Kaposi sarcoma (KS) is the most common AIDS-defining tumour in HIV-infected individuals in Africa. Kaposi sarcoma herpes virus (KSHV) infection precedes development of KS. KSHV co-infection may be associated with worse outcomes in HIV disease and elevated KSHV viral load may be an early marker for advanced HIV disease among untreated patients. We examined the prevalence of KSHV among adults initiating antiretroviral therapy (ART) and compared immunological, demographic and clinical factors between patients seropositive and seronegative for KSHV.3) and CD4 (90 vs. 80 cells/mm3) counts than KSHV negative subjects. We found no associations between KSHV seropositivity and body mass index, tuberculosis status, WHO stage, HIV RNA levels, full blood count or liver function tests at initiation. Those with detectable KSHV viremia (n = 19), however, appeared to present with signs of more advanced HIV disease including anemia and WHO stage 3 or 4 defining conditions compared to those in whom the virus was undetectable.We analyzed cross-sectional data collected from 404 HIV-infected treatment-naïve adults initiating ART at the Themba Lethu Clinic, Johannesburg, South Africa between November 2008 and March 2009. Subjects were screened at ART initiation for antibodies to KSHV lytic K8.1 and latent Orf73 antigens. Seropositivity to KSHV was defined as positive to either lytic KSHV K8.1 or latent KSHV Orf73 antibodies. KSHV viremia was determined by quantitative PCR and CD3, 4 and 8 lymphocyte counts were determined with flow cytometry. Of the 404 participants, 193 (48%) tested positive for KSHV at ART initiation; with 76 (39%) reactive to lytic K8.1, 35 (18%) to latent Orf73 and 82 (42%) to both. One individual presented with clinical KS at ART initiation. The KSHV infected group was similar to those without KSHV in terms of age, race, gender, ethnicity, smoking and alcohol use. KSHV infected individuals presented with slightly higher median CD3 (817 vs. 726 cells/mmWe demonstrate a high prevalence of KSHV among HIV-infected adults initiating ART in a large urban public-sector HIV clinic. KSHV viremia but not KSHV seropositivity may be associated with markers of advanced HIV disease. Since there has been greater access to antiretroviral therapy (ART) -3, increWhile clinical Kaposi sarcoma is known to be a marker of advanced HIV disease and is one of the WHO stage 4 and AIDS-defining illnesses , it is uWe enrolled subjects in a cohort study to determine the impact of KSHV on response to HAART as well as the effects of HAART on KSHV control. This cross-sectional analysis forms part of this larger study and aimed to measure the prevalence of KSHV infection among these HIV-infected adults initiating ART in a large treatment programme in Johannesburg, South Africa and to compare T-lymphocyte subpopulations and other demographic, clinical and laboratory factors between patients seropositive and seronegative for KSHV at enrolment.This cross-sectional study utilized data from patients enrolled in care at the Themba Lethu Clinic in Johannesburg, South Africa. Currently, Themba Lethu has over 23,000 HIV infected adults enrolled in its comprehensive HIV care, management and treatment program. Since inception, over 16,000 of these patients have been initiated on ART at this clinic. Care at the clinic is provided according to the guidelines from the South African National Department of Health . Patient3 or WHO stage 4 defining illness) and who were attending group counselling sessions at Themba Lethu were invited to participate in the study. Patients who did not meet these criteria or had a history of prior ART use were excluded from the study.Between November 2008 and March 2009, all HIV-positive treatment naïve patients > 18 years of age who met the National guidelines criteria for initiation of ART . Detection of antibodies to a single antigen has been shown to potentially underestimate the prevalence of KSHV, therefore, the ELISA to detect antibodies to latency associated nuclear antigen was performed in addition to the lytic K8.1 ELISA to provide a more accurate assessment of KSHV antibody status . KSHV viAdditional data was extracted from the electronic patient record. Demographic variables of interest included gender, age at study enrolment, race, as well as ethnicity (using mother and father tongue as a proxy). Clinical data on initiating ART regimen, WHO clinical stage, body mass index (BMI), tuberculosis status and HIV RNA level at enrolment were also extracted as well as laboratory results for full blood counts and liver function tests.The prevalence of KSHV among the study group was estimated and is presented with corresponding 95% confidence bounds. Demographic, clinical and laboratory characteristics of the participants at study enrolment were stratified by KSHV status and summarized as simple proportions or medians with interquartile ranges (IQR). Logarithmic transformations of optical densities for lytic K8.1 and latent Orf73 were performed and are presented as geometric means. Crude prevalence ratios for participant presenting features were estimated using log-binomial regression models stratified by KSHV serostatus. This analysis was also further stratified by reaction to lytic K8.1 or latent Orf73 antigen. Models were adjusted for age, sex and presenting CD4 count where appropriate.Approval to conduct this study and use of data from the Themba Lethu site was granted by the Human Research Ethics Committee of the University of the Witwatersrand.All eligible subjects initiating ART at Themba Lethu Clinic between November 2008 and March 2009 were invited to participate and we enrolled 404 of these. Response rates were high: it is estimated that fewer than 5% of those invited to participate refused. However, in order to determine if the sample was representative of the untreated population accessing HIV care at that time, we compared this sample to the general population presenting for treatment initiation at Themba Lethu during the recruitment period that were either not invited or refused to participate in the study. The presenting features of the study group were very similar to the Themba Lethu Clinic general population at ART initiation Table  in termsThe median age of the study group was 38 years (IQR 32-45 years) and 262 (65%) were women. The median CD4 count at ART initiation was 87 cells/μL (IQR 40-149 cells/μL) and nearly 40% presented with a WHO stage III/IV defining condition. The majority of participants were started on standard public-sector first-line ART regimens: 86% on stavudine, lamivudine and efavirenz and 7% on stavudine, lamivudine and nevirapine. The remaining 7% who presented with a contra-indication to one of the standard first-line regimens were initiated on zidovudine, lopinavir/ritonavir or tenofovir-based regimens.Among the study participants, 193/404 tested positive to lytic KSHV K8.1 and/or latent KSHV Orf73 antibodies at ART initiation; the prevalence of KSHV in this urban population was estimated at 48% (95%CI: 43-53%). Of those positive for KSHV, 76  were reactive to lytic K8.1 alone, 35  to latent Orf73 and 82  to both. Only one individual presented with clinical KS at ART initiation. This individual was positive to both lytic and latent KSHV antigen but did not have a detectable KSHV viral load.Of the 193 individuals serologically positive to KSHV, 167 (87%) had samples available for KSHV viral load testing. KSHV DNA was detected in 19 (11%) of the buffy coat samples of those serologically positive to KSHV with a median of 10.6 (IQR 6.7-37.5) copies/uL and values ranging from 1.91 - 109.8 copies/uL. A higher proportion of those positive to both lytic and latent KSHV antibodies had detectable KSHV viral loads (20%) compared to those positive to only lytic (3%) or only latent (8%). The estimates suggested that those with a detectable KSHV viral load were more likely to be male , have a WHO stage III/IV illnesses  and hemoglobin ≤ 8 g/dL  compared to those without a detectable KSHV viral load, although these results lacked precision .3) and CD4 (90 vs. 80 cells/mm3) than KSHV negative subjects . KSHV positive individuals presented with slightly higher median CD3  and CD8  cell counts. Higher BMI (≥ 18.5 kg/m2) was associated with reactivity to both lytic K8.1 [PR = 1.33 (0.94-1.90)] and latent Orf73 [PR = 1.46 (0.94-2.26)] in models adjusted for age, gender and CD4 cell count  for lytic K8.1 and 0.34 95%CI 0.32-0.37) for latent Orf73. Presence of antibodies to latent Orf73 was associated with higher median CD3  demonstrated in this setting is comparable with findings from similar settings among HIV-infected populations ,35. In cAdvanced age, male gender, nutrition, anemia, concurrent tuberculosis and other opportunistic infections have been demonstrated to be associated with an advanced stage of HIV disease and mortality among untreated individuals ,19-22,37The optical density for lytic and latent KSHV was comparable to other work in similar settings with high HIV prevalence . The opttat proteins and activation of HIV replication [Co-infection with other viruses such as hepatitis, Epstein-Barr and human papilloma has been shown to increase the risk of HIV disease progression and mortality in immune suppressed HIV infected individuals -51. Therlication . Despitelication .Our findings must be considered in light of possible limitations of the study. Firstly, due to the cross sectional nature of the analysis, we cannot make inferences about causal relationships between KSHV and the factors under investigation. As KSHV transmission has been shown to occur even early in life ,40, presDespite these limitations, this study offers some insight into, as yet, unanswered questions around the clinical effect of KSHV co-infection. We demonstrate a high prevalence of co-infection with KSHV among a group of treatment naïve, HIV-infected adults initiating ART at a large urban clinic in Johannesburg, South Africa. The study population was similar to the general population accessing care at Themba Lethu Clinic with respect to presenting features. The results may, therefore, be reasonably extrapolated to HIV positive individuals accessing care at urban public sector clinics in South Africa. Although there appeared to be some immunological differences in terms of CD3, CD4 and CD8 cell counts between the KSHV positive and negative groups, KSHV seropositivity was not associated with other known risk factors for disease progression such as age, gender and concurrent tuberculosis infection among the HIV-infected untreated population. If we assume that KSHV co-infection has little or no impact among the untreated population, it may follow that KSHV co-infection would have little effect on outcomes among treated individuals, unless KSHV has a large direct impact on the effectiveness of antiretrovirals. Future research efforts in this field should be focused on longitudinal studies to determine if KSHV seropositivity, particularly viremia, poses a risk for HIV treatment outcomes, development of KS immune reconstitution inflammatory syndrome and mortality in the presence of antiretroviral therapy.The authors declare that they have no competing interests.All authors contributed to the conception and design of the study. MM, PM, DW and CW contributed to acquisition of data. MM performed the statistical analysis. MM, MF, DW and CW interpreted the results and MM, MF, PM and ME drafted the manuscript. All authors revised the manuscript critically for intellectual content and have approved the submitted version.


Starting HAART in a very advanced stage of disease is assumed to be the most prevalent form of initiation in HIV-infected subjects in developing countries. Data from Latin America and the Caribbean is still lacking. Our main objective was to determine the frequency, risk factors and trends in time for being late HAART initiator (LHI) in this region.+ count ≤200cells/mm3 prior to HAART. Late testers (LT) were those LHI who initiated HAART within 6 months of HIV diagnosis. Late presenters (LP) initiated after 6 months of diagnosis. Prevalence, risk factors and trends over time were analyzed.Cross-sectional analysis from 9817 HIV-infected treatment-naïve patients initiating HAART at 6 sites  from October 1999 to July 2010. LHI had CD4+ available (n = 8515), 76% were LHI: Argentina (56%[95%CI:52–59]), Chile (80%[95%CI:77–82]), Haiti (76%[95%CI:74–77]), Honduras (91%[95%CI:87–94]), Mexico (79%[95%CI:75–83]), Peru (86%[95%CI:84–88]). The proportion of LHI statistically changed over time (except in Honduras) , with a tendency towards lower rates in recent years. Males had increased risk of LHI in Chile, Haiti, Peru, and in the combined site analyses (CSA). Older patients were more likely LHI in Argentina and Peru , but not in CSA . Higher education was associated with decreased risk for LHI in Chile  . LHI with date of HIV-diagnosis available, 55% were LT and 45% LP.Among subjects starting HAART (n = 9817) who had baseline CD4LHI was highly prevalent in CCASAnet sites, mostly due to LT; the main risk factors associated were being male and older age. Earlier HIV-diagnosis and earlier treatment initiation are needed to maximize benefits from HAART in the region. Since the introduction of highly active antiretroviral therapy (HAART) for the treatment of HIV infection, the benefits in survival have been clearly established 3 and/or a history of an AIDS-defining illness). Consequently, these patients were late HAART initiators Despite efforts to improve the care of people living with HIV, a considerable proportion of subjects do not obtain medical attention until they are in very advanced stages of the disease http://ccasanet.vanderbilt.edu/) has been described elsewhere www.iedea-hiv.org) with the purpose of collecting HIV data from Central and South America and the Caribbean to be able to describe the unique characteristics of the HIV epidemic in this region. Six CCASAnet sites contributed data to this study: Fundación Huésped in Buenos Aires, Argentina (FH-Argentina); Fundación Arriarán in Santiago, Chile (FA-Chile); Le Groupe Haïtien d'Etude du Sarcome de Kaposi et des Infections Opportunistes in Port-au-Prince, Haiti (GHESKIO-Haiti); Instituto Hondureño de Seguridad Social and Hospital de Especialidades in Tegucigalpa, Honduras (IHSS/HE-Honduras); El Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán in Mexico City, Mexico (INNSZ-Mexico); and El Instituto de Medicina Tropical Alexander von Humboldt in Lima, Perú (IMTAvH-Peru). Institutional review board approval was obtained locally for each participating site and for the CCASAnet data coordinating center (DCC) at Vanderbilt University, Nashville, TN, USA.The CCASAnet cohort (3 or an AIDS-defining illness (ADI) prior to or at HAART initiation. LHI were further classified as either late testers (LT) or late presenters (LP), corresponding to those who started HAART within 6 months of HIV diagnosis (LT) or more than 6 months after HIV diagnosis (LP). The remaining patients were considered non-late HAART initiators (NLHI). All study definitions were chosen a priori.The source population for this cross-sectional analysis was HIV-infected adults receiving medical care at the 6 participating CCASAnet sites. Treatment-naïve patients who started HAART between October 1999 and July 2010 were included. HAART was defined in all sites as all regimens with at least 3 antiretroviral drugs . All participant sites are part of local programs for universal free access to HAART. Late HAART initiators (LHI) were defined as those subjects with a non-missing baseline CD4 cell count (6 months before or 1 week after starting HAART) who either had baseline CD4≤200 cell/mmEach participant site contributed data from their database using a standard data transfer protocol. Demographic, clinical, and laboratory data for all sites were prospectively collected and periodically recorded. The databases are updated routinely and sent to the DCC. Data were checked for errors and inconsistencies.We collected data on sex, age at HAART initiation, probable route of infection , marital status , employment status (employed/unemployed), and years of education at first clinic visit. In sites with available data (FH-Argentina and INNSZ-Mexico), sexual probable route of infection was further classified as homosexual or heterosexual. Baseline CD4 cell count was defined as the measurement closest to HAART initiation but not more than 6 months prior to, or 7 days after, the date of HAART start. Values not available within this time frame were considered missing.Trends in the proportion of LHI across the study period were assessed non-parametrically using Friedman's ‘super smoother’ 3 (IQR 49–219); baseline CD4 cell count was missing for 1302 subjects (13%). The median time between HIV diagnosis and HAART initiation was 153 days ; date of diagnosis was missing for 1836 (18.7%) subjects. The time period of the study differed between sites, although all sites contributed data from 2003–2008.A total of 9817 subjects started HAART during the study period. Patient characteristics stratified by site and combined are shown in p<0.001 for FH-Argentina, FA-Chile, GHESKIO-Haiti, and IMTAvH-Peru; p = 0.02 for INNSZ-Mexico; and p = 0.86 for IHSS/HE-Honduras). Rates of LHI tended to be lower in more recent years for most of the sites. The rates of LHI in INNSZ-Mexico and GHESKIO-Haiti increased in earlier years followed by a decrease in later years. In contrast, in FH-Argentina the rate of LHI decreased in earlier years and stayed roughly constant from 2004 to 2009. Note that 95.2% of patients started HAART with CD4<350 or an ADI.Of 8515 patients with a recorded baseline CD4 cell count, 6431 (76% [95%CI: 74–77]) were LHI: 56% [95%CI: 52–59] in FH-Argentina, 80% [95%CI: 77–82] in FA-Chile, 76% [95%CI: 74–77] in GHESKIO-Haiti, 91%[95%CI: 87–94] in IHSS/HE-Honduras, 79% [95%CI: 75–83]) in INNSZ-Mexico and 86% [95%CI: 84–88] in IMTAvH-Peru. At HAART initiation, 70.4% of patients had CD4<200 (with or without ADI), 30.5% had an ADI (regardless of CD4+ count), and 25.6% had both characteristics. The proportion of LHI over time for each site is shown in In multivariate logistic analyses including age, sex, years of education, and date of HAART initiation, male sex was associated with an increased risk of LHI in FA-Chile, GHESKIO-Haiti, IMTAvH-Peru, and in the combined site analyses , but not in FA-Chile, IHSS/HE-Honduras, INNSZ-Mexico, or IMTAvH-Peru   were late testers and 2716 (45%) were late presenters, corresponding to 42% and 34% of the 7901 patients in the overall cohort with complete data. The proportion of late HAART initiators who were LT was 50% for FH-Argentina, 23% for FA-Chile, 63% for GHESKIO-Haiti, 56% for IHSS/HE-Honduras, 48% for INNSZ-Mexico, and 59% for IMTAvH-Peru. Temporal trends were seen across sites . NotablyMale sex was associated with late presentation and especially late testing for most sites and when all sites were considered together . The estimated rates of LHI were 56% in FH-Argentina, 80% in FA-Chile, 76% in GHESKIO-Haiti, 89% in IHSS/HE-Honduras, 78% in INNSZ-Mexico, and 86% in IMTAvH-Peru. The only notable changes in multivariate analyses were 1) education was associated with LHI in FH-Argentina  and 2) the association between age and LHI in IMTAvH-Peru slightly weakened .3 that is the recommended by most of the current international guidelines The present study conducted among cohorts in different sites from 6 Latin-American countries shows that a significant proportion of patients starting HAART in this region do so after they have experienced an AIDS-defining illness or when the CD4 cell count is lower than 200, far below the cutoff of 350 cells/mm3Recently, in a large cohort of 14 sites in the USA and Canada (NA-ACCORD), late presentation to care seem to be have been decreasing between 1997 and 2007, based on the change in the median of CD4+ count at presentation to care The outstanding risk factor for LHI in the multivariate analysis was male sex. Older age and less education were also associated with higher rates of LHI in many of the sites. Even though the AIDS epidemic in most of the participating countries is driven by MSMs, in the sites where these data were available (INNSZ-Mexico and FH-Argentina) MSMs tended to have a somewhat lower risk of being LHI. In the combined analysis of all cohorts, the same factors  were significantly associated with late testing (recent diagnosis in LHI) and with late presentation (diagnosis more than 6 months before HAART initiation). These risk factors are similar to those reported in other studies for patients diagnosed in advanced stages One limitation of our study is the number of missing CD4 cell counts at HAART initiation from some of the sites. The analysis presented excluded those patients without data, which may bias the results. However, we obtained similar results using multiple imputation techniques which allow the inclusion of all patients initiating HAART. Another potential limitation is that we may have had insufficient power to detect some risk factors for LHI due to there being very few NLHI in some sites. The heterogeneity between rates of LHI at the different sites is also noteworthy, and suggests that there are important differences between clinic settings, perhaps in traditions, culture, HIV stigma, testing services, education, or something else. Unfortunately, with only six sites, we do not have sufficient data to investigate site-specific factors associated with LHI.It is important to emphasize that our study did not measure the rate of late testing, but rather the proportion of patients who started HAART who were considered late testers. Of course, these patients represent only those who made it to care and received treatment. Our study does not consider persons in late stages of disease who do not know their HIV status, or diagnosed patients in late stages of disease who have not started treatment.3 or with an AIDS-defining illness in Latin-American and the Caribbean, which is substantially below the current cutoff recommended in international guidelines In conclusion our study shows a high rate of HAART initiation at CD4 cell counts <200 cell/mmFigure S1Probability of being a LHI over time adjusting for age, sex, and years of education.NOTE. 95% confidence intervals are reported. The adjusted rates of LHI statistically changed over time for most sites . FH-Argentina, Fundación Huésped in Buenos Aires, Argentina; FA-Chile, Fundación Arriarán in Santiago, Chile; GHESKIO-Haiti, Le Groupe Haïtien d'Etude du Sarcome de Kaposi et des Infections Opportunistes in Port-au-Prince, Haiti; IHSS/HE-Honduras Instituto Hondureño de Seguridad Social and Hospital de Especialidades in Tegucigalpa, Honduras; INNSZ-Mexico, El Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán in Mexico City, Mexico; and IMTAvH-Peru, El Instituto de Medicina Tropical Alexander von Humboldt in Lima, Perú. LHI, late HAART initators.(EPS)Click here for additional data file.Table S1Number of patients by Calendar year of time of HAART initiation by site.NOTE. HAART, highly active antiretroviral therapy; FH-Argentina, Fundación Huésped in Buenos Aires; FA-Chile, Fundación Arriarán in Santiago, GHESKIO-Haiti, Le Groupe Haïtien d'Etude du Sarcome de Kaposi et des Infections Opportunistes in Port-au-Prince; IHSS/HE-Honduras Instituto Hondureño de Seguridad Social and Hospital de Especialidades in Tegucigalpa; INNSZ-Mexico, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán in Mexico City; and IMTAvH-Peru, Instituto de Medicina Tropical Alexander von Humboldt in Lima; LHI, late HAART initiators.(DOCX)Click here for additional data file.Table S2a.Odds ratios  for late HAART initiation using multiple imputationNOTE. FH-Argentina, Fundación Huésped in Buenos Aires, Argentina; FA-Chile, Fundación Arriarán in Santiago, Chile; GHESKIO-Haiti, Le Groupe Haïtien d'Etude du Sarcome de Kaposi et des Infections Opportunistes in Port-au-Prince, Haiti; IHSS/HE-Honduras Instituto Hondureño de Seguridad Social and Hospital de Especialidades in Tegucigalpa, Honduras; INNSZ-Mexico, El Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán in Mexico City, Mexico; and IMTAvH-Peru, El Instituto de Medicina Tropical Alexander von Humboldt in Lima, Perú. aData shown are odds ratios . Estimates are adjusted for all variables in the table as well as date of HAART initiation.(DOCX)Click here for additional data file.


Across the MVC development program, patients who received MVC-containing regimens experienced greater increases in CD4+ cell counts than those observed in comparator arms in primary analyses. Here we present longer term immunological data from this program.Long-term (96 week) data from subjects with CCR5-tropic HIV infection in the following ongoing MVC studies were included in the analysis: (1) MOTIVATE study (MVC QD and BID vs placebo (PBO), each combined with optimized background therapy in treatment-experienced [TE] subjects); and (2) MERIT study . Additionally, interim week 24 data from the ongoing 96-week 1078 study  were summarized. Descriptive statistics are presented for data at baseline and at week 96 (MERIT/MOTIVATE) or week 24 (1078) pertaining to change in CD4+ and CD8+ cells.Greater increases in CD4+ cells in MVC-containing groups persisted through 96 weeks in the MOTIVATE and MERIT studies, and through 24 weeks in the 1078 study (Table Greater increases in CD4+ and CD8+ counts were consistently achieved with MVC-containing regimens, compared to regimens without MVC, and persisted through at least 2 years of therapy in both TN and TE patients. These differences were independent of changes in HIV-1 RNA and are evident with multiple different MVC-containing regimens.


The lower sales price of generic lamivudine has caused healthcare administrators to consider abolishing fixed-dose antiretroviral combinations (FDCs) that contain lamivudine and emtricitabine. The alternative is to administer the individual components of the FDCs separately, thus incorporating the new generic lamivudine medication.The Balearic Islands Health Service ordered the discontinuation of the treatment with FDCs in July 2010, but FDCs were reintroduced in August 2010. At that point, an independent, retrospective cost analysis was performed by Son Llàtzer Hospital. A total of 75 patients who were treated from July to August 2010 underwent replacement of their FDC treatment with the individual components. Additionally, 150 patients who continued using FDCs were randomly selected. For both patient groups, the antiretroviral therapy that was administered and the costs associated with management of adverse events were recorded. The study period used for the cost calculations was the average number of days that patients used separate components of FDCs (120 days). An alternative analysis was performed to consider the costs of the extra follow-up visit  that was required for patients who changed their antiretroviral therapy.Considering antiretroviral therapies and adverse events, the administration of the separate components increased the total daily cost by 0.72 € per patient compared to treatment with FDCs. When the cost of an extra follow-up visit was considered, the daily cost increased by 3.61 € per patient.Our study suggests that the discontinuation of FDC treatment and the replacement with the administration of separate antiretroviral agents could lead to an increase in healthcare costs due to the higher rate of adverse events that was observed with the discontinuation of FDCs. Lentivirus genus. The infection produced by HIV leads to the development of the acquired immunodeficiency syndrome (AIDS). HIV preferentially attacks CD4+ cells, a type of T lymphocyte, which prevents the immune system from reacting to opportunistic infections that are produced by other viruses, bacteria, or fungi. According to the latest World Health Organisation (WHO) data in December 2011, the number of people infected by HIV is estimated to be 34 million [Human immunodeficiency virus (HIV) is a retrovirus of the Because of the complexity associated with the selection of a specific treatment, the severity of the related side effects and the necessity of preventing the appearance of resistant viral strains, the current treatment of HIV-1 is based on a combination of antiretroviral agents. This therapy, known as “highly active antiretroviral therapy” (HAART), has evolved over the years from a regimen of more than 20 pills per day to a single daily pill that combines fixed doses of several antiretroviral agents [Antiretroviral therapy (ART) should be administered indefinitely to patients infected with HIV-1. The therapy, which has possible short- and long-term side effects, requires constant therapeutic compliance to complex drug regimens. Fixed-dose antiretroviral combinations (FDCs) have led to the simplification of antiretroviral therapy, which has improved patient quality of life and treatment compliance .TM  and TruvadaTM (emtricitabine and tenofovir), have also been subject to interruptions in favour of the administration of the separate components. In these cases, the emtricitabine component was substituted with generic lamivudine.Due to the current economic crisis and budget restrictions, the arrival of generic lamivudine with a more competitive sales price has led some healthcare administrators to consider breaking up FDCs that contain lamivudine (3TC) and emtricitabine (FTC), and administrating the separate components that includes the new generic lamivudine. FDCs containing emtricitabine, such as AtriplaTo estimate the effect of this decision at Son Llàtzer Hospital, a retrospective study was performed to analyse information about the administration of ART and the healthcare resources that are used to manage adverse events (AEs). In the present study, an analysis of the ART and AEs associated costs was performed for patients treated with FDCs and for patients treated with combinations of separately administered antiretrovirals.TM (lamivudine and zidovudine), KivexaTM (abacavir and lamivudine), and TrizivirTM  were replaced with the separate administration of their individual antiretroviral agents; generic lamivudine for KivexaTM and generic zidovudine and lamivudine for CombivirTM and TrizivirTM. In contrast, and because generics are still unavailable for the components of AtriplaTM  and TruvadaTM (emtricitabine and tenofovir) emtricitabine was replaced with generic lamivudine, which is perceived to be equivalent to emtricitabine.An independent, retrospective study was conducted at Son Llàtzer Hospital between June 2010 and July 2011. Information regarding ART and the management of AEs was collected from patients infected with HIV-1. A total of 75 patients experienced the substitution of their FDC treatment with individual antiretroviral agents (exposed group). The schematic in Figure Using a hospital database of 434 patients with controlled HIV, 150 patients observed between March and November 2010, and who continued receiving FDCs, were randomly selected (non-exposed group); these patients continued receiving FDCs because their expected appointment dates preceded the FDCs disruption. The following baseline characteristics were recorded for both group of patients: gender, age, weight, date of HIV diagnosis, mechanism of transmission, history of AIDS, HCV infection status, psychiatric history, current use of methadone or psychopharmaceuticals, date of efavirenz initiation, date of FDC initiation and type, non-nucleoside analogue reverse transcriptase inhibitor use, protease inhibitor use, and integrase inhibitor use . Data were also collected from the visit prior to the baseline visit (visit −1) and from two serial visits after the baseline visit (visits +1 and +2). For the non-exposed patients, the baseline visit was the closest visit to July 2010. At each visit, the CD4+ T lymphocyte counts, HIV-1 viral load, serum glutamic oxalacetic transaminase (SGOT), serum glutamic pyruvate transaminase (SGPT), cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides, and the presence of AEs were recorded for both group of patients. During the process of identifying AEs, the potential relationship with ART was indicated (unrelated or likely related). This decision was based on the investigator’s criteria and on the attending physician’s annotations in the patient’s chart . The severity of AEs was recorded according to the World Health Organization criteria. The possible reintroduction of the FDCs on visits +1 and +2, changes to other treatments, and failures to follow-up were also recorded.The average time that the exposed patients were treated with individual antiretroviral agents 120 days) was used as a temporal horizon for the cost analysis. Given that this analysis was performed from a hospital perspective, only healthcare costs that were directly associated with the pharmaceutical cost and the cost of managing the AEs were included. For the cost analysis, only AEs that were related to ART were considered. The consumption of antiretroviral agents was calculated using the posology from the corresponding Summary of Product Characteristics, and considering the ex-factory price that results from converting the catalogue price of the Spanish General Council of Official Colleges of Pharmacists  with the0 days waIn the exposed group, as a consequence of the change in ART experienced with the replacement of their FDCs, the Son Llàtzer Hospital scheduled one follow-up visit for these patients. The costs related to this follow-up visit were included in an alternative scenario and entail the cost associated with the consumption of the following healthcare resources: a medical appointment, biochemistry, haemogram, coagulation profile, urinalysis, analysis of lymphocyte populations, and determination of the viral load. The costs considered in this analysis are expressed in Euros (€) from 2011, and are detailed in Table The mean age of the patients in the exposed group (n = 75) was 44 years, and in the non-exposed group n = 150), 46 years. The percentage of women was similar in both groups of patients, with 24% in the exposed group and 25% in the non-exposed group. There were no statistically significant differences in the baseline patient characteristics of the exposed and non-exposed group, including patient weight, mechanism of HIV transmission, concomitant pathology, and type of FDC used at the beginning of the study .No AEs were found in the exposed patients that were previously treated with a lamivudine containing FDCs, KivexaTM, CombivirTM or TrizivirTM, (n = 15).In total, 21 AEs (28.0%) were observed in the exposed group, and 7 AEs (4.7%) were observed in the non-exposed group. Of the AEs that were likely related to ART, there were 14 (18.7%) in the exposed group at visit +1, immediately after discontinuation with the FDC, compared with 2 (1.3%) in the non-exposed group . It should be noted that the 14 AEs observed in the exposed group were found in patients who were initially under stable treatment with an emtricitabine containing FDCs, AtriplaThe differences on AEs likely related with ART at visit +1 between both groups of patients were extensively studied. When the AEs were analysed excluding those patients with HIV-1 viral load greater than 50 copies/mL at visit −1, statistically significant differences were also found. In the exposed patients with viral load lower than 50 copies/mL at visit −1 (n = 62), 11 (17.7%) AEs likely related to ART were found, while only 2 (1.4%) AEs were observed in the non-exposed group of patients (n = 141) . In addition, another analysis excluding patients with HIV-1 viral load > 50 copies/mL at baseline visit was carried out. There were found 13 (20.3%) AEs likely related with ART at visit +1 in 64 exposed patients compared with 2 (1.5%) AEs found in 136 non-exposed patients .Another analysis was performed excluding those patients who recently started treatment with FDCs (less than 6 month of treatment with FDCs at the beginning of the study). In the exposed group of patients (n = 63), 11 (17%) AEs likely related with ART were observed at visit +1 compared with 1 (0.7%) AEs in the non-exposed group (n = 132) . Statistically significant differences were also observed when the patients who recently started treatment with efavirenz (less than 6 months) were excluded. In the exposed group (n = 50), 12 (24.0%) AEs were found compared with 2 (2.4%) AEs in the non-exposed group (n = 84) . The results of these analyses are summarized in Table TM, while the other patient presented with insomnia, anxiety, and abnormal dreams . There were two other cases of neuropsychiatric AEs in the exposed group, but they were considered to be unrelated to ART due to the absence of a suggestive temporal relationship. Additionally, there were two cases of hepatic toxicity, two cases of diarrhoea, and one case of vomiting  patients. In 8 (12.6%) of these patients, the FDCs were introduced after the appearance of AEs that were likely related to ART. There were 6 (8%) patients who received a new FDC in the exposed group, and there were 4 (2.6%) patients who received a new FDC in the non-exposed group. On visit +2, 21 exposed patients continued with individual antiretroviral agents, and FDCs were reintroduced in 10 of these patients. The mean time that patients in the exposed group were treated with individual components of FDCs was 120 days. In the non-exposed group, the average cost per patient was 3,017.50 € during the study period, while the average cost per patient was 3,103.84 € in the exposed group  and because in general, lamivudine is associated with few AEs.In our study, there were no statistically significant differences between both groups of patients in variables such as age, gender, weight, mechanism of transmission, concomitant pathologies and type of ART, what otherwise could have explained the higher rate of AEs in the exposed group. The only statistically significant difference between exposed and non-exposed patients was the HIV-1 viral load at visit −1 (prior to baseline visit), but when a reanalysis was carried out excluding those patients, the differences found in AEs appearance continued to be significant. At baseline visit, there were also more patients with HIV-1 viral load > 50 copies/mL in the exposed group compared with the non-exposed group, without being this difference significant. When those patients were excluded from the analysis, the difference in AEs between both groups remained statistically significant. Therefore, it seems unlikely that the poorer control of the viral load in the exposed patients could be the reason for the higher rate of AEs observed in this group. Patients who recently started with ART have also more probabilities of present AEs. Thereby, reanalyses were carried out excluding patients with less than 6 months under treatment with FDCs or efavirenz, maintaining the differences in the AEs rate between both groups of patients.et al., mild neuropsychiatric toxicity was found in some patients who switched from lamivudine to emtricitabine [Among the AEs, neuropsychiatric events occurred most frequently, which was similar to what was observed at the initiation of efavirenz treatment, regardless of whether the patients had been undergoing stable treatment. Studies have demonstrated a relationship between the presence of specific polymorphisms in cytochromes CYP2B6, CYP2A6, and CYP3A4 and a higher risk of neuropsychiatric toxicity that is associated with the discontinuation of efavirenz ; howevercitabine .Although there are no data that demonstrate greater toxicity of lamivudine compared to emtricitabine , these ANo significant differences were found in the rate of virologic failure between patients exposed and patients not exposed to FDCs disruption. However, the number of patients included in this study was small, the time of exposure to the change was short (an average of 120 days), and the majority of patients returned to using FDCs when their reintroduction was allowed.Finally, it should be noted that the regional approval to separately administer FDCs components implies the access to different levels of healthcare quality according to the geographic area of residence, despite the availability of a common National Healthcare System in Spain. One methodological limitation of this cost analysis is that it was based on a single study centre and was not randomised. Nevertheless, the data recorded during this study reflect usual clinical practices. Efficacy parameters for different strategies have not been considered, as the objective of this study was not to perform a cost-effectiveness analysis; rather, the objective of the study was to analyse the possible savings that are associated with FDCs discontinuation in Son Llàtzer Hospital.The results of this study suggest that breaking up FDCs to separately administer the individual antiretroviral agents leads to an increase in costs for the Son Llàtzer Hospital. These additional costs were related to the management of AEs and the additional follow-up visits that require a change in ART in our hospital.This work was supported by an unrestricted research grant sponsored by Gilead. The authors have not transmitted any conflicts of interest, because the concept, design and development of the model have been carried out independently. VL, IO and MAC are PORIB employees a consultant company specialized in economic evaluation of health technologies.FH and MAC conceived of the study and performed a general coordination of the project. VL and IO have made substantial contributions to design of the study, analysis, interpretation of the results and were involved in drafting the manuscript. FH, JMG, APareja, APayeras, JS and CC have played a key role in acquisition of data and validating the assumptions taken in the study design. All the authors have participated sufficiently in the work to take public responsibility for appropriate portions of the content. All of them have reviewed the final version of the manuscript and have given a final permission of the version to be published.


There are limited data on clinical outcomes of ART-experienced patients with cryptococcal antigenemia. We assessed clinical outcomes of a predominantly asymptomatic, ART-experienced cohort of HIV+ patients previously found to have a high (8.4%) prevalence of cryptococcal antigenemia.The study took place at All Africa Leprosy, Tuberculosis and Rehabilitative Training Centre and Black Lion Hospital HIV Clinics in Addis Ababa, Ethiopia. A retrospective study design was used to perform 12-month follow-up of 367 mostly asymptomatic HIV-infected patients (CD4<200 cells/µl) with high levels of antiretroviral therapy use (74%) who were previously screened for cryptococcal antigenemia. Medical chart abstraction was performed approximately one year after initial screening to obtain data on clinic visit history, ART use, CD4 count, opportunistic infections, and patient outcome. We evaluated the association of cryptococcal antigenemia and a composite poor outcome of death and loss to follow-up using logistic regression.Overall, 323 (88%) patients were alive, 8 (2%) dead, and 36 (10%) lost to follow-up. Among the 31 patients with a positive cryptococcal antigen test (titers ≥1∶8) at baseline, 28 were alive , 1 dead and 2 lost to follow-up (titers ≥1∶1024). In multivariate analysis, cryptococcal antigenemia was not predictive of a poor outcome . A baseline CD4 count <100 cells/µl was associated with an increased risk of a poor outcome  while an increasing CD4 count  and receiving antiretroviral therapy at last follow-up visit  were associated with a reduced risk of a poor outcome.Unlike prior ART-naïve cohorts, we found that among persons receiving ART and with CD4 counts <200 cells/µl, asymptomatic cryptococcal antigenemia was not predictive of a poor outcome. Recent reports highlight the alarming issue of cryptococcal meningitis in Sub-Saharan Africa and make it clear that there is still much to be done to improve the diagnosis, management, and prevention of cryptococcal disease Previous CRAG screening studies included only ART-naïve individuals, and there are no data on the clinical benefit of screening ART-experienced HIV patients. Accordingly, WHO guidelines for CRAG screening do not include recommendations for individuals who are already receiving ART A retrospective study design was utilized to perform a 12-month clinical follow-up of 367 HIV-infected patients from our prior CRAG screening study. The design and results of the baseline screening assessment, performed at two ART clinics in Addis Ababa, Ethiopia, have been reported previously Patient follow-up was performed from June-August 2012, approximately one year after enrollment in the baseline study. The following information was gathered by medical chart and computer registry data abstraction: clinic visit history, ART use, CD4 counts, development and treatment of opportunistic infections including cryptococcal disease, lumbar puncture results (if performed) and whether the patient was alive, dead, or lost to follow-up. For the deceased, cause of death was ascertained from the medical chart. Loss to follow-up was defined as no follow-up visits or not having visited the clinic within the last 6 months. For those who were lost to follow-up and/or medical record could not be found, patient information was cross-referenced with a computer registry at both sites. Registry data included dates of past clinic visits, CD4 count results and whether the patient had died. Written informed consent was obtained from all participants for the baseline CRAG screening. Study approval was obtained from the Institutional Review Boards of Emory University, Addis Ababa University, and the Armauer Hansen Research Institute.2 statistic, and for continuous variables a two-sample t-test was performed. Univariate and multivariate logistic regression were performed to evaluate the association of cryptococcal antigenemia as well as other potential confounding risk factors and a poor outcome. Risk factors with biologic plausibility or known to be associated with HIV clinical outcomes were included in the multivariate model. Model building and selection was based on the purposeful selection of covariates strategy as previously described All data were entered into an online REDCap database A total of 367 HIV-infected patients had one-year follow-up performed including 31 persons with baseline cryptococcal antigenemia. None of the patients were clinically suspected to have meningitis at baseline. In regards to clinical outcomes at time of follow-up, 323 persons were alive (88%), 8 were confirmed dead (2%) and 36 were lost to follow-up (10%) . Of patiAmong the 31 patients with cryptococcal antigenemia, 28 were alive (90%), 1 dead (3%), and 2 lost to follow-up (7%) . Twenty-Among patients with a negative CRAG test at baseline, 295 of 336 were alive (88%), 7 dead (2%) and 34 were lost to follow-up (10%) . Among tIn univariate analysis, patients with a CD4 count <100 cells/µl at baseline were more likely to have a poor outcome compared to those patients with a CD4 count of 100–200 cells/µl . ART use at baseline and last follow-up visit and an increasing CD4 count were associated with a reduced risk of a poor outcome .In multivariate analysis, there was no association between serum cryptococcal antigenemia and a poor outcome  . IndepenOutcomes were further analyzed among study individuals who had a CD <100 cells/µl at baseline. In the study, there were 117 persons with a CD4<100 cells/µl, including 13 who were serum CRAG positive. Poor outcomes were observed in 23% of those who were serum CRAG positive (3 of 13), as compared with 20% who were serum CRAG negative (21 of 104). 90% (94 of 104) of individuals with a CD4<100 cells/µl were on ART at baseline. Of the 13 patients with cryptococcal antigenemia, 10 were on ART at baseline including 2 of the 3 patients with poor outcomes. In univariate analysis, there was no association between serum cryptococcal antigenemia and a poor outcome among those who had a CD4<100 cells/µl at baseline (p = 0.81).Our study found no association of cryptococcal antigenemia  with a poor outcome  at one year in a HIV-infected cohort in Addis Ababa, Ethiopia. In contrast to prior studies Our study is the first to investigate clinical outcomes of patients with cryptococcal antigenemia in an ART-experienced cohort. In particular, our study’s findings are different than those from previous studies among ART-naïve persons that found cryptococcal antigenemia to be predictive of the development of CM and a significant risk factor for mortality Our results indicate that among ART-experienced persons, continued adherence to ART may be sufficient in controlling the progression of asymptomatic cryptococcal antigenemia in those with a CD4<200 cells/µl, except in the case of extremely high titers. In our cohort, poor outcomes occurred only among three patients with high CRAG titers (>1∶1024) while all CRAG positive patients alive at follow-up had a titer ≤1∶128. Notably all three individuals also had a CD4<100 cells/µl. A prior study from South Africa also found a correlation between poor outcomes and higher CRAG titers The results of our study emphasize that the initiation and continuation of ART is vital for improving survival and quality of life for persons living with HIV. The receipt of ART at last follow-up, an increasing CD4 count, and a CD4 count >100 were all associated with a reduced risk of a poor outcome in multivariate analysis. These findings are in accordance with the many studies demonstrating improved clinical outcomes and decreased mortality among individuals receiving ART in both developed countries >100 cells/µl, an undetectable or low HIV RNA level sustained for 3 months, and at least 1 year of antifungal drug exposure with close patient follow-up. Reinstitution of maintenance therapy is to be considered if CD4 decreases below 100 cells/µl Treatment guidelines for the management of cryptococcal disease were not followed in the two clinics studied, suggesting the need for continued improvement of HIV-related care. Infectious Diseases Society of America (IDSA) clinical practice guidelines recommend lumbar punctures and blood cultures to be performed on all patients with asymptomatic antigenemia, followed by treatment as symptomatic meningoencephalitis if positive. If there is no evidence of meningoencephalits, treatment with fluconazole is recommended until immune reconstitution has occurred. Immune reconstitution is defined as having a CD4 cell count Current WHO screening guidelines recommend serum cryptococcal antigen screening among ART-naïve individuals with a CD4<100 cells/µl A combined outcome of death and lost to follow-up was used to define a poor outcome as lost to follow-up has been found to be associated with poor outcomes in RLS. In a meta-analysis of one Indian and sixteen Sub-Saharan Africa studies, mortality among lost to follow-up patients was estimated to be 40% Our study is subject to several limitations: neither lumbar punctures nor repeat CRAG testing were performed and the study was carried out at only two HIV clinics. A lack of lumbar punctures precluded us from evaluating rates of CM and whether lumbar punctures should be completed in asymptomatic cryptococcal antigenemic patients receiving ART. Serial CRAG testing would have allowed us to evaluate if receipt of ART and CD4 increase lead to clearance of cryptococcal antigenemia. Lastly, our study took place in only two sites in Addis Ababa and therefore care is needed before generalizing our findings.We found no association of cryptococcal antigenemia with a poor outcome (death or lost to follow-up) in an ART-experienced, asymptomatic cohort of HIV-infected persons in Ethiopia at one-year follow-up. Importantly, our study raises questions about the clinical significance of low-level cryptococcal antigenemia among patients receiving ART and supports interim WHO guidelines recommending CRAG screening only for ART-naïve patients with low CD4 counts as well as CSF testing in symptomatic patients presenting with meningitis.


With widespread use of antiretroviral (ARV) drugs in Africa, one of the major potential challenges is the risk of emergence of ARV drug-resistant HIV strains. Our objective is to evaluate the virological failure and genotypic drug-resistance mutations in patients receiving first-line highly active antiretroviral therapy (HAART) in routine clinics that use the World Health Organization public health approach to monitor antiretroviral treatment (ART) in Togo.Patients on HAART for one year (10-14 months) were enrolled between April and October 2008 at three sites in Lomé, the capital city of Togo. Plasma viral load was measured with the NucliSENS EasyQ HIV-1 assay  and/or a Generic viral load assay . Genotypic drug-resistance testing was performed with an inhouse assay on plasma samples from patients with viral loads of more than 1000 copies/ml. CD4 cell counts and demographic data were also obtained from medical records.A total of 188 patients receiving first-line antiretroviral treatment were enrolled, and 58 (30.8%) of them experienced virologic failure. Drug-resistance mutations were present in 46 patients, corresponding to 24.5% of all patients enrolled in the study. All 46 patients were resistant to non-nucleoside reverse-transcriptase inhibitors (NNRTIs): of these, 12 were resistant only to NNRTIs, 25 to NNRTIs and lamivudine/emtricitabine, and eight to all three drugs of their ARV regimes. Importantly, eight patients were already predicted to be resistant to etravirine, the new NNRTI, and three patients harboured the K65R mutation, inducing major resistance to tenofovir.In Togo, efforts to provide access to ARV therapy for infected persons have increased since 2003, and scaling up of ART started in 2007. The high number of resistant strains observed in Togo shows clearly that the emergence of HIV drug resistance is of increasing concern in countries where ART is now widely used, and can compromise the long-term success of first- and second-line ART. Implementation of antiretroviral therapy (ART) is recognized as a public health priority in resource-limited countries. In order to allow a rapid roll out of ART, countries use the World Health Organization (WHO) public health approach, which proposes standard first-line therapy, together with treatment initiation and switch guided by clinical disease progression and, where possible, with monitoring of CD4 cell counts . The staIn 2010, these guidelines were revised and recommended less toxic drugs in first-line therapy by replacing stavudine (d4T) with tenofovir (TDF) [Togo is a small country of 5.5 million inhabitants, located in west Africa, with an estimated HIV prevalence of around 3% in the general population [A total of 188 HIV-1-positive patients receiving first-line ART for 12 months (+/-2 months) were consecutively enrolled between April and October 2008 in three sites in Lomé: the University Hospital Tokoin; and two non-governmental organizations for HIV care, (EVT (Espoir Vie Togo) and CRIPS (Centre de Réflexion et d'Initiative pour la Promotion de la Santé). The study was approved by the National Ethics Comitee and Ministry of Health (N°0269/2007/MS/DGS/DPLET/CBRS). Only patients who declared that they were ARV treatment naïve prior to the start of first-line treatment and those without prior use of ARVs for prevention of mother to child transmission of HIV were included in this study. After written informed consent, whole blood was collected and plasma was separated from cells by centrifugation at 3000rpm for five minutes and stored at -80°C in three aliquots.http://www.hivfrenchresistance.org/). HIV-1 subtypes/CRFs were determined by phylogenetic tree and recombination analysis as previously decribed [Whole blood less than six hours old was used to determine the CD4 lymphocyte counts using a FACSCALIBUR flow cytometer . Plasma viral load was measured with the NucliSENS EasyQ HIV-1 assay  and/or a Generic viral load assay  . Amino adecribed .3 (IQR 54-173) was seen, which increased to a median of 293 cells/mm3 (IQR 188-431) among the same 160 patients at the time of enrolment in this study, i.e., about 12 months later.During the study period, 580 HIV-1-infected patients attended one of the three clincs for their follow-up visit at M12, and a total of 188 were included in this study. The median duration of ARV therapy prior to study enrollment was 12 months, ranging from 10 to 14 months. The median age of patients was 37 years (IQR 32-43), and only 66 (35.1%) were male (Table 3 (IQR 97-154) to 121 cells/mm3 (IQR 50-249) versus 112 cells/mm3 (IQR 54-176) to 347 cells/mm3 (IQR 269-475). With the exception of two patients, all received the generic drug, Triomune, a fixed-dose combination of stavudine (d4T), lamivudine (3TC) and nevirapine (NVP). The other two patients received AZT+3TC+EFV or AZT+3TC+IDV. Importantly, during the 12-month ART period, 104 (52.7%) patients had interrupted their treatment; the duration of this interruption ranged from one to 168 days, and for 22 patients, this period exceeded one month. Treatment interruption was reported for patients with and without virological failure at comparable rates.However, CD4 count increases were lower for the patients with virological failure, i.e., from 98 cells/mmFor 58 (30.8%) patients, plasma viral load (VL) was above 1000 copies/ml, and for nine of them, VL was between 1000 and 5000 copies/ml. Genotypic drug-resistance testing analyses were done on 56 samples for which sufficient material was available. Mutations conferring resistance to NRTIs were detected in 46 of 56 (82.2%) patients with VLs above 1000 copies/ml, including seven of the nine patients with VLs between 1000 and 5000 copies/ml. This corresponds to at least 24.5% of patients receiving ART for 12 months.Details of the drug-resistance profiles and corresponding patient characteristics are shown in Table The presence of the K65R also means that tenofovir (TDF) will not be effective when used in the second-line regime, and the Q151M mutation commonly confers multi-drug resistance to NRTIs . In seven patients, the presence of one or two NRTI mutations  was also seen, but this had not yet resulted in drug resistance. Two patients had virus mutations indicative of the TAM-1 profile , and two of the TAM-2 profile . No major mutations were seen in the protease gene.The predominant HIV-1 variant in this study population was CRF02_AG . Other variants were CRF06_cpx , subtype G , and 13 (28.3%) were unique recombinant forms.Scaling up highly active antiretroviral therapy (HAART) to achieve universal access is the current priority of WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS). Several cohort studies, using virological monitoring, have shown that ART treatment in resource-poor settings has efficacy rates similar to those reported for developed countries -12. HoweIn contrast, in this study in Togo, more than 80% of patients with virological failure at M12 were already resistant to ARVs, corresponding to 24.5% of all the patients enrolled in this study. Moreover, since the first-line regimen included two drugs with low genetic barriers, the majority of patients with HIV harbouring drug-resistance mutations were resistant to two of the three drugs from their regimens ; eight of 46 (17.4%) were resistant to all drugs in their ARV treatments. A total of 11 (23.9%) patients already harboured mutations conferring resistance to drugs for second-line regimes, such as TDF (n = 3) or the new NNRTI, etravirine (n = 8).This is in agreement with observations from a recent study in Malawi, which also showed clearly that when only clinical and CD4 count cell criteria are used to monitor first-line ART failure, extensive NRTI and NNRTI resistance emerges, with 23% patients having resistance profiles that compromise second-line ART . ImportaIn Togo, efforts to provide access to ARV therapy for infected persons have increased since 2003, and scaling up of ART started in 2007. However, during the scaling-up period, the national programme encountered problems with stock management involving ARV drug substitution with the same molecules, administered separately as individual pills instead of as fixed-dosed combinations, or even interruption of the treatment.Overall, our study shows major problems with the ART programme in Togo during the first year of scaling up HAART in the country, but does not reflect the situation in Togo three years later, which could be different. In a previous study, we reported also that 10% of recently diagnosed ARV-naive HIV-1 positive patients in 2007 were infected with HIV strains that already harboured a drug-resistance mutation . HoweverOur results show clearly that the emergence of HIV drug resistance is of increasing concern in countries where ART is now widely used, and can compromise long-term success in treatment outcomes. Since individual patient monitoring for viral load and drug resistance is not yet possible, the system that WHO (HIVRESNET) has established for the surveillance of transmitted drug resistance and the monitoring of ART resistance at sentinel sites should be implemented in order to inform health authorities on the efficiency of first- and second-line ART and allow recommendations on future ART strategies . The higThe authors declare that they have no competing interests.AYD and NV carried out the viral load assays, genotypic drug-resistance test and phylogentic analysis. MM organized quality assurance for viral load between different sites. AM, AP, KO and MS enrolled patients and collected data on patient history. PP, AS, AYD, MPD, MP and ED participated in the design of the study. AYD, MPD and PP coordinated the study. AYD, NV, ED and MP drafted the manuscript. All authors read and approved the final manuscript.


Rifampicin reduces the plasma concentrations of nevirapine in human immunodeficiency virus (HIV) and tuberculosis (TB) co-infected patients, who are administered these drugs concomitantly. We conducted a prospective interventional study to assess the efficacy of nevirapine-containing highly active antiretroviral treatment (HAART) when co-administered with rifampicin-containing antituberculosis treatment (ATT) and also measured plasma nevirapine concentrations in patients receiving such a nevirapine-containing HAART regimen.3 started on rifampicin-containing ATT followed by nevirapine-containing HAART. In control group we included 51 HIV patients without tuberculosis and on nevirapine-containing HAART. They were assessed for clinical and immunological response at the end of 24 and 48 weeks. Plasma nevirapine concentrations were measured at days 14, 28, 42 and 180 of starting HAART.63 cases included antiretroviral treatment naïve HIV-TB co-infected patients with CD4 counts less than 200 cells/mm97 out of 114 (85.1%) patients were alive at the end of 48 weeks. The CD4 cell count showed a mean increase of 108 vs.113 cells/mm3 (p=0.83) at 24 weeks of HAART in cases and controls respectively. Overall, 58.73% patients in cases had viral loads of less than 400 copies/ml at the end of 48 weeks. The mean (± SD) Nevirapine concentrations of cases and control at 14, 28, 42 and 180 days were 2.19 ± 1.49 vs. 3.27 ± 4.95 (p = 0.10), 2.78 ± 1.60 vs. 3.67 ± 3.59 (p = 0.08), 3.06 ± 3.32 vs. 4.04 ± 2.55 (p = 0.10) respectively and 3.04 μg/ml (in cases).Good immunological and clinical response can be obtained in HIV-TB co-infected patients receiving rifampicin and nevirapine concomitantly despite somewhat lower nevirapine trough concentrations. This suggests that rifampicin-containing ATT may be co administered in resource limited setting with nevirapine-containing HAART regimen without substantial reduction in antiretroviral effectiveness. Larger sample sized studies and longer follow-up are required to identify populations of individuals where the reduction in nevirapine concentration may result in lower ART response or shorter response duration. There are 33.3 million people living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) in the world . Out of For HIV-TB co-infected patients, the WHO and NACO recommends efavirenz-based ART as rifampicin, which is an essential component of anti-tuberculosis treatment (ATT) reduces the plasma concentration of nevirapine . Also, tThe present study was conducted to explore the efficacy and safety of nevirapine-based ART in HIV-TB co-infected ART-naïve Indian patients who were given rifampicin-based anti-tuberculosis (ATT) concomitantly with HAART. The study also measured their serum nevirapine concentrations and correlated them with the immunological and virological responses to HAART.3 and with normal renal and hepatic function  were included. The other inclusion criteria were age > 18 years, non-pregnant as confirmed by a negative urine pregnancy test, and absence of concomitant diabetes mellitus. Hepatitis B and C serologies were done and patients testing positive were excluded, as it could have a bearing on hepatotoxicity of study drugs which was one of the outcomes. Also, patients on anti-epileptic drugs, immunosuppressants and other drugs that induce liver microsomal enzyme systems were excluded. HIV infection was documented by licensed ELISA test kit (As per NACO guidelines). CD4/CD8 cell counts were determined by flow- cytometry (BD FACS CALIBUR). Viral load testing was done using AMPLICOR HIV-1 Monitor Test, version 1.5, manufactured by ROCHE Diagnostics. The protocol was approved by the institutional research Ethics Committee of the All India Institute of Medical Sciences, New Delhi. All participants gave signed informed consent to participate in this study.This was a prospective study conducted at the All India Institute of Medical Sciences (AIIMS), New Delhi between September, 2007 and March, 2011. Patients who tested positive for HIV by ELISA and were ART-naïve and presented with concomitant TB were enrolled as cases. Patients, who tested positive for HIV by ELISA, were ART-naïve and without TB were enrolled as controls. Only patients having CD4 count < 200 cells/mmAll patients underwent a detailed physical examination. Their body weight and height were measured and their basal metabolic index (BMI) was calculated. Haemoglobin, complete blood counts, erythrocyte sedimentation rate, fasting blood glucose, renal function tests, liver function tests, serum albumin, serum uric acid and routine urinalysis were done for all patients. In addition, their CD4 counts and plasma HIV viral load were determined at baseline, six months and 12 months.3. Those who had haemoglobin less than 8 g/dl were administered stavudine in place of zidovudine. The doses that were administered were in accordance with the NACO guidelines. Zidovudine was given in a dose of 300 mg twice a day, lamivudine 150 mg twice a day and stavudine 30 mg twice a day. Nevirapine was administered at a dose of 200 mg once a day for the first 14 days  as per NACO guideline, and then the dose was escalated to 200 mg twice a day. The patients were advised to take the drug at 9 am for the first 14 days and at 9 am and 9 pm during the rest of the period of follow up.Cases were started first on anti-tuberculosis treatment (ATT) according to the Revised National Tuberculosis Control Programme (RNTCP) guidelines for directly observed therapy, short-course (DOTS) . After tPatients were assessed at day 14 after the start of ART, then at day 28, and every 4 weeks thereafter through 48 weeks. A complete haemogram and liver and kidney function tests were obtained at all these visits, and CD4 counts were measured at 8 weeks, 24 weeks and 48 weeks after the start of ART. HIV plasma viral load was measured at baseline, at 24 weeks and at the end of 48 weeks only in the cases. Trough nevirapine concentrations were assessed at day 14, day 28, day 42 and at day 180, 12 hours after the evening dose of nevirapine.Vital status, clinical progression, Immunological and virological responses, mortality, and drug toxicity were assessed as outcome measures.3 at the end of 24 weeks. Disease progression was defined as a new or recurrent WHO stage 4 conditions, after at least 6 months of ART. Virologic response was defined as plasma viral load less than 400 copies/ml after 6 months of ART and drug toxicity was characterized as per the division of AIDS Table for Grading the Severity of Adult and Pediatric Adverse Events, December 2004.Immunological failure was defined as a fall in CD4 counts to baseline concentrations, a 50% fall from the peak CD4 count during treatment or persistent counts below 100 cells/mmBlood samples for Nevirapine concentrations measurement were taken 12 hours after drug intake. Each patient was properly counselled about taking the drug in time so that the sample can be drawn exactly at 12 hours. Wherever feasible, the patient was asked to take the drug in front of the research staff and the sample was collected at 12 hours. In others, telephonic conversation was used to ensure that the patient has taken the drug on time. All samples were stored at -80°C until analyzed. At the time of processing of the sample, each plasma sample was allowed to reach room temperature. Nevirapine was procured from Indian Pharmacopoeia Commission IPC, Ghaziabad, India. Tablet Olanzapine  was procured commercially from Sun Pharmaceuticals Ltd., Mumbai, India. Thermo Finnigan High Performance Liquid Chromatographic system  with PDA detector controlled by ChromQuest (Ver.4.5) software was used to elude the analyte. Purospher Star RP-C18e, 55 × 4 mm, 3 μ particle  was used for analytical separation. Electron spray ionization technique in positive mode was applied using Tubo Ionspray source  in a 4000 Q trap MS/MS . Tandem Mass spectroscopy was controlled using Analyst (Ver.1.4.2) software. The same procedure for nevirapine measurement was used in controls as used in the cases.Plasma spiking of nevirapine in the concentration of 0.07, 0.14, 0.28, 4.48 and 17.9 ng/ml was prepared by using blank plasma. For this, known amount of the nevirapine and olanzapine was added to blank human plasma (obtained from Blood Bank of AIIMS) and separate calibration curve was made. For the analysis of standard calibration curve, best fit was obtained with the inbuilt algorithm of Analysist. Ver. 1.4.2 was used. Best fit obtained for spiking was subjected to quantify unknown concentration. The best fit plotted the ratio of peak height between analyte and internal standard in "abscissa (Y)" axis and taking the ratio of their concentration in "ordinate (x)" axis.Data were recorded on a pre-designed data sheet and managed on an 'Excel' spreadsheet. All entries were doubly checked for any possible recording error. Mean, frequency and medians were calculated for all quantitative variables along with the respective standard deviations and Interquartile ranges. Being a pilot study, initially sample size calculation was not planned and data was gathered as per the sample of convenience. On later calculation, sample size required was 127 patients per group for 80% power. All analysis was done by Intention to treat analysis principle. The Mann Whitney U-test was used to compare the mean nevirapine concentrations at day 28 in patients alive at 24 and 48 weeks, and those who died during the study period. The generalised estimation equations were used to find out the predictors of immunological response in terms of the increase in CD4. Statistical analysis was performed using statistical software package STATA version 11.0 .A total of 114 patients (63 in cases and 51 in control group) were eligible and enrolled during the study period. They were followed for a period of 48 weeks after the start of ART. The baseline characteristics of these two groups are summarized in table The study outcomes are given in detail in table The mean ± SD nevirapine concentrations of cases and control at 14, 28, and 42 days were 2.19 ± 1.49 vs. 3.27 ± 4.95(p = 0.10), 2.78 ± 1.60 vs.3.67 ± 3.59(p = 0.08) and 3.06 ± 3.32 vs. 4.04 ± 2.55 (p = 0.10) respectively and was 3.04 μg/ml at 180 days in cases. The box plot of nevirapine concentrations is shown in Figure At the end of 48 weeks, there were a total of 17 deaths in the study population. The exact cause of death was not known for the majority of patients. One of the deaths occurred due to CNS TB, another due to progressive multifocal leucoencephalopathy (PMLE), whereas yet another was due to severe pulmonary TB causing respiratory failure. Two of these patients had shown an increase in CD4 counts at two months. Only two patients had adverse drug reactions. One developed stavudine-induced neuropathy after 80 days of receiving the drug and the other zidovudine-induced anaemia after 62 days. Stavudine was substituted by zidovudine in the first patient and stavudine was substituted to zidovudine in the second. None of the patients in either group had grade 3 or 4 adverse drug reaction.There were 8 patients in this study who developed immune reconstitution inflammatory syndrome (IRIS). One of the patients had abdominal TB with retroperitoneal lymph nodes. He developed fever and had appearance of new nodes in the cervical area with the start of ART. He was managed with non steroidal anti-inflammatory drugs and improved subsequently. Steroids were not needed for the management of any IRIS case.This is the first study sponsored by National AIDS Control Organization, Ministry of Health & Family Welfare, Government of India from North India for estimation of plasma nevirapine concentrations in patients receiving nevirapine-containing HAART regimen along with rifampicin-based ATT. Its results indicate that good survival benefit is associated with concomitant administration of ATT and HAART. The mortality was slightly higher in the cases compared to controls. There are confounding factors like absence of tuberculosis in the control group that could be responsible for this difference in mortality. Overall good virological response was obtained in cases. The rate of immunological failure was statistically similar in both the groups. CD4 response  is one of the determinants of the effect of HAART ,18. Good50) of the drug for the wild type virus. The IC50 of free drug nevirapine for the wild type virus is 0.01 mcg/ml. As the drug is 60% protein bound in the plasma and only 40% circulates as free drug, the IC50 after adjusting for the degree of protein binding is 0.025 mcg/ml. The mean inhibitory quotient (IQ = Cmin/IC50) found in our study was 104 and even for the lowest nevirapine trough concentration observed (0.92 mcg/ml) was 37. Thus the minimum concentration of nevirapine in the plasma of patients in our study was at least 37 times the median inhibitory concentration of nevirapine for the wild type HIV virus. However the minimum IQ for effective therapy has not been defined yet for nevirapine in the international literature and needs further investigation.Our study shows that good outcomes in terms of vital status and clinical, immunological and virological responses can be obtained in HIV-TB co-infected patients who are administered nevirapine based ART along with rifampicin-based ATT. This is in agreement with earlier studies done by Manosuthi et al , Sathia The mean Nevirapine trough concentrations were different in the lead in period and during the maintenance dose. The mean nevirapine trough concentrations were sub therapeutic in the lead in period or during the period of dose escalation compared to the trough concentrations at maintenance doses. From pharmacokinetic point of view, Nevirapine administration at dose of 200 mg twice daily would be preferred compared to the Nevirapine 200 mg single dose as supported by Mohammad Lamorde, et al.  However,We have observed a nevirapine trough concentration which is very similar to that observed in the only published study done on Indian subjects as cited above . It is oThere are several limitations of the present study. Being the sample of convenience, the sample size is small, and the calculated power of the study is 42% for the observed difference of 0.89 μg/dL (p = 0.08). For 80% power the sample size requirement was 127 per group for the observed difference. Also, viral load of controls could not be done and are not available for comparison. However, we came up with some novel findings. To summarise, rifampicin-containing ATT may be co administered with nevirapine-containing HAART regimen, especially in resource limited setting, without substantial reduction in the antiretroviral effectiveness. The nevirapine-containing HAART regimen is much cheaper alternate treatment for HIV and TB coinfection as compare to efavirenz-containing HAART regimen. The studies with larger sample size and longer follow-up will be more helpful to identify the individuals who have reduction in nevirapine concentrations that may result in lower ART response or shorter response duration.The authors declare that they have no competing interests.SS provided inputs to the study design, helped in data analysis and interpretation, wrote the manuscript, and did final editing. SD, NS, AB, KC, NB, RCS, ME and SKS reviewed literature, and helped in interpreting data and writing the manuscript. SK, TV and AKR conducted laboratory tests for nevirapine levels. HA, NK and JCS conducted laboratory tests for CD4 cell count and plasma viral load. VS did data analysis. RLM edited the manuscript. All authors approved and read the final manuscript.


In Burundi Triomune® is the first-line HIV treatment and it is estimated to reach 30% of those in need, but efficacy monitoring does not rely on viral load (VL) quantification, due to cost and technical limitations. Furthermore nevirapine (NVP) is known to have a highly variable pharmacokinetics (PK) and pharmacogenetics (PG), but no data are currently available in this population.To study virological outcome, PK and PG of nevirapine-based HAART in Burundi, by relying on previously validated alternative tools for samples collection.A cross-sectional analysis was performed at the rural hospital of Kiremba, northern Burundi. All patients on HAART (>6 months) presenting for care and willing to participate were enrolled. After sample collection, whole blood (50 µL) was spotted on Whatman 903 Cards ; afterwards plasma  was spotted on glass paper filter . DBS were used for VL testing (NucliSENS EasyQ HIV-1 v2.0) and PG analysis . A validated HPLC method was used to measure NNRTIs concentrations on DPS.2 (±2.8). The majority of them (90.8%) were in WHO stage 3 and last CD4+ cell count was 543 cell/mm3 (±345). 237 were on first line treatment (220 on NVP and 17 on EFV) and 2 (0.8%) on second line (LPV/r). Mean time on treatment was 25.7 months (±13.7) and it correlated to the last CD4+ count . 43 (18%) had a detectable viral load with 14 patients (5.8%) having more than 800 copies/ml. Nevirapine and efavirenz Ctrough were 7727 ng/ml (± 3796) and 4027 ng/ml (± 3041). CYP2B6 mutated SNPs were common  and associated to increasing exposure (p=0.01 and p=0.02). A higher proportion of patients  had viral loads below 800 copies/ml in the higher range of NVP concentration (Ctrough >4300 ng/ml).239 patients  were enrolled; mean (±SD) age and BMI were respectively 37.9 years (±10) and 20.7 Kg/mDPS and DBS showed to be useful tools to collect and transport samples from a rural area of Burundi. Even with the limit of a cross-sectional analysis a high effectiveness was noted, showing 82% of patients with undetectable VL at a mean of 2 years since start of treatment. High NVP plasma concentrations along with favorable genetic profile could partially explain these results.


Pneumocystis jirovecii and summarize the evidence for resistance to sulfamethoxazole and dapsone.We review studies of dihydropteroate synthase gene mutations in  Pneumocystis pneumonia (PCP) remains a major cause of illness and death in HIV-infected persons. Sulfa drugs, trimethoprim-sulfamethoxazole (TMP-SMX) and dapsone are mainstays of PCP treatment and prophylaxis. While prophylaxis has reduced the incidence of PCP, its use has raised concerns about development of resistant organisms. The inability to culture human Pneumocystis, Pneumocystis jirovecii, in a standardized culture system prevents routine susceptibility testing and detection of drug resistance. In other microorganisms, sulfa drug resistance has resulted from specific point mutations in the dihydropteroate synthase (DHPS) gene. Similar mutations have been observed in P. jirovecii. Studies have consistently demonstrated a significant association between the use of sulfa drugs for PCP prophylaxis and DHPS gene mutations. Whether these mutations confer resistance to TMP-SMX or dapsone plus trimethoprim for PCP treatment remains unclear. We review studies of DHPS mutations in P. jirovecii and summarize the evidence for resistance to sulfamethoxazole and dapsone. Pneumocystis pneumonia (PCP), caused by Pneumocystis jirovecii (formerly P. carinii f. sp. hominis), remains the most common AIDS-defining opportunistic infection, as well as the most frequent serious opportunistic infection in HIV-infected persons, in the United States and Europe. Despite the fact that this infection can be prevented, certain patients continue to be at increased risk for PCP. Specifically, PCP frequently signals HIV infection in patients not previously known to be HIV-infected   used both chart abstraction and patient interview as sources of clinical information regarding PCP prophylaxis  that are beyond the scope of this review  in these other organisms. Thus, the presence and association of DHPS, but not DHFR, gene mutations with the use of specific PCP prophylaxis regimens argue strongly both for the importance of SMX and dapsone against Pneumocystis and the central role of DHPS mutations in the potential development of TMP-SMX or dapsone resistance.Trimethoprim inhibits another of the integral enzymes in folate synthesis, DHFR . In othe–,,,–Pneumocystis that contained DHPS mutations had a greater than threefold increased risk for death within 3 months compared to patients with the wild-type DHPS, after important mortality cofactors such as age, CD4+/cell count, and arterial oxygen partial pressure (PaO2) were controlled for. Whether this increased death rate was due to failure of TMP-SMX for PCP treatment is unclear. In fact, 12 (63%) of 19 PCP patients with Pneumocystis that contained DHPS gene mutations responded to PCP treatment with TMP-SMX. Kazanjian and co-workers found that the presence of DHPS mutations was associated with an increased risk for PCP treatment failure with TMP-SMX or dapsone plus trimethoprim  of 21 PCP patients with Pneumocystis that contained DHPS gene mutations responded to PCP treatment with one of these two regimens. In addition, this study found no association between the presence of DHPS mutations and death at 4 weeks. In contrast to these prior two studies, Navin and colleagues found no association between the presence of DHPS mutations and overall number of deaths at 6 weeks, death attributable specifically to PCP, or PCP treatment failure , the patient’s overall health status , the underlying HIV/AIDS , and, of course, those specific factors related to PCP . In each individual report, the overall number of patients studied and the subset of patients who had Pneumocystis that contained DHPS mutations and were treated with TMP-SMX or dapsone plus trimethoprim were too small to account for these factors and to detect small differences in outcome that may be related to drug resistance. Furthermore, these and future observational studies that examine DHPS genotype and PCP treatment outcome are complicated by the absence of validated PCP clinical treatment guidelines, practice standards, and definitions of treatment success or failure.Whether Pneumocystis that contains DHPS mutations can be expected. Next, the treatment options for PCP in these regions are often limited to TMP-SMX, since regimens such as pentamidine, clindamycin plus primaquine, trimetrexate, and atovaquone are unavailable. The existence of TMP-SMX–resistant Pneumocystis in these regions, combined with the general absence of invasive diagnostic procedures  and intensive care facilities , stresses the importance of further study (While the declining incidence of PCP in the United States and Europe, as a result of combinations of antiretroviral therapy and PCP prophylaxis, might lessen the enthusiasm for continued study of this issue, brief consideration of a number of factors that warn of a future "perfect storm" suggests that continued study is important. First, most HIV-infected persons worldwide reside in sub-Saharan Africa, Southeast Asia, and Latin America, places where access to antiretroviral therapy and PCP prophylaxis are limited. Second, PCP is increasingly being recognized as an important cause of illness in these regions. In many of these regions, programs to use TMP-SMX as multiopportunistic infection prophylaxis are being implemented, and


The Malawian government recently changed its prevention of mother-to-child transmission (PMTCT) regimen and plans to change its first-line antiretroviral therapy (ART) regimen to Tenofovir(TDF)/Lamivudine/Efavirenz as a fixed-dose combination tablet. Implementation could be challenging if baseline creatinine clearance (CrCl) screening were required to assess renal function prior to TDF therapy. Our goal is to determine predictors of CrCl<50 ml/min among HIV-infected, ART-naïve individuals.3, gender, and pregnancy with CrCl<50 ml/min.Data on HIV-infected, ART-naïve adults screened for enrollment into 5 HIV clinical trials in Lilongwe, Malawi were combined for a pooled analysis of predictors for CrCl<50 ml/min. CrCl was derived from the Cockroft-Gault equation. Multivariable logistic regression modeled the association of age, body mass index (BMI), hemoglobin, CD4 cell count <350 cells/mmThe analysis included 3508 patients with values for creatinine clearance. Most subjects were female (90.6%) with a median age of 26 years (IQR 22–29). The median CD4 cell count was 444 (IQR 298.0–561.0), and 85.2% percent of women in our study were pregnant. Few patients had CrCl<50 ml/min . A BMI less than 18.5 in non-pregnant females ) was associated with CrCl<50 ml/min. Hemoglobin level higher than 10 g/dL in males  and non-pregnant females  was protective against CrCl<50 ml/min.Our findings indicate few patients would be excluded from a TDF-based antiretroviral regimen, suggesting baseline creatinine clearance assessment may not be necessary for implementation. However, in ART settings individuals with low BMI or anemia could potentially be at increased risk for lower CrCl. Country Progress Report, over 930,000 Malawians currently live with HIV and approximately 84,000 new HIV infections occur annually Malawi has one of the highest HIV prevalence rates in the world. National HIV adult prevalence in Malawi reached a high of 26% in 1998 and has since decreased to about 12% in 2010 Malawi's current first-line antiretroviral therapy and former prevention of mother-to-child transmission (PMTCT) regimen consists of stavudine, lamivudine and nevirapine. Stavudine has long-term side-effects such as lactic acidosis, hepatic steatosis and lipo-atrophy A creatinine clearance (CrCl) rate ≥50 ml/min is recommended before starting TDF for efficient renal clearance All involved studies were approved by the National Health Sciences Research Committee, the University of North Carolina Ethics Committee. The BAN study was also approved by CDC ethics committee. All subjects provided written informed consent for the participation in the specified clinical trial that included data collected from screening onward.This cross-sectional study combines data on 3508 HIV-infected, ART-naïve adults screened for enrollment to five HIV clinical trials conducted in Lilongwe, Malawi from 04/08/2004 to 07/26/2009: 625 screened for the HIV Prevention Trial Network 052 ; 268 for the AIDS Clinical Trial Group (ACTG) A5175 , A5208 , A5221 ; and 2615 for the Breastfeeding, Antiretroviral, and Nutrition Study  3, the threshold for antiretroviral (ART) initiation according to Malawi guidelines. The eligibility criteria for initiating ART in Malawi is a CD4 cell count of less than 350 cells/mm3 or a WHO stage 3 or 4 defining condition. The PMTCT regimen for Malawi states that all pregnant women regardless of status are eligible for ART. Given there is a 40–50% increase in serum creatinine in pregnant women The outcome for this analysis was CrCl<50 ml/min based on dichotomization of CrCl calculated from the Cockroft-Gault equation (CG): Creatinine clearance = [(140-age)*(weight in Kg)*]/(72*Creatinine mg/dL) 2-square test, while differences in means were assessed using the student's t test and Wilcoxon rank-sum test. Descriptive characteristics were stratified by pregnancy status due to the large amount of pregnant women in our study. Analysis of variance was used to assess the homogeneity of each covariate across each clinical trial. Multivariable logistic regression using SAS 9.2 assessed risk factors associated with CrCl<50 ml/min, while adjusting or stratifying on screening population. A sensitivity analysis assessing CrCl of <90 ml/min in pregnant women was conducted to assess the robustness of CrCl in pregnant women in our models.Bivariate analyses were used to assess the crude association for each covariate with CrCl<50 ml/min according to both CrCl equations. Differences in categorical variables were assessed using the χ3 (IQR 298.0–561.0). The median weight of our study participants (57 kg (IQR 52–63)) is comparable to a study of 4 ART clinics where the median weight of individuals seeking ARVs was 55 kg (IQR 49–63) Most study subjects were female (90.6%) with a median age of 26 years (IQR 22–29). The median CD4 cell count was 444 cells/mmFew patients had CrCl<50 ml/min by the CG equation . The proportion with CrCl<50 ml/min differed by study population . Among a2 was significantly associated with increased odds for CrCl<50 ml/min in both the HPTN 052 and combined ACTG trials in univariate analysis , but not associated with CrCl<50 ml/min in the combined ACTG trials of our main models. Hemoglobin values greater than 10 g/dL was protective against a CrCl<90 ml/min in the BAN trials (OR = 0.65 95%CI = 0.51–0.83), but only significantly associated with CrCl<50 ml/min in the HPTN052 trial of our main models. CD4 cell count was found to be protective against CrCl<90 ml/min in the BAN trials (OR = 1.31 95%CI 1.18–1.45), but not associated with CrCl<50 ml/min in any trial of our main models .Among 3508 HIV-infected, ART-naïve adults screened for enrollment to five HIV clinical trials conducted in Lilongwe, Malawi, we found that CrCl<50 ml/min was rare, suggesting that few patients would be excluded from receiving the public provision of TDF-based antiretroviral regimen based on this criteria. The small proportion of patients with low CrCl is comparable to other studies assessing CrCl in HIV positive individuals in populations similar to ours Many indicators suggest our population is comparable to other HIV-infected, ART-naïve cohorts within Malawi. Studies conducted in the PMTCT populations of Thyolo District Hospital located in rural Malawi have shown the median age of PMTCT study participants is 22 years, making our study sample of comparable age to other Malawian PMTCT cohorts 3 (1.9%), and below 200 cells/mm3 (6.9%).Our cohort's median CD4 cell count, at 444 cells/ml, is higher than most studies assessing risk factors associated with low creatinine clearance in HIV-infected individuals 2 was associated with both mild and advanced renal insufficiency Our study's association between low BMI and CrCl<50 ml/min agrees with the current literature on renal insufficiency among HIV-infected, ART-naïve individuals. A cross-sectional survey of 2588 individuals assessing creatinine clearance in HIV-infected patients in France found that a BMI<22 kg/mLow hemoglobin values are associated with renal insufficiency in people living with HIV. Time to death due to end-stage renal disease in individuals living with HIV is significantly shorter for those with low hemoglobin values compared to normal values Our findings show increases in hemoglobin and BMI have significant protective affects against CrCl<50 ml/min is consistent with other literature. HIV/AIDS-associated nephropathy (HIVAN) is associated with low hemoglobin levels Models stratified by pregnancy show only increases in age to be a significant factor associated with CrCl<50 mg/dl in ART-naïve pregnant individuals, while lower BMI and hemoglobin are associated with a increased likelihood of CrCl<50 mg/dl for non-pregnant individuals. The lack of significant factors associated with CrCl<50 mg/dl and pregnancy could possibly be due to the renal changes that occur during pregnancy 3 (52.6%). Of the 38 individuals, 11 had a BMI under 18.5 (28.9%), and 7 of these also had a hemoglobin <11 g/dl and CD4 <200 cells/mm3. This suggests that when clinically assessing patients for potential CrCl<50 ml/min in a general clinical setting, a disproportionate number of afflicted individuals (18.4%) will have low hemoglobin, BMI, and CD4 cell counts. While we were not able to develop a clinical algorithm for assessing CrCl<50 ml/min due to small numbers of clients with this outcome, developing and validating such an algorithm prospectively with a larger study sample could be possible.While CD4 cell count was not significant in our multivariate models, 20 of the 38 individuals with CrCl<50 ml/min using the CG equation also had CD4 counts less than 200 cells/mmThere are some limitations to our study. We recognize that the CG equation does not addresses renal tubular function as can be assessed by evaluating proteinuria through dipstick, urine protein∶creatinine ratio, or fractional excretion of phosphate. The clinical trials included in this pooled analysis were all conducted in the urban city of Lilongwe and may not be representative of all the PMTCT and ART populations in Malawi. A recent WHO report suggests that only 17% of Malawi's population live in urban areas Enrollment criteria for the respective trials varied, and if CD4 clinic data were available and it precluded patients from the study, they would not have been referred for trial screening. The ACTG 5221 and ACTG 5208 trials did not screen individuals with known high CD4 counts, and the BAN study did not enroll individuals with known CD4<250 cells/µL. Therefore, the pooled population may have oversampled sicker individuals for the ACTG screening population and healthier individuals for the BAN screening population. Such misrepresentation is expected to be minimal as individuals presenting for ART tend to be sicker on average and those presenting for PMTCT tend to be healthier. However, it is possible patients screened for the five clinical trials may not be representative of a routine clinic setting because screened individuals might be healthier than normal.The majority of our population consists of pregnant women screened through the BAN study. This could potentially create an underrepresentation of HIV-infected, ART-naïve men. However, a main goal of our study is to focus on predictive factors of potential renal failure for pregnant mothers in a PMTCT program. Additionally, regardless of the gender imbalance across studies, the data used in this pooled analysis is, to our knowledge, the only data containing serum creatinine values of HIV-infected, ART-naïve individuals in Malawi. It is possible the CG equation could misrepresent creatinine clearance in our study because the majority of our population is pregnant and the equation requires the weight and gender of each subject. To address this potential limitation, we included a sensitivity analysis using CrCl<90 ml/min in pregnant individuals as an outcome.Our study suggests that few eligible HIV-infected Malawians would be excluded from a TDF-based ART regimen. Limited resources for measuring serum creatinine should be directed towards individuals with low values for BMI or hemoglobin and who are not pregnant, since these individuals are at the greatest risk for a CrCl<50 ml/m.