Introduction. Antiretroviral Therapy has transformed HIV infection into a chronic manageable disease; it requires near perfect adherence rates (as high as 95%). In this study, we assessed antiretroviral treatment adherence rate and associated factors among people living with HIV in Dubti Hospital. Methods. A retrospective cross-sectional study design was conducted within February 1–30, 2014. All HIV-infected patients above the age of 18 years who took first line Antiretroviral Therapy were eligible for inclusion of the study. Adherence Scale was used for labeling patients as adherent or nonadherent. All HIV-infected patients record data were collected from the medical records, entered, and analyzed using Epi Info 7 and SPSS Version 20. Multivariable analysis was used to identify the relative effect of explanatory variables on low adherence rate. Results. A total of 370 patients aged 18 years and above, who started ART, were included in this study. The self-reported adherence rate of the patient on ART was 81.1%. Independent predictors of adherence were treatment duration. Conclusion. Adherence rate was associated with time to ART. That is, the longer they were on ART, the lesser they adhered. In an effort to improve the quality of life among HIV-infected people, multiple strategies including treatment of patients with Antiretroviral Therapy have been implemented worldwide. Antiretroviral medications for HIV/AIDS are among the most efficacious and the most life transforming of therapeutic innovations of recent years. Antiretroviral Therapy (ART) changes a uniformly fatal disease to a manageable chronic illness with proper use and good adherence level. Antiretroviral Therapy requires near perfect adherence rates (as high as 95%) –3. FailuUnfortunately, maintaining adequate levels of adherence to antiretroviral medications has proved challenging not only for persons living with HIV, but also for healthcare providers because a failing regime as a result of poor adherence will lead to increased opportunistic infections, increased hospitalization, and outpatient visits and thus increased work load , 4. SuboAdherence to medication is a dynamic behavior affected by factors related to treatment regimen complexity, patient-related variables, patient-healthcare provider relationships, and the quality of healthcare services . PatientEthiopia is one of the seriously affected countries in sub-Saharan Africa, with more than 1.3 million people living with HIV . In Ethi2 with an estimated 1,411,092 population according to the 2011 census and projection. The Region is generally characterized by desert climatic condition with stony and sandy crust lands and harsh climate for most of the year with annual temperature between 26 and 52 degrees Celsius in the Dallol Woreda. Afar ethnicity is the dominant native of the region particularly in the rural area, with the Muslim dominant religion followers. Hospital gives service for thousands of HIV/AIDS patients since 2005 from rural and urban areas. There were 2350 HIV/AIDS patients on follow-up among which 1059 started ART treatment and were on follow-up.A hospital based retrospective cross-sectional study design was carried out within February 1–30, 2014, at Dubti Hospital in Afar region using secondary data source. Afar Regional State is one of the nine regional states, administratively divided into five zones and 32 woredas, and Semera is the administrative capital of the region. The Region is located bordering Eritrea in the North, Djibouti in the East, Tigray and Amhara in the West, Oromia and Somali regional state South and South East, respectively. The Region lies in the Great Rift Valley of East Africa about 120 meters below sea level around the Dallol depression. It has an area of 97,256 kmP = 0.73) [The study population consists of all HIV-infected patients aged 18 and above who were seen at Dubti Hospital HIV Clinic, Afar region. The study participants were any people living with HIV who had been on ART in the hospital within February 1–30, 2014, and who have complete registration; intake and follow-up forms were included. Patients who transferred out and lost to follow-up , women who were pregnant, and lactating mothers in WHO stage I or II within February 1–30, 2014, were excluded from the study. The study subjects were randomly selected based on the inclusion criteria. Profiles of all patients on ART during the study period were evaluated. The sample size was calculated using single population proportion formula with the assumption of proportion of Antiretroviral Treatment adherence of ( = 0.73) , 5% precOnce the desired patient medical records were identified from the eligible medical records, the required information from the patient medical records was collected using data abstraction form developed to capture basic information about clinical, laboratory, and demographic record. Data abstraction format was developed from ART entry and follow-up form being used in the ART clinic of the Dubit Hospital and Ministry of Health. Pretest of the data abstraction forms was done to get concrete insights into the study record, how data's abstracted from medical records, and were finalized data abstraction form. An input that was obtained from the pretest was incorporated into the data abstraction forms. A total of two days of training were given for data collectors and supervisors. Data quality was censured by using pretested data abstraction form and close supervision by checking the collected data daily for completeness. All the completed data were examined again for completeness and consistency during data entry, storage, and analysis by principal investigator.The main outcome measure was self-reporting adherence rates within February 1–30, 2014, on ART follow-up date. The independent variables were sex, age, marital status, educational status, occupation, residency, duration on ART, CD4 count, WHO stage, type of ART drug used, and disclosure status.P < 0.25 were included in a multivariable logistic regression analysis.Data was entered and cleaned using Epi Info Version 7. SPSS Version 20 was used for analysis to measure the association of patient's characteristics on adherence rate and calculate adherence rates of the patients. Multivariable logistic regression model was used to identify associated factors of adherence rate using odd ratios with 95% CI. Significant factors in a bivariate analysis with Ethical approval from the institutional review board of the Dubti Hospital was obtained. Permission to conduct the study in follow-up unit was obtained from the medical director's office of the hospital. Names or identification numbers of HIV/AIDS patients were not included in the data abstraction sheet.μL (IQR = 87.5–261.3 cells/μL). Three hundred and two (81.6%) of the patients had disclosed their serostatus to their partner and other close relatives. the mean treatment duration on ART was 47.7 months (s.d = 26.3 months). The minimum treatment duration was 1 month and the maximum was 104 months. The overall prevalence of self-reported adherence rate was 81.1%  of them were females and the mean age was 32.9 (SD = 9.1) and also 171 (46.2%) were in age group greater than 30 years. Eighty-two percent (82.2%) of the cohort started ART on the late stage of the disease (stages 3-4). The median CD4 count was 169 cells/as 81.1% .P value up to 0.25 were included in the multivariable logistic regressions. Finally in the multivariable logistic regression analysis showed those patients was longer treatment duration on ART, the lesser they adhered   .Ensuring Antiretroviral Therapy patients' adherence is one of the major challenges to public health in many developing countries. Good adherence to antiretroviral medications is critically important for the success of therapy in patients who are on ART. Proper use of ART suppresses HIV viral replication, consequently slowing down disease progression, improving immunity, and delaying mortality. In our finding, self-reported adherence rate of HIV patients who were on ART was found to be higher than in most developed countries, where rates ranged from 50% to 70% , 18. TheThere was association between time of ART treatment and self-reported adherence. Also note that a negative association between time on ART and adherence may also stem from the fact that individuals feel tired after taking their medications over long periods of time and they felt healthy . SimilarIn conclusion, this study showed that the self-reported adherence rate of Afar region was higher than in most developed countries but in line with other similar studies in Ethiopia. Time of ART associated with self-reported adherence rate.There are limitations to our study because of its cross-sectional design and the convenience of the sample used. Being an intended baseline study, we assessed only self-reported adherence to therapy at a single time point. This therefore makes it impossible to evaluate variations in adherence over time for an individual. Self-reporting was used as the only method of measuring adherence. This method has the disadvantages of recall bias and eliciting only socially acceptable responses and hence may overestimate the level of adherence. Hence, the extent of generalizability is limited only to those similar patients.


Central nervous system (CNS) penetration-effectiveness (CPE) rank was proposed in 2008 as an estimate of penetration of ARV regimen into the CNS, and validated as predictor of CSF HIV-1 replication. Results on predictive role of CPE on neurocognitive and clinical outcome were conflicting.Retrospective, cross-sectional analysis of neurocognitive profile in HIV-infected cART-treated patients. All patients underwent neuropsychological (NP) assessment by standardized battery of 14 tests on 5 different domains. People were classified as having NCI if they scored >1 standard deviation (SD) below the normal mean in at least two tests, or >2 SD below in one test. Linear and logistic regression analyses were fitted using as outcome Npz8 and impaired/not impaired respectively.3; 18% HCV infected; HIV-RNA <40 cp/mL in 84%). Current ARV regimen was 2NRTIs+1NNRTI 50.3%, 2NRTI+1PI/r in 32.6%, NRTI sparing in 11.1%. Mean CPE of current regimens was 6.6 (95% CI 6.5–6.7). As per test multivariable analysis, higher CPE values were associated to poor NP tasks . The association between higher CPE and increased NCI risk was confirmed at multivariable logistic regression, with a 1.24-fold risk of NCI occurrence for each point increase of CPE of current regimen at the time of NP testing , male 82%; median current CD4 586/mmting see . In a seIn our analysis, higher CPE rank is associated to poorly performing at NP tasking. Even if selection bias could not be excluded due to retrospective cross-sectional design, these results fitted with the direct correlation between high CPE and HIV dementia recently recorded in a large observational database. We think that CPE use to guide ART in patients neurocognitively impaired should be revised.


The National AIDS Control Organization of India has been providing free second line antiretroviral therapy (ART) since 2008. This observational study reports the survival and virologic suppression of patients on second-line ART under programmatic condition and type of mutations acquired by those failing therapy.170 patients initiated on second-line therapy between 2008 and 2012 were followed up till 2013. Viral Load (VL) was repeated at 6 months for all patients and at 12 months for those with VL >400 copies/ml at 6 months. Adequate virological response was defined as plasma HIV-1 VL <400 copies/ml and virological failure was defined as VL >1000 copies/ml. Genotyping was done in 16 patients with virological failure.Out of 170 patients, 110 (64.7 %) were alive and on therapy and 35 (20.5 %) expired. In the first year the occurrence of death was 13.7 /100 person years while between1 and 5 year it was 3.88 /100 person years. In the first year, duration of immunological failure >12 months, weight <45 kg, WHO clinical stage 3 and 4 and WHO criteria CD4 count less than pretherapy baseline  and beyond first year poor first and second line adherence and first line CD4 count < 200/μL  had high risk of death.119/152 (78.2 %) had adequate virological response and 27/152 (17.7 %) had virological failure. High viral load at baseline and poor second line adherence (Odds Ratio 3.4 & 2.8 respectively) had increased risk of virological failure. Among those genotyped, 50 % had major Protease Inhibitor mutation (M46I commonest) however 87.5 % were still susceptible to darunavir.Second line therapy has shown high early mortality but good virological suppression under programmatic conditions. Of the 4.8 million people living with HIV (PLHIV) in Asia, nearly half (49 %) are in India. There has been a massive scale-up of antiretroviral therapy (ART) services in India since the National AIDS Control Organization (NACO) launched the ART centres providing free antiretroviral drugs in 2004. As of September 2014, there were 453 fully functional ART centres across the country providing free first line ART to 810,339 PLHIVs , presence of WHO immunological criteria CD4 count less than pretherapy (at the start of first line) baseline ; weight <45 kg ,WHO clinical stage 3 and 4  had higher risk of death. Beyond first year, patients with CD4 count less than pretherapy baseline , poor adherence during first line  as well as during second line therapy  had higher risk of death  had ongoing viremia and 27  had virological failure at one year. Viral load ≥177,000 copies/ml at baseline  and <95 % adherence during second line treatment  was significantly associated with second line failure  7, 17 and 18 did not amplify. All samples were HIV 1 virus subtype C. 50 % (8/16) had major PI mutation, 62.5 % (10/16) had minor PI mutation, 81.25 % (13/16) had NRTI mutation and 93.75 % (15/16) had NNRTI (non nucleoside reverse transcriptase) mutation Table . Median n = 5) was the commonest mutation, followed by N88S (n = 3), I50L (n = 2), I84V (n = 2), V 82A (n = 1). 6 patients with >12 months of second line therapy as compared to 2 patients with <12 months therapy had at least one major PI mutation. Fourteen (87.5 %) patients were susceptible to darunavir (DRV) while two were associated with low level resistance to DRV. 6 (37.5 %) patients were associated with high resistance, 3 (18.75 %) had low level resistance and 7 (43.75 %) were still susceptible to atazanavir (ATV).Among PI mutations, M46I (n = 10) patients had ≥3 TAM . 81.25 % (n = 13) had more than 1 NNRTI mutation.Y181C and G190A was the most common NNRTI mutation present in 37.5 % (n = 6) patient each. ESS were ≥ 2.5 in 56.25 % (9/16) patients.M184V was the commonest NRTI mutation and was present in 13 out of 16 patients. 62.5 %  had adequate virological response at one year. Similar findings were observed in studies from other resource limited settings , 14, whiPoor adherence during second line therapy was an important risk factor for virological failure in our study similar to other studies , 3, 19. Interestingly, 17/50 (34.0 %) of our patients who had ongoing viremia or virological failure at 6 months adequately suppressed their viral load at 12 months. Similar findings were observed in a study where 62 % patients suspected of second-line ART failure, responded to enhanced adherence support and had a two-log decrease in their level of HIV on subsequent VL testing . These fGag substrate mutations can cause drug resistance mutations that confer PI resistance in the absence of protease mutations [This is the first study to report the mutations acquired by second line failure patients in the National program. Median GSS was very low (1.0) in our study. 62.5 % patients had ≥3 TAM which they must have acquired during first line therapy and suggests that patients were failing on first line therapy long before detection. It also implies that they were relatively on PI monotherapy and at risk of developing PI mutations. 93.75 % of the patients in our study had NNRTI mutation, which may be due to re-emergence of archived mutations from first-line NNRTI regimens. Etravirine susceptibility scores (ESS) was ≥ 2.5 in 56.25 % patients, which is a concern as best virologic suppression are seen when the ESS score is less than or equal to 2.0 and this drug is also a part of the WHO recommended third line regimen. 50 % of our second line failure patients had major PI mutation which is much higher than previous studies , 23 but utations –28. Thisutations . Similarutations . As M46Iutations , 31. N88The major limitations of our study was the inability to do viral load testing for all patients at 12 months and the fact that genotyping was not done at the start of second line therapy.In this observational study there was high early mortality but good long term outcome as well as virological suppression in patients starting second line therapy under programmatic conditions in India. This early mortality can be circumvented by introducing routine virological monitoring in the program which will help in early detection of patients with failure. Virological response in our cohort was similar to other resource poor settings. Although 50 % of our second line failure patients had major PI mutation most were still susceptible to darunavir. Thus, darunavir in combination with integrase inhibitor which has not been used in the program remains a good option as a third line ART for the National program.


Latinos living with HIV in the Americas share a common ethnic and cultural heritage. In North America, Latinos have a relatively high rate of new HIV infections but lower rates of engagement at all stages of the care continuum, whereas in Latin America antiretroviral therapy (ART) services continue to expand to meet treatment needs. In this analysis, we compare HIV treatment outcomes between Latinos receiving ART in North America versus Latin America.HIV-positive adults initiating ART at Caribbean, Central and South America Network for HIV (CCASAnet) sites were compared to Latino patients (based on country of origin or ethnic identity) starting treatment at North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) sites in the United States and Canada between 2000 and 2011. Cox proportional hazards models compared mortality, treatment interruption, antiretroviral regimen change, virologic failure and loss to follow-up between cohorts.p<0.001 for all). In multivariable analyses, CCASAnet patients had a higher risk of mortality after ART initiation (adjusted hazard ratio (AHR) 1.61; 95% confidence interval (CI): 1.32 to 1.96), particularly during the first year, but a lower hazard of treatment interruption , change to second-line ART  and virologic failure .The study included 8400 CCASAnet and 2786 NA-ACCORD patients initiating ART. CCASAnet patients were younger (median 35 vs. 37 years), more likely to be female (27% vs. 20%) and had lower nadir CD4 count (median 148 vs. 195 cells/µL, HIV-positive Latinos initiating ART in Latin America have greater continuity of treatment but are at higher risk of death than Latinos in North America. Factors underlying these differences, such as HIV testing, linkage and access to care, warrant further investigation. In 2012, the World Health Organization (WHO) estimated there were 1.3 million HIV-positive individuals in the United States and Canada and 1.5 million in the countries of Latin America (including Mexico) . US LatiFor HIV-positive Latinos in Mexico, Central America and South America, the availability of HIV care and antiretroviral therapy (ART) has expanded rapidly over the past decade, with approximately 75% of the estimated 790,000 persons in need of ART able to access treatment . Latin ANorth America) to those in patients in six Latin American countries  using the regional databases of the International Epidemiologic Databases to Evaluate AIDS (IeDEA) network.The goal of this study was to estimate regional differences in clinical characteristics at ART initiation, mortality, ART discontinuation or changes and virologic failure among HIV-positive Latinos in the Americas. We compared outcomes of HIV-positive Latino patients initiating ART in Canada and the United States  and the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD). These consortia have been profiled elsewhere ,18.Briefly, CCASAnet is a network of clinical sites in seven diverse Caribbean, Central and South American countries that pools data collected as part of HIV treatment and care programmes. In this study, we included data from eight CCASAnet sites in six countries: Hospital Fernández and Centro Médico Huésped in Buenos Aires, Argentina (HF/CMH-Argentina); Instituto Nacional de Infectologia Evandro Chagas in Rio de Janeiro, Brazil (INI-Brazil); Fundación Arriarán in Santiago, Chile (FA-Chile); Instituto Hondureño de Seguridad Social and Hospital de Especialidades in Tegucigalpa, Honduras (IHSS/HE-Honduras); Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán in Mexico City, Mexico (INNSZ-Mexico); and Instituto de Medicina Tropical Alexander von Humboldt in Lima, Peru (IMTAvH-Peru). The CCASAnet site in Haiti was not included, given Haiti's African ethnic ancestry and non-Hispanic cultural heritage.NA-ACCORD includes ≥200 sites in 25 single and multisite cohorts throughout the United States and Canada. In this study, data from 11 NA-ACCORD clinical cohorts were included: Fenway Community Health Center , HIV Research Network, Johns Hopkins HIV Clinical Cohort , Montreal Chest Institute Immunodeficiency Service Cohort, Ontario HIV Treatment Network Cohort Study, Retrovirus Research Center, Southern Alberta Clinic Cohort, Study of the Consequences of the Protease Inhibitor Era, University of Alabama at Birmingham 1917 Clinic Cohort, University of Washington HIV Cohort and Vanderbilt-Meharry Centers for AIDS Research (CFAR) Cohort. These sites included patients from 17 US states, Puerto Rico, and 4 Canadian provinces . LatinosOur analysis cohort was restricted to ART-naive adult HIV-positive patients initiating ART between 2000 and 2011. Patients with an undetectable HIV-1 RNA viral load (VL) prior to reported date of ART initiation were excluded. Outcomes were assessed using data collected through 31 December 2011.Clinical and epidemiological data were collected at each centre, de-identified and sent to the Data Coordinating Center at Vanderbilt University, USA. Institutional ethics review boards from all sites and Vanderbilt approved the project, waiving the requirement for individual patient informed consent.The time from ART initiation to each of five long-term outcomes was assessed: all-cause mortality, treatment interruption, major treatment change, virologic failure and loss to follow-up. ART was defined as a combination of three antiretroviral agents from at least two classes, or a triple nucleoside/nucleotide reverse transcriptase inhibitor regimen containing abacavir or tenofovir. Patients without an event were censored at 31 December 2011 or the date of their last clinical, pharmacy or laboratory visit, whichever occurred first.Participant deaths in NA-ACCORD are recorded by the individual cohorts when the death can be confirmed, and deaths among patients lost to care are ascertained using routine surveillance and matching of US national and Canadian provincial death indexes. In CCASAnet, methods to ascertain death differ across sites. At IHSS/HE-Honduras, deaths are recorded after field workers contact patient family members following a missed visit. At all other sites, deaths occurring at affiliated hospitals or other clinical sites are recorded, as are notifications of deaths by relatives of patients. Additionally, study staff at INI-Brazil, FA-Chile, INNSZ-Mexico and IMTAvH-Peru sites query government death registry databases for patients lost to care at least annually.Treatment interruption was defined as an interruption of the initial ART regimen for >14 days. Major treatment change included switching to a “second-line” regimen, defined as (1) a change to a boosted protease inhibitor (PI)-based regimen; (2) switching to a different PI if a patient's first regimen included a boosted PI; (3) switching to a “third-line” drug ; or (4) changing to non-nucleoside reverse transcriptase inhibitor (NNRTI), boosted PI or switching, deleting or adding a third-line drug for those patients who had started treatment on a third-line drug. Virologic failure was defined as at least one of the following: (1) VL >400 copies/mL after six months of therapy, (2) VL <400 copies/mL followed by a single value >1000 copies/mL or (3) VL <400 copies/mL followed by two consecutive VL >400 copies/mL. The threshold of 400 copies/mL was chosen based on the detection limit for assays used at many of the sites during the study period. Patients who did not have a VL measurement after ART initiation were excluded from the virologic failure analyses. Patients who had a gap between VL measurements of greater than one year were censored at the last measurement prior to the gap. Loss to follow-up (LFU) was defined as lack of information about the patient within 180 days prior to the database closing date; for patients lost to follow-up, the date of LFU was defined as date of their last visit.Univariate comparisons were performed using Wilcoxon rank sum and chi-square tests. Kaplan-Meier estimates and corresponding confidence intervals (CIs) of the probability of mortality were calculated for each consortium. The cumulative incidence and corresponding 95% CI of treatment interruption, ART regimen change and virologic failure were also estimated and these models accounted for mortality as a competing risk. Separate multivariable Cox proportional hazards models were fit to compare the hazard of death, major treatment modification and treatment failure between patients in CCASAnet and NA-ACCORD. All multivariable models were adjusted for age, sex, reported mode of transmission, nadir CD4+ T-cell count (CD4 count) and clinical AIDS prior to treatment initiation, initial ART regimen and year of ART initiation. Restricted cubic splines were used for continuous variables to account for non-linear trends . MultiplDifferent frequencies of VL measurement between cohorts may have biased the results since patients with more VL measurements had more opportunities to be classified as a treatment failure. We thus compared the incidence of a detectable VL greater than six months after ART initiation while accounting for the number of VL measurements using a multivariable negative binomial regression model. We report the adjusted relative proportions of detectable VL per measurement and corresponding 95% CI.Latino includes Brazilians). However, the ethnic heritage of Brazil includes a large component of African migration, and we performed subregion analyses which excluded patients initiating ART in Brazil and patients born in Brazil initiating ART in North America. We also performed a subregion analysis comparing NA-ACCORD patients reporting Mexico as their country of origin with CCASAnet patients from Mexico.Brazilian HIV treatment sites contributing data to CCASAnet were included in the primary analysis, as were Brazilian patients living in the United States or Canada and enrolled in NA-ACCORD  at one of 8 CCASAnet sites in Latin America and 2786 (25%) in one of 11 NA-ACCORD cohorts with clinical sites in 17 US states and 4 Canadian provinces . CCASAnep<0.001 for all). Median follow-up was 3.3 years (interquartile range (IQR): 1.2 to 6.0) for patients initiating ART in CCASAnet and 2.7 years (IQR: 1.0 to 5.6) for Latinos in NA-ACCORD.Demographic and clinical characteristics of patients starting ART in each cohort are shown in Crude mortality rates were 2.1 and 1.4 per 100 person-years for ART initiators in CCASAnet and NA-ACCORD, respectively. All-cause mortality early after ART initiation was higher in CCASAnet: 4.4% (95% CI: 4.0 to 4.9%) died during the first year in CCASAnet compared with 1.5% (95% CI: 1.0% to 2.0%) in NA-ACCORD . After op=0.35), though CCASAnet patients were younger  and less likely to have an AIDS diagnosis before ART initiation .In multivariable Cox analyses, CCASAnet patients had a higher hazard of mortality after ART initiation (adjusted hazard ratio (AHR) 1.61; 95% CI: 1.32 to 1.96), adjusting for age, sex, CD4 count, year of ART initiation, intravenous drug use, prior AIDS diagnosis and ART regimen . Among pThe cumulative incidence of an ART treatment interruption, major treatment change, virologic failure and LFU were lower for CCASAnet participants . The cumOne and five years after ART initiation, the cumulative incidence of a regimen change among patients initiating ART in CCASAnet was 0.07 and 0.23, respectively, and among Latinos initiating ART in NA-ACCORD, 0.13 and 0.39 b. SimilaPatients initiating ART in CCASAnet also had a lower cumulative incidence of virologic failure  and patients born in Brazil initiating ART in North America (n=2). The hazard ratio of death in CCASAnet compared to NA-ACCORD was lower when Brazilians were excluded , whereas there was little difference in the hazard ratios of treatment interruption, regimen change or virologic failure. Similarly, the percentage of VL measurements that were detectable after six months remained lower for patients initiating ART in CCASAnet in analyses excluding Brazil .Brazilian CCASAnet sites and Brazilian patients enrolled in NA-ACCORD were included in the primary analyses, but given the large component of African migration to Brazil we performed subregion analyses (Supplementary Table 2) that excluded patients initiating ART in Brazil , although the hazard ratio was in the same direction as primary analyses. Patients initiating ART in Mexico had a lower hazard for virologic failure , although again this may have been driven by differences in the frequency of measurements. The percentage of detectable VL measurements was lower among patients initiating ART in Mexico  but this difference was not statistically significant.Latinos in the United States and Canada started ART with less severe immunosuppression and had greater survival, particularly in the first 12 months of care, as compared with individuals starting ART in Latin America, but Latinos in North America also appear to be at greater risk for treatment interruptions, treatment regimen changes, virologic failure and LFU.The lower risk of mortality observed among Latinos in North America compared to those living in Latin America was most pronounced in the early years of ART. Early mortality in resource-limited settings has been well documented, and our results are largely consistent with other comparisons between resource-limited settings (primarily sub-Saharan Africa) and North America and Europe . PatientCompared to non-Hispanic whites, Latinos in the United States as a group are diagnosed at a more advanced HIV disease, and foreign-born, non-English speaking and male Latinos are at particularly high risk of delayed diagnosis –32. BarrPrior studies have also identified important differences among native and foreign-born Latinos in the United States, which may be representative of broader geographic trends. Studies from the United States found that foreign-born Latino males are more likely to have acquired HIV through heterosexual contact as compared to US-born Latinos. Among HIV-positive Latinas, foreign-born women were older at first sexual contact, had fewer episodes of non-HIV sexually transmitted diseases and lower rates of drug and alcohol abuse ,33,34.We examined health outcomes at CCASAnet sites in aggregate, but prior studies have found that mortality and programme retention vary considerably between countries in Latin America, which likely reflects differences in the underlying demographics of the HIV epidemic in the region, as well as local social and economic characteristics –13,35,36A strength of this study was the large number of subjects contributing data from multiple countries. However, the largest number of North American Latino patients with known foreign birth location had migrated from Mexico, whereas the majority of CCASAnet patients were located in South America. Limitations of our data included the proportion of patients with no reported country of birth in NA-ACCORD. Other limitations included the lack of information on causes of death and potential confounding of the treatment interruption analysis related to how accurately sites record gaps in ART use (i.e. adherence) versus gaps in prescriptions for ART. Although we assessed time to virologic failure, we did not assess the role of adherence and viral resistance in treatment failure, nor toxicity or other reasons for ART change.Mortality rates were higher in Latin America, possibly due to treatment initiation at more advanced stages of HIV disease, whereas treatment interruption, major regimen modification, virologic failure and LFU were higher in North America, where barriers to receiving quality HIV care may be higher for Latino populations. These results emphasize once again the need for early diagnosis and treatment initiation in Latin America and reinforce the key role of ensuring US Latino HIV patients have consistent access to care to improve treatment outcomes.Click here for additional data file.


This study examined retention rates and associated predictors of methadone maintenance treatment (MMT) duration among 128 newly admitted patients in Taiwan. A semi-structured questionnaire was used to obtain demographic and drug use history. Daily records of methadone taken and test results for HIV, HCV, and morphine toxicology were taken from a computerized medical registry. Cox regression analyses were performed to examine factors associated with MMT duration. MMT retention rates were 80.5%, 68.8%, 53.9%, and 41.4% for 3, 6, 12, and 18 months, respectively. Excluding 38 patients incarcerated during the study period, retention rates were 81.1%, 73.3%, 61.1%, and 48.9% for 3 months, 6 months, 12 months, and 18 months, respectively. No participant seroconverted to HIV and 1 died during the 18-months follow-up. Results showed that being female, imprisonment, a longer distance from house to clinic, having a lower methadone dose after 30 days, being HCV positive, and in the New Taipei city program predicted early patient dropout. The findings suggest favorable MMT outcomes of HIV seroincidence and mortality. Results indicate that the need to minimize travel distance and to provide programs that meet women’s requirements justify expansion of MMT clinics in Taiwan. Treating heroin dependence and stemming the human immunodeficiency virus (HIV) infection amongst heroin users challenge public health professionals and health providers over the last three decades. The use of methadone maintenance treatment (MMT) to treat heroin dependence and reduce infectious diseases has gradually become prevalent. Countries in South East Asia and East Asia, including China, Indonesia, Malaysia, Thailand, and Vietnam, have been launching and expanding MMT programs as an essential response to reduce the harms of injection drug use. This trend of adopting harm reduction as an approach to reduce the ill effects of heroin dependency followed a series of important announcements and recommendations made by international organizations. In 2002, the United Nations Office on Drugs and Crime (UNODC) announced that based on systematically reviewed evidence from addiction studies, drug addiction should be considered a chronic and relapsing disease . Later oMethadone maintenance treatment (MMT) has been shown to reliably reduce drug use , overdosThis paper reports secondary analyses from a larger project entitled “A Prospective Study of Effectiveness of Methadone Maintenance Treatment,” an 18-month multi-site study that collected data on quality of life, mortality and HIV seroconversion as well as on the duration of MMT and associated factors . The resPatients had to meet the following criteria to be included in the study: at least 20 years of age, literate, self-reported usage of heroin within the past 6 months, and currently enrolled in an MMT program. In accordance with the Taiwan Civic Law, being 20 years old is considered as an adult. Of the 599 participants, we analyzed 128 newly admitted patients, who were approached with an explanation of the study’s purpose and procedures within 5 days of starting MMT. The participants were followed semi-annually for 18 months. All participants received 100 Taiwan dollars (approximately 3 US dollars) for each interview.A semi-structured questionnaire was used to obtain demographic and drug use history. The demographic items asked about the participant’s age, age at first heroin use, gender, education, living address, marital status, and employment. Education was categorized based on whether the patients had completed the compulsory 9 years of education in Taiwan. House-to-clinic distance was calculated from the patient’s home address to the MMT clinic using a Google map. Results of HIV and HCV tests, daily records of methadone taken, and morphine toxicology test results were taken from a computerized medical registry. Mortality data were obtained from the death records of the Taiwan Department of Health for the corresponding period. Arrest and incarceration records were provided by the Taiwan Ministry of Justice.Statistical analyses were performed using SPSS 19.0 for Windows. MMT duration was calculated from records of patients’ admission and dropout dates or the last day of follow-up . Cox multivariate regression analyses were performed twice, once on all 128 patients and once on non-incarcerated patients, to predict treatment dropout from age, age at first heroin use, gender, education, house-to-clinic distance, marital status, employment, incarceration, methadone dose after 30 days, and program site. Items with missing values were omitted from the analyses. The criterion for statistical significance was p < 0.05.As shown in The average number of days participants were in MMT was 344.65(203.68). Four patients withdrew from MMT within 30 days of treatment. Retention rates were 80.5% (n = 103), 68.8% (n = 88), 53.9% (n = 69), and 41.4% (n = 53) for individuals who consistently stayed in treatment for 3 months, 6 months, 12 months, and 18 months respectively. Of 128 participants, 38(29.7%) had to leave MMT during the study because they had been convicted of a crime and became incarcerated. For the remaining 90 patients, retention rates were 81.1% (n = 73), 73.3% (n = 66), 61.1% (n = 55), and 48.9% (n = 44) for those who stayed in treatment consistently for 3 months, 6 months, 12 months, and 18 months, respectively. None were seroconverted to HIV positive and one died because of accidents unrelated to overdose. The annual mortality rate was 0.5% per life year.The Cox regression analysis on the 128 patients revealed that patients who were women, imprisoned, HCV positive, lived a long distance from the clinic, low methadone dose after 30 days of admission, and treated in New Taipei City were associated with shorter duration of MMT . The CoxWe found that being male, married, living close to the clinic, living in Taipei City, and being prescribed a higher methadone dosage 30 days after admission, HCV positive and not imprisoned were positively associated with continuing (not dropping out of) MMT. No patient was tested HIV positive and one died because of accidents unrelated to overdose during the study period. These findings are consistent with prior studies showing that staying longer in MMT is associated with such positive patient outcomes as lower overdose mortality, fewer HIV/HCV infections, less drug use overall, fewer injections, and a better quality of life ,15.Studies from Western countries have shown that younger patients are the most likely to drop out of substance abuse treatment programs  and thatOne third of our participants became incarcerated during the 18months of the study, and incarceration was a significant predictor of early attrition. A previous study found involvement in the criminal justice system to be associated with less time in treatment . Legal pHigher methadone doses have also been associated with longer duration in MMT ,22. In aOur finding that distance from the clinic is associated with MMT retention is noteworthy but not surprising, because travel costs are important considerations for patients needing access to treatment. Because methadone is a 24-hour agonist that patients must take every day, they may have to take a half day off from work or spend more money on transportation to keep up with their medication. In such circumstances, reporting daily to the MMT clinic can be a heavy burden in terms of both time and cost for patients who live far from the clinic. Accessibility to clinics has been shown to be a crucial factor influencing MMT adherence and retention ,13. KellThe present study has a few limitations. As our participants were not recruited randomly from methadone clinics in northern Taiwan, the findings may not generalize to other Taiwanese methadone patients. Although our clinic-based sample was large, our participants still may have differed from the general population of heroin users in relevant respects. Examples of such possible differences are demographics, MMT modality, and patterns of drug use. Second, because ours was an observational study with no comparison group, confounding factors such as maturation, local policy change, and testing may have biased our results. The average number of days in treatment was fairly long in our study. Previous studies suggest that patients who remain in MMT programs more than three months are much more likely to stay in the program longer than other patients ,24. The An important strength of this study lies in its ability to use a prospective design. As a result, the conclusions of this study can provide evidence that MMT as a harm reduction program reduce the mortality and new HIV infections. Factors associated with duration of MMT are gender, methadone dose after 30 days, incarceration, program site, HCV and the geographic distance that clients travel to outpatient treatment clinics. Minimizing the travel distance might improve retention and duration of MMT.


Treatments in patients with multidrug resistance often involve the use of multiple agents with partial antiviral activity and overlapping metabolic toxicities. Enfuvirtide is therefore a welcome addition to the antiretroviral management of patients with multiclass resistant virus, given the low risk of systemic toxicities and novel mechanism of action relative to existing drug classes.The aim of this study was to evaluate the effectiveness of ENF plus optimized background regimen (OBR) in a Mexican cohort of highly HIV-1 ARV-experienced patients.Prospective cohort of treatment-experienced HIV-1-infected adults with virological failure who started therapy with an ENF-containing regimen. The effectiveness of ENF treatment was evaluated with percentages of undetectable HIV-1 RNA viral load after 24 and 48 weeks of treatment, and changes in CD4+ cell counts.p <0.0001 compared to baseline. Increase CD4+ cells were also statistically significant at weeks 24 and 48 with respect to the baseline. Pain at the site of injection was the main adverse event in 100% of patients.Forty patients >18 years were included. After 24 weeks of treatment, 91% of patients had HIV-1 RNA viral load <400 copies/mL and 65.8% had <50 copies/mL. At week 48 of treatment, 81.4% of the patients had HIV-1 RNA <400 copies/mL and 55.5% had <50 copies/mL; in both cases Our study provides clinically important evidence of the effectiveness and safety of ENF in highly ARV-experienced HIV-1-infected patients. These findings strengthen the results of previous randomized controlled trials with this agent. Although rates of multiple regimen failure have decreased dramatically over the past decade, mortality rates for those who have experienced failure of at least two regimens remain high . Some stENF was approved in 2003 as a salvage therapy agent following the success of the Phase III TORO (T-20 vs Optimized Regimen Only) clinical trials. TORO 1  and TORO 2  assessed the safety and efficacy of ENF plus an optimized background (ENF + OB) versus optimized background alone (OB) in approximately 1000 treatment-experienced patients (n = 663 ENF + OB and n = 334 OB) ,6. RESISWhen patients had ENF as a part of their OB, response was improved in both groups. At 48 weeks, 58.5% of enfuvirtide-naïve patients in the tipranavir/ritonavir arm who received enfuvirtide had a treatment response compared with 25.6% of enfuvirtide-naïve patients randomized to the control arm and receiving enfuvirtide.(10) copies/mL versus 15% in the CPI arm. This result was more pronounced in enfuvirtide-naïve patients who received enfuvirtide plus boosted darunavir and OB since 81% had a decline in plasma viral load of >1 log(10) copies/mL, versus 56% of patients taking boosted darunavir and OB without enfuvirtide. Few real life trials have demonstrated the effectiveness of ENF in highly HIV-1 antiretroviral (ARV)-experienced patients. The aim of this study was to evaluate the effectiveness of ENF plus OB regimen (OBR) in a Mexican cohort of highly HIV-1 ARV-experienced patients.Clinical trials POWER 1 and POWER 2 randomized highly treatment-experienced patients to ritonavir-boosted darunavir plus OB or CPI plus OB . At 48 wWe developed a prospective cohort of treatment-experienced HIV-1-infected adults who started therapy with an ENF-containing regimen. The first end point occurred after patients completed 24 weeks of treatment. Secondary end point was the evaluation to 48 weeks of treatment.(ELISA) and Western blot (WB), virological failure, mutations detected from three classes of antiviral drugs and naïve to ENF. Patients had previous treatment with at least three classes of antiretroviral (ARV) drugs including Nucleoside analog reverse-transcriptase inhibitors (NRTIs), Non-nucleoside reverse-transcriptase inhibitors (NNRTIs), and Protease inhibitors (PIs), only one patient had history of integrase inhibitor use (IIN), with mutation resistance documented for each class.Patients were >18 years of age with confirmed HIV-1 infection by Enzyme-Linked ImmunoSorbent Assay An individualized OBR was chosen for each patient. The regimen included three to five ARV agents, with ≥2 fully active drugs according to HIV-1 resistance testing and previous antiretroviral drug experience.Clinical history regarding ARV regimens, CD4+ cells count, HIV-1 RNA viral load, and serum laboratory parameters at the beginning of the therapy with ENF (baseline) and at 24 and 48 weeks later was recorded.pol sequences using the Stanford database. The presence of resistance was defined according to Stanford HIVdb (SS) ranges as follows: 0–9 = susceptible; 10–14 = potential low-level resistance; 15–29 = low-level resistance; 30–59 = intermediate resistance; and ≥60 = high-level resistance.Mutations were assessed from plasma HIV-1 The genotype sensitivity score (GSS) was defined as the total number of drugs (excluding enfuvirtide) in a participant’s optimized background antiretroviral regimen to which their HIV isolate had genotypic sensitivity, as deduced from gene sequence and mutation analyses. This was calculated based on the drug resistance scores extracted from the Stanford HIV data base (HIVdb). Each antiretroviral drug (ARV) was assigned a score according to the five-level Stanford HIVdb interpretation: 1.00, 0.75, 0.50, 0.25 and 0.00 for susceptible, potential low-level resistance, low-level resistance, intermediate resistance and high-level resistance. The GSS was the sum of all scores for all ARVs in the patient’s OBR regimen. The arithmetic sum of the individual score for the specific drugs provided the total GSS of that treatment. We classified the total GSS score in the following categories: 0 to 1, 1 to 2, or ≥2. The 0 to ,1 group contains viral sequences almost entirely resistant to the drugs in their regimen, and the ≥2 group contains viral sequences susceptible to ≥2 drugs given in their OBR regimen .The effectiveness of ENF treatment was evaluated with percentages of undetectable HIV-1 RNA viral load after 24 and 48 weeks of treatment. We also evaluated changes in CD4+ cell counts.Tolerability endpoints were drug tolerability, death, and immune reconstitution and inflammatory syndrome reactions (ISRs). Other evaluations were changes in fasting lipids levels , and creatinine from baseline to weeks 24 and 48.Baseline characteristics were summarized using medians and interquartile ranges (IQR) for continuous variables and proportions for categorical variables. Nonparametric paired tests were used to evaluated CD4 counts and viral load changes. Descriptive statistics were used to evaluate changes in CD4+ cell count and HIV-RNA viral load from baseline. The following statistics were calculated for continuous variables: mean, standard deviation, median with IQR. For categorical variables, number of values in each category and percentage of the values with regard to number of patients in the study population were calculated. Explorative statistical methods were used regarding the efficacy endpoints and changes in safety-relevant laboratory parameters. Significance changes from baseline were tested using the Wilcoxon signed-rank test. All analyses were carried out using SPSS software .We included 40 patients; 37 patients fulfilled the inclusion criteria for the 24-week analyses and 27 of those patients were followed through the 48-week analyses. Two patients died because of advanced disease at the beginning of the ENF regimen (<12 weeks). These deaths were not associated with ENF treatment.The median age of the overall cohort at enfuvirtide initiation was 44.8 years (SD ±8.79) and 89.5% were men. CDC Class C AIDS was found in 64.8% of patients and median of previous ARV treatment was 5 (IQR 5–7) Table . When weThe median calculated GSS of the current regimen without taking into account enfuvirtide was 1.5 (IQR 1.24-2.0), 1.5 (IQR 1.0-1.63) in patients with failure and 2.0  in patients with out failure, P = 0.07. Fifteen (40.5%) patients had a GSS ≥2. Per group, DRV/r and non-IP OBR group had the mayor proportion of the patients with GSS ≥2; TPV/r had majority of GSS 1 to <2 regimens (Table (10)] ]). After 24 weeks of treatment, 91% of patients (n =37) had HIV-1 RNA viral load <400 copies/mL and 65.8% had <50 copies/mL; median, <50 copies/mL [<1.6 log(10)] (IQR <50–137 copies/mL [<1.6–2.1 log(10)]). At week 48 of treatment, 81.4% of the patients (n = 27) had HIV-1 RNA <400 copies/mL and 55.5% had <50 copies/mL; median, <50 copies/mL [<1.6 log(10)] (IQR <50–185 copies/mL [<1.6–2.26 log(10)]), in both cases (p <0.0001 compared to baseline).At baseline, the median HIV-1-RNA viral load was 17,677 copies/mL  (p = 0.372). TC showed no significant increase at either period. There was no significant increase in creatinine compared to baseline values , TG showed a significant increase  viral load decrease through 12-month follow-up in a retrospective cohort of 67 treatment-experienced patients  studies) in highly treatment-experienced patients ,6. Outsipatients . Belperi regimen .As to regimen tolerability, a mild increase in plasma lipid levels during the initial 24 weeks of treatment was not sustained at the final follow-up, at variance with reports elsewhere. Elevation of lipids at baseline may be attributed to those previous and currently exposure to PI-based regimens ,14.et al. were higher [For the injection site reaction, observed at 6 and 12 months, our findings are consistent with previous studies , althouge higher .et al. who reported 52% of their patients developed ISRs, and 14.1% of the entire cohort discontinued therapy as a result of ISRs [ENF was fairly well tolerated by patients in this study. Although 19% of patients developed ISRs, it was not associated with discontinuation therapy. These data differ from those observed in the TORO studies, in which ISRs were observed in 98% of patients receiving ENF, leading to treatment discontinuation in 4.4% of the study participants ,6 and Lo of ISRs .Despite being a retrospective, descriptive design study with a small number of patients and lack of a control group or randomization, this Mexican study also demonstrates that ENF is a valuable therapy option in highly ARV-experienced HIV-1-infected patients who have advanced disease, resistance to traditional ARV drug classes, and clinical progression with very few or no treatment options.Currently, there is no new different drugs families in HIV, regarding drugs with different mechanism of action and no cross-resistance mutations, some people with HIV multi-drug resistance has only integrase inhibitors and sometimes CCR5 antagonist or partial activity of a PI to integrate an OBR; then, ENF will continue as part of salvage therapy in highly ARV-experienced patients.3, and RNA HIV-1 plasma viral load is less than 100,000 copies/ml.ENF has been successfully used to produce durable reductions in viremia even in patients with multi-drug resistance. The likelihood of a sustainable virologic and immunologic responses is maximized when the patient has at least 2 other active agents besides ENF in the OBR, CD4+ cells counts are greater than 100 cells/mmDespite its adverse injection site effects, the addition of ENF to an optimized background antiretroviral regimen did not exacerbate toxicities associated with antiretroviral therapy, and patients treated with enfuvirtide experienced a significantly lower incidence of diarrhea and other gastrointestinal side effects.In conclusion, our study provides clinically important evidence of the effectiveness and safety of ENF in highly ARV-experienced HIV-1-infected patients. These findings strengthen the results of previous randomized controlled trials with this agent.


This study aimed to evaluate plasma concentration of selected cancer-associated inflammatory and immune-modulated cytokines in HIV+ patients with advanced Kaposi sarcoma (KS), and to explore candidate biomarkers capable of predicting clinical outcome in response to chemotherapy (CT) plus combination antiretroviral therapy (cART).Thirty-seven plasma cytokines/chemokines were assessed by Luminex technology in 27 consecutive HIV+ KS patients, followed-up during CT and cART of maintanence (m-cART). Associations between plasma concentration of biomarkers and patient clinical response to m-cART were evaluated by means of Hazard Ratios (HRs) and corresponding 95% Confidence Intervals (CIs).p = 0.01; HR:0.32, 95% CI:0.10–0.99, p = 0.05; HR:0.72, 95% CI:0.54–0.96, p = 0.03, respectively). The multivariate analysis confirmed the associations of baseline plasma G-CSF and HGF concentration with m-cART clinical complete remission response .Plasma baseline concentration of Granulocyte colony-stimulating factor (G-CSF), Hepatocyte growth factor (HGF) and endoglin were found to be associated with m-cART clinical response (HR:1.56, 95%CI:1.09–2.22, Our exploratory study suggested that plasma G-CSF, HGF and endoglin may be novel predictors of clinical response during m-cART in HIV+ KS patients. Nonetheless, these findings should be further validated in an independent population study. Kaposi sarcoma (KS) is the most frequent malignant lesion in patients with AIDS, even after the widespread use of combination antiretroviral therapy (cART), and it is characterized by spindle cell proliferation, inflammatory cell infiltration, angiogenesis, edema, and invasiveness , 2. The KS treatment choice considers the tumour extent and growth, the patient's symptoms, the immunological and virological conditions, the opportunistic co-infections, and the related complications , 9. The In this exploratory clinical study, circulating cytokines and other signalling molecules, involved in angiogenesis, inflammation and tumour growth, were measured among HIV+ advanced KS patients before CT and during maintenance therapy. The study tested the hypothesis that candidate non invasive biomarkers were associated with KS patients clinical response to m-cART.3; CD8 cell counts 53.9 (range: 38.9–74.5) %, with median value of 860 (range: 279–2205) cells/mm3.Blood samples for the 27 KS HIV+ patients before starting debulking CT were available; baseline plasma concentrations for the 37 immunological biomarkers and routinely evaluated HIV RNA, KSHV DNA and CD4/CD8 cell counts are shown in Table Tumour clinical responses observed, considering clinical maximum response to m-cART (at T2), were: complete remission (CR) in 13/27 patients (48.2%), 3/27 patients (11.1%) were on stable partial remission (PR), 3/27 patients (11.1%) showed new PR, and 8/27 patients (30%) showed rapid disease progression.To evaluate the association between plasma concentrations of the 37 biomarkers and patient's clinical response to m-cART, HRs and 95% CIs were calculated for continuous variations of these immunological parameters assessed at baseline, before starting CT (T0).p = 0.01). Plasma concentrations of HGF  and of endoglin  were associated to favourable clinical response to m-cART.Plasma concentrations of 3 out of 37 immunological biomarkers were found to be significantly associated to m-cART clinical response of KS HIV+ patients Table . In partp = 0.009; HR: 0.19, 95% CI: 0.04–0.95, p = 0.04) . Median responses to m-cART according to the concentration of the three plasma biomarkers measured at baseline and found to be statistically significant were: 52.1 months for G-CSF <157 pg/ml (vs. 24.3 months for ≥157 pg/ml), 54.2 months for HGF ≥111 pg/ml (vs. 11.3 months for <111 pg/ml), 54.2 months for endoglin ≥1113 pg/ml (vs. 10.2 months for <1113 pg/ml). All Log-rank tests were statistically significant , likewise for HIV RNA or KSHV DNA viral loads or CD4 cell counts.Identification of predictive and prognostic biomarkers for patients with different diseases and undergoing different therapeutic options is a very active area of investigation. Multiplex cytokines, chemokines, angiogenetic and growth factors were evaluated in a group of consecutive HIV+ patients with advanced KS, who were treated with CT plus cART followed by m-cART. Baseline plasma concentrations of G-CSF, HGF and endoglin were associated to clinical treatment response. At the multivariate analysis, G-CSF and HGF baseline plasma concentrations were confirmed to be associated to clinical complete remission response to m-cART.For KSHV-related diseases, measurement of circulating biomarkers for the prediction of clinical outcome is still at an early stage but rapidly evolving . We prevThe specific roles of each biomarker are complex and multifactorial, considering that the cytokines involved in KS disease modulate multiple immune, inflammatory and other kind of responses. They are provided by chronically activated cells of the immune system or in autocrine/paracrine manner by the neoplastic cells themselves. Nonetheless, the biomarkers found to be correlated with HIV+ KS patients clinical outcome were three well defined growth factors with emerging biological roles.in vitro capability of reducing both spontaneous and VEGF-induced angiogenesis [Endoglin is a membrane glycoprotein, co-receptor for the transforming growth factor beta (TGF-β) superfamily, which preferentially binds TGF- β1 and TGF- β3. This protein is highly expressed by activating proliferating cells with a key function in angiogenesis . In AIDSogenesis . Disturbogenesis .HGF and its Met receptor are involved in the pathogenesis of KS whose biological features are compatible with the biological properties of HGF for invasive growth, tumour proliferation, and neovascularisation , 25, 26.G-CSF belongs to the family of glycoprotein molecules that stimulate the production of white blood cells, particularly granulocytes, and also mobilizes hematopoietic stem cells into peripheral blood . MoreoveThe small sample size and length of patient follow-up represent the main weakness of our exploratory study. In addition, although several biomarkers were screened, we could not array matched healthy donors and/or HIV+ non KS patients to be evaluated in parallel. Despite these limits, our results showed that multiplexed analysis of plasma biomarkers is useful for the evaluation of prognostic markers of clinical outcome and of potential predictive markers of treatment response that may support the clinical management of HIV+ KS advanced patients. Being this a small pilot study designed to assess feasibility, our findings are suggestive rather than definitive. Nonetheless, the observed association of three plasma biomarkers justifies the validation of these findings in a large population study.Twenty seven consecutive HIV+ patients with advanced KS stage (≥T1), according to the AIDS Clinical Trials Group (ACTG) classification , were coClinical evaluation of treatment response was performed after the end of debulking CT and every two months during m-cART. Study endpoint for the evaluation of clinical and biological correlations was set at the maximum response to m-cART.Clinical response to the therapy was recorded according to ACTG criteria  in the fIn particular, for the statistical analysis, patients were categorized into two main groups: CR patients versus no CR patients .After each patient provided written informed consent, peripheral blood samples were collected at consecutive visits: before starting  and after debulking CT (T1), and at the time of maximum clinical response during m-cART (T2).Whole blood was processed immediately for cytofluorimetric analysis and T lymphocyte CD4 and CD8 subsets were evaluated by a single platform whole blood lysing technique (EPICS XL flow cytofluorimeter). Plasma HIV RNA viral load was assessed by RealTime HIV-1 assay . Plasma KSHV DNA viral load was measured by a TaqMan real-time PCR home made method. Our molecular assay reported a good sensitivity, with consistent and comparable KSHV DNA viral loads detected in both plasma and PBMCs specimens from patients with different KSHV-related diseases , 37. Thep-value < 0.05 was considered statistically significant. Due to the exploratory nature of this study, no attempt was made to correct for multiplicity of analyses and nominal p values were reported.Survival probabilities were estimated by means of the Kaplan-Meier method, and compared using the log-rank test. Median response to m-cart was also calculated. The association between immunological and virological biomarkers and disease progression was estimated by means of the Cox proportional hazards model. Hazard Ratios (HRs) and corresponding 95% confidence intervals (CIs) were calculated for continuous variations of the considered biomarker concentration. Analyses were firstly adjusted for HIV RNA and KSHV DNA levels. Biomarkers with a statistically significant association with clinical response to the treatment were thereafter included in a multivariate model and were then plotted. Analyses were performed by means of SAS, version 9.2 . All statistical tests were two-sided and


Plaque psoriasis is a debilitating skin condition that affects approximately 2% of the adult population and for which there is currently no cure. Tofacitinib is an oral Janus kinase inhibitor that is being investigated for psoriasis.The design of this study has been reported previously (NCT00678210). Patients with moderate to severe chronic plaque psoriasis received tofacitinib  or placebo, twice daily, for 12 weeks. Lymphocyte sub-populations, cytomegalovirus (CMV) and Epstein-Barr virus (EBV) DNA were measured at baseline and up to Week 12.Tofacitinib was associated with modest, dose-dependent percentage increases from baseline in median B cell count at Week 4 (24–68%) and Week 12 (18–43%) and percentage reductions from baseline in median natural killer cell count at Week 4 (11–40%). The proportion of patients with detectable CMV and EBV DNA  increased post-baseline in tofacitinib-treated patients. However, multivariate analyses found no relationship between changes in CMV or EBV viral load and changes in lymphocyte sub-populations or tofacitinib treatment.Twelve weeks of treatment with tofacitinib had no clinically significant effects on CMV or EBV viral load, suggesting that lymphocyte sub-populations critical to the response to chronic viral infections and viral reactivation were not significantly affected. Replication of these findings during long-term use of tofacitinib will allow confirmation of this observation. Psoriasis is a debilitating and recurring immune-mediated inflammatory disease that affects 0.91–8.5% of the adult population according to geographic region . TofacitThis exploratory analysis investigated the effect of oral tofacitinib on lymphocyte sub-populations to identify any impact of tofacitinib on immunosurveillance during a Phase IIb, 12-week, placebo-controlled study in patients with moderate to severe plaque psoriasis . The potIn the present study, potential for viral reactivation in general was evaluated using CMV and EBV DNA copy numbers as surrogates of viral-specific immune surveillance. To complement evaluation of lymphocyte sub-populations during tofacitinib treatment, changes in inflammatory activity during tofacitinib treatment were assessed using serum levels of CRP as a marker.This was a Phase IIb, randomized, double-blind, parallel-group, placebo-controlled study conducted in 42 centers in the United States and Canada (NCT00678210). Patients were aged ≥18 years with moderate to severe chronic plaque-type psoriasis covering ≥15% of the total body surface area, had stable disease for ≥6 months, a Psoriasis Area and Severity Index (PASI) score ≥13 and were eligible for phototherapy or systemic treatment of psoriasis [The study design has been reported elsewhere . Briefly+ , CD3+/CD4+ , CD3+/CD8+ , CD19+ (B cells), and CD16+/CD56+ .Whole blood and serum were collected and analyzed. Lymphocyte populations were identified and quantified by fluorescence-activated cell sorting (FACS) analysis at baseline, Weeks 4 and 12, or early termination. Lymphocyte subset markers analyzed included: CD3Serum CRP levels were measured at baseline and Week 12 or early termination. Blood CMV and EBV DNA was measured at baseline, Weeks 4 and 8 (CMV only), and Week 12 or early termination. Viral loads were quantified by real-time polymerase chain reaction (PCR) using DNA isolated directly from peripheral blood leukocytes and expressed as viral DNA copies/500 ng of total DNA. CMV or EBV DNA levels >0 copies/500 ng total DNA were defined as detectable.For continuous endpoints measured longitudinally, a repeated mixed-effect model was used to analyze change from baseline, where treatment, visit week, and interaction between treatment and visit week were included as fixed factors, along with baseline value as the covariate. For continuous endpoints evaluated at a single time point, analysis of covariance (ANCOVA) was used to analyze change from baseline, and the baseline value was included as covariate. For categorical data, comparisons between groups were performed using a Chi-squared test. Missing values were not imputed in any of these analyses.Spearman’s correlation analyses, based on the ranks of variables, were performed between change in viral load or CRP level, and change in lymphocyte sub-population cell counts. A linear model was used to assess potential relationships between change in viral load or CRP level, and change in lymphocyte sub-population cell counts, and doses of tofacitinib.Baseline demographics, disease characteristics, and laboratory values  were similar between groups Table .Table 1+) cell count at Week 4, returning to near baseline levels by Week 12  cell counts (Table H cell count <200 cells/mm3. Among patients with a TH cell count of ≥500 cells/mm3 at baseline (n = 170), two, two, one, and three patients receiving placebo, tofacitinib 2 mg, 5 mg, or 15 mg BID, respectively, had a single post-baseline measurement of <500 cells/mm3. Only one patient had two consecutive TH cell counts <500 cells/mm3 (Week 4 and Week 12). This patient received tofacitinib 2 mg BID. While there was some variability in TC (CD3+/CD8+) cell counts, these changes did not appear to be dose dependent  across groups, ranging from 0.62–0.93 at baseline, 0.58–0.94 at Week 4, and 0.56–0.92 at Week 12.Overall, there was a good correlation between total lymphocyte count and sub-population cell counts  CMV viral load at baseline was 0 copies/500 ng total DNA  in all groups. The median change from baseline in CMV DNA was 0 copies/500 ng total DNA at Week 4, Week 8, and Week 12  , which was reported as a mild adverse event. He reported no other adverse signs or symptoms at this time and continued study treatment. CMV levels subsequently reduced to 92 copies/500 ng total DNA at Day 70 while on treatment. Once the initial positive test was relayed to the investigator site, study treatment was discontinued on Day 86, and on Day 87 his CMV level was 19 copies/500 ng total DNA. The event subsequently resolved. Another patient had a single incidence of CMV DNA ≥5 copies/500 ng total DNA. This patient received tofacitinib 15 mg BID, and had a CMV viral load of 7 copies/500 ng total DNA at Week 8, with no adverse events reported. The patient discontinued treatment and the elevated CMV levels resolved.No comparison of baseline vs post-baseline CMV detectability was possible for patients with detectable CMV at baseline, due to limited sample size Tables  and 3. IThe median  EBV viral load at baseline was 0.0 copies/500 ng total DNA 0.0, 1.3) in all groups  change from baseline in EBV viral load was 0  for all groups except for the tofacitinib 15 mg BID group, in which the median EBV DNA count increased by 0.7 copies/500 ng total DNA  . The number of patients in whom EBV became detectable post-baseline was significant vs placebo in the tofacitinib 2 mg BID (p = 0.0124) and 15 mg BID p = 0.0038) groups . Changes in CRP level showed a weak inverse correlation with larger changes in total T cell, TH cell, TC cell, and B cell counts after 12 weeks of treatment  (Table Spearman’s rank correlation coefficient (rho) analyses of pooled patient data showed that EBV viral load, but not CMV viral load, was weakly correlated with larger changes in total T cell, TC cell count (p = 0.043) or dose of tofacitinib (p = 0.026)  Table .Table 5Clinical data describing the impact of immunosuppressive therapies on the overall risk of infection and serious infection are limited in patients with psoriasis compared with rheumatoid arthritis (RA). However, there is emerging evidence to suggest that the infection risk associated with various therapies used in the RA setting may not be replicated in the psoriasis setting -24. More+) count at Week 4, which appeared to normalize across all doses by Week 12. Dose-dependent percentage changes in median B cell and NK cell count were observed with tofacitinib treatment, with B cell count increased from baseline and NK cell count decreased from baseline at Week 12. Overall, changes in lymphocyte sub-populations observed in this study appear consistent with observations in patients receiving tofacitinib for RA [In this investigation, there was no clinically significant relationship between changes in CMV or EBV viral load and changes in lymphocyte sub-populations. Minimal and transient effects on T cell counts were identified in patients receiving tofacitinib, which may be related to modulation of cytokines, resultant modulation of adhesion molecules, and consequent trafficking of T cells. This is supported by dose-dependent percent changes from baseline in median total T cell  [H cell count <500 cells/mm3 at baseline, fewer than 5% of patients in each group had a post-baseline TH cell count <500 cells/mm3. In other settings in which patients may be immunocompromised, including bone marrow transplantation, a significant correlation with the occurrence of opportunistic infection has been observed only in patients with a TH cell count below 115 cells/mm3 [Tus (HIV)  was not ells/mm3 ,28. BaseH cell, TC cell, and B cell counts after 12 weeks of treatment, is consistent with the recruitment of lymphocytes to sites of inflammation and release of lymphocytes as inflammation resolves.In the present study, mean baseline CRP levels for each group ranged from 3.10 to 5.47 mg/L, which is above the 3.0 mg/L threshold for high relative risk of cardiovascular disease . TofacitThere is published evidence to suggest an association between active plaque psoriasis and reactivation of CMV, with one study identifying a correlation between psoriasis disease activity in CMV seropositive patients and severity of CMV-antigenemia . In the In the HIV setting, a CMV viral load of >200 copies/mL predicts the future occurrence of CMV end organ disease . There iThere are few published studies describing the effects of other therapies for RA or psoriasis on CMV or EBV viral load. A study with 62 patients, aged 2–28 years, receiving biologic (including infliximab and etanercept) or nonbiologic treatment for juvenile RA, Crohn’s disease, or ulcerative rectocolitis detected CMV DNA in 1.6% of patients and EBV in 4.8% of patients . All butPotential limitations of this analysis were the duration of exposure to tofacitinib (12 weeks) and the use of lymphocyte subsets (CD4 and CD8) as surrogates of virus-specific CD4+ and CD8+ cells. While no effect of tofacitinib exposure on viral load was observed over the 12-week study period, one cannot be certain that such an effect would not be observed over a more prolonged period of exposure. With regard to lymphocyte subsets it is possible, albeit unlikely, that tofacitinib treatment could affect the number or function of virus-specific cells without markedly affecting the total number of cells. The absence of an observed increase in viral load suggests that the number and function of these virus-specific cells was sufficient to control viral replication.In patients with psoriasis, 12 weeks of tofacitinib treatment had no clinically significant effects on CMV or EBV viral load, suggesting that lymphocyte sub-populations critical to the response to chronic viral infections and viral reactivation were not significantly affected. Replication of these findings during long-term use of tofacitinib will allow confirmation of this observation.


Reverse transcriptase (RT) mutations contribute to hepatitis B virus resistance during antiviral therapy with nucleos(t)ide analogs. However, the composition of the RT quasispecies and their interactions during antiviral treatment have not yet been thoroughly defined. In this report, 10 patients from each of 3 different virological response groups, i.e., complete virological response, partial virological response and virological breakthrough, were selected from a multicenter trial of Telbivudine treatment. Variations in the drug resistance-related critical RT regions in 107 serial serum samples from the 30 patients were examined by ultra-deep sequencing. A total of 496,577 sequence reads were obtained, with an average sequencing coverage of 4,641X per sample. The phylogenies of the quasispecies revealed the independent origins of two critical quasispecies, i.e., the rtA181T and rtM204I mutants. Data analyses and theoretical modeling showed a cooperative-competitive interplay among the quasispecies. In particular, rtM204I mutants compete against other quasispecies, which eventually leads to virological breakthrough. However, in the absence of rtM204I mutants, synergistic growth of the drug-resistant rtA181T mutants with the wild-type quasispecies could drive the composition of the viral population into a state of partial virological response. Furthermore, we demonstrated that the frequency of drug-resistant mutations in the early phase of treatment is important for predicting the virological response to antiviral therapy. Globally, approximately one-third of the human population has been infected with the human hepatitis B virus (HBV), and 6% of infections develop into chronic infections34One possible reason for the development of NA resistance is that HBV quasispecies with drug-resistant mutations obtain a survival advantage under the selective pressure of antiviral drugs6891010 copies/mL and 4.60 Log10 IU/mL, respectively; and median baseline ALT levels were 130.5 IU/L. The baseline characteristics of the 30 enrolled patients were as follows: median age was 31.5 years; 24 (80%) patients were male; median baseline levels of HBV DNA and HBsAg were 9.09 LogThe aforementioned 107 samples were subjected to ultra-deep sequencing using the 454 GS FLX+ System. The sequenced DNA segments covered the critical LdT-resistance region of the RT gene2Two critical LdT-resistant mutations, rtA181T and rtM204I, were distributed differently in the three patient groups . These tIn the complete-virological-response (CVR) group , neither7The rtA181T mutation also causes a stop-codon mutation in the overlapping surface protein (S protein) gene , i.e., s13βUPU + βM(1- PU)][δPU + (1- PU)]L) and viral clearance (γL) at a given time would determine the changing rate of the viral load (βU and βM), the frequency of the specified mutants in the population (PU), the relative packaging efficiency of the S protein (δ) of the specified mutants, and the viral load at the moment (L). The viral clearance is determined by both the clearance efficiency (γ) and the viral load at the moment (L).We established a mathematical model of HBV dynamics , in whicδ ≤ 0.5) prevents rtA181T mutants from achieving dominance when coexisting with the wild-type quasispecies, in accord with the observed frequencies of rtA181T mutants (1.7 ~ 10.6%) in the viral populations of PVR patients (δ ≈ 1) sW196L mutation in the overlapping S protein To investigate the relationships between the compositions and frequencies of the drug-resistant mutants at the early phase and the virological responses to treatment, we examined the time-serial data from all three patient groups in their early-phase samples. The frequencies of rtA181T mutants were significantly lower in the CVR patients than in the other two sub-optimal groups at baseline  after antiviral treatment, as defined in the EASL guidelines35The clinical relevance of suboptimal virological responses relates to a high risk of developing resistance to long-term anti-HBV treatmentHowever, it is controversial whether drug-resistant mutants originate from quasispecies at the baseline or develop during antiviral treatment2425There are several limitations to this study. First, although deep sequencing is informative, bias resulting from PCR and relatively high error rates introduced by the sequencing system are inevitable. To avoid false-negative calls in cases of extremely low-frequency variants and false-positive calls in the detected variants, several experimental control and calculation steps were taken in this study. We used a conservative cutoff of 1% to distinguish authentic mutations from sequencing errors; this cutoff may have also led to missing information about the rtA181T and rtM204I mutations if present at proportions less than 1%. Second, the present findings were only observed in a LdT-treated cohort. Further research using this approach must be conducted in patients treated with other NAs to substantiate the results. Despite these limitations, our study demonstrated for the first time that the dynamics of different viral quasispecies in the RT region are associated with distinct virological response outcomes.In conclusion, our in-depth analysis of rtA181T and rtM204I mutants suggests that patient virological responses to antiviral therapy are determined by the presence and composition of critical drug-resistant mutants at an early stage of treatment. This investigation identified details about the mechanism of drug-resistance selection in this clinical cohort and provided the opportunity to perform sophisticated molecular phylogenetic analysis, which in turn permitted the development of a mathematical model that successfully led to an in-depth understanding of microevolution in a viral quasispecies population. Further technological improvements for accessing more accurate sequence reads with lower viral loads and other research advances using approaches similar to those of this study may eventually lead to the application of such techniques for personalized antiviral therapy.10 above its nadir during week 12 to the week-52 treatment. Ten subjects with matched HBV DNA levels, genotypes, and HBsAg levels at baseline were selected from each of the three patient groups . In total, 107 samples  were subjected to ultra-deep sequencing using a 454 GS FLX+ System. A flowchart of the patients enrolled in this study is shown in The patients analyzed in our study were selected from a phase-IV, 2-year, multicenter, randomized, controlled trial with LdT ± ADV treatment . The detailed study design and the main efficacy results of this trial have been published27The study was approved by the Ethics Committee of Nanfang Hospital, Southern Medical University. Written informed consent was obtained from all of the patients. All of the experiments were performed in accordance with approved guidelines of Southern Medical University.Laboratory assessments were conducted every 12 weeks from baseline to the end of the study. HBV DNA levels and HBV serological markers were measured with the Roche COBAS TaqMan platform (with a lower limit of detection of 12 IU/mL or 69.84 copies/mL) and with an ARCHITECT i2000SR in the central laboratory, respectively. Serum ALT levels were assessed at local laboratories according to standard procedures. Genotypes were determined by sequencing the small S region and by using the phylogenetic method described previously4, 0.3 μM fusion primers F/R, and 1.0 unit of KOD Plus DNA polymerase . The PCR products were purified using a QIAQuick PCR Purification kit  and were mixed together at an equimolar concentration for amplification by emulsion PCR. Ultra-deep sequencing was then performed on a 454 GS FLX+ System . The distribution of the sequence read length is shown in HBV DNA was extracted from the sera of the 107 patients using a QIAamp UltraSens Virus kit  according to the manufacturer’s protocol. A pair of fusion primers was designed to amplify a fragment of the HBV reverse transcriptase (RT) gene spanning from amino acid 96 to 217, a region within which the mutations known to be responsible for LdT resistance are located. The fusion primers consisted of 454 GS adaptor sequences at the 5′ end, followed by a sample-specific barcode and HBV-specific primers at the 3′ end. The sequences of the forward (F) and reverse (R) primers were 5′-CCATCTCATCCCTGCGTGTCTCCGACTCAGXXXXXXXXGCTGCTATGCCTCATCTTC-3′ (415–433 nt), and 5′-CCTATCCCCTGTGTGCCTTGGCAGTCTCAGXXXXXXXXTCAAGATGYTGTACAGACTT-3′ (782–763 nt), respectively (the string of “X” characters indicates the sample-specific barcode sequence). The PCR reaction was performed in a total volume of 50 μl that contained 1 μl of extracted HBV DNA, 1× Buffer, 0.2 mM dNTPs, 1.0 mM MgSO+ System, and the Sanger method was used to evaluate the sequencing errors of the 454 GS FLX+ System. Taking the Sanger sequencing result of the plasmid as a reference sequence, any mismatches between the sequencing result of the 454 GS FLX+ System and the Sanger method were considered sequencing errors. The plasmid was sequenced together with the clinical samples in 6 separate runs and showed an overall mismatch error rate of 0.016%. Over the 6 sequencing runs, a mean of 1.3 nucleotides per sequence was observed to have a mismatch error rate ≥1%  frequency of mutation ≥1%; 2) quality score ≥20; and 3) coverage ≥500.All of the sequence reads from a single patient were aligned using the MUSCLE (version 3.8.31) software with default parametersA system of ordinary differential equations was implemented for modeling the dynamics of quasispecies. We separately specified the total amounts of rtA181T, rtM204I mutants, and drug-sensitive wild-type viruses in the system. The rate of fluctuation in the total viral amount is determined by the difference between the rates of viral replication and clearance. Dynamic-model HBV dynamics were modeled according to the methods of Nowak MARMThe observed change of rtA181T and rtM204I mutant frequencies in the PVR and VB groups enabled us to assign parameters for the aforementioned dynamic model and further explore the mechanism of HBV dynamics during antiviral therapy .


An increasing number of patients in Africa are experiencing virologic failure on second-line antiretroviral therapy (ART) and those who develop resistance to protease inhibitors (PI) will require third-line ART, but no data on the outcomes of third-line are available from the region. We assessed the virologic outcomes and survival of patients started on salvage ART in a Southern African private sector disease management programme.Retrospective observational cohort study with linkage to the national death register. Adults (≥18 years) who started salvage ART between July 2007 and December 2011 were included. Salvage ART was defined by inclusion of darunavir or tipranavir in an ART regimen after having failed another PI. For Kaplan–Meier (KM) analysis, patients were followed up until event, or censored at death (only for virologic outcomes), leaving the programme, or April 2014.152 patients were included. Subtype was known for 113 patients: 111 (98 %) were infected with subtype C. All 152 had a genotype resistance test demonstrating major PI resistance mutations. Salvage drugs included were: darunavir/ritonavir (n = 149), tipranavir/ritonavir (n = 3), raltegravir (n = 58), and etravirine (n = 8). Median follow-up was 2.5 years (IQR = 1.5–3.3). 82.9 % achieved a viral load ≤400 copies/ml and 71.1 % ≤50 copies/ml. By the end of the study 17 (11.2 %) of the patients had died. The KM estimate of cumulative survival was 87.2 % at 2000 days.Virologic suppression was comparable to that demonstrated in clinical trials and observational studies of salvage ART drugs conducted in other regions. Few deaths occurred during short term follow-up. Third-line regimens for patients with multidrug resistant subtype C HIV in Africa are virologically and clinically effective. The emergence of resistance to antiretroviral drugs is an inevitable consequence of expanding access to antiretroviral therapy (ART) and longer durations of exposure. Currently less than 15 % of patients in ART programmes in Africa are on second-line ritonavir-boosted protease inhibitor (PI) regimens , but thiThe 2013 World Health Organization (WHO) ART guidelines recommended that national programmes should develop policies and conduct pilot studies for third-line ART for patients with multi-class resistance after second-line failure . Newer AWe evaluated virologic and clinical outcomes on salvage ART in the Southern African private health care sector amongst patients who had previously experienced virologic failure on a PI-containing regimen and in whom a genotype antiretroviral resistance test (GART) prior to starting salvage ART demonstrated at least one major PI mutation. Our broader aim was to inform advocacy and planning for third-line ART in programmes in sub-Saharan Africa.On 31 December 2011 there were a total of 96,527 adult patients (≥18 years) receiving ART in the Aid for AIDS (AfA) programme, 152 of whom fulfilled our inclusion criteria for salvage therapy. The characteristics of our cohort are shown in Table The following salvage drugs were prescribed: darunavir/ritonavir (n = 149), tipranavir/ritonavir (n = 3), raltegravir (n = 58) and etravirine (n = 8). NRTI drugs were included in 149 salvage regimens: tenofovir (TDF)/emtricitabine (FTC) in 105, TDF/FTC/zidovudine (AZT) in 22, AZT/lamivudine (3TC) in 9, and other NRTI combinations in 13. In 2 patients although salvage therapy was authorised it could not be verified from documentation available that they had been dispensed salvage therapy. These 2 patients were, however, included in the analyses as we could not determine that they definitely had not been dispensed salvage therapy.10 increase in VL, and aOR = 0.59, 95 % CI = 0.39–0.90 per 10 point increase on Stanford database, respectively). There was a non-significant trend towards the inclusion of raltegravir in the salvage regimen being associated with a higher odds of suppression .The median duration of follow-up on salvage therapy was 2.5 years IQR = 1.5–3.3). By date of administrative censor (30 April 2014), 17 of 152 patients (11.2 %) had died. 145/152 (95.4 %) patients had at least 1 viral load done on salvage therapy: 126/145 achieved a VL ≤400 copies/ml (86.9 %) and 108/145 achieved a VL ≤50 copies/ml (74.5 %). Of all 152 patients, 82.9 % were therefore documented to have suppressed VL ≤400 copies/ml and 71.1 % VL ≤50 copies/ml. Kaplan–Meier (KM) estimates of cumulative proportions of all 152 patients suppressing to a VL ≤400 copies/ml at 1000 days was 92.2 % and VL ≤50 copies/ml was 83.4 % . The KM estimate of survival at 2000 days was 87 %. These results are striking given that this cohort of patients had previously failed multiple lines of therapy.The proportion of patients achieving virologic suppression in our study was near to that achieved in the ANRS 139 TRIO trial conducted in France in which patients with multiclass resistant HIV were treated with darunavir, raltegravir, etravirine and either NRTIs or enfuvirtide. In that single-arm trial, 88 % of participants achieved virologic suppression (VL <50 copies/ml) at 96 weeks . While aThe need for evidence regarding the implementation of third-line ART in resource-limited settings has been recognized by the WHO . Our datImportant limitations of our study were the retrospective observational study design, which could have resulted in selection and information bias, and potential limited generalizability to the public sector. While there are important socioeconomic differences between private and public sector patients in the region, which could affect outcomes, we felt that our results are applicable to public sector programmes as similar treatment guidelines were followed and 5 year outcomes were previously reported to be similar between AfA and a large South African public sector programme . Of noteAfA has been providing ART, GART and new salvage drug options for longer than public sector programmes, thus providing us with the first opportunity to assess outcomes on salvage drugs in an African setting. These data provide the first evidence of the potential effectiveness of third-line regimens based largely upon a backbone of darunavir/ritonavir and raltegravir together with NRTI drugs, in a predominantly subtype C African epidemic. Availability of GART and darunavir/ritonavir and raltegravir (or dolutegravir) needs to be planned for the future as more patients fail second-line PI regimens for longer durations in public sector programmes on the continent. Our results provide evidence that third-line regimens for patients failing second-line ART with multidrug resistant HIV in Africa are likely to be effective.We conducted a retrospective observational cohort study of adults (≥18 years) enrolled with the Aid for AIDS (AfA) disease management programme, who started salvage ART between 1 July 2007 and 31 December 2011. Salvage ART was defined by inclusion of darunavir or tipranavir in an ART regimen after having experienced virologic failure on another PI. No patients had prior exposure to an integrase inhibitor. All patients had a GART performed prior to starting a salvage ART regimen that was used to inform choice of drugs in this regimen. These GARTs were performed at quality-assured private sector laboratories and results were sent to the patient’s doctor and to AfA. Certain laboratories reported the HIV subtype on the laboratory results sheet routinely, but for some patients (n = 39) this information was not supplied. Salvage drugs that became available during the study period were initially darunavir and later raltegravir and etravirine—these were prescribed to patients commencing salvage regimens after they became available if indicated, but were not added as single drugs for a patient already on salvage ART. Access to tipranavir was very limited.AfA is a private sector HIV disease management programme that provides HIV care for patients on medical insurance and corporate treatment programmes , 26. HIVImportant differences between AfA and the public sector ART programme in South Africa are: (1) the AfA programme started in 1998 whereas the public sector programme started in 2004; (2) in AfA some patients received initial ART with dual NRTIs for affordability reasons in the late 1990s; (3) certain drugs were available in the private sector before the public sector; (4) GART has been available for patients failing ART in AfA since 2001; and (5) darunavir was readily available to patients on the AfA programme from 2007, and raltegravir from 2009. These two drugs became available in the public sector programme in 2013.Commencement of salvage ART was checked against the pharmacy claims history on the AfA database. Vital status was available for all patients at the date of data censor: (1) for South Africans through linkage to the South African national death register and (2) for patients outside South Africa from the clinical records. The Stanford HIV Drug Resistance Database (version 6.2.0) was used to calculate mutation scores.For Kaplan–Meier (KM) analyses of time to virologic suppression or death, patients were followed up until the date of the event or censored at death (only for virologic outcomes), leaving the programme, or date of administrative censor (30 April 2014). Multivariate logistic regression analysis was performed using STATA 13, StataCorp, TX, US, with all variables hypothesised to be associated with outcome included in the model. Virologic rebound was defined as ≥1 viral load (VL) >1000 copies/ml after initial suppression.