiological derangement in HIV infection is an uncontrolled CD4 T cells decline –3. StudiThe advent of Highly Active Antiretroviral therapy (HAART) has revolutionized the management of PLWHA over the past decades , 11. It This study therefore sought to evaluate and compare the efficacy (immune reconstitution propensity) and safety  of tenofovir, lamivudine, and efavirenz regimen (tenofovir cohort) to zidovudine, lamivudine, and efavirenz regimen (zidovudine cohort) and further assess how human related factors affect efficacy and safety of these HAART regimens in PLWHA.This was a prospective observational study involving only participants who enrolled on a naïve tenofovir, lamivudine, and efavirenz regimen known as tenofovir cohort and those on zidovudine, lamivudine, and efavirenz also known as zidovudine cohort at Komfo Anokye Teaching Hospital (KATH) in 2016. The above-mentioned HAART regimens are the commonly used and readily available first-line therapeutic options for the management of HIV 1 infections at KATH and in Ghana, with tenofovir regimen believed to have a favorable dosing schedule and more tolerable effects than the zidovudine regimen. The only difference between the two cohorts was either the use of tenofovir or zidovudine in the respective cohorts, with all other variables being constant. Also the sampling technique used for selection of patients for participation in the study was systematic random sampling and thus did not interfere with the choice of treatment. The selection of HAART regimen was thus the sole responsibility of the clinician in charge of the adult HIV clinic at the study site, guided by patients' comorbidities, tolerability, and acceptance. A total of 106 patients were recruited for the study estimated from the annual HIV/AIDS cases at KATH. A total of 80 participants were in the tenofovir cohort while 26 were in zidovudine cohort.Included in the study were adults aged 18 years and above and newly diagnosed of HIV 1 in 2016. In addition, only those with no past exposure to HAART known as HAART naïve were considered for the study. Furthermore and more importantly, to be considered for the study, one must have been on any two of the commonly prescribed regimens, namely, tenofovir with lamivudine and efavirenz (tenofovir cohort) or zidovudine with lamivudine and efavirenz. Only those with baseline CD4 T cells with or without viral load determined before the initiation of a naive HAART were considered. Those with HIV 2 infection or both HIV1 and HIV 2 were excluded from the study. These were necessary to limit confounding factors and provide similar conditions for a plausible comparison.μL) at a median period of five months (range 4–6 months) after HAART initiation at the serology unit of the Komfo Anokye Teaching Hospital.Each patient who consented for inclusion in the study was given a unique identification number and allocated a designated location in the data collection notebook in an ordered fashion. Data on demographics and vital signs  were obtained from patients' folders and laboratory reports. Patients were made to undertake CD4 T cell absolute count, viral load, and full blood count before the initiation of naïve HAART. Patients were followed up to assess the occurrence of adverse drug reactions/events especially during the first five weeks after HAART initiation. Study subjects were made to repeat CD4 T cells absolute count using flow cytometer  per manufacturer's protocol  to ensure the research protocol does not breach research ethics involving human subjects. Finally, during recruitment of study subjects, a written informed consent was obtained from the study participants freely, after the purpose of the study has been explained to them, and they or their immediate relations have been assured of client confidentiality and anonymity of data.μL) with 33% at stage II (200–499 cells/mL).As shown in μL at baseline (p < 0.0001). Also, within each treatment group, there was significant increase in posttreatment CD4 T cells count from baseline after 5 months of treatment. The extent of CD4 count change between baseline and posttreatment was assessed between the two cohorts. Tenofovir regimen (TLE) recorded a significantly (p < 0.0001) higher median CD4 cell increase of 214 (0–795) cells/μL compared to zidovudine regimen (ZLE) which recorded a median increase of 109.5 (21–275) cells/μL. Furthermore, the univariate Mann–Whitney tests to determine the CD4 count change between those with and without individual comorbidities and young and older adults were unexpectedly found not to be significantly associated with any difference in CD4 count change after HAART as observed. Interestingly, females were found to have higher median CD4 T cell change 217 (7–516) cells/μL compared to males 149.5 (21–401) cells/μL. However in a multivariate analysis gender and likewise other variables were found not to be associated with CD4 T cell change. Thus the significant change in the CD4 T count recorded among the study participants prior to TLE/ZLE administration within 5 months was independent of age, gender, comorbidities (TB and hepatitis B infections), and baseline CD4 and CD8 cell counts. Contrary to that, the observed CD4+ count change among the study participants varied significantly across the treatment groups.Out of 106 participants recruited into the study, 17 were lost to follow-up while 89 were successfully followed up for a median period of five months (20th week). From In this study during follow-up, one participant each on TLE and ZLE died with the one from ZLE cohort said to have had Kaposi sarcoma. Two participants on TLE change from efavirenz to nevirapine due to intolerable CNS effects (psychosis) while one patient on ZLE was switched to TLE due to unfavorable dosing schedule and side effects. In terms of serious ADRE, one participant with Kaposi sarcoma in tenofovir cohort experienced tenofovir induced nephropathy and two experience intolerable psychosis. From p < 0.0001) increase in median CD4 T cell absolute count after five months of being on HAART compared to baseline CD4 T cell absolute count before HAART initiation. This study finding agrees with many studies that HAART enhances immune recovery [Many studies support the assertion that HAART enhances immune recovery which partly is reflected as an increase in absolute CD4 T cell count , 11. Howrecovery , 15, 19.p < 0.0001) higher median increase in CD4 T cell absolute count of 214 (0–795) cells/μl compared to zidovudine treatment arm of 109.5 (21–275) cells/μl five months after HAART. The finding is consistent with a systematic review by Gallant et al. which purported tenofovir-based HAART to elicit superior immune recovery rate than zidovudine-based HAART but an equipotent in virologic suppression [ naf, vpr, and tat viral proteins on CD4 T cells through the activation of NF-kappa β and TNF-α [The extent of CD4 cells change five months to HAART between the two cohorts when assessed. Tenofovir treatment arm yielded a significantly  elevated median CD4 count 217 (7–516) compared to males 149.7 (21–401) cells/μL. However in a multivariate analysis, the association was not statistically significant. This was unexpected as it finds no association between any of the variables evaluated. With regard to age, children and younger adults generally have lager thymic volume reserve at baseline than the elderly and are expected to have superior immune recovery [The significant change in the CD4+ count recorded among the study participants prior to TLE/ZLE administration was found to be independent of age and HIV comorbidities (TB and hepatitis B infections). In a univariate analysis, gender was associated with CD4 count change as females recorded a significantly  were in the tenofovir group. Likewise, the most common ADREs category was CNS side effects with over 93% CNS effects experienced by those in the tenofovir cohort. This also reveals a possible potentiated interaction of tenofovir and efavirenz resulting in synergized CNS adverse effects of the tenofovir regimen. Efavirenz and its metabolite 8-hydroxyefavirenz are known to reach higher concentrations in the CSF and likewise tenofovir increasing the risk of neurotoxicity and disturbance of brain bioenergetics from an inconclusive brain mitochondrial polymerase-nthetase , 32, 35.necrosis . One patnecrosis , 23. Thenecrosis , 32, 35.n = 106), and this could be attributed to the difficulty the investigators had in getting naïve HAART patients to enroll at the beginning of the study. The individuals who participated in this study however are a reflection of the annual estimate of HAART naïve HIV cases that visited the hospital and the attrition rate is also found to be below the 20% margin [Despite the evidence generated in this study, data on the HIV RNA load, a primary biomarker, could not be obtained for all of the study patients during the follow-up phase in the study, due to breakdown of Cobas Ampliprep HIV 1 analyzer at the facility. If this were done the evidence generated in this study could have been more robust. This study could not also obtain follow-up data for LFT, FBC, and RFT on about two-thirds of the study participants due to financial constraints and hence results on these parameters could not be assessed for more definitive evaluation of safety of the HAART pharmacotherapy. Again the number of participants involved in the study was relatively small (% margin . FinallyWe therefore recommend a study with a much more robust design such as a multicenter noninferiority trial or a national cohort study to compare the efficacy and safety of tenofovir-based HARRT regimens and zidovudine-based HAART regimens in Ghana. Also we recommend an evaluation of the comparative effect of tenofovir-based and Zidovudine-based HAART regimens on markers of thymic functionality and immune activation in people living with HIV/AIDS.The tenofovir-based cohort had a superior immune reconstitution potential compared to zidovudine-based cohort. Patients on the zidovudine regimen also improved significantly with regard to CD4 T cell repopulation. The immune reconstitution potentials of both HAART pharmacotherapy were independent of age, gender, baseline CD4 and CD8 T cells count, herbal medicine use, and HIV related comorbidities. Patients on the tenofovir-based regimen and females reported to have had more ADREs compared to those on zidovudine-based regimen. Although the tenofovir treatment arm in this study showed a superior immunological recovery, its use must be closely monitored to address the occurrence of ADREs to improve compliance.