In resource-poor settings, mortality is at its highest during the first 3 months after combination antiretroviral treatment (cART) initiation. A clear predictor of mortality during this period is having a low CD4 count at the time of treatment initiation. The objective of this study was to evaluate the effect on survival and clinic retention of a nurse-based rapid assessment clinic for high-risk individuals initiating cART in a resource-constrained setting.3. All HIV-infected individuals aged 14 years or older initiating cART with CD4 counts of ≤100 cells/mm3 were eligible for enrolment into HREC and for analysis. Adjusted hazard ratios (AHRs) control for potential confounding using propensity score methods.The USAID-AMPATH Partnership has enrolled more than 140,000 patients at 25 clinics throughout western Kenya. High Risk Express Care (HREC) provides weekly or bi-weekly rapid contacts with nurses for individuals initiating cART with CD4 counts of ≤100 cells/mm3. After adjusting for age, sex, CD4 count, use of cotrimoxazole, treatment for tuberculosis, travel time to clinic and type of clinic, individuals in HREC had reduced mortality , and reduced loss to follow up  compared with individuals in routine care. Overall, patients in HREC were much more likely to be alive and in care after a median of nearly 11 months of follow up .Between March 2007 and March 2009, 4,958 patients initiated cART with CD4 counts of ≤100 cells/mmFrequent monitoring by dedicated nurses in the early months of cART can significantly reduce mortality and loss to follow up among high-risk patients initiating treatment in resource-constrained settings. Combination antiretroviral treatment (cART) has proven itself to be an effective therapeutic mechanism for suppressing viral replication and enabling reconstitution of the immune system, thus allowing patients to recover and live with HIV disease as a chronic illness -3. If adIn resource-poor settings, mortality is at its highest during the first 3 months after cART initiation -12. It iRecent estimates by the World Health Organization (WHO) indicate that although 6.7 million individuals in low- and middle-income settings are receiving cART, this represents only 47% coverage of individuals who are in clinical need . The masHere, we describe the impact of a nurse-clinician approach  on mortaThis was a retrospective analysis of prospectively collected routine clinical data. The study was approved by the Indiana University School of Medicine Institutional Review Board and the Moi University School of Medicine Institutional Review and Ethics Committee.The Academic Model Providing Access to Healthcare (AMPATH) was initiated in 2001 as a joint partnership between Moi University School of Medicine in Kenya, the Indiana University School of Medicine, and the Moi Teaching and Referral Hospital. The USAID-AMPATH Partnership was initiated in 2004 when AMPATH received ongoing funding through the United States Agency for International Development (USAID) and the United States Presidential Emergency Plan for AIDS Relief (PEPFAR). The initial goal of AMPATH was to establish an HIV care system to serve the needs of both urban and rural patients and to assess the barriers to and outcomes of antiretroviral therapy. Details of the development of this programme have been described in detail elsewhere .The first urban and rural HIV clinics were opened in November 2001. Since then, the programme has enrolled more than 140,000 HIV-infected adults and children in 25 Ministry of Health (MOH) facilities and numerous satellite clinics in western Kenya (data for satellite clinics are incorporated into their "parent" clinic). Although located within the MOH facilities, the AMPATH clinics are dedicated to HIV and HIV/TB care, treatment and support. All HIV- and tuberculosis-related care and treatment are provided free at the point of care.The HIV clinical care protocols used by the USAID-AMPATH Partnership are consistent with those recommended by WHO and have been described in detail elsewhere . BrieflyDuring these visits patients are seen by multiple care providers, including nurses, clinicians, pharmacy technicians, nutritionists, peer outreach workers and social workers. For new patients, clinical contact begins at registration, followed by the nurse who checks vital signs. The patient also sees a peer outreach worker for documentation of locator information, then goes on to see the doctor/clinical officer. Returning patients go directly to the nurse and then follow a course similar to that established for new patients. All patients newly initiated on cART who miss a scheduled clinic visit trigger an outreach attempt within 24 h, through either a telephone contact or home visit conducted by trained peers. Standard first-line antiretroviral regimens used are either nevirapine-based or efavirenz-based .3 or less and initiating cART.Beginning in March 2007, the High Risk Express Care (HREC) programme was implemented in a step-wise fashion in USAID-AMPATH Partnership clinics. As of May 2008, HREC had been rolled out to all parent clinics. The selection of clinics to pilot the programme was based primarily on space availability, patient volume and clinic congestion, and the general capacity of healthcare personnel to pilot a new programme. Once a clinic had implemented HREC, all patients meeting the criteria for HREC were eligible for referral to the programme. The criteria for referral to HREC are having a CD4 count of 100 cells/mmOnce a patient is identified as eligible for HREC, the clinical officer or physician prescribes a two-week supply of cART and then refers the patient to HREC (within the same clinic location). The patient is seen by a clinical officer or physician 2 weeks after antiretroviral initiation and then monthly. The HREC nurse is then responsible for interim weekly visits either physically or by telephone for a period of 3 months. The patient is seen monthly by a clinical officer or physician. In HREC, returning patients do not queue in the waiting bay or go through the nursing station, clinician room, pharmacy or any other referral points within the clinic. Instead, such patients go directly to the "Express Care room", which provides "one-stop care". The HREC nurse maintains a list of scheduled return visits, and if a patient misses a clinic appointment, the outreach team is activated as per routine protocol.2 ≤ 93%), the patient is referred immediately to the clinical officer or physician. The nurse does not dispense drugs during an HREC visit as these are prescribed during monthly clinical officer or physician visits. A summary of similarities and differences between HREC and Routine Care can be found in Table The HREC visit for the high-risk patients is focused on identifying co-morbidities and complications of cART and reinforcing medication adherence. The nurse asks about adherence to medication by asking whether the patient has missed any of his/her medications in the previous 7 days and then conducting a pill count. If the patient is not perfectly adherent, he or she is referred to the clinical officer or physician. The nurse reviews a symptom checklist  and measures temperature and transcutaneous oxygen saturation. If the patient reports any symptoms or meets the pre-set threshold for either temperature (≥37.2°Celsius) or oxygen saturation , defined as being absent from the clinic for at least 3 months with no information regarding vital status, and a composite outcome defined as LTFU or death. The rationale for the composite outcome is that loss to follow up in such a high-risk population is likely to mean that a patient has died, even if the death has not yet been reported to the clinic ,30-34. AThe primary explanatory variable is being in the HREC programme (versus remaining in Routine Care). Our analyses quantify the effect of HREC on mortality, loss to follow up, and the composite outcome of death or loss to follow up using crude and adjusted hazard rate (HR) ratios.a priori based on their potential to independently affect changes in risk of mortality and/or loss to follow up: CD4 count ; receipt of treatment for tuberculosis at the time of cART initiation (yes/no); receipt of cotrimoxazole or dapsone prophylaxis within 28 days of cART initiation (yes/no) [Our adjusted HR ratios control for the following potential confounding variables, all measured at time of cART initiation and selected (yes/no) ,17; travth day following the most recent visit to the clinic.We included all eligible patients and categorized them as having been enrolled into HREC at initiation of cART or having remained in Routine Care. The distributions of the time to event outcomes are summarized using Kaplan-Meier curves. Event times and censoring times are defined as follows: for analysis of mortality, the event time is the date of death; others are censored at the time of their last clinic visit. For the analysis of loss to follow up, patients were defined as lost if they had not returned to clinic for more than three consecutive months; for these patients, the event time is the 90Individuals whose reported follow-up time is zero days had 1 day added for the purpose of analysis. Those who died were censored on their death date, and patients whose most recent clinic was less than 90 days prior to the close of the database were censored at the date of their last clinic visit. For the loss to follow up analysis, the earliest possible event time is 90 days after the initiation of cART; hence our tests and regression models use a start time of day 90. Finally, for the composite outcome, the event time is the earliest of death date or loss to follow up date, where the LTFU date is defined as we have explained.p(x), is estimated by fitting a logistic regression model of HREC status (yes/no) on potential confounding variables x. The propensity score model is checked for lack of fit using the Hosmer-Lemeshow goodness-of-fit test [The adjusted HR ratios control for potential confounding variables using inverse weighting by the treatment propensity score method . For eacfit test . The adjfit test , stabilix has been eliminated; hence, to the extent that x contains all relevant confounders, the adjusted HR is equivalent to the exposure effect from a marginal structural proportional hazards model and can be interpreted as the causal effect of HREC on the event of interest [Because the propensity scores represent the probability of receiving HREC as a function of individual-level covariates (listed here), the weight for each individual is inversely proportional to the (estimated) probability of his or her actual HREC status. The weighted sample can therefore be viewed as one where differential selection into HREC attributable to interest ,38.All analyses were done using STATA Version SE/10 .3 who initiated cART at one of the USAID-AMPATH clinics during the study period. Of these, 635 were enrolled into HREC. Reasons why patients were not enrolled into HREC included that the HREC programme had not yet been rolled out to a particular clinic, that the patient lived too far to allow them to attend clinic weekly or bi-weekly, and lack of available space in the clinic for expansion of the HREC programme.There were 4,958 patients aged 14 years or older with CD4 counts of ≤100 cells/mmAs summarized in Table There were 426 deaths among the study population: 39 in HREC and 387 in Routine Care. The crude incidence rate of death during the follow-up period was 5.7 per 100 person-years in HREC compared with 10.6 per 100 person-years in Routine Care  Figure . After aThere were also 1,299 patients lost to follow up during the same period, including 134 in HREC and 1,165 in Routine Care. The crude incidence rate of LTFU among HREC was 18.7 per 100 person-years versus 29.7 in Routine Care  Figure . After aWhen we assessed the combined endpoint of LTFU and death, there were 1,725 events in 4639.5 person-years of follow up, for a crude incidence rate of 24.2 per 100 person-years in HREC versus 39.5 in Routine Care  Figure . OverallThe first few months following initiation of cART is a critical time for severely immune-suppressed HIV-infected patients. These data suggest that more frequent monitoring of patients in the early months by a dedicated nurse can significantly improve survival and retention in care among these high-risk patients and improve their retention in care. Although further evaluation is needed, this intervention may be relatively easy to implement in other resource-constrained environments.and frequent assessments. Rapid because this makes accessing healthcare more accessible to patients (by not having to wait as long and by not having to spend as much time in the clinic); frequent because it makes it more likely that early warning symptoms  can be identified within days, as opposed to weeks, of their onset. If, for example, the monthly standard of care visits were simply made more rapid, such symptoms as fever or rash would go unattended for potentially weeks, thereby increasing the risk of full-blown immune-reconstitution disease, more severe toxicities, etc.To our knowledge, the concept of frequent nurse-based rapid assessments is among the few interventions other than cotrimoxazole prophylaxis that has been associated with a profound reduction in early mortality among high-risk HIV-infected patients initiating cART in low-income settings ,14. We bWe also postulate that more frequent monitoring is effective at improving early patient outcomes through both direct and indirect mechanisms. For example, earlier identification of the signs and symptoms of drug toxicity, opportunistic infections and immune reconstitution syndrome likely leads to earlier interventions to address these issues; thus patients should experience a direct survival advantage in the short-term.Indirectly, HREC may have improved adherence to cART and thus improved short-term outcomes. Adherence may be improved in the HREC population because of the weekly contact, reminders and supports; as a result of improved adherence, patients will be more likely to experience complete virologic suppression, have improved immune-response, and be less likely to develop resistance, therefore indirectly contributing to survival benefits over the short and long term. HREC may have improved retention by enabling patients to be seen quickly without having to wait in long queues and without having to pass through multiple stations , thereby making their healthcare more accessible to them.There are some additional costs associated with HREC. For example, there are added direct costs to patients arising from increased transportation required to and from the clinic. They may also have to miss more work because of more frequent clinic visits, translating into increased opportunity costs. The nurses hired to work on HREC were hired explicitly for that purpose, and this certainly adds to the overall programme expense on personnel. Whether these additional costs and expenses are justified when weighed against the costs associated with increased morbidity, mortality and loss to follow up is the subject for a detailed cost-effectiveness analysis that is beyond the scope of the present evaluation.3. These data have therefore been able to assess the effect of more frequent monitoring in a setting where the vast majority of patients were already receiving cotrimoxazole or dapsone. Second, the effect of HREC was strong across three different versions of the primary outcome, suggesting a robust effect. By evaluating the impact of HREC on both mortality and LTFU, we took account of the two crucial factors determining the success of an HIV treatment programme: keeping patients alive and in care. Moreover, we used statistical methods that appropriately and robustly adjusted for measured confounders.There are two key strengths to these findings. First, the standard of care in AMPATH is already to provide cotrimoxazole or dapsone until a patient's CD4 count is above 200 cells/mmThere are also limitations to this analysis. First, the choice of clinics in which HREC was rolled out to first may have created a variety of potential biases in our analysis related to a possible higher quality of care offered at those clinics. For example, this may have created some selection bias , and ascertainment bias . Similarly, although all patients were eligible to be enrolled into HREC, only a small proportion were enrolled. If the providers who were more likely to refer patients to HREC were also the ones more likely to be current with clinical protocols  and/or more likely to be better clinicians, those patients referred by them may have been more likely to have better outcomes anyway.However, for those patients referred, it was the HREC nurse who had the majority of clinical contact with them, thereby reducing any potential provider bias on the part of the referring clinician. Similarly, a slightly smaller proportion of patients enrolled into HREC were WHO Stage III/IV at treatment initiation. Although these issues may have biased the findings favourably towards HREC, the use of propensity score methods helps to overcome this possible bias because weighting in inverse proportion to the treatment propensity score creates a pseudo-sample wherein allocation to HREC is independent of the confounders that have been included in the propensity score. Hence the weighted dataset can be analyzed as if the group allocation were random. A limitation of this method is that there may be non-random allocation to HREC based on unmeasured factors to the extent that receipt of HREC depends on unmeasured factors. We acknowledge that residual bias may therefore remain due to potential unmeasured confounders, including adherence to cART .In conclusion, we have demonstrated that weekly rapid assessments by nurses, either by phone or in person, with immediate referrals to clinical officers or physicians if needed, can significantly improve survival among high-risk HIV-infected patients initiating cART in a sub-Saharan African setting. Although the cost effectiveness of the Express Care model needs to be thoroughly evaluated, our experience and findings suggest that this may be an innovative way of increasing patient volume, improving the quality of care, and greatly improving patient outcomes in the short term.The authors declare that they have no competing interests.PB was primarily responsible for the writing of the manuscript. AS, RK, JS, JM, and SK are practicing physicians in Kenya who developed the Express Care programme and contributed significantly to the generation of hypotheses and interpretation of results for the manuscript. JH is the biostatistician on record for this analysis and provided significant input and technical assistance in the methodological approaches used. AK was the analyst for the study. KWK critically reviewed the manuscript for issues of design and interpretation. ES was the data manager responsible for providing and overseeing the data. All authors have read and approved the final version of this manuscript.


The purpose of this study is to describe the clinical characteristics, microscopic findings, and treatment response to albendazole of microsporidial keratoconjunctivitis among immunocompromised individuals with HIV/AIDS.This is a retrospective case series. Diagnosis of microsporidial keratoconjunctivitis was confirmed by subspecialist examination and conjunctival swabs examined by light microscopy. HIV infection was documented, and absolute CD4+ T cell count was determined. Patients were treated with albendazole and followed for clinical response.Light microscopy from the conjunctival swabs demonstrated myriad small, round to oval microsporidial organisms that stained positively with modified acid-fast methods. Two of the patients initially not taking highly active antiretroviral therapy (HAART) and presenting with an absolute CD4+ T cell count less than 100 cells/μL had a more severe form of keratoconjunctivitis than the third patient . All patients were started or continued on HAART. Two of the patients responded to oral albendazole, with resolution of symptoms and signs. The third patient did not initially respond, perhaps because of an immune recovery inflammatory syndrome, but subsequently had temporary improvement with albendazole.Microsporidial keratoconjunctivitis is a rare ocular complication of HIV/AIDS. Light microscopic evaluation of conjunctival swabs may be a useful minimally invasive first step toward diagnosis of microsporidial keratoconjunctivis in settings where electron microscopy is not available. Based on the limited available information, albendazole often is effective for this condition, and is widely available in developing countries at low cost. Encephalitozoon, Enterocytozoon, Nosema, Pleistophora, and Trachipleistophora [Microsporidia are obligate intracellular spore-forming eukaryotic protozoan parasites, some of which are pathogenic in humans . They arstophora . The spostophora  in its istophora . Althougstophora .It is not clear how microsporidia enter into the cornea; traumatic inoculation or contact with contaminated water or food has been suggested . Once in3); in these patients, morbidity can be significant [Clinical symptoms and disease associated with microsporidiosis vary with the species that causes the infection and the host’s immune status . Most canificant .Microsporidial infections of the ocular surface in humans are rare diseases. Microsporidial keratoconjunctivitis has been described primarily in patients with HIV infection , but alsDiagnosis of ocular microsporidiosis is based on scrapings or biopsy of the conjunctiva or cornea. Pathologically, microsporidial spores are ovoid and may be found in the cytoplasm of the epithelial cells, sometimes measuring only 2 × 1 μm. There will be few accompanying inflammatory cells in individuals with pronounced immunodeficiency. The organisms are Gram positive and stain well with Giemsa stain; characteristic periodic acid–Schiff-positive granules are found in one end of the mature microsporidial spores. Diagnosis may be aided by the use of electron microscopy and confocal microscopy in vivo , 9, sophThe best treatment for microsporidial keratitis has not been established. Treatment with 0.02% polyhexamethylene biguanide does not offer any significant advantage over placebo . MicrospAlthough one case has been reported in a patient who had lived in Mozambique , to the We retrospectively reviewed the clinical features, microscopic observations, and treatment response to albendazole of a cluster of immune-compromised patients with keratoconjunctival microsporidiosis seen at the anterior segment clinic of Menelik II Hospital, the primary cornea and external diseases center for the Department of Ophthalmology, Addis Ababa University. In each case, best-corrected visual acuity had been measured at 6 m for each eye of each patient. Clinical findings were based on slit-lamp biomicroscopy by a consultant cornea specialist.Specimens were obtained and evaluated by the Department of Microbiology and Parasitology of Black Lion Hospital, Addis Ababa University. Conjunctival swabs, as a minimally invasive first step toward diagnosis, were collected from each patient suspected of having microsporidiosis and directly smeared on a slide and allowed to air-dry prior to fixation with methanol. The slides were stained with the modified trichrome stain solution for 90 min and then rinsed for 10 s with acid alcohol, rinsed briefly with 95% ethanol, and incubated for 5 min in 95% ethanol and for 10 min in 100% ethanol. The slides were air-dried and examined microscopically with oil immersion. The microsporidial spores stain dark violet against a pale-green background.After confirmation of microsporidial keratitis, CD4+ T cell counts were determined, and highly active antiretroviral therapy (HAART) initiated or continued. For patients who failed to improve on HAART alone, either one or two courses of albendazole was initiated, as alternative treatments were not available in Ethiopia at the time of the study. Patients’ response to the treatment was evaluated clinically following treatment.Among over 3,000 patients seen in the cornea and external diseases clinic between June 2008 and November 2008 inclusive, three cases of microsporidial infection were identified, all in patients with HIV/AIDS.A 10-year-old female patient from Addis Ababa, discovered to be HIV seropositive a year previously, presented with 3 months history of redness, tearing, photophobia, and reduction of vision of both eyes. Her best-corrected visual acuity was 6/60 (6/24 with pin hole) and counting fingers at 4 m (no improvement with pin hole) in the right and left eyes, respectively. She had a healed zoster scar over the left side of the forehead. The conjunctivae were hyperemic with ciliary flush. Corneal sensation was diminished bilaterally, and diffuse epithelial and subepithelial whitish corneal infiltrates were present  redness, episodic photophobia, and blurring of vision. She gave history of having had loss of vision in the right eye following severe redness, pain, photophobia, and excessive tearing 2 years prior to her presentation. She denied a previous history of contact with animals or agricultural trauma. She was known to be HIV positive, having taken HAART for the past 4 years, with a recent CD4+ T cell count of 259 cells/μL. She had not been taking topical therapies at the time of presentation.On examination, the visual acuity of the left eye was 6/9. The bulbar conjunctiva was injected nasally, and the cornea had yellowish stromal and intraepithelial infiltrates that stained with fluorescein, although there was no epithelial defect (findings similar to those illustrated in Fig. A 24-year-old woman from Addis Ababa presented with a 7-month history of bilateral foreign body sensation, redness, tearing, and reduction in vision, which had not improved with 1 month of topical corticosteroids. She was known to be HIV positive, but had not received HAART previously. She had no history of contact with animals or agricultural trauma. At initial presentation, her visual acuity was 6/24 and 6/9 on the right and left eyes, respectively. In each eye, the conjunctivae were hyperaemic, and there were diffuse intraepithelial whitish infiltrates over the cornea with punctate fluorescein staining. Light microscopy of a conjunctival swab revealed myriad small, round to oval microsporidial organisms that stained positively with modified acid-fast method for microsporidia.After the CD4+ T cell count was found to be 45 cells/μL, HAART was initiated 1 day after taking the conjunctival swab. One month after HAART, there was little symptomatic or objective improvement in the ophthalmic findings, and the CD4+ T cell count had improved to 179 cells/μL. Thereafter, she was treated with albendazole 400 mg twice daily for 2 weeks. At the second month, she presented with worsening of redness and severe foreign body sensation and no visual improvement; she developed a corneal epithelial defect over the left eye, and the preexisting intraepithelial lesions had become more flocculent in appearance Fig. . AlthougThe first case of microsporidiosis in an HIV-infected individual was reported in 1985 , 12, 15,Although the second case was on HAART for 4 years before presentation, the other two cases presented with a CD4+ T cell count <100 cells/μL. We hypothesize that the lesser degree of ocular discomfort and less dramatic physical findings in the second patient might have been related to her successful treatment with antiretroviral therapy, although a small series such as this one is unable to confirm such a hypothesis. If so, early diagnosis of HIV infection and initiation of HAART may improve the clinical course of microsporidial keratoconjunctivitis in some cases, in addition to the numerous other benefits of such therapy for patients with advanced HIV/AIDS , 15. SucDetection of microsporidiosis classically has relied on electron microscopy and the histopathology of corneal or conjunctival biopsy specimens, the latter being essential for accurate speciation. In our report the microsporidial spores were identified using the simple, inexpensive approach of using modified acid-fast staining technique applied to a specimen taken from a conjunctival swab, a minimally invasive approach that is potentially an appropriate first step toward the diagnosis of microsporidiosis in settings with limited resources. While in our cases simple conjunctival swabs yielded the diagnosis, the approach likely would have lesser sensitivity and specificity than more invasive approaches; corneal scraping and/or conjunctival biopsy likely would be needed in some instances to make the diagnosis.Therapeutically, there is no standard medical therapy for corneal microsporidiosis. However, the most frequently used approach has been topical fumagillin  and/or oMicrosporidiosis should be considered in the differential diagnosis of chronic keratoconjunctivitis in immunodeficient patients. Reciprocally, patients with microsporidial keratoconjunctivitis should be evaluated for possible immunodeficiency syndromes such as HIV/AIDS, given the known association between these conditions, and the increasing availability of effective treatment for HIV/AIDS. Based on our small sample and the limited reported experience in the literature, albendazole, which is inexpensive and widely available, is a practical treatment approach when the diagnosis of microsporidial keratoconjunctivitis is recognized in a resource-constrained setting.


Multicentric Castleman disease (MCD) is a lymphoproliferative disorder caused by human herpesvirus 8 (HHV8) infection HIV associated MCD (HIV-MCD) presents with various clinical symptoms. Many HIV-negative MCD patients are often treated with anti-human interleukin-6 (IL6) receptor monoclonal antibodies (tocilizumab), and successful results have been reported. IL-6 plays an important role in the development of both HIV-positive and HIV-negative MCD; however, the efficacy of tocilizumab in HIV-MCD patients is unknown. We herein report the clinical and biologic courses of two HIV-MCD patients treated with tocilizumab. In both cases, a significant and rapid clinical improvement was observed after the first infusion. However, the treatment efficacy was not maintained for a long period, and relapse occurred at 15 and 22 weeks, respectively. Both patients received rituximab and subsequently achieved complete clinical remission. Our report, in addition to data presented in the literature, suggests that tocilizumab could be an initial treatment option in patients with HIV-MCD. Multicentric Castleman disease (MCD) is a lymphoproliferative disorde, and HIV-associated MCD (HIV-MCD) is caused by human herpesvirus 8 (HHV8) infection in HIV-positive patients . HIV-MCD4/μ, albumin 3.8 g/dl and CRP 0.15 mg/dl.A 44-year-old male who was HIV-1 seropositive for several years and did not start treatment with combination antiretroviral therapy (cART), with a CD4 cell count of 188 cells/μl and a viral load of 74 copies/μl, was diagnosed with Kaposi’s sarcoma and treated with two cycles of liposomal doxorubicin and cART. Hepatitis C and B were negative. Eight months after being diagnosed with Kaposi’s sarcoma, he presented with a high fever, fatigue and lymph nodes swelling throughout his body. Blood tests revealed anemia (hemoglobin: 8.3 g/dl), thrombocytopenia (3.3×104/μ), a low albumin level (2.3 g/dl) and a high CRP level (10.75 mg/dl). The high fever persisted for two weeks. A lymph node biopsy demonstrated remarkable infiltration of polyclonal plasma cells and plasmablastic cells in the interfollicular areas. Lymph node architecture was retained. Vascular proliferation was observed between the follicles, with perivascular hyalinization. The levels of HHV8 and human IL6  in the blood were 460,000 copies/μl and 41.7 pg/ml, respectively. The patient was diagnosed with HIV-MCD and 8 mg/kg of tocilizumab was administered intravenously. The persistent high fever disappeared within a few hours. There were no adverse events of tocilizumab treatment. After one week, the laboratory abnormalities recovered: hemoglobin 10.8 g/dl, platelets 11.2×104/μ, an albumin level of 2.1 g/dl, a CRP level of 8.18 mg/dl, an HHV8 titer of 3,400,000 copies/μl and a hIL6 level of 305 pg/ml, indicating HIV-MCD relapse. A second lymph node biopsy showed angiofollicular hyperplasia and interfollicular plasma cell infiltration. HHV8 antigens were more strongly positive in lymphocytes than that observed on the first biopsy. The patient received tocilizumab infusions once in week for two weeks (the 15th and 16th weeks); however, his symptoms and blood test abnormalities worsened. Tocilizumab was discontinued and he recovered following the administration of four cycles of rituximab treatment. He has since remained in remission for four years.The HHV8 concentration and hIL6 level in the blood decreased to 120 copies/μl and 18.2 pg/ml, respectively, after treatment  and hyper gammaglobulinemia . He was diagnosed with HIV-MCD based on the findings of a lymph node biopsy. The follicles showed varied degrees of involution and hyalinization of the germinal centers with prominent mantle zones that intruded into the germinal centers, completely effacing them. In the mantle zone cells, variable numbers of plasma cells and lymphocytes with HHV8 antigens were observed. The levels of hIL6 and HHV8 in the blood were 53.5 pg/ml and 390,000 copies/μl, respectively. The patient received 8 mg/kg of tocilizumab 10 days after appearance of symptoms. Following the administration of tocilizumab, the high fever immediately decreased. The abnormal values on the blood examinations improved two weeks after treatment: hemoglobin 14.8 g/dl, platelets 12.9×104/μl, albumin 4.4 g/dl and CRP 0.07 mg/dl. The levels of HHV8 and hIL6 decreased to 5,100 copies/μg and 35 pg/ml, respectively, eight weeks after treatment , although hepatitis B was negative. In 2012, he presented with a high fever and fatigue with swollen lymph nodes throughout his body. A blood test showed anemia (a hemoglobin level of 6.1 g/dl), a low albumin level (2.4 g/dl), a high CRP level (13.59 mg/dl), a low platelets count  and will assist in elucidating these issues. The accumulation and analysis of case reports is required to evaluate when and how tocilizumab should be administered with or without other drugs, including rituximab, ganciclovir and etoposide, in patients with HIV-MCD.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.IL6: Anti-human interleukin-6; HIV-MCD: HIV associated multicentric Castleman disease; HHV8: Human herpesvirus 8; CRP: C-reactive protein; cART: Combination antiretroviral therapy; hIL6: Human IL6; vIL6: Viral IL6.Although Hanabusa H. has received honoraria from Baxter Healthcare, NovoNordisk, Bayer, Pfizer, and KaketsuKen; and has served on advisory boards for Baxter Healthcare (limited to hemophilia care), he has no competing interest related with this case report (Tocilizumab and Chugai Co.). Nagao and Nakazawa declare that they have no competing interests.AN, SN and HH cared for the patients. AN wrote the manuscript. HH designed the study and helped to draft the manuscript. All authors have read and approved the final manuscript.


APOBEC3G is a host defense factor that potently inhibits HIV replication. We hypothesize that HIV-infected children with a genetic variant of APOBEC3G will have a more rapid disease progression.Human Antiretroviral therapy (ART)-naïve children, aged 1–12 years old with CD4 15-24% and without severe HIV-related symptoms were enrolled. The children had CD4% and absolute CD4 counts every 12 weeks and HIV-RNA every 24 weeks until 144 weeks. ART was started when CD4% declined to < 15% or AIDS-related events developed.APOBEC3G genetic variants were performed by PCR-based restriction fragment length polymorphism techniques from peripheral blood mononuclear cells. Random-effect linear regression analysis was performed to correlate APOBEC3G genotypes and disease progression.3 for CD4 count and 4.7 log10copies/mL for HIV-RNA.147 children, 35% male, with a median (IQR) age of 6.5 (4.3-8.8) years were enrolled. CDC N:A:B were 1:63:36%. Median baseline values were 20% for CD4% 605 cells/mmAPOBEC3G genotypes AA (186H/H), AG (186H/R), GG (186R/R) were 86%, 12%, and 2% respectively. The APOBEC3G genotype GG was associated with a significant decline in CD4% -5.1% (−8.9 to −1.2%), p<0.001, and CD4 counts −226 (−415 to −34) cells/mm3, p<0.001 by random-effect liner regression analysis. No significant associations of APOBEC3G genotypes with HIV-RNA changes overtime (p=0.16) or progression to CDC B and C (p=0.49) were observed.The frequencies of APOBEC3G genotype GG was significantly associated with a more rapid decline in CD4. APOBEC3G’s antiviral effects on HIV disease progression in children should be further explored. APOBEC3G)[Association between the nfection. Howevernfection. There ipies/ml].APOBEC3G genotypes and the AIDS disease progression. A previous report in Argentinian HIV-infected children has also shown that there was no affect of APOBEC3G genotypes and AIDS onset[APOBEC3G genotype GG, thus, the association of APOBEC3G genotypes and sharp decline of CD4% may have occurred by chance. The interpretation of our findings should be cautious as failure to demonstrate a statistically significant difference between study groups at baseline. For example, different of baseline CDC classification ratio, and higher baseline CD4 cell counts of subtype GG group than the other two groups, although the baseline CD4% was similar, does not ensure that the groups are equivalent, particularly with the small sample size of the subtype GG that limits statistical power. Second, we could not see a correlation of APOBEC3G genotypes with the clinical patterns of long term non-progressors,  becaThe strengths of our study are the large number of ART-naïve vertically transmitted HIV-infected children with moderate immune deficiency in Asia enrolled with the long-term clinical data with 144-weeks of follow-up. Further studies should be evaluated for better understanding of APOBEC3G’s antiviral effects on the disease progression in the HIV-infected children.APOBEC3G genotypes, H186 in GG, was significantly associated with decline in CD4% and the CD4 count over time in Thai and Cambodian ART-naïve HIV-infected children with moderate immune deficiency.In conclusion, our data showed that a genetic variant of th International Workshop on HIV Pediatrics, 20 – 21 July 2012, Washington DC, USA.This study was presented as poster presentation (poster number P_11) in 4This is a sub-study of the Pediatric Randomized Early versus Deferred Initiation in Cambodia and Thailand study .All authors declare no conflict of interest and that member of their immediate families do not have a financial interest in or arrangement with any commercial organization that may have a direct interest in the subject matter of this article.TB, MI, YI, and WS were involved in the study design, collection of data, and writing of the manuscript. KM, TP, JA, AM, and SV were involved in the study design and collection of data. TN was involved in the study design. PP was involved in the study design and writing of the manuscript. JS and TB analyzed the data and wrote the manuscript. TI collected the data and assisted in the writing of the manuscript. All authors reviewed the draft of the manuscript before submission. All authors have read and approved the final manuscript.CIP TH001:HIV Netherlands Australia Thailand (HIV-NAT) Research Collaboration, Thai Red Cross AIDS Research Center, Bangkok, Thailand; Dr.Kiat Ruxrungtham, Dr.Jintanat Ananworanich, Dr.Thanyawee Puthanakit, Dr.Chitsanu Pancharoen, Dr.Torsak Bunupuradah, Stephen Kerr, Theshinee Chuenyam,Sasiwimol Ubolyam, Apicha Mahanontharit,Tulathip Suwanlerk,Jintana Intasan,Thidarat Jupimai,Primwichaya Intakan, Tawan Hirunyanulux, Praneet Pinklow, Kanchana Pruksakaew,Oratai Butterworth, Nitiya Chomchey,Chulalak Sriheara,Anuntaya Uanithirat,Sunate Posyauattanakul,Thipsiri Prungsin,Pitch Boonrak,Waraporn Sakornjun, Tanakorn Apornpong,Jiratchaya Sophonphan,OrmrudeeRit-im,Nuchapong Noumtong,Noppong Hirunwadee,Dr.Chaiwat Ungsedhapand,Chowalit Phadungphon,Wanchai Thongsee,Orathai Chaiya,Augchara Suwannawat,Threepol Sattong,Niti Wongthai,Kesdao Nantapisan,Umpaporn Methanggool,Narumon Suebsri,Dr.Chris Duncombe,Taksin Panpuy,Chayapa Phasomsap,Boonjit Deeaium,Pattiya JootakarnCIP TH003:Bamrasnaradura Infectious Diseases Institute, Nonthaburi,Thailand; Dr.Jurai Wongsawat,Dr.Rujanee Sunthornkachit, Dr.Visal Moolasart,Dr.Natawan Siripongpreeda,Supeda Thongyen,Piyawadee Chathaisong,Vilaiwan Prommool, Duangmanee Suwannamass,Simakan Waradejwinyoo,Nareopak Boonyarittipat,Thaniya Chiewcharn,Sirirat Likanonsakul,Chatiya Athichathana, Boonchuay Eampokalap,Wattana Sanchiem.CIP TH004:Srinagarind Hospital,Khon Kaen University,Khon Kaen,Thailand; Dr.Pope Kosalaraksa,Dr.Pagakrong Lumbiganon, Dr.Chulapan Engchanil,Piangjit Tharnprisan,Chanasda Sopharak,Viraphong Lulitanond,Samrit Khahmahpahte,Ratthanant Kaewmart, Prajuab Chaimanee, Mathurot Sala, Thaniita Udompanit,Ratchadaporn Wisai,Somjai Rattanamanee, Yingrit Chantarasuk,Sompong Sarvok,Yotsombat Changtrakun,Soontorn Kunhasura, Sudthanom KamollertCIP TH005:Queen Savang Vadhana Memorial Hospital, Chonburi,Thailand; Dr. Wicharn Luesomboon, Dr.Pairuch Eiamapichart,Dr.Tanate Jadwattanakul,Isara Limpet-ngam,Daovadee Naraporn,Pornpen Mathajittiphun,Chatchadha Sirimaskul,Woranun Klaihong,Pipat Sittisak,Tippawan Wongwian, Kansiri Charoenthammachoke,Pornchai Yodpo.CIP TH007:Nakornping Hospital,ChiangMai,Thailand;Dr.Suparat Kanjanavanit, Dr.Maneerat Ananthanavanich, Dr.Penpak Sornchai,Thida Namwong,Duangrat Chutima,Suchitra Tangmankhongworakun,Pacharaporn Yingyong,Juree Kasinrerk, Montanee Raksasang,Pimporn Kongdong,Siripim Khampangkome, Suphanphilat Thong-Ngao,Sangwan Paengta,Kasinee Junsom, Ruttana KhuankaewM,Parichat Moolsombat,Duanpen Khuttiwung,Chanannat Chanrin.CIP TH009:Chiangrai Regional Hopsital, ChiangRai, Thailand; Dr.Rawiwan Hansudewechakul,Dr.Yaowalak Jariyapongpaiboon, Dr.Chulapong Chanta,Areerat Khonponoi, Chaniporn Yodsuwan, WaruneeSrisuk,Pojjavitt Ussawawuthipong,Yupawan Thaweesombat,Polawat Tongsuk,Chaiporn Kumluang,Ruengrit Jinasen,Noodchanee Maneerat,Kajorndej Surapanichadul, Pornpinit Donkaew.CIP TH010:National Pediatric Hospital,PhnomPenh,Cambodia;Dr.Saphonn Vonthanak, Dr. Ung Vibol,Dr.Sam Sophan,Dr.Pich Boren,Dr.Kea Chettra,Lim Phary,Toun Roeun, Tieng Sunly,Mom Chandara,Chuop Sokheng,Khin Sokoeun,Tuey Sotharin.CIP TH011:Social Health Clinic,Phnom Penh,Cambodia;Dr.Saphonn Vonthanak,Dr.Ung Vibol,Dr.Vannary Bun,Dr.Somanythd Chhay Meng,Dr.Kea Chettra,Sam Phan,Wuddhika In vong,Khuon Dyna.CIP TH012:PrapokklaoHospital,Chantaburi,Thailand;Dr.Chaiwat Ngampiyaskul,Dr.Naowarat Srisawat, Wanna Chamjamrat,Sayamol Wattanayothin,Pornphan Prasertphan,Tanyamon Wongcheeree, Pisut Greetanukroh,Chataporn Imubumroong, Pathanee Teirsonsern.


However, many interesting points are uncovered through this review like the possibility of achieving high intracellular concentration of drugs, very good antiretroviral activity, improved bioavailability, reduced toxicity and release of the drugs from nanocarriers for long time reducing the need for frequent dosing. Indeed, a lot of assignments left behind for researchers to overcome the challenges hindering the wider application of nanomedicines in treatment of HIV/AIDS.Human immunodeficiency virus continued to be the greatest challenge and killer disease of the 21st century despite the advent of potent highly active antiretroviral therapy which are limited by their severe adverse effects, significant drug interactions, frequent dosing, limited bioavailability, and less access to viral reservoir sites like macrophages. Nano-medicines are becoming new hopes in avoiding these shortcomings of conventional antiretroviral drugs. The emphasis of this review is mainly the application of polymers based nanomedicines in pharmacotherapy of HIV/AIDS. Most of the studies to date on this area are  Nano-medicine is a term implying the application of nanotechnology (the technology that uses nanosized particles) for therapy and diagnosis of diseases. Nanoparticles have improved pharmacokinetics and tissue distribution of therapeutic agents there by diminishing toxicity by their preferential accumulation at the target site. In addition, they improve therapeutic potential of drugs by facilitating intracellular delivery and prolonging their retention time either inside the cell or in blood circulation ,2.Nanoparticles can be categorized into three groups: Inorganic nanoparticles, solid lipid nanoparticles and polymer nanoparticles. Inorganic nanoparticles are the generic term for several nanoparticles such as gold and magnetic nanoparticles. Solid lipid nanoparticles combine the advantages but avoiding the disadvantages of other colloidal carriers such as emulsions, liposomes and polymeric microparticles and nanoparticles. Polymer nanoparticles involve various natural or biocompatible synthetic polymers ,3,4.Polymer therapeutics is a family of compounds and drug delivery technologies that uses water-soluble polymers as a common core component. One of the biggest advantages of using these polymers in drug delivery is the capability to manipulate their properties such as molecular weight, linkers and many more to adapt to the drug delivery requirements. They can be subdivided into several groups: polymer drugs, polymeric –protein conjugates, polymer drug conjugates, multicomponent polyp lexes being developed as non-viral vectors, polymer micelles and dendrimers ,3.Polymer-protein conjugates using polyethylene glycol (PEG) called PEGylation as polymer component are currently the most advanced class of polymer therapeutics. They are developed to avoid some of the drawbacks of peptide, protein and antibody-based drugs like a short half-life, poor stability and solubility, increased clearance by the reticuloendothelial system (RES) and immunogenicity. PEGylation has been employed in treatment of viral hepatitis as well as different types of malignancies ,5.Polymer-drug conjugates are becoming a fast growing field, where nearly a dozen of polymeric conjugates advancing to the clinical trial stage. Several advantages of these technologies are being reported over the corresponding parent drugs by different clinical trials including fewer side effects, enhanced therapeutic efficacy, ease of drug administration, and improved patient compliance. The therapeutic efficacy of these agents is increased primarily through an enhanced permeability and retention (EPR) effect of long-circulating polymers .Dendrimers are nanostructures obtained from macromolecules such as polyamidoamine (PAMAM), and polypropyleneimin; and are highly branched with an inner core. They are unique in that they have series of branches, multivalences, well defined molecular weight and globular structure with controlled surface functionality. The presence of multivalency nature enables the attachment of several drug molecules, targeting groups and solublising groups onto their surfaces in a well defined manner. Beside their use in drug delivery, dendrimers are also pharmaceutically active compounds against some diseases ,6.Micelles are formed from amphiphilic surfactants which spontaneously associate in aqueous medium to form core (hydrophobic)-shell (hydrophilic) structures or vesicles. Polymeric micelles are able to reach parts of the body that are poorly accessible. However, their targeting ability is limited by the low drug loading and low drug incorporation stability leading to the loaded drug to be released before getting to the site of action ,8.In general, nanomedicines particularly polymer based drug delivery systems are highly fascinating and hence attracting the attention of scientists from different corners of the world. This is especially true for the diagnosis, prevention and treatment of intracellular infections like hepatitis, tuberculosis and HIV/AIDS  which caIf left untreated, HIV infection is associated with very high viral load in the body leading to progressive fall in immune cells particularly CD4+ T cells. This can be interrupted by treatment with highly active antiretroviral therapy (HAART), which should contain at least three drugs regimens made up of at least two classes of antiretroviral agents. However, the great challenge is that immediately after initial infection, this virus is able to establish reservoirs where it escapes from the effect of drugs and keeps releasing the viral progeny to the blood as long as the patient lives. This makes it one of the chronic and lifelong diseases especially with the introduction of HAART. There are two types of viral reservoirs within tissues that serve this role. The anatomical reservoirs; these are tissues inaccessible to optimal levels of antiviral drugs due to due to the presence of barriers, such as the blood–brain barrier (BBB), blood-cerebrospinal fluid barrier, and blood-testes barrier. and the others are cellular reservoirs; cells in which this virus remains latent and hence escaping the action of antivirals due to the presence of efflux proteins such as P-glycoprotein and multidrug resistance protein on the cell surface preventing the drugs from attaining therapeutic intracellular concentrations ,11.Dendritic cells within lymphoid tissue trap a large number of extracellular virions on their surface to protect virus from antiretroviral drugs. On top of this, latently infected CD4+ T cells help the HIV to persist despite the presence of effective antiretroviral therapy as it is not replicating at this stage. Last but not least, monocytes/macrophages that are specifically found in brain, pulmonary alveoli, spleen and lymph nodes are relatively long-lived cells since HIV has very low cytopathic effects on them making them a persistent reservoir of HIV regardless of the presence of highly active antiretroviral therapy -13. TherThe HIV/AIDS epidemic is one of the major public health threats especially in sub-Sahara countries. Globally, about 35.3 million people were living with HIV in 2012 which is an increase from previous years as more people are receiving the life-saving antiretroviral therapy. The prevalence of HIV/AIDS continues to increase and it is expected that over 90 million people will ultimately be infected in Africa alone. On the other hand, there were 2.3 million new HIV infections and 1.6 million AIDS deaths in 2012 globally. In 2012, 9.7 million people in low- and middle-income countries received antiretroviral therapy, representing 61% of all who were eligible under the 2010 World Health Organization (WHO) HIV treatment guidelines. However, under the 2013 WHO guidelines, the HIV treatment coverage in low- and middle-income countries represented only 34% of the 28.3 million people eligible in 2013. Antiretroviral therapy not only prevents AIDS-related illness and death: it also has the potential to significantly reduce the risk of HIV transmission and the spread of tuberculosis. From 1996 to 2012, antiretroviral therapy averted 6.3 million AIDS-related deaths worldwide, including 5.2 million deaths in low- and middle-income countries .However, despite the clear advantages of HAART in management and prevent of HIV, there are several significant shortcomings. Significant drug interactions, additional and or synergistic toxicity as a result of combination, low adherence rate secondary to pill burden and frequent dosing, and potential for development of drug resistant virus which is even more difficult to treat. An additional important issue is that upon discontinuation of treatment or when resistance develops, even with HAART, the viral load rebounds in the blood . Lastly,Targeted delivery to HIV reservoir sites would be of significant benefit because many antiretroviral drugs do not penetrate these sites optimally which contribute not only to viral persistence, but also to the development of drug resistance ,19.N-Formyl- Methionyl-Leucyl-Phenylalanine) nanocarriers for improving HIV drug delivery. They showed that uptake by macrophages increased many folds, and also accumulation of nanocarriers into macrophages of liver, kidneys and spleen increased in similar manner. This implies that by covalent conjugation of macrophage targeting moiety fMLF to PEG, it is possible to achieve a higher accumulation in macrophages residing in tissues  delivery with a combination of three antiretroviral drugs in single nanoparticle was that of Destache and co-workers. It was showed that nanoparticles based delivery of single dose of lopinavir/ritonavir and efavirenz resulted in better and sustained suppression of the HIV-1 from both serum and tissues  for at least a month compared to free drugs administration in mice model. This seems permanent solution for the high non-adherence rate which in turn lead to resistant but more difficult to treat virus; hence treatment failure. The same study showed parenteral delivery of antiretroviral drugs is possible and hence overcome the issue of absorption and metabolism with the resultant improvement in bioavailability these drugs.This finding created very good opportunity for future researchers to design delivery of highly active antiretroviral therapy using nano-polymers technology which is very significant breakthrough in HIV/AIDS therapy .in vitro drug release was higher from PLGA compared to the other nanoparticles for both drugs. For both drugs, release from PLGA nanoparticles was greater than 95% within 10 hours and acute toxicity to animal cells was not detected [In another study, nanoparticles for delivery of zidovudine-lamivudine combination was formulated and characterized by Sankara V and co-workers. Nanoparticles of AZT-3TC were prepared through emulsion polymerization in a continuous aqueous phase of different polymers such as poly (lactic-co-glycolic acid) PLGA(50:50), poly(lactic acid), and poly(methyl methacrylate) PMMA, methyl methacrylate- sulfopropylmethacrylate (MMA-SPM). It was observed that detected .Very latest study of Annemarie and co-workers investigated delivery of three antiretrovirals combination in single nano-polymers similar to the work of Destache and co-workers. In this work, they developed nanoparticles of biodegradable polymer, poly- containing efavirenz (EFV) and boosted lopinavir  by a highpressure homogenization method. The investigators of this study demonstrated the significant uptake of the combination of antiretroviral drugs particles compared to the soluble free antiretroviral drugs, the subsequent release of levels of antiretroviral drugs in the nuclear, cytoskeleton, and membrane fractions of cells with no toxicity for 28 days .Even though, nanomedicines are the promising future of HIV/AIDS prevention and treatment, several hurdles remain unresolved, including but not limited to toxicity, unwanted biological interactions and the difficulty and cost of large-scale synthesis of nanopharmaceuticals . AnotherFurthermore, most studies involving nanocarriers use a single antiretroviral drug, which would effectively select out resistant virus in targeted tissues ,36. highIn this review, we have gone through many works done on the application of nano-polymers for the treatment and prevention of HIV infections. This paper showed that nanopolymers of different quality are designed and evaluated for delivery of ARVs. Of all, surprising thing is the fact that some polymers like dedrimers have an inherent antiviral activity beside their carrier roles which further makes them more appropriate to use them for delivery of ARVs in medicine.In this paper, we have also discovered very promising features for HIV therapy such as improving residence time of the drugs at the targeted sites, several fold increase in the uptake of the drugs to those previously less accessible viral reservoir tissues, improved antiviral efficacy and significantly reduced toxicity of antiretroviral drugs. Moreover, we have observed that, through application of nanomedicines, there will be the possibility of dosing ARVs every month or more intervals tackling the current problems of non-adherence related to frequent and larger dose administration of conventional formulations. Not only these but also there will be possibility of designing sustained release and controlled release ARV regimens to be delivered through transdermal, subcutaneous and intramuscular routes enabling the drugs to bypass first pass effect. These findings clearly suggest the hope that HIV can be completely eradicated from the body through the application of nano-polymers for delivery of ARVs in the near future.However, a lot of assignments left behind for researchers to overcome the challenges hindering the wider application of nanomedicines in treatment of HIV/AIDS. Beside this, clinical trials involving the use of nano-polymers to deliver HAART regimens should be designed to investigate both the beneficial and drawbacks of this technology.The authors declare that they have no competing interests.JLL has searched the important literatures, and drafted the manuscript. MAW has also searched the important literatures, and drafted the manuscript. Likewise GDS has searched the important literatures, and drafted the manuscript. Finally, all authors read and approved the final manuscript.


Human polyomavirus JC is the causative agent of a deadly form of sudden onset dementia, progressive multifocal leukocoencephalopathy (PML). PML is highly prevalent in immunodeficient populations, specially those undergoing chemotherapy, immunosuppressive treatments for autoimmune conditions, and HIV-1/AIDS patients. In fact, before the highly active antiretroviral therapy (HAART) regimens became available, PML was a leading cause of death in HIV-1 seropositive individuals. However, patients under HAART show increased survival times with better prognoses. In this report we described the main differences between PML before and after the HAART era; highlighting the new patterns of presentation, the neurotropism of other human polyomaviruses, and the increased prevalence of immune reconstitution inflammatory syndrome (IRIS), as a complication of PML in patients under HAART. Lastly, we propose a revised classification of human poliomavirus-associated cerebral disorders that may reflect more accurately what clinicians encounter in their everyday practice. Since the introduction of highly active antiretroviral therapy (HAART), morbidity and mortality secondary to opportunistic disorders in patients infected with HIV-1 have significantly decreased . MoreoveHuman polyomaviruses JC and BK  rarely cause disease, except for patients with an underlying immunocompromise. JC virus (JCV) is the causative agent of a fatal demyelinating disorder termed progressive multifocal leukoencephalopathy (PML) . PML is Before HAART became widely available, there was no treatment for polyomavirus-associated disorders, and death from PML occurred as early as 3 months after diagnosis . The onemultifocal versus unifocal), and the nature of the clinical presentation—classic  versus variant (involvement of the cerebellar peduncles and/or brainstem)  , which mFurthermore, we have noticed a growing number of cases reporting worsening of PML after introduction of HAART –21. ThisLastly, we would like to comment about the newly discovered neurotropism of BKV . AlthougIn conclusion, all the aforementioned data suggest that human polyomaviruses are playing a major role in the post-HAART era, and nothing but a multidisciplinary study of their biology and the pathogenesis of their associated diseases will lead to more efficacious interventions.


Minor protease inhibitor (PI) mutations often exist as polymorphisms in HIV-1 sequences from treatment-naïve patients. Previous studies showed that their presence impairs the antiretroviral treatment (ART) response. Evaluating these findings in a larger cohort is essential.To study the impact of minor PI mutations on time to viral suppression and time to virological failure, we included patients from the Swiss HIV Cohort Study infected with HIV-1 subtype B who started first-line ART with a PI and two nucleoside reverse transcriptase inhibitors. Cox regression models were performed to compare the outcomes among patients with 0 and ≥1 minor PI mutation. Models were adjusted for baseline HIV-1 RNA, CD4 cell count, sex, transmission category, age, ethnicity, year of ART start, the presence of nucleoside reverse transcriptase inhibitor mutations, and stratified for the administered PIs.P = .196). The time to virological failure was also similar . In addition, the impact of each single minor PI mutation was analyzed separately: none was significantly associated with the treatment outcome.We included 1199 patients of whom 944 (78.7%) received a boosted PI. Minor PI mutations associated with the administered PI were common: 41.7%, 16.1%, 4.7% and 1.9% had 1, 2, 3 or ≥4 mutations, respectively. The time to viral suppression was similar between patients with 0 (reference) and ≥1 minor PI mutation (multivariable hazard ratio (HR): 1.1 [95% confidence interval (CI): 1.0–1.3], The presence of minor PI mutations at baseline has no effect on the therapy outcome in HIV infected individuals. Minor protease inhibitor (PI) mutations are very common among treatment-naïve patients infected with HIV-1 but their impact on treatment outcome is poorly understood It was assumed that minor PI mutations among treatment-naïve patients might facilitate the emergence of major PI mutations and therefore lead to a worse therapeutic response to PIs. Other studies analyzing this issue were quite controversial. Perno et al. found evidence that the presence of minor PI mutations, particularly at position 10 and 36, lead to early treatment failure and to a higher number of acquired major PI mutations at the time of treatment failure Therefore, we aimed studying the impact of minor PI mutations on virological outcome in first-line antiretroviral therapy (ART) using the dataset of the Swiss HIV Cohort Study (SHCS) The SHCS has been approved by the following ethical committees of all participating institutions: Kantonale Ethikkommission Bern; Ethikkommission beider Basel; comité d’éthique du département de médicine de Hôpitaux Universitaires de Genève; commission d’éthique de la recherche clinique, Lausanne; comitato etico cantonale, Bellinzona; Ethikkommission des Kanton St.Gallens; and Ethik-Kommission Zürich, all Switzerland. Written informed consent has been obtained from all participants.We used data from the SHCS, a nationwide, multicenter, clinic-based cohort with continuous enrolment and semi-annual study visits. Data up to 13 September 2011 were considered. The SHCS is very representative and includes about 66% of patients living with AIDS in Switzerland and 75% of all patients receiving antiretroviral therapy We included HIV-1 subtype B infected individuals who started first-line ART between 1 January 1999 and 1 July 2010 with an unboosted PI or a boosted PI and two nucleoside reverse transcriptase inhibitors (NRTIs) and who had CD4 cell counts and HIV-1 plasma RNA levels measured before start of ART. A genotypic resistance test performed while ART-naïve was an additional inclusion criterion. Patients were excluded if they had viruses with ≥1 transmitted major PI mutation or if they had no HIV-1 RNA measured during first-line ART We studied the following endpoints: a) time to viral suppression, b) time to virological failure, and c) accumulation of major mutations at the time of virological failure. Time to viral suppression was defined as the time to the first viral load <50 copies/mL. Virological failure was defined as 2 consecutive values >500 copies/mL after at least 180 days of continuous treatment, 1 value >500 after 180 days followed by a treatment change or no viral suppression for more than 180 days. To fulfill the criteria of a virological failure, patients needed a minimum time of follow-up, therefore the analysis of time to virological failure was restricted to patients with ≥1 HIV-1 RNA measurement after 180 days of continuous treatment or to patients with ≥1 HIV-1 RNA measurement after previous viral suppression. The accumulation of major mutations at virological failure was studied in patients who experienced a virological failure on first-line ART and who had a genotypic resistance test performed between the virological failure and treatment change.Minor PI mutations were defined based on the IAS-USA recommendations We performed Fisher’s exact tests and Wilcoxon rank sum tests to compare categorical and continuous baseline characteristics, respectively. We plotted Kaplan-Meier curves and used log-rank tests to compare the virological outcome between patients with and without minor PI mutations. In addition, we performed univariable and multivariable Cox regression to analyze the time to viral suppression and the time to virological failure. Multivariable models were adjusted for the following potential confounders: sex, ethnicity, age, transmission category, baseline CD4 cell count, baseline HIV-1 RNA level, calendar year of ART start and the presence of NRTI mutations We also studied the impact of specific minor PI mutations on virological outcome. Here, only mutations with a prevalence ≥5% were considered. Despite this restriction, the number of events for some mutations was quite small, particularly the number of virological failures. Therefore, we used other methods that can deal better with rare events. It was shown that propensity scores are a good alternative to control for imbalances between groups when there are only small numbers of events per confounder The accumulation of major PI mutations at the time of virological failure was compared with Fisher’s exact test.Statistical analyses were performed with Stata 11 .P<.001).The median CD4 cell count was higher among patients without minor PI mutation, 255 cells/µL compared to 223 cells/µL (P = .010). The most common NRTI combinations were lamivudine/zidovudine (43.3%), emtricitabine/tenofovir (33.2%) and lamivudine/abacavir (9.6%), no differences were observed between patients with and without minor PI mutations. 869 patients (72.5%) had the required minimum follow-up time to study the time to virological failure. Baseline characteristics of excluded patients did not markedly differ except that excluded patients started ART earlier .In the SHCS, 1265 subtype B-infected patients started first-line ART with a PI and 2 NRTIs and had a resistance test performed while ART-naïve. Patients were excluded from analysis if they had major PI mutations detected (n = 1), missing baseline HIV-1 RNA levels or CD4 cell counts (n = 14), or no HIV-1 RNA follow-up before the first ART change (n = 51). Finally, 1199 of 1265 patients (94.8%) were included to study the time to viral suppression. In The prevalence of the most common minor PI mutations related the respective administered PI therapies is shown in The time to viral suppression and the time to virological failure were similar between patients with and without minor PI mutations . ResultsAdditionally, we studied the impact of the number of minor PI mutations on the virological outcome. Compared to patients without minor PI mutations, HRs of the time to viral suppression were 1.1 (95% CI: 0.9–1.2), 1.1 (95% CI: 0.9–1.4), 1.5 (95% CI: 1.1–2.1) and 1.4 (95% CI: 0.9–2.3) for patients with 1, 2, 3, ≥4 minor PI mutations, respectively. For the time to virological failure HRs were 1.1 (95% CI: 0.6–1.8), 0.5 (95% CI: 0.2–1.5), 0.3 (0.1–3.8) and 1.0 (0.1–10.3) for patients with 1, 2, 3, ≥4 minor PI mutations, respectively. Comparing patients with <3 and ≥3 minor PI mutations did not alter conclusions, the HR for the time to viral suppression was 1.2 (95% CI: 0.9–1.4) and for the time to virological failure 0.6 (95% CI: 0.2–2.0).We additionally studied the effect of specific minor PI mutations on the virological outcome. No specific minor PI mutation was associated with a worse treatment outcome . We studWe performed a sensitivity analyses and ran separate models for ART with unboosted PI and boosted PIs. For the time to viral suppression, multivariable HRs were 1.0 (95% CI: 0.6–1.9) and 1.2 (95% CI: 1.0–1.4) for therapies with unboosted and boosted PI, respectively. For the time to virological failure, multivariable HRs were 1.1 (95% CI: 0.6–2.0) and 0.6 (95% CI: 0.2–1.6) for unboosted and boosted PI therapies, respectively.P = 1.000).The accumulation of major PI mutations was not higher among patients detected with a minor PI mutation while ART-naïve. Of 63 patients who experienced a virological failure on first-line ART, 43 (68.3%) had a resistance test performed. 7/19 (36.8%) patients without minor PI mutations and 9/24 (37.5%) accumulated a major mutation, respectively (We found that the presence of minor PI mutations did not influence the virological outcome of first-line ART in HIV subtype B infected individuals. The prevalence of some minor PI mutations was found to be very high. Therefore, it is of great value to know that these mutations did not exhibit a negative impact on therapy outcome. In our study, neither the time to viral suppression, nor the time to virological failure differed between patients with and without minor PI mutations. Moreover, the risk for the emergence of a major PI mutation was not increased.Today, first-line ART often includes non-nucleoside reverse transcriptase inhibitors, especially in resource-limited settings. However, PIs may increasingly be needed as good alternatives, especially in the presence of transmitted drug resistance mutations which seem to be seriously on the rise in resource-limited settings To our knowledge, this is the largest study analyzing the impact of minor PI mutations on treatment outcome. We were able to include 1199 treated patients from the highly representative dataset of the SHCS. Despite the large number of patients included, the sample size was too small to perform an analysis for some specific minor PI mutations. Therefore, we had to restrict the analysis to the most prevalent minor PI mutations and used the propensity score method. The regression adjustment with propensity scores is a good option when the number of exposed patients is large and the number of events small. This method has the advantage that the Cox regression only had to be adjusted for one co-variable, the propensity score. If too many variables are included in a regression model relative to the number of events, estimates can be incorrect Our study supports findings from previous smaller studies that found no negative impact of minor PI mutations on therapy outcome We convincingly demonstrated that minor PI mutations have no effect on virological outcome in PI-containing first-line ART, at least in patients infected by HIV-1 subtype B.


To report the viral load and CD4 count in HIV-infected, antiretroviral naïve, first -time HIV-testers, not immediately eligible for treatment initiation by current South Africa treatment guidelines.This was a cross-sectional study in a high-volume, free-of-charge HIV testing centre in Soweto, South Africa.We enrolled first time HIV testers and collected demographic and risk-behaviour data and measured CD4 count and viral load.3 and 13,000 (IQR: 2050-98171) copies/ml, respectively. Female first time HIV testers had higher CD4 counts (419 IQR: 262-582 vs. 303 IQR: 199-418 cells/mm3) and lower viral loads  compared to males. Of 183 participants with CD4 count >350 cells/mm3, 62 (34%) had viral loads > 10,000 copies/ml.Between March and October 2011, a total of 4793 adults attended VCT and 1062 (22%) tested positive. Of the 1062, 799 (75%) were ART naïve and 348/799 (44%) were first-time HIV testers. Of this group of 348, 225 (65%) were female. Overall their median age, CD4 count and viral load was 34 years (IQR: 28-41), 364 (IQR: 238-542) cells/mm3 have high viral loads. HIV-infected men at their first HIV diagnosis are more likely to have lower CD4 counts and higher viral loads than women.A large proportion of HIV infected adults not qualifying for immediate ART at the CD4 count threshold of 350 cells/mm ART initiation is traditionally based on CD4 counts. In conjunction with viral loads, they allow prognostication. This study reports the distribution of CD4 counts and viral loads in ART-naïve, first-time HIV testers and relates CD4 counts to current South African ART initiation thresholds, and the proportion of participants not qualifying for immediate initiation of ART by the CD4 criterion but who have high viral loads and high potential of onward HIV transmission.We analysed data collected at the ZAZI clinic which is a free-of-charge, voluntary counselling and testing (VCT) facility on the campus of the Chris Hani Baragwanath Academic Hospital in Soweto, South Africa. The clinic is connected by a pedestrian bridge to a busy taxi rank. ZAZI tested 15,824 walk-in patients from October 2010 to September 2011. Participants included in this analysis had to be ART-naïve, self-report being HIV tested for the first time, and have no clinical evidence of an AIDS defining condition (WHO Stage 1 or 2 diseases).3 as per South African HIV treatment guidelines This was a cross-sectional study. All consenting participants were sequentially enrolled, had demographic and behavioural profiles captured and were symptom-screened for tuberculosis and other opportunistic infections. Behavioural profile questions related to number of sexual partners, condom and alcohol usage in the month prior to testing were collected using face-to-face interviews in routine VCT counselling procedure by counsellors. Blood draws for CD4 count and viral load were taken at the time of HIV diagnosis. Those eligible for ART  were not retested. Positive rapid tests were confirmed with a second rapid test . Discordant rapid test results were resolved with a laboratory HIV ELISA test. Blood was drawn and stored in tubes in room temperature where laboratory staff would collect them daily at scheduled times. No blood stayed overnight in the clinic. HIV-infected clients received CD4 and viral load results within two days of testing and those eligible for treatment and care were referred to local clinics.Viral Load testing was conducted using the Nuclisens Nucleic Acid Sequence Based Amplification  test platform for most tests  and the Real Time HIV-1 Amplification Polymerase Chain reaction (PCR)  platform in a few instances. CD4 cells were enumerated using the dual platform method. Written consent was obtained from each participant for their information to be stored in the clinic database and used for research purposes. The study was approved by the University of the Witwatersrand Human Research Ethics Committee.10 viral load versus CD4 count, and included the least squares line by gender on a scattergram. All hypothesis testing used two-sided tests at 5% significance level using SAS 9.3  statistical software.Median and interquartile ranges were determined for age, CD4 count and viral loads. Continuous measures were compared using the Kruskall-Wallis non-parametric test. CD4 count was categorised dichotomously based on the South African treatment guidelines while viral loads were classified using >10,000 copies/ml as probable high infectivity, based on prior HIV transmission related studies.3 (IQR: 188-446) and 26,000 copies/ml , respectively. Ineligible participants were excluded from further analyses.A total of 4,793 adults attended VCT between March and October 2011, of whom 1062 (22%) tested HIV-positive . Of the 3 (IQR: 238.0-541.5); median CD4 count in females was higher than males . A total of 183 (53%) participants had CD4 count >350 cells/mm3; the proportion of females with CD4 above 350 cells/mm3 was higher than males . Males presented at older age than females . The overall median CD4 count was 364 cells/mm3, 62 (34%) had a viral load > 10,000 copies/ml.Overall the median viral load for ART-naïve, first time testers was 13,000 copies/ml . Females had a markedly lower median viral load compared to males . Overall, 187 (54%) participants had viral loads > 10,000 copies/ml. The proportion of males with viral loads >10,000 copies/ml was significantly higher than females . Of the 183 participants with CD4 count >350 cells/mm3 and with viral loads >10,000 copies/ml were similar . The distribution of CD4 counts within the two viral load strata  was not statistically different  vs. 13/39 (33%), p = 0.0011). Those with a CD4 ≤ 350 cells/mm3 were more likely to have more than one partner than participants with CD4 > 350 (p = 0.0414). Condom use, alcohol use and reason for HIV testing were similar between the two CD4 strata of ≤ 350 and > 350 cells/mm3  interventions.We report CD4 counts and viral loads in adult first-time HIV testers who were well, ART naïve, and diagnosed with HIV at an easily accessible, high volume, free-of-charge VCT centre. A large proportion of HIV infected adults not qualifying for immediate ART at the CD4 count threshold of 350 cells/mm3) and/or high viral loads . Indeed, almost half of all the asymptomatic first-time testers in this study qualified for immediate initiation of ART according to current South Africa guidelines; most were men. This result underlies the importance of reducing the time to first testing in men. Other studies have noted gender differences in viral loads and CD4 at various stages of the disease, where females develop AIDS at higher CD4 counts and lower viral loads.Our results show that most asymptomatic adults requesting HIV testing for the first time had low CD4 counts  is undetectable.TasP requires population screening approaches to identify HIV-infected people at the earliest possible opportunity and start them on suppressive antiretroviral therapy to prevent further transmission. This potentially optimal HIV-testing setting  identified HIV-infected individuals with high viral loads and relatively low CD4 counts. More research is needed to encourage sexually active adults to cyclically present themselves for HIV testing. Moreover, viral load estimation at the time of HIV diagnosis might be a better measure than CD4 count when making decisions about initiation of ART in the context of TaSP. Our data suggest that for TasP to succeed, ART treatment initiation criteria require revision, with a view to commencing therapy irrespective of CD4 counts.


Antiretroviral therapy (ART) scale-up in resource-limited countries, with limited capacity for CD4 and HIV viral load monitoring, presents a unique challenge. We determined the effectiveness of first-line ART in a real world pediatric HIV clinic and explored associations between readily obtainable patient data and the trajectories of change in CD4 count and HIV viral load.We performed a longitudinal study of a cohort of HIV-infected children initiating ART at the Korle-Bu Teaching Hospital Pediatric HIV clinic in Accra, Ghana, aged 0-13 years from 2009-2012. CD4 and viral load testing were done every 4 to 6 months and genotypic resistance testing was performed for children failing therapy. A mixed linear modeling approach, combining fixed and random subject effects, was employed for data analysis.Ninety HIV-infected children aged 0 to 13 years initiating ART were enrolled. The effectiveness of first-line regimen among study participants was 83.3%, based on WHO criteria for virologic failure. Fifteen of the 90 (16.7%) children met the criteria for virologic treatment failure after at least 24 weeks on ART. Sixty-seven percent virologic failures harbored viruses with ≥ 1 drug resistant mutations (DRMs); M184V/K103N was the predominant resistance pathway. Age at initiation of therapy, child’s gender, having a parent as a primary care giver, severity of illness, and type of regimen were associated with treatment outcomes.First-line ART regimens were effective and well tolerated. We identified predictors of the trajectories of change in CD4 and viral load to inform targeted laboratory monitoring of ART among HIV-infected children in resource-limited countries. There is an unprecedented global effort to scale-up antiretroviral treatment (ART) and provide universal access to HIV care to all HIV-infected individuals. In resource-limited settings, outcomes of pediatric HIV treatment have been comparable to outcomes in resource-rich countries,2. SeverThe success story of ART scale-up in resource-limited countries presents a unique challenge with regard to laboratory monitoring of treatment. The therapeutic benefits of ART are often limited by long-term toxicities and evolution of drug-resistant virus-11. In rWe recently reported that a targeted approach based on predictors of CD4 recovery can be a viable and cost-effective way of monitoring ART in HIV-infected children in resource-limited settings. To valiThis was a single-center prospective observational longitudinal study of HIV-infected children initiating ART at the Pediatric HIV/AIDS Care program at Korle-Bu Teaching Hospital in Accra, Ghana, from October 2009 to September 2012. The program currently cares for over 1,100 children. The first-line regimen available at the clinic is non-nucleoside analog (NNRTI)-based ART consisting of zidovudine (ZDV) plus lamivudine (3TC), plus either nevirapine (NVP) or efavirenz (EFV). Written consents from parents or guardians and assents from children were obtained before enrollment in the study. The study was reviewed and approved by the Ethics and Protocol Review Committees of University of Ghana Medical School and Yale School of Medicine.At the time of enrollment, participants and guardians were interviewed to collect demographic and background information and their medical records were reviewed. The participants were seen and examined at the pediatric HIV clinic every 4-6 months, and more frequently as necessary, in accordance with local standard-of-care. CD4 cell count/percentage and HIV viral load determinations were done every 4-6 months. Adherence was determined by caregivers report and categorized according to WHO guidelines: adherence is said to be “good adherence” , “fair adherence” , and “poor adherence” . The stuClinical failure is defined as the appearance or reappearance of WHO clinical stage 3 or stage 4 events after at least 24 weeks on ART in a treatment-adherent child. Immunological failure is defined as developing or returning to the following age-related immunological thresholds after at least 24 weeks on ART, in a treatment-adherent child: (1) CD4 count of <200 cells/μL or percent CD4 <10% for a child ≥2 years to <5 years of age, (2) CD4 count of <100 cells/ μL for a child 5 years of age or older. Virologic failure is defined as a persistent HIV viral load of ≥ 5,000 copies/ml, after at least 24 weeks on ART, in a treatment-adherent child. Based oCD4 absolute cell count and cell percentage were quantified by a dual-platform flow cytometry technology using a FACSCount system  at the clinical laboratory at Korle-Bu Teaching Hospital (KBTH) according to manufacturer’s instructions. The HIV RNA viral load testing was performed using the COBAS ® AMPLICOR Monitor test . The limit of HIV-1 RNA detection was 50 copies/mL. The laboratory is certified by the South African Public Health Reference Laboratory and participates in an external quality assurance testing program by the South African Public Health Reference Laboratory.http://hivdb.stanford.edu) to generate a mutation list and subtype information. The resulting mutation list was compared with the WHO mutation lists for HIVDR surveillance[http://hivdb.stanford.edu).HIV genotyping was performed at Noguchi Memorial Institute of Medical Research (NMIMR), University of Ghana, using an in-house reverse transcriptase polymerase chain reaction (PCR) protocol. The reverse transcriptase (RT) and protease (PR)-coding regions were amplified in separate reactions using gene-specific primers and one-step RT-PCR techniques previously published. The seqeillance,22. HIV-Descriptive statistics, such as counts, percents and quartiles were used to summarize characteristics of children in the study. CD4 absolute counts and viral loads were log-transformed prior to statistical modeling. Linear mixed effects modeling was the primary statistical analysis. Along with such fixed effects as child’s gender, primary caregiver status, ART regimen and WHO HIV clinical staging, a random intercept with unstructured covariance was included. This allowed each child to have his/her specific constant variation around the group means. Intra-class correlation (ICC) for each outcome of interest was calculated to quantify the variability in the observed data due to individual child.Longitudinal analyses were performed using mixed models to examine differences in CD4 cell count, CD4 percentage and HIV viral load by gender, WHO clinical staging and other demographic characteristics. Mixed model analysis was used as this approach does not require all participants to have the same number of measurements and uses all available outcome data, thus providing an unbiased estimate of the model parameters, given that missing outcomes are missing at random (MAR). Under the MAR assumption we expect that the missing outcomes are only dependent on the observed data and not on the unobserved data. Along wNinety HIV-infected children aged 0 to 13 years initiating ART were enrolled to the study between October 2009 and September 2012. The number of available visits ranged between 1 and 9, with a median of 4 visits. This corresponded to a median of 16 months of follow-up (ranging from 0 to 32 months). Table The effectiveness of first-line regimen among study participants was 83.3% using WHO criteria for virologic failure. Fifteen of the 90 (16.7%) children met the WHO virologic criteria for treatment failure, i.e., HIV RNA of ≥ 5,000 copies/ml after at least 24 weeks on ART. The med6 copies/mL in others.Since our setting reflects real world pediatric HIV care where laboratory measures are sparse and usually missing at random , we modeled the CD4 and HIV viral load outcomes. At first available visit, absolute CD4 count ranged between 9 and 3,293 cells/μL, corresponding to 2.2-8.1 on the log scale. CD4 percentage ranged between 0% and 50.5%, and viral load was at a minimum of 63 copies/mL in some children and at a maximum of 3.6 × 10Table The only significant changes in CD4 percentage over the follow-up period were attributable to the age at initiation of ART therapy and the number of available follow up visits Table . SimilarThe rate of decrease in HIV viral load slowed over time. Table The median time to virologic failure was 7.8 months. Of the 15 children meeting criteria for virologic failure, sequence results were available for 12 (80%); we were not successful in amplifying DNA from three of the failures. Eight of the 12 children (67%) harbored drug resistant mutations (DRMs) and four (33%) did not harbor any DRMs Table . Sixty-sThe second-line regimen widely available in the clinic is 3TC, abacavir (ABC), and lopinavir/ ritonavir. We investigated the susceptibility of the genotypes at virologic failure to second-line regimen. Of the 12 out of the 15 failures with successful genotypic data, susceptibility to 3TC and emtricitabine (FTC) was reduced in 66.7% of the subjects (data not shown). Susceptibility to ABC, the second nucleoside analog of the second-line regimen, was potentially reduced in 75% of subjects. For the other NRTIs , susceptibility was still at 91.7%. All the children were still susceptible to ritonavir-boosted protease inhibitors (PIs).Our study demonstrates the effectiveness of NNRTI-based first-line regimens used at Korle-Bu Teaching Hospital for HIV-infected children. For 83.3% of the study participants, the first-line ART regimen was effective. At 24 months of follow-up, about 71% of our participants had viral load <400 copies/ml. Both absolute CD4 cell counts and CD4 cell percentages demonstrated a sustained immunologic response through 24 months of follow-up for all participants. Our findings are consistent with reports of effectiveness of ART in HIV-infected children from other countries in sub-Saharan Africa.Furthermore, we found high tolerance of the first-line ART regimen in our population based on the low levels of toxicity, and fewer regimen switches. Our rates of regimen switching and toxicity are comparable to previous studies in the region and in other resource-limited settings,6. Thereet al found that 58% of a cohort of children in Abidjan with detectable viral load after three to five months on therapy harbored HIV DRMs[The rate of virologic treatment failure after at least 24 weeks was 16.7% among our study participants on their first-line regimen. This is consistent with previously reported rates in pediatric HIV cohorts from the sub-region ranging from 13% to 44%. First, HIV DRMs. TherefoAt virologic failure, 67% of the children harbored viruses with ≥ 1 DRMs, and dual-class resistance was observed in 50% with M84V/K103N being the predominant resistance pathway. Most importantly, our study adds to the limited data on the contribution of early virologic failure to evolution of DRMs in HIV-infected children in sub-Saharan Africa. FurtherThe arguments against routine use of laboratory monitoring in resource-limited settings are sustained by consideration of cost, technical expertise, and lack of infrastructure. While eThere are certain limitations to our study. First, this is a single center study and, therefore, one has to be cautious in generalization of our findings. Moreover, the limitations of this analysis include having a relatively small sample size for an observational longitudinal analysis. However, some of the limitations reflect realities in carrying out such a study in a resource-limited setting. At the same time, an important strength of our study is the setting of a real world pediatric HIV clinical care in a resource-limited country with all the perennial laboratory capacity challenges that could represent an overwhelming majority of pediatric HIV clinics in sub-Saharan Africa.In conclusion, our study demonstrates that available first-line ART regimens at Korle Bu Teaching Hospital in Accra, Ghana are effective and well tolerated. We also identified important predictors of the trajectories of change in CD4 and viral load after ART initiation, which can inform further studies and feasible targeted laboratory monitoring of ART among HIV-infected children in resource-limited countries. Furthermore, our findings support the scale-up of universal access to the current ART regimens. However, the scale-up should be concurrent with the use of innovative and low cost technologies for laboratory monitoring of ART as the proportion of children with early virologic failure and DRMs is not trivial and is of public health concern. National programs should invest in laboratory capacity to provide at least targeted CD4 and viral load monitoring.The authors declare that they have no competing interests.OB, JP, EB, LR, VSN, and EP designed the study. OB, JP, EB, MP, WA, JK, BG, and KWCS acquired the data. All authors contributed to the data analysis and drafting of the paper. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/13/476/prepub