Major protease mutations are rarely observed following first-line failure with PIs and interpretation of genotyping results in this context may be difficult. We performed extensive phenotyping of viruses from five patients failing lopinavir/ritonavir monotherapy in the MONARK study without major PI mutations by standard genotyping.Phenotypic susceptibility testing and viral infectivity assessments were performed using a single-cycle assay and fold changes (FC) relative to a lopinavir-susceptible reference strain were calculated.>10-fold reduced baseline susceptibility to lopinavir occurred in two of five patients and >5-fold in another two. Four of five patients exhibited phylogenetic evidence of a limited viral evolution between baseline and failure, with amino acid changes at drug resistance-associated positions in one: T81A emerged in Gag with M36I in the protease gene, correlating with a reduction in lopinavir susceptibility from FC 7 (95% CI 6–8.35) to FC 13 (95% CI 8.11–17.8). Reductions in darunavir susceptibility (>5 FC) occurred in three individuals.This study suggests both baseline reduced susceptibility and evolution of resistance could be contributing factors to PI failure, despite the absence of classical PI resistance mutations by standard testing methods. Use of phenotyping also reveals lower darunavir susceptibility, warranting further study as this agent is commonly used following lopinavir failure. Indeed, rates of virological failure to PI-based second-line therapies are significant.8 In these settings, lopinavir/ritonavir monotherapy has been explored in patients failing the WHO-recommended first-line therapy with a non-NRTI regimen and found to be inferior to triple-drug regimens containing a PI.12Global scale-up of antiretroviral therapy is witnessing a transition of substantial numbers of patients to second-line regimens containing the PI lopinavir coformulated with the booster agent ritonavir (lopinavir/ritonavir). Given the high prevalence of multiple NRTI mutations at virological failure in resource-limited settings (conferring cross-resistance to other NRTI),14 In contrast, PI/r monotherapy has been explored as a maintenance regimen in multiple trials as a strategy to reduce cost and risk of toxicity over the longer term.17 The MONARK trial investigated the efficacy of lopinavir/ritonavir monotherapy in comparison with lopinavir/ritonavir + two NRTIs at treatment initiation in treatment-naive patients. Higher rates of virological failure were reported in the monotherapy arm.14 Of the 23 genotyped patients experiencing virological failure in the lopinavir/ritonavir monotherapy arm at 96 weeks, 5 (21.7%) had major PI resistance mutations versus 0/5 of those genotyped in the triple-therapy arm.18 These data are consistent with a wide literature on virological failure with PI/r, where lower prevalence of major PI resistance mutations relative to other classes is generally observed.20 An earlier analysis of MONARK exploring non-protease determinants of failure had reported that pre-therapy mutations in Gag cleavage site sequences were significantly associated with the virological outcome of a first-line lopinavir/ritonavir single-drug regimen, in spite of the absence of consistent association with either the emergence of major PI resistance mutations or with changes in Gag sequences at the time of virological failure.21In better-resourced settings, only one trial to date has explored first-line ritonavir-boosted PI monotherapy  in antiretroviral-naive patients.et al.22). Identification of broad genotypic predictors of PI susceptibility using Gag–protease remains elusive, most probably due to the importance of coevolution of residues on individual Gag sequences.24 The inclusion of full-length patient-derived Gag alongside its coevolved protease in in vitro phenotypic assays has been shown to substantially affect PI susceptibility  in patients not exposed to PI26 and in a heavily treated patient with multiple major resistance mutations in protease.27 There are no data using this method for the most relevant clinical application: assessment of susceptibility to PI following failure of this class of drug (when major mutations in protease are not detected by standard population sequencing-based methods).Numerous studies have provided evidence for the role of Gag in PI susceptibility, with amino acid changes located both in and outside of the Gag cleavage sites  was accompanied by reductions in phenotypic susceptibility to lopinavir and the other PIs saquinavir, atazanavir and darunavir.Given the clinical and public health needs to better understand virological failure on PI therapy, and the lack of predictive power of gag–protease from both baseline and failure plasma samples was successfully amplified from five patients. Reasons for exclusion of the other 18 patients are presented in Figure Paired baseline and failure samples of the 23 patients experiencing virological failure whilst on lopinavir/ritonavir drug selective pressure in MONARK (up to week 96) were available. Full-length gag–protease was amplified from patient samples as previously described.28 Clonal sequence analysis of 10 viral variants for each sample was performed in MEGA 5.0 software using ClustalW. The variant that most closely represented the consensus for each timepoint was selected for phenotypic testing, along with other variants of interest.Full-length 27 In this assay, normalization by p24 or volume of viral input dose have been shown to be equivalent for multiple viruses.29PI susceptibility and single-round infectious titre were determined using previously described single-cycle assays.30 using the ClustalW algorithm and imported into the PHYLIP program for phylogeny construction (http://evolution.genetics.washington.edu/phylip.html) using the maximum likelihood method under the generalized time reversible (GTR) model of nucleotide substitution.31 Maximum likelihood trees were constructed with the confidence tested using 500 bootstrap replications. Phylogenetic trees were viewed using FigTree v1.3.1 (http://tree.bio.ed.ac.uk/software/figtree/) and MEGA 5.0 software.Sequences were aligned in MEGA 5.0 softwaret-test .Genetic distance calculation was carried out in MEGA 4.1 using default parameters, based on amino acid alignments. Data were expressed as mean amino acid substitutions per site. Differences in MPWGD between screening and failure were calculated using Student's 18 The five patients detailed here were infected with subtypes B (two patients), CRF02_AG (two patients) and G (one patient), as determined by the REGA subtyping tool33 (http://dbpartners.stanford.edu:8080/RegaSubtyping/stanford-hiv/typingtool/). The patients had a range of viral loads at time of failure . In addition, a number of mutations previously associated with PI susceptibility or resistance in Gag were present at both screening and time of treatment failure: E12K, R76K, T375N, I376V and L449P (Table S2).22 The emergence of Y79F in failure variant 6 (F6) and F9 correlated with PI exposure.One individual (Patient 1403) was infected with a subtype CRF02_AG virus and experienced therapy failure at week 24 with a viral load at 24 000 copies/mL. At this timepoint, very low non-suppressive lopinavir levels were present in the plasma (75 ng/mL) and missed doses were reported. Clonal sequence analysis revealed the presence of the V82A major PI resistance mutation in 1 of the 10 viral variants isolated from the time of treatment failure, as well as a number of protease polymorphisms at both screening and failure . There was little variation in MPWGD at screening and time of failure  and screening and failure viral variants were phylogenetically distinct by maximum likelihood analysis  and five from the time of treatment failure . Of note, the F5 variant containing the major PI resistance mutation V82A displayed significantly reduced susceptibility to lopinavir (17-fold). For the remaining variants, reduced susceptibility in comparison with the reference strain was observed to both atazanavir and lopinavir [>10-fold change (FC) in ECTable S1). In addition, a number of mutations that have been previously associated with PI susceptibility or resistance in Gag were present at both screening and time of treatment failure: Y79F, T81A, M200I, H219Q, S373P, T375N, R380K, I389T and S451N (Table S2). A number of amino acid positions correlated with PI exposure: 12, 63, 70, 310, 370 and 376 in Gag and 36 in protease (Tables S1 and S2). T81A was seen in only 1 of 10 screening variants but in all failure variants. Overall, E12K, T81A and M36I were of greatest interest as they have been previously associated with PI exposure and reduced susceptibility.35The second individual (Patient 3204) was infected with a subtype B virus and experienced virological failure at week 40 Table . No lopi90 did not significantly change the relationships between clones . There was a significant difference in MPWGD between baseline (0.019) and time of treatment failure  and phylogeny was consistent with ongoing evolution and selection during PI therapy  and two from the time of treatment failure (F1 and F2). Figure y Figure .Table S1). In addition, a number of mutations that have been previously associated with PI susceptibility or resistance in Gag were present at both screening and time of treatment failure: E12K, R76K, V370A and L449P (Table S2).Patient 1404 was infected with subtype CRF02_AG virus and experienced virological failure at week 48 of the trial with a low viral load of 212 copies/mL. The lopinavir plasma trough concentration was unavailable for this timepoint, although the lopinavir level at week 24 was <1000 ng/mL and missed doses were reported at weeks 20, 40 and 48. The minor resistance mutation A71T was present in protease of viral variants from screening and the time of treatment failure, along with a number of polymorphisms: I13A, K20I, M36I, R41K, H69K, L89I and I93M . MPWGD was reduced at the time of treatment failure (0.002) in comparison with baseline . Screening and failure viral variants clustered in a stepwise fashion in a maximum likelihood analysis  and two from the failure timepoint (F1 and F4). For this patient, reduced PI susceptibility to atazanavir and lopinavir was observed with the screening variants and F1, with each displaying similar FC ECs Figure , consistTable S1). In addition, a number of mutations that have been previously associated with PI susceptibility or resistance in Gag were present at both screening and time of treatment failure: E12K, R76K, H219Q, V370A, R380K, K436R and S451N (Table S2).The second individual (Patient 4201) was infected with a subtype G virus and experienced virological failure at week 48 of the trial. The patient had a lopinavir trough concentration >6000 ng/mL at this timepoint, though levels were undetectable at the week 24 visit. Adherence reporting suggested erratic drug exposure from week 20 onwards. A number of protease polymorphisms were present both at baseline and time of treatment failure: I13V, K14R, K20I, E35Q, M36I, R41K, R57K, Q61N, C67E, H69K, V82I and L89M . Furthermore, the use of EC90 revealed two screening variants with >5 FC to darunavir, which were <5-fold when EC50 was considered. Finally, there was a significant difference in MPWGD between baseline (0.014) and time of treatment failure . The screening and failure viral variants clustered separately on the maximum likelihood phylogenetic tree, supporting ongoing viral evolution during PI monotherapy  and one from failure F2). The baseline viral variants S1 and S5 displayed significant reductions in susceptibility to a number of PIs, most notably to lopinavir where ≥16-fold reduction in susceptibility in comparison with the reference strain was observed .Patient 508 was infected with subtype B and experienced late therapy failure at week 96 with a viral load at 25 300 copies/mL. Although lopinavir plasma trough concentrations were unavailable beyond week 48, those prior to this timepoint were consistently >2000 ng/mL and very few missed doses were reported. A number of protease polymorphisms were present both at baseline and time of treatment failure: N37S, P39Q, I62V, L63P, V77I and I93L. Only one change in Gag associated with PI susceptibility or resistance was present—V370A . MPWGD at baseline (0.011) and time of treatment failure  were not significantly different and baseline and failure viral variants intermingled on phylogenetic analysis, in contrast to the other patients studied  and the time of treatment failure . Figure  and S3 agag alongside its coevolved protease in phenotypic assays, we set out to examine in this proof-of-concept study whether testing phenotypic PI susceptibility of multiple full-length gag–protease sequences from individual patients failing therapy in the absence of major PI resistance mutations could be more illuminating. The paired nature of these samples, one taken before treatment and one at time of treatment failure, enabled a comparison of PI susceptibility and amino acid sequence of viruses before and after PI/r monotherapy. Uniquely, we were able to contextualize our phenotypic data with lopinavir plasma concentrations, adherence and clinical data.The MONARK clinical trial offered the unique opportunity to carry out the most detailed analysis of PI/r monotherapy failure to date, focusing on the most relevant patients failing lopinavir/ritonavir single-drug first-line treatment: those who do so in the absence of major PI mutations by bulk population sequencing. Given the evidence for the importance of the inclusion of full-length gag–protease sequences that decreases in phenotypic susceptibility can occur (in two of four failures occurring before 96 weeks) when no major PI mutations during lopinavir/ritonavir therapy are detected using standard techniques. Use of multiple clones in phenotypic analysis enabled us to test lower-frequency variants and this approach was vindicated by the detection of a protease V82A major mutation in a single clone at virological failure in Patient 1403. This viral population with reduced lopinavir susceptibility (17-fold for lopinavir) would have been missed by both consensus sequencing and consensus strain susceptibility testing. We detected a second individual (Patient 3204) with an emergent reduction in PI susceptibility (13-fold to lopinavir), also on a background of reduced susceptibility and associated with amino acid changes in Gag and M36I in protease. M36I has been associated with PI exposure,36 though was not linked to reduced susceptibility in a commercial phenotypic susceptibility system incorporating only patient-derived protease sequences.37 The resistance pathway involving M36I could therefore involve the Gag positions in Table S2.We show using multiple patient-derived 38 The CCOs for lopinavir/ritonavir monotherapy have not been established but may be lower given that CCOs are derived from clinical studies conducted with triple-agent antiretroviral therapy. In light of these data, one would not restart lopinavir/ritonavir monotherapy in these individuals and atazanavir is probably not an alternative given the overlapping susceptibility profiles observed both in the presence39 and absence of major protease mutations.26The lower and upper clinical cut-offs (CCOs) for lopinavir are 10 and 50, derived using a protease-containing phenotypic assay with an assay reference strain also derived from NL4.3.26 3 subtype A and 3 subtype C25). Reduced darunavir susceptibility of 5-fold emerged at failure in Patients 3204 and 1404, having been significantly lower pre-therapy  and would not have detected the reduced susceptibility observed in our study. Therefore, our approach, if validated by larger studies, could potentially be used to assess patients for darunavir/ritonavir-based salvage therapy.An alternative to restarting the same PI in resource-limited settings might be a switch to a darunavir/ritonavir-based third-line regimen. However, this study has revealed a possible compromise of darunavir activity in three of five individuals with virological failure. In Patient 4201, there was an FC of 5 relative to the reference strain both before and after virological failure. Comparable levels of reduction in darunavir susceptibility were previously seen in only 1 of 15 treatment-naive isolates tested using this assay  that was also present at treatment failure. This degree of reduction in PI susceptibility was the same as observed for variant 1403 F6, which contained the V82A major PI resistance mutation, implying clinical relevance in the FCs observed for gag-associated mutations. Patient 4201 failed at week 48 of the clinical trial, at which time an adequate lopinavir trough plasma concentration was present and self-reported adherence was high at most appointments. This indicates that the reduced PI susceptibility may have enabled viral replication in the presence of PI/r monotherapy. We hypothesize that the reduced PI susceptibility present in baseline viral variants reduces the therapeutic forgiveness of suboptimal adherence, thus rendering these patients more likely to experience virological failure.Finally, our work has demonstrated some degree of reduced baseline susceptibility (>5-fold to any PI) in all five patients. Data for one patient in particular, Patient 4201, provided evidence that a significant reduction in PI susceptibility at baseline may contribute to treatment failure. The baseline variants for this patient displayed up to 16-fold reduction in susceptibility to lopinavir . The characteristics of emerging virus populations following maintenance may not be the same as those observed in our analysis. A final consideration relates to data from both MONET and OK04 demonstrating successful resuppression with the addition of two nucleosides following viral rebound on maintenance with PI monotherapy.17 In the latter, resistance testing was undertaken and two nucleosides only reintroduced if there was no genotypic evidence of lopinavir resistance.16 It is still possible that the period of suppression under maintenance strategies will differentially impact the nature of emerging virus at rebound. Our approach should therefore be repeated using samples from maintenance studies in the future.Of note, our findings are in patients treated with lopinavir/ritonavir monotherapy and therefore may not be generalizable to triple-therapy regimens containing this PI. Furthermore, treatment guidelines now specify that boosted lopinavir or darunavir should only be used as monotherapy following viral suppression with a triple combination regimen . K. A. S. was funded by Public Health England .This study was funded by the I. C.-C. is an employee of AbbVie Laboratories and may own stock or options in AbbVie. I. C.-C. was involved in interpretation of data and review of the manuscript; however, final content was decided by the principal investigator (R. K. G.). All other authors: none to declare.JAC Online .Table S1, Table S2 and Figure S1 are available as Supplementary data at


Reducing viral-load measurements to annual testing in virologically suppressed patients increases the estimated mean time those patients remain on a failing regimen by 6 months. This translates to an increase in the proportion of patients with at least one Thymidine Analogue Mutation from 10% to 32% over one year. In the current era of effective treatment, reducing the frequency of virological monitoring may become more common. Current treatment guidelines recommend viral load monitoring every 3 to 4 months in clinically stable patients with suppressed viral load . However+ve patients with long-term virological control.We aimed to investigate the effects of reducing the frequency of viral load tests to annually among HIVWe used data from the Australian HIV Observational Database (AHOD). Patients were required to fulfil the following inclusion criteria: commenced combination Antiretroviral Therapy (cART) on or after 1 January 1997; remained virologically suppressed (<400 copies/mL) while on a stable cART regimen for at least one year; and had two or more viral load measurements per year.Person-year methods were used to calculate the rate of virological failure  within one year or one measure of virological failure followed by a change of treatment within one year). Baseline date was the end of the first year of experiencing suppressed viral load while on a stable regimen. Follow-up was calculated from baseline to the time of virological failure; or (a) the date treatment was stopped/interrupted for more than 14 days or (b) the last visit date for patients who did not fail (censored).To estimate the additional time a patient remained on a failing regimen if HIV viral load testing occurred annually we created a paired dataset by duplicating patient data and allowing each patient to act as his/her own control. The first line of data in each pair included all the viral load measures and the true stop or failure date from the observed data. The second line included a theoretical annual HIV test date calculated as the anniversary date of the baseline date. The patients’ censor or failure date was therefore the last anniversary date from baseline that was greater or equal to the observed true stop or failure date. We calculated the additional time on a failing regimen as the time to failure using the observed data subtracted from the theoretical data.We estimated the rate of accumulation of Nucleoside Reverse Transcriptase Inhibitor (NRTI), non- Nucleoside Reverse Transcriptase Inhibitor (NRTI) and Thymidine Analogue Mutation (TAM) resistance mutations if the rate of viral load testing was reduced to annual testing. Estimates were based on the rates of resistance accumulated in patients remaining on failing regimens as reported by Sigaloff et al.  and CozzTo illustrate the absolute impact of reduced viral load testing we applied the failure rate reported in AHOD to a hypothetical population of 1000 HIV patients who had been virologically suppressed on cART for one year, and subsequently followed for two years. We estimated the number of patients who would be expected to fail virologically based on AHOD data, the reduced number of viral load tests over the two years if only annual virological monitoring, and contrast that with the increase in proportion of failing patients who develop resistance during the two-year period.By March 2013, 3551 patients were recruited to AHOD, of whom 2651 started cART on or after 1 January 1997; 584 (16%) patients fulfilled our study inclusion criteria. Most were male (92%) with overall mean age of 50 years (SD: 11.2). The median viral load at cART initiation was 68 200 copies/ml .Overall 76 patients (13%) experienced virological failure over 1946 person-years (py) of follow-up with a failure rate of 3.9 per 100 py. Of the failures 64 (84%) switched treatment following two consecutive failures while 12 patients (16%) switched treatment after a single measurement of >400 copies/ml. The mean extra time patients remained on a failing regimen if viral load testing is reduced to annual was estimated at 6 months (SD: 3.1).Based on the data from Cozzi-Lepri et al.  we estimIn our hypothetical population of 1000 patients, if we applied the failure rate observed in AHOD 3.9/100 py) we estimate that 80 patients would have failed within two years. Regular three monthly viral load testing would yield approximately 9000 viral load tests over a complete 2-year period (including tests at baseline and at year 2). Reducing viral load testing to annually would reduce the viral load tests to 3000, a saving of around 6000 viral load tests over two years. However, based on the data from Sigaloff et al. [.9/100 pyWe reported a relatively high rate of virological failure of almost 4 per 100 py among virologically suppressed patients in AHOD. Reducing viral load testing to annually increased the time patients remained on a failing regimen for an additional 6 months. While this translates to 6000 less viral load tests over two years, the proportion of the 80 failures with at least one TAM could increase from 10% to 32% (applying the rates reported by Sigaloff et al. [There is considerable variation in rates of developing antiretroviral resistance mutations in the published literature ,6. The lThere are some limitations to our analysis. First, we have used >400 copies for the virological failure cutoff as the data spanned over 10 years of data where many of the AHOD sites will still using assays at this level. However, using a higher viral load level in some ways may indicate true virological failures rather than virological blips that might range between 50 and 400 copies/mL. Second, we censored patients with treatment interruptions of greater than 14 days. We therefore would have excluded some patients who had one measure of virological failure and who stopped treatment, therefore still failing off treatment and subsequently accumulating resistance. Thirdly, we assumed that patients with virological failure were still taking some of their cART, thereby maintaining selection pressure for the evolution of resistance mutants. If these patients had discontinued all cART, ongoing viral evolution may not be occurring. Finally, we are unable to determine whether reducing the frequency of viral load testing would decrease the frequency of attendance or have an effect on adherence in this model.Despite effective and well-tolerated regimens, stable and suppressed patients continue to fail therapy. While annual viral monitoring could reduce virological testing costs, our study suggests there could be a substantial increase in the numbers of failing patients who develop resistance which has its own costs due to more expensive resistance testing, treatment regimens and potential community costs of increased transmission of drug resistance virus. The pros and cons of reduced frequency of viral load monitoring in stable patients warrants more research, including well-conducted randomised trials.


Few HIV antiretroviral adherence interventions target patients before they start treatment, assess adherence readiness to determine the timing of treatment initiation, or tailor the amount of adherence support. The Supporting Treatment Adherence Readiness through Training (START) intervention, based on the information-motivation-behavioral skills model of behavior change, is designed to address these gaps with the inclusion of (1) brief pill-taking practice trials for enhancing pretreatment adherence counseling and providing a behavioral criterion for determining adherence readiness and the timing of treatment initiation and (2) a performance-driven dose regulation mechanism to tailor the amount of counseling to the individual needs of the patient and conserve resources. The primary aim of this randomized controlled trial is to examine the effects of START on antiretroviral adherence and HIV virologic suppression.A sample of 240 patients will be randomized to receive START or usual care at one of two HIV clinics. Primary outcomes will be optimal dose-taking adherence (>85 % prescribed doses taken), as measured with electronic monitoring caps, and undetectable HIV viral load. Secondary outcomes will include dose-timing adherence (>85 % prescribed doses taken on time) and CD4 count. Primary endpoints will be month 6 (short-term effect) and month 24 (to test durability of effect), though electronic monitoring will be continuous and a fully battery of assessments will be administered every 6 months for 24 months.If efficacious and cost-effective, START will provide clinicians with a model for assessing patient adherence readiness and helping patients to achieve and sustain readiness and optimal treatment benefits.NCT02329782. Registered on 22 December 2014.ClinicalTrials.gov identifier The online version of this article (doi:10.1186/s13063-016-1287-3) contains supplementary material, which is available to authorized users. The success of HIV antiretroviral therapy (ART) remains dependent on high adherence –4. WhileN = 54) precluded adequate statistical power, but effect size estimates were 0.22 (dose-taking adherence), 0.75 (dose-timing adherence), and 0.41 (complete virologic suppression) over the first 6 months of treatment, with the latter two far exceeding the average 0.19 effect size found in a recent meta-analysis of ART adherence interventions that, like START, were not focused solely on patients already demonstrating adherence problems [Most ART adherence interventions are designed to help patients achieve and maintain adherence readiness, but few target patients before they start treatment or tailor the amount of adherence support . The Supproblems . These pIn the present study, we are evaluating the effects of the START intervention on the primary outcomes of dose-taking adherence and undetectable viral load in a multisite randomized controlled trial, the protocol of which this article describes in detail. The primary objective of the study is to determine whether START is superior to usual care in helping patients achieve optimal (>85 %) dose-taking adherence, and complete viral suppression  6 months (short-term efficacy) and 24 months (long-term efficacy) after starting ART.If effective, START will provide clinicians with an intervention that (1) informs providers and patients when the patient is ready to adhere well and start treatment, (2) enhances adherence readiness from the outset of treatment through the full course of therapy, and (3) tailors the amount of adherence support based on individual patient needs and performance, thus more efficiently using clinic resources, fostering better acceptance from providers and patients, and increasing the likelihood of successful program adoption and dissemination.3) because of the influence that prior ART history may have on adherence and clinical outcomes, and also due to our interest in determining whether early-stage patients can adhere as well as other patients to treatment. There is no way to blind the participants to whether they are receiving the intervention; this could potentially influence adherence performance and retention, as clients may feel more or less incentive to perform well in light of whether they receive the intervention. We do not see a way to prevent this potential bias, nor do we have a way to distinguish such effects from actual intervention effects; however, this limitation will be cited in reports of study findings.In this multisite randomized controlled trial, we will evaluate the effects of the START intervention on ART adherence and HIV virologic suppression. We will recruit 240 patients with HIV at two HIV clinics, with each randomized to receive either START or usual care at a 1:1 ratio at each clinic (60 patients in each arm at each site). Random assignment codes will be computer-generated and placed in a sequential list that will be maintained by the principal investigator. Assignments will be issued to study coordinators once candidates have enrolled and completed the baseline survey. The randomization will be stratified by prior ART history (naïve or experienced) and CD4 count , as measured with electronic monitoring caps, and undetectable HIV viral load. Secondary outcomes will include dose-timing adherence (>85 % prescribed doses taken on time) and CD4 count. Primary endpoints will be month 6 (short-term effect) and month 24 (to test durability of effect), though electronic monitoring will be continuous and a fully battery of assessments will be administered every 6 months for 24 months. See Fig. The study protocol has been reviewed and approved by institutional review board (IRB) at the University of California, Los Angeles (UCLA), and a certificate of confidentiality has been obtained from the National Institute of Mental Health. Any protocol modifications will be submitted to the IRB for review, and participants will be informed if warranted. The trial is registered with the National Institutes of Health (NIH) ClinicalTrials.gov registry and assigned the number NCT02329782.The study will take place at St. Mary’s Comprehensive AIDS Resource and Education Clinic in Long Beach, CA, USA, and UCLA Clinical AIDS Research and Education (CARE) Center. The St. Mary’s clinic serves over 1500 clients with HIV, of whom about 60 % are nonwhite and 85 % are male. The UCLA CARE center has nearly 1300 clients with HIV, of whom 83 % are male and 40 % are nonwhite. Both clinics have highly productive research units that conduct primarily biomedical and therapeutics research. Both research units have highly trained study coordinators who are experienced in research ethics, evaluation procedures, protocol implementation, and provision of adherence treatment support and counseling , and they will be trained to be the project’s site coordinators and intervention counselors.3, patient is on prophylactic medication to limit risks associated with the intervention’s imposed delay in starting ART; (5) patient is age 18 years or older; and (6) patient speaks English. Providers will inform eligible patients of the study, and patients who interested in participating will be referred to the study coordinator for consent procedures, eligibility screening, baseline survey, and randomization. Written informed consent will be obtained from all participants at enrollment. For control patients, the baseline visit is scheduled for the same day or within 1 week of the screening assessment. The baseline visit for intervention patients will take place on the same day as the last pretreatment intervention session .Eligibility criteria include (1) patient and provider plan to start or restart (not currently on ART) the patient on ART; (2) patient has stable health status and no acute opportunistic infections or medical conditions (including acute HIV infection) that warrant starting ART immediately, as determined by the patient’s provider; (3) detectable HIV viral load at last test (within past 6 months); (4) if CD4 count is <200 cells/mmWe calculated the size of effects that this sample can detect with 80 % power (two-tailed test) with regard to the primary outcomes. On the basis of the pilot study , we expeUsual care procedures to enhance adherence at the clinics will continue to be implemented for all participants. Strategies for assessing adherence readiness at the study sites include educating the patient about the importance of adherence, evaluating patient commitment and motivation to adhere to treatment, and assessing whether barriers to adherence need to be addressed before initiating treatment . Once ART is initiated, routine inquiries about adherence occur at regular follow-up visits . What varies across individual patients is the staff member who discusses these issues with the patient  and the amount of time spent on these issues. Structured, systematic counseling protocols and practice trials are not part of usual care. We will measure adherence support received by patients as part of usual care in the participant surveys, as described below.information about ART and the importance of adherence is a prerequisite but in itself is insufficient to alter behavior, and that motivation for adherence and behavioral skills to adhere well and overcome barriers are critical determinants of adherence. Motivation is fed by beliefs that the medication will be helpful (treatment efficacy) and confidence that one can adhere even in difficult circumstances (adherence self-efficacy). Behavioral skills such as problem-solving and adherence self-monitoring help to identify adherence barriers and effective solutions to these barriers. While not emphasized in the traditional IMB model, the social context in which adherence occurs and the support the patient receives can be important to all three of these components, both positively and negatively. One’s support network can be a source of information and can transmit beliefs about treatment that affect motivation. Social support can maintain or break down psychological well-being and psychosocial functioning, thereby impacting the patient’s ability to develop and use behavioral skills needed to adhere well. Each component of the IMB model is present in the START components and specific sessions, as shown in Table START is a comprehensive program of adherence training based on the IMB model of health behavior , which aSTART consists of pretreatment , early treatment, and ongoing maintenance training (using a performance-based dose regulation mechanism to tailor the amount and intensity) phases, each of which is outlined below. Sessions are administered to individual patients by the interventionist, who will be a trained research coordinator with adherence counseling experience . Each session lasts approximately 30 minutes. Exercises often involve completing worksheets or the use of handouts, which are given to the patient to use as a reference at home. Sessions are structured and manualized but still allow flexibility for tailoring the content of the exercises to the needs of the individual patient. Figure This phase is composed of a series of up to four 1-week practice trials accompanied by adherence counseling and a dose regulation mechanism in which patients discontinue the practice trials and initiate ART once >85 % dose-taking adherence is achieved in a single practice trial, thus demonstrating adherence readiness. Using 85 % adherence to define readiness is consistent with what the literature indicates is needed for optimal treatment benefits with the new, more potent ART regimens . With toSession 1 Following an introduction and description of the ART regimen, the counselor will provide education about concepts such as viral load, drug resistance, and the importance of dose-timing to ensuring a constant adequate drug level. The importance of being ready to adhere well before starting treatment will be emphasized. Motivational interviewing (MI) techniques [chniques  will be Sessions 2–5 The number of sessions depends on the number of practice trials the patient needs to complete. Electronically monitored adherence results during the preceding week’s practice trial are reviewed with the patient. The electronic monitoring printout provides a chronology graph that depicts exactly the time that doses were taken each day. Good adherence is reinforced, and missed doses are identified, including any patterns that may be apparent. Patients are asked to identify barriers that contributed to missed or late doses, and antecedents to these scheduled doses are discussed. The stages of problem-solving are introduced . MI techniques will be used, and the patient will be encouraged to take a leading role in identifying key barriers, coming up with potential solutions, and evaluating his or her experience in using these solutions, all of which are designed to maximize the patient’s feelings of autonomy and self-efficacy and increase the likelihood that these strategies will be successfully adopted.If dose-taking adherence during the practice trial is 85 % or greater, the patient will be considered ready to start ART, no further practice trials will be completed, and ART will be prescribed. The specific ART regimen planned for the patient will be reviewed. The patient will be asked to describe his or her daily routine and optimal ways for integrating the medication doses into his or her daily life. Doses will be connected with specific daily activities or behaviors so that these routinized activities can serve as reminder triggers for taking medication doses. Common side effects associated with the specific antiretrovirals prescribed will be discussed; side effect management handouts outlining possible strategies to manage specific side effects will be reviewed; and the patient will be encouraged to identify strategies that are feasible for to adopt if side effects occur.If dose-taking adherence to the practice trial is <85 %, the patient will be given another 1-week supply of vitamins for the next practice trial and encouraged to use the strategies identified in the session to overcome adherence barriers during the coming week. Linking the doses to routinized daily activities will be discussed. For those who are unable to achieve 85 % adherence after completing four practice trials, the decision whether to start treatment will be left up to the patient and his or her provider. Adherence results from the practice trials are shared with the patient’s provider to assist in making this decision. Similarly, adherence data once the patient is on ART, but none of the survey data, will also be shared with the provider.Training sessions are scheduled at weeks 2 and 4 following onset of ART to help patients maintain a high level of adherence readiness and self-efficacy once they start the actual ART regimen. There is no dose regulation during this phase, as all patients receive both sessions. Session content revolves primarily around identification of barriers, resolution of adherence barriers, and side effect management. The exceptions to this rule are the components of social support enhancement (week 2) and addressing attitudes toward treatment and adherence (week 4), which will take place in only one session each.The pre- and early-treatment phases help patients to be ready to adhere well at the beginning of treatment, but the skills needed to sustain adherence readiness over the long term may be quite different from those needed at initiation; hence the need for ongoing support. Maintenance modules will start at week 12 and thereafter at each routine clinic visit scheduled by the primary care provider as part of usual care, with the goal of helping patients sustain a high level of adherence over the course of treatment. Each module is composed of biweekly sessions and is dose-regulated such that patients who achieve >85 % dose-taking adherence during the prior month receive only one session while others receive sessions until >85 % adherence is achieved during the 2-week period preceding each successive session. For example, if the patient’s adherence from weeks 8 to 12 is 85 % or greater, then the patient will receive just the training session at week 12 and not return until the next routine clinic visit. However, if the patient’s adherence is <85 %, the patient will return for another session at week 14. The number of these biweekly sessions will be capped at three within each module. As with the pretreatment training, this dose regulation mechanism allows for varying the amount of training to the needs of the individual patient and for more efficient use of limited clinic resources for adherence support. The content of the maintenance training sessions will be similar to that during the early-treatment training phase, with continued emphasis on identification and resolution of adherence barriers, side effect management, and use of social support to help ensure commitment and motivation for long-term adherence.Fidelity in intervention administration will be achieved through training, supervision, and monitoring. The intervention counselors will be research coordinators experienced in coordinating HIV treatment research, including provision of adherence support during clinical trials. They are not involved in provision of usual care, thus limiting any risk of contamination of the usual care control. Training will include review of the manual, extensive role-playing of session exercises, and use of basic MI techniques. Sessions will be audiotaped and reviewed by the supervisor, who will use them to give feedback for improvement. The supervisor will listen to each session of the first three intervention participants of each counselor and then each session of every fifth participant of each counselor. Feedback will be provided and problem cases discussed during biweekly supervision.Below are descriptions of the primary and secondary outcomes with regard to ART adherence, virologic suppression, immune function and HIV care retention  for all participants once ART is initiated, will be measured electronically and continuously throughout the study using the Medication Event Monitoring System (MEMS) caps. MEMS caps house a microelectronic chip that records the date and time of each bottle-opening, enabling a precise, objective assessment of the timing of each dose and the patient’s pattern of pill-taking. Participants will be instructed to refill the bottle when removing the last remaining dose, to use the bottle provided for the monitored medication, and to remove only one dose at a time when the medication will be ingested. Participants do not always follow these instructions , so we will assess this via self-report using a “past 2 weeks” time frame at each primary assessment and will adjust the number of prescribed does taken during this time period, which has been validated and shown to strengthen the relationship between adherence and viral load . We willData taken from the caps are downloaded into a software file that calculates summary scores that include percentages of prescribed doses taken (dose-taking adherence) and prescribed doses taken within a specified window of time (dose-timing adherence). For the analysis, we will examine both mean dose-taking adherence and proportion with ≥85 % dose-taking adherence as primary outcomes, as well as mean dose-timing adherence and proportion ≥85 % dose-timing adherence as secondary outcomes. We will also ask participants to self-report the number of doses missed in the last week and percentage of prescribed medications taken in the last month, which will be used as secondary outcomes.At each survey assessment, clients are asked about their number of HIV care provider appointments scheduled, attended, and missed in the past 6 months.Clients will be asked to provide informed consent for access to medical record data, which we will use to access HIV viral load and CD4 assay results from the clinic’s electronic medical charts. These assays are performed routinely as part of usual care at regular clinic visits, which are scheduled every 3–6 months for patients on ART. Undetectable viral load and change in log-transformed mean viral load are primary outcomes; change in CD4 count is a secondary outcome.Participants will be asked at each follow-up assessment whether a provider has engaged them in specific adherence-related discussions. Participants will be asked to “indicate whether or not your provider(s) discussed the following with you to help you adhere to your ART regimen during the last 6 months.” For example, “Did your providers discuss with you how to reduce or overcome any problems you’ve had in adhering to your ART regimen?” Participants respond to each of six items using a 3-point response scale, with 0 = “No, this was never discussed”; 1 = “Yes, a little time was spent discussing this”; and 2 = “Yes, a lot of time was spent discussing this.”Only U.S. Food and Drug Administration–approved antiretroviral medications prescribed and monitored by the primary care providers as part of routine clinical care will be used in the study. Thus, we do not anticipate any medication-related adverse events beyond those seen in routine HIV medical care. Any adverse medication events that occur as part of usual medical care and noted by study staff will be communicated with the participant’s consent to their primary medical care provider. Loss of confidentiality is a potential adverse event, and we have set up several mechanisms to ensure confidentiality of participants. The nature of any information that may need to be disclosed to protect the participant or others is included as part of the consent process.A single independent monitor will be appointed to oversee the study. To allow effective monitoring, the independent monitor will be provided with periodic reports, which will include subject enrollment, subject retention, the number of patients who drop out of the study with reasons for dropping out, and a listing of all adverse events that are plausibly related to study procedures. Periodic reports will be provided to the independent monitor at 6-month intervals; however, adverse events that are considered directly related to aspects of study participation will be reported immediately to the monitor, the IRB, and the NIH. After review of the periodic reports, the independent monitor may ask for clarification or additional information from the principal investigator. After such information is provided, if requested, the independent monitor will make a recommendation regarding the continuation, modification, or termination of the study. All communications from the independent monitor will be shared with the IRBs and the NIH.We have set up several mechanisms to ensure the confidentiality of data collected from the participants. All paper files are stored in locked file cabinets, and electronic files are stored in password-protected, encrypted files. Furthermore, both paper and electronic files are identified only by a participant’s identification number. Identifying information linking participants to their study identification number is retained in a locked cabinet accessible only by the principal investigator and study coordinator. The final dataset will reside with the principal investigator.The primary aim of the analysis is to determine whether the START intervention is superior to usual care in helping patients achieve optimal adherence and virologic suppression in both the short and long term. Dose-taking adherence and viral load are the primary outcomes. Continuous adherence will be assessed for normality and transformed if needed; viral load data will be log-transformed. Our primary analysis is based on an intent-to-treat approach, with secondary analyses involving study completers. Attrition weights will be used to account for dropouts, and all analyses will incorporate design effects from this weighting in the calculation of standard errors and tests of significance. Analyses will be conducted to compare groups at months 6 and 24 to assess short- and long-term effects.In addition to simple between-group comparisons at each time interval , we will conduct analysis of the trajectory of outcomes. Longitudinal analyses will be performed, using mixed effects models to examine differences in trajectories of adherence and HIV viral load across the two groups, controlling for patient characteristics. Linear mixed effects models will be used for continuous outcomes, while nonlinear mixed effects models will be used for binary outcomes . Along with a fixed linear term for time, a random subject-specific intercept will be incorporated, with the appropriate covariance structure of the repeated measures being determined during analysis. Covariates added to the models will include components of our conceptual IMB framework and intervention , as well as correlated process variables . To adequately model longitudinal HIV viral load, which has a high proportion of values below the limit of detection, a Bernoulli/log-normal random effects mixture model with left censoring will be used . AnalysiA fully specified statistical analysis plan will be written before unmasking of the data. The article presenting the primary findings from this study will follow the outline provided in Additional file In this study, we will conduct a rigorous, controlled evaluation of the innovative ART adherence intervention START. Unlike most other ART adherence interventions that target people who are already on ART , 15, 20,An added innovation of START is highlighted in its design, which features components that are lacking in most ART adherence interventions to date: (1) inclusion of pretreatment, early-treatment, and ongoing maintenance training phases; (2) use of brief practice trials for determining adherence readiness and the timing of ART initiation; and (3) inclusion of a dose regulation mechanism that adjusts the amount of pretreatment and maintenance training based on the patient’s recent adherence performance. START combines these features with a goal of producing a robust and lasting effect on both adherence and clinical outcomes, as well as to be sensitive to and consistent with community practice, the limited resources available to most clinics and providers , and the wide range of adherence skills present among patients. This flexibility and attention to individual patient needs should increase the acceptability of the program to patients, providers, and clinic administrators, thus improving the likelihood of future translation into usual care.Our pilot controlled trial of START revealed evidence of the intervention’s potential promise, with medium to large effects on both behavioral adherence and undetectable viral load . If thisEnrollment is active.


Recent data indicates that low vitamin D (25(OH)D) levels can lead to a worst prognosis in HIV-infected individuals, even in those on successful antiretroviral therapy (ART) [1]. Portugal is the European country that has the largest average sun exposure time but prevalence of hypovitaminosis D is mostly unknown. Our aim was to determine the prevalence of hypovitaminosis D in HIV patients in Lisbon and the possible association with ART.From 2012 to January 2014, plasma samples from 518 HIV-infected patients were collected to 25(OH)D levels determination. Data on demographic features  and clinical/laboratory parameters were collected from clinical files , HBV/HCV co-infection and ART). 25(OH)D status was defined as: deficiency <20 ng/mL, insufficiency 20–30 ng/mL, optimal >30 ng/mL.Median age was 46 years old (±11); 62.0% (321/518) were male; 81.3% (421/518) were Caucasian and 78.6% (407/518) were Portuguese. Most patients , were HIV-1 infected, 22.9% (114/498) and 4.0% (20/498) of them were HCV and/or HBV co-infected, respectively. Mean CD4+ cell count was 648 cells/µL (±333) and nadir was 219 cells/µL (±179). On treated patients VL was <40 HIV RNA/mL in 86.7% (417/481). The median levels of 25(OH)D was 20.0 ng/mL (range 4.1–99.7) and we found differences between values observed during Winter (median 16.7 ng/mL) and Summer (median 24.9 ng/mL) (p<0.0001). Low 25(OH)D levels were not correlated to ethnicity (p=0.066). 25(OH)D level was <30 ng/mL in 80.1% (415/518) of the patients, from which 30.9% (160/518) and 49.2% (255/518) had insufficiency and deficiency levels, respectively. Most  were on ART: regimens containing PI (47.5%), NNRTI , II (1.2%), PI+NNRTI (3.9%). Comparing the 25(OH)D level along the different ART regimens  there were differences between PI and EFV (p=0.044).In this study, 80.1% of the HIV-infected patients had hypovitaminosis D and ART regimens with EFV were more often associated with low 25(OH)D levels. Understanding the impact of the different antiretroviral drugs on 25(OH)D status could help to decide in clinical practice whether 25(OH)D supplementation or drug switch are the best options for each patient.


Response to antiretroviral therapy (ART) among individuals infected with HIV-2 is poorly described. We compared the immunological response among patients treated with three nucleoside reverse-transcriptase inhibitors (NRTIs) to boosted protease inhibitor (PI) and unboosted PI-based regimens in West Africa.This prospective cohort study enrolled treatment-naïve HIV-2-infected patients within the International Epidemiological Databases to Evaluate AIDS collaboration in West Africa. We used mixed models to compare the CD4 count response to treatment over 12 months between regimens.p=0.02), median length of follow-up  and baseline median CD4 count . CD4 count recovery at 12 months was higher for patients treated with boosted PI-based regimens than those treated with three NRTIs or with unboosted PI-based regimens .Of 422 HIV-2-infected patients, 285 (67.5%) were treated with a boosted PI-based regimen, 104 (24.6%) with an unboosted PI-based regimen and 33 (7.8%) with three NRTIs. Treatment groups were comparable with regard to gender  and median age at ART initiation . Treatment groups differed by clinical stage (21.2%, 16.8% and 17.3% at CDC Stage C or World Health Organization Stage IV for the triple NRTI, boosted PI and unboosted PI groups, respectively, In this observational study using African data, boosted PI-containing regimens had better immunological response compared to triple NRTI combinations and unboosted PI-based regimens at 12 months. A randomized clinical trial is still required to determine the best initial regimen for treating HIV-2 infected patients. In the 2013 guidelines [Between one and two million people are estimated to be living with HIV-2 infection in West Africa , the regidelines , WHO recidelines –11. Althidelines . Anotheridelines .In the context of the large and still ongoing scale-up of ART in the West African region, HIV-2 infection causes specific operational, clinical and public health challenges . First, Owing to its low prevalence and its geographical restriction to West Africa, response to ART in HIV-2 infection is still poorly understood ,18. TherWhereas the data have generally favoured boosted PI regimens over those comprised of triple NRTIs, to our knowledge, only one report from a European collaboration  and two www.iedea.org/), funded by the US National Institutes of Health [Since 2006 a network of adult and paediatric HIV clinics in West Africa has existed as part of the global IeDEA Collaboration  Baseline demographics and clinical data: birth date, gender, HIV clinical stage (WHO or CDC stage), ART initiated, clinical assessment, medical history; 2) Follow-up: clinical assessment ; 3) Biological data: CD4 count, haemoglobin, aspartate transaminase, alanine transaminase and plasma HIV RNA viral load (when available); 4) Outcomes: death, loss to follow-up and transferred out.Patients aged >17 years at ART initiation and with an HIV-2 infection confirmed by two or three rapid HIV tests based on country-specific national algorithms were eligible for this analysis. Only those patients who initiated ART with three NRTIs or a PI-based regimen were included. Patients without documented CD4 count at ART initiation and/or with unknown gender were excluded.ART was provided to the HIV-2 infected patients according to the national guidelines. In West Africa, HIV-2 treatment guidelines were based on WHO recommendations . Up to 2After initiation into care, patients were typically followed up every six months or were seen in between scheduled visits if illness occurred. T-CD4 lymphocyte counts were measured every six months. The absolute CD4+/CD8+ T-cell counts were performed using standard flow cytometry .CD4 count trajectories over the first 12 months of ART were modelled using linear mixed models (LMMs), with baseline defined as the date of ART initiation. We included all CD4 count measurements between baseline (or the first CD4 count recorded within a window of six months prior to baseline) and 24 months of follow-up (or six months later at the latest). In the main analysis, patients who switched initial treatment were right censored at the date of switching. We modelled the CD4 count changes over time  using frTo address possible informative dropout we performed a sensitivity analysis restricted to patients remaining in care beyond the 12 months of ART (patients deceased or lost to follow-up were excluded). Patients were defined as lost to follow-up if they were not known to have died, not known to have transferred out and not seen at the clinic at least once in the last six months prior to the closure date of the database .In a second sensitivity analysis, we performed the multivariable LMM in an intent-to-treat analysis.As of March 2013 the IeDEA-WA database contained 2005 patients infected with HIV-2 . p=0.02). Baseline CD4 cell count was lower in the unboosted PI group  compared to the boosted PI group  and to the NRTI group . Median follow-up time was higher for the unboosted PI group  compared to 17.7 months (2.4 to 36.6) and 12.9 months (0 to 38.9) for patients treated with a boosted PI-based and a three-NRTI regimen, respectively (p<0.001). Twenty-one (63.6%) patients initially treated with three NRTIs started their first-line ART regimen between 2008 and 2012, compared to 191 (67.0%) patients treated with a boosted PI-based regimen and 9 (8.6%) patients treated with an unboosted PI-based regimen (p<0.001). Of the patients treated with a PI-based regimen (boosted or not) 55% were female, compared to 42.4% of the patients treated with three NRTIs (p=0.35). The median age at ART initiation was 45.5 (38.9 to 52.1), 44.2 (36.9 to 51.2) and 46.1 (40.7 to 51.9) years for patients treated with a boosted PI-based, unboosted PI-based and triple NRTI regimen, respectively (p=0.59). Twelve months after starting ART there were 12 (2.8%) deaths in total, with similar proportions in the three treatment groups . Twenty-four percent of patients were lost to follow-up after 12 months (p=0.43).Of 422 eligible patients, 285 (67.5%) started a boosted PI-based ART regimen, 104 (24.6%) an unboosted PI-based regimen and 33 (7.8%) a triple NRTI regimen . The subn=210), followed by indinavir for 25.3% (n=72) and saquinavir for three patients (1.1%). In the unboosted PI group 88 (84.6%) patients were treated with indinavir and 16 (15.4%) with nelfinavir.The triple NRTI ART combinations prescribed were AZT+3TC and ABC for 22 patients (66.7%), stavudine+3TC and didanosine for six patients (18.2%), stavudine+3TC and ABC for three patients (9.1%) and AZT+3TC and didanosine for two patients (6.1%). For patients treated with a boosted PI-based regimen, the initial combinations mostly prescribed were AZT+3TC and lopinavir-ritonavir for 130 patients (45.6%), stavudine+3TC and lopinavir-ritonavir for 52 patients (18.3%) and AZT+3TC+indinavir and ritonavir for 34 patients (11.9%). For patients treated with an unboosted PI-based regimen, the initial combinations mostly prescribed were AZT+3TC+indinavir for 61 patients (58.7%), stavudine+3TC+indinavir for 25 patients (24.0%) and AZT+3TC+nelfinavir for 9 patients (8.7%). Lopinavir-ritonavir was the most frequently prescribed PI for 73.7% in the boosted PI group (Treatment modification during the first 12 months of ART was reported for 11 (33.3%) patients initially treated with three NRTIs: five patients switched to a boosted PI-based regimen, four to another NRTI-based combination and two to an NNRTI-based regimen. Of 45 (15.8%) patients initially treated with a boosted PI-based regimen who had a treatment modification within 12 months, 38 were still treated with a boosted PI-based regimen, three were treated with three NRTIs, two with a NNRTI combination, one with an unboosted PI-based regimen and one with two NRTIs. Of 27 (26.0%) patients initially treated with an unboosted PI-based regimen, 24 were treated with a boosted PI-based regimen, two with an NNRTI combination and one with three NRTIs. The median times from ART initiation to treatment modification were 5.7 (2.9 to 8.9), 4.9 (2.8 to 8.7) and 5.8 (2.0 to 8.8) months for patients initially treated with three-NRTI, unboosted PI-based and boosted PI-based regimens, respectively. Reasons for ART modification were not recorded in the database.p=0.0291), with gender (p=0.0302) and with the type of first ART regimen (p=0.0045). Compared to patients with a baseline CD4 count <50 cells/µl, patients with baseline CD4 count ≥350 had lower CD4 count recovery (−99 cells/µl (−164 to −34)) 12 months after ART initiation. Compared to women, men had a lower CD4 count recovery after 12 months of ART (−39 cells/µl (−71 to −8)). We found no association between CD4 response to ART and age, baseline haemoglobinaemia, year of ART initiation, country and initial clinical stage (data not shown).p=0.0045). Compared to patients initially treated with a boosted PI-based regimen, CD4 count recovery was lower for patients treated with three NRTIs or with an unboosted PI-based regimen (−72 cells/µl (−129 to −16); −42 cells/µl (−74 to −10), respectively) at six months. The difference in CD4 count recovery between the three treatment groups persisted at 12 months  were similar to those from the main analysis. CD4 count changes at 12 months estimated from these two models, according to baseline CD4 count, are shown in The results of the sensitivity analysis restricted to patients remaining in care . Indeed, in the WHO guidelines of 2010  this ARTAnother limitation is the use of suboptimal triple NRTI regimens in West Africa. Some combinations used in this study, such as AZT+3TC+ABC, are not well tolerated and are known to be less potent than triple NRTI regimens used elsewhere in Africa.Because the three groups of patients compared in our study differed in terms of baseline CD4 count, baseline clinical stage and follow-up duration, this analysis was possibly affected by selection bias and the results should be interpreted with caution, as in all observational cohorts comparing treatment regimens . In resoAgence Nationale de Recherches sur le Sida et les hépatites virales (ANRS). The critical issue of second-line regimens for HIV-2, including the optimal sequence of integrase inhibitors and/or boosted PIs, could potentially be addressed by a study enrolling the subjects failing therapy in those two arms of the FIT-2 trial.In conclusion this study further demonstrates the inferiority of unboosted indinavir and triple nucleoside regimens for the treatment of HIV-2 infection. Limitations inherent in this observational design will be addressed by the First-Line Treatment for HIV-2 trial  already underway in five countries in West Africa and funded by the


We investigated MTX pharmacokinetics and evaluated the effects of renal function (eGFR), age and use of different classes of ARVs.Clinical outcomes for lymphoma in people living with HIV (PLWH) are similar to those in the general public. However, a number of concerns remain including pharmacological interactions between cytotoxic chemotherapy and antiretroviral therapy (ARVs). Much attention has focussed on pharmacokinetic interactions attributable to effects on hepatic microsomal enzymes, but not on competition for the renal organic anion transport system. High-dose (3 g/m® 5600) daily after administration until levels were <0.04/mmol/L. MTX elimination half-life was correlated with age, renal function and antiretroviral regimen.Forty-three PLWH treated with ARVs and (R)-CODOX-M/IVAC are included in the analysis. Plasma MTX concentration was measured , eGFR (p = 0.67) or use of non-nucleoside reverse transcriptase inhibitors (NNRTIs) or integrase inhibitors (p = 0.15). Similarly, different NRTI backbones did not affect MTX elimination kinetics (p = 0.68), despite the potential overlapping competition for active renal tubular transporters between MTX and tenofovir.One hundred and fifty timed plasma MTX levels were collected. The median MTX elimination half-life was 21.7 h (range 9.4–204.4). MTX elimination half-life was not influenced by age (Although there is potential competition for active renal tubular transporters between MTX and tenofovir, no prolongation of MTX half-life was observed. These findings are reassuring to clinicians managing patients with dual diagnoses. Human immunodeficiency virus (HIV) infection substantially increases the risk of developing non-Hodgkin lymphoma (NHL) . This is2 methotrexate. This regimen is used with antiretroviral therapy in PLWH diagnosed with BL/BLL and has been shown to achieve outcomes comparable to the HIV-negative patients  [(R)-CODOX-M/IVAC  is the standard chemotherapy regimen for BL/BLL in the UK and includes 3 g/mof 73 %) .However, chemotherapy in PLWH may be complicated by clinically significant pharmacokinetic interactions between cytotoxic drugs and antiretrovirals (ARVs). No data on the pharmacokinetics (PK) of high-dose MTX in PLWH are available. We investigated MTX PK and evaluated the effects of renal function (eGFR), age and use of different classes of ARVs.2) plasma was collected and sent to Great Ormond Street Hospital for Children in London for MTX concentration measurement  daily. Treatment with folinic acid rescue and urinary alkalinization continued until MTX concentrations <0.05 mmol/L were achieved. No patients received glucarpidase as salvage for methotrexate toxicity. Clinical data on renal, liver function and ARV regimen (nucleoside reverse transcriptase inhibitors (NRTIs) backbones and use of third agent) were collected. Comparison of MTX elimination half-life (t½) with relevant clinical variables was performed using t test (StatView 1989).All people living with HIV (PLWH) treated with (R)-CODOX-M/IVAC for HIV-associated Burkitt/Burkitt-like lymphoma between 2007 and 2014 at the National Centre for HIV Malignancy, Chelsea and Westminster Hospital, London, are included in the analysis. As part of routine care, following methotrexate infusion (3 g/m3 (range 10–864), the median CD4 percentage 13 % (range 2–39), the median CD8 cell count 884 cells/mm3 (range 272–2065) and the median CD8 percentage 55 % (range 22–77). The median plasma HIV viral load for the cohort was 10,860 copies/mL (range 0–1.9 M).We treated 43 PLWH  with HIV-associated BL/BLL with (R)-CODOX-M/IVAC. At the start of chemotherapy, the mean age was 42 years (range 24–71) and the mean duration of HIV infection was 28 months (range 0–295). Two (5 %) had a prior AIDS-defining illness, and 12 (28 %) were established on combination antiretroviral therapy (cART) prior to lymphoma diagnosis, of whom ten (83 %) had an undetectable plasma HIV viral load. For the whole cohort, the median CD4 cell count was 225 cells/mmThe combination antiretroviral therapy that was concomitantly prescribed with the methotrexate included 36 (84 %) patients on a nucleotide/side reverse transcriptase inhibitor (NRTI) backbone of tenofovir/emtricitabine backbone and seven (16 %) on a backbone of abacavir/lamivudine. Twenty-two (51 %) patients were on integrase inhibitors (INI), 18 (42 %) on non-NRTIs (NNRTIs), one (2 %) on a ritonavir-boosted protease inhibitor, one (2 %) on both NNRTI and INI, and one (2 %) on INI and maraviroc.2 methotrexate, but accurate timings of the sample collection were not available for 33 samples. The 150 timed MTX levels from 43 PLWH included 18 samples from women and 132 from men. The median half-life (t½) of methotrexate was 21.7 h (range 9.4–204.4). The elimination half-life of methotrexate was not affected by eGFR (p = 0.67)     or by NRTI backbones (p = 0.9). Following methotrexate, only one patient developed CTCv4.0 grade 1 acute nephrotoxicity, and his elimination half-life of methotrexate was 38.8 h.Elevated serum concentrations of methotrexate at 24, 48 and 72 h  were recorded for 31/150 (21 %) time points. An elevated level was not associated with use of NNRTIs rather than integrase inhibitors (Pharmacokinetic drug interactions can significantly affect the efficacy and toxicity of chemotherapy. The most frequent mechanism of these interactions is the inhibition and induction of hepatic cytochrome P450 (CYP) microsomal enzymes by co-administered drugs. The CYP enzymes are responsible for the vast majority of drug metabolic deactivation and clearance. Many drugs including antiretroviral agents increase or decrease the activity of various CYP isoenzymes by inducing their biosynthesis or by inhibiting their activity, resulting in adverse drug interactions. For example, ritonavir is a potent inhibitor of CYP3A4 activity, leading to increased bioavailability of many of the substrates of CYP3A4 including cytotoxic chemotherapy agents, and resulting in overdosing and excess toxicity. This pharmacological drug interaction has been shown to be of clinical significance in treating patients with HIV-associated lymphoma. Patients receiving ritonavir-boosted PI-based cART experienced greater myelosuppression and subsequently increased the risk of hospitalization for severe neutropenic sepsis with CDE  for HIV-associated NHL . Since cMethotrexate is eliminated by renal clearance with almost 90 % excreted unchanged in the urine. Although the mechanism of MTX excretion in the human kidney has not been completely elucidated, the finding that MTX clearance exceeds creatinine clearance in several studies suggests that there is active tubular secretion as well as glomerular filtration . The phaThere is a clear relationship between plasma MTX levels, adverse events and treatment efficacy with important individual differences . This in2 MTX as part of the CODOX-M/IVAC regimen with concomitant cART. While the definition of high-dose MTX is not clear in the literature, the overall plasma half-life (t½) of MTX following intravenous administered as a dose >30 mg/m2 is 8–12 h, although this may be longer when higher doses such as 3 g/m2 are administered [In this study, we evaluated the clearance of MTX in PLWH receiving 3 g/mnistered .p = 0.71). This has been previously demonstrated in the HIV-negative setting where no significant reduction in MTX clearance was observed in older (>60 years old) patients treated with 4 g/m2 for primary central nervous system lymphoma [The median plasma MTX half-life in our study population was 21.7 h (range 9.4–204.4). There was no significant difference in MTX clearance in patients with reduced eGFR (p = 0.67); this is surprising since impaired renal function reduces MTX elimination, but only 29 (19 %) samples were taken from patients with estimated GFR below 90 mL/min. Similarly, age did not influence plasma MTX half-life (lymphoma .p = 0.15). Tenofovir disoproxil fumarate (TDF) is recommended as first-line nucleotide reverse transcriptase inhibitor (NRTI) for HIV-1 treatment. Prolonged treatment with TDF has been linked to nephrotoxicity characterized by eGFR decline and proximal tubular dysfunction, especially if used in combination with boosted PIs [p = 0.68).The influence of co-administered ARVs on MTX elimination was evaluated by class of antiretroviral. There was no statistically significant difference in half-life between patients on non-nucleoside reverse transcriptase inhibitors (NNRTIs) and those on integrase inhibitors (sted PIs . TDF is sted PIs . Thus, tThis study has some limitations. Firstly, data have been retrospectively collected, and MTX concentration testing sent in a real-life clinical practice and not in a pre-scheduled clinical trial setting. Important genetic polymorphisms influence MTX metabolism, causing pharmacokinetic variability, but no pharmacogenetic analysis was undertaken in this cohort. Finally, the influence of other medications such as NSAIDs, penicillin drugs and proton pump inhibitors has not been evaluated.2 MTX as part of chemotherapy for BL/BLL, the elimination half-life of MTX was not affected by eGFR, age or ARV regimen. This is despite the potential overlapping competition for active renal tubular transporters between MTX and tenofovir. These findings are reassuring to clinicians managing patients with dual diagnoses, but prospective data on the PK and the pharmacodynamics of ARV and cytotoxics are warranted to improve treatment of cancer in PLWH.Pharmacological drug–drug interactions in the management of HIV-associated lymphomas have had important clinically significant effects. Plasma methotrexate levels influence both its efficacy and its toxicity, and the elimination is by renal clearance. In an analysis of 43 people living with HIV who were treated with 3 g/m


PI/r monotherapy has been suggested as an attainable maintenance strategy in patients achieving stable HIV suppression in plasma. The objective of trial was to compare the virological outcome of two different PI/r QD monotherapy strategies (LPV/r or DRV/r) with maintaining a triple PI/r-based ARV regimen.3, without previous PIs virological failure. Eligible patients were randomized to continue PI/r+2NRTIs (Arm A), to switch to LPV/r 800/200 mg QD monotherapy (Arm B), or to switch to DRV/r 800/100 mg QD monotherapy (Arm C). Primary endpoint was proportion of patients with plasma HIV-1 RNA <50 cp/mL (TLOVR) at 48w by intent to treat (ITT) analysis (missing/re-induction=failure). FDA snapshot and ITT switch-included analysis (ITT-SI) were also used. In ITT-SI, patients who had <50 copies/mL at 96w were counted as successes even if they had confirmed HIV-RNA elevations and had subsequently successfully intensified by NRTI.Phase III, open-label, non-inferiority (−12% margin), randomized trial of HIV adults with HIV-RNA <50 cp/mL for at least 48 weeks while on PI/r-based cART, CD4 nadir >100 cell/mmDue to slow recruitment, only 103 patients were included. No differences were observed between the three arms with respect to gender, age, HIV transmission, CD4 nadir and at screening. At randomization, 61 patients were receiving TDF/FTC (60%), 19 ZDV/3TC (18%), 8 ABV/3TC (8%), 75 LPV/r (73%), 13 ATV/r (13%), 4 DRV/r (4%). Differences in proportion of virological success by groups using Arm A as comparator according to FDA TLOVR were reported in Compared to maintaining a PI/r-based triple ARV regimen, LPV/r QD monotherapy tended to have higher rate of virological failure and of discontinuation due to adverse event. In contrast, the response rate at week 96 during DRV/r QD mono-therapy was non-inferior to that of triple PI/r-based ARV therapy. A re-induction with 2NRTI was adequate to obtain an undetectable viremia in most of patients with virological failure.


The combination of lamivudine plus a protease inhibitor boosted with ritonavir (PI/r) has become an alternative as simplification strategy in HIV-infected patients with toxicity/intolerance to other nucleoside analogues (NA). Lamivudine plus darunavir/r (DRV/r) could be an adequate once daily option.Prospective cohort study of 48 HIV-infected patients on suppressive triple therapy-based HAART, HBV negative, who switched to lamivudine 300 mg plus DRV/r 800/100 mg once daily.Mean age was 50 yrs (35–74), and 65% were male. Thirty patients (63%) had HCV co-infection . Median time of HIV infection was 19.1 years, and CD4+ count nadir was 220 cells/µL (2–604). They had received a mean of three regimens before (2–20), and 20 (42%) had a previous AIDS diagnosis. In eight cases, a previous resistance test showed two to seven secondary mutations in the protease gene, without resistance to DRV/r (one patient with the I84V mutation). At baseline, patients had viral suppression (<50 copies/mL) for a median time of 1263 days (341–1884), and they were receiving predominantly a PI based regimen  or an efavirenz-based regimen (seven). The main reason to switching to this dual therapy was toxicity , mainly renal toxicity attributed to tenofovir (24 cases). During 104.3 patients-year of follow-up (median 912 days), only two patients (4%) failed at 27 and 505 days, due to non-adherence and lost to follow up, respectively. Total cholesterol and triglycerides increased significantly during the first six months after initiation  and decreased after. Median estimated glomerular filtration rate (eGFR) improved during follow up . In patients with renal toxicity as cause of switch there was a mild, no significant improvement during the first year (from 63.3 to 68.7 mL/min), although an improvement in protein-uria levels  was observed soon after initiation.Dual therapy with lamivudine plus darunavir boosted with ritonavir once daily is safe and effective as simplification strategy in HIV-infected patients.


While antiretroviral therapy (ART) has increased the survival of HIV patients and turned HIV infection into a chronic condition, treatment modifications and poor adherence might limit this therapeutic success.Patients from the Austrian HIV Cohort Study, who started their first ART after Rilpivirine became available in February 2011, were analyzed for factors associated with treatment modification which could be either a change of drugs or a stop of the regimen. A drug was considered as stopped when the regimen was interrupted for more than eight days. Drugs of particular interest were Darunavir (DRV), Atazanavir (ATV), Raltegravir (RAL), Rilpivirine (RPV) and Efavirenz (EFV). RPV and EFV were analyzed only when taken as single tablet regimen. Other drugs were summarized as “other.” Proportional hazards regression methods were used to identify predictors of discontinuation and Kaplan–Meier estimates were used to calculate probabilities of discontinuation. Patients who died were censored at the date of death.965 patients started ART, 282 with DRV, 161 with ATV, 96 with RAL, 108 with RPV and 118 with EFV. Median time for taking initial ART is 11.6 months. 322 (33.4%) patients modified their initial ART. The overall probability of modification at one year was 28.7%, at two years 40.0% and at three years 49.8%. In a multivariable proportional hazards regression analysis, AIDS diagnosis at baseline and injecting drug use (IDU) of men compared with men who have sex with men (MSM) have a higher risk of switch/stop. Compared with DRV, RPV showed a much lower and ATV and particularly “other” a higher risk for discontinuation .Availability of more effective/convenient treatment (28.9%) was the main reason for discontinuation, especially in the group “other” (43.5%), RAL (34.6%) and DRV (31.6%). Non-specified patient or physician wish to modify therapy was revealed in 17.4% and 9.3% respectively. EFV was modified in 52.8% due to central nervous system toxicity and ATV in 27.8% for gastrointestinal toxicity including hyperbilirubinemia.Rates of modification and interruption were still high in recent years, particularly in the first year of ART. The decreased rate of modification found in patients treated with Rilpivirine may be attributed to selection of patients according to guidelines.


It is unclear whether antiretroviral therapy (ART) should be initiated during acute HIV infection. Most recent data provides evidence of benefits of early ART.We retrospectively compared the clinical and immunological course of individuals with acute HIV infection, who received ART within 3 months (group A) or not (group B) after diagnosis.Among the 84 individuals with acute HIV infection, 57 (68%) received ART within 3 months (A) whereas 27 (32%) did not receive ART within 3 months (B), respectively. Clinical progression to CDC stadium B or C within 5 years after the diagnosis of HIV was less common in (A) when compared to (B) (P = 0.002). After twelve months, both the mean increase in CD4+ T cell count and the mean decrease in viral load was more pronounced in (A), when compared to (B) . Twenty-four months after diagnosis the mean increase from baseline of CD4+ T cells was still higher in group A compared to group B .Initiation of ART during acute HIV infection is associated with a lower probability of clinical progression to more advanced CDC stages and significant immunological benefits. Since the introduction of the first antiretroviral substances the question when to start treatment has not been fully answered. International guidelines on the timing of antiretroviral therapy (ART) have changed recommending earlier treatment initiation due to emerging data showing beneficial effects of early ART. There is abundant data assessing the timing of ART in chronic HIV infection based on a certain threshold of CD4+ T cells. Several studies provide strong evidence that treatment initiation at a threshold of a CD4+ T cell count of <350 cells/μl improves survival and delays disease progression . For patDespite growing evidence of benefits of early initiation of ART, it is not clear whether treatment should be initiated during asymptomatic acute HIV infection. Several studies assessing ART during acute HIV infection show beneficial effects on laboratory progression markers. Potential positive effects of initiation of ART during acute HIV infection include reduction of viremia , lower vFurthermore, early detection and treatment of acute HIV infection is fundamental to avoid transmission in this critical period of high viremia and thus, high infectivity . HoweverThe objective of this retrospective study was to evaluate the clinical and immunological course of individuals starting or deferring ART during acute HIV infection. The primary endpoint was the CD4+ T cell count at 12 months after HIV diagnosis (absolute or relative delta CD4+). Secondary endpoints were (i) CD4+ T cell count at month 24, (ii) HIV-RNA levels at 12 and 24 months, as well as (iii) clinical progression to CDC B and C manifestations within 5 years.The study was approved by the ethics committee of the Medical University of Vienna (EK number 1297/2013). The study subjects had provided written informed consent to document their data in the Austrian HIV database.This study was performed at the Department of Dermatology, Medical University of Vienna. The Austrian HIV Cohort Study (AHIVCOS) database system and stored case files were used for data collection. Epidemiological characteristics including date of birth, sex and country of birth were collected for each patient. Furthermore, HIV infection characteristics such as mode of infection with HIV , clinical symptoms at presentation , Centers for Disease Control and Prevention (CDC) stage and ART regimen.The following immunological parameters were evaluated at the time of diagnosis and 1, 3, 6, 12 and 24 months after diagnosis: CD4+ T cell count (cells/μl), CD8+ T cell count (cells/μl), CD4+/CD8+ ratio and HIV RNA level (copies/mL).Moreover, we assessed clinical progression to CDC B and C manifestations within 5 years. Significant treatment interruption was defined as an ART interruption of more than 1 month.In accordance with the SPARTAC trial , acute HStatistical analyses were performed using IBM SPSS Statistics 21 . Continuous variables were reported as mean ± standard deviation or median (interquartile range), while categorical variables were reported as number of patients with (proportion of patients with) the certain characteristic. Student’s t-test was used for group comparisons of continuous variables when applicable. Otherwise, Mann-Whitney U test was applied. Group comparisons of categorical variables were performed using Chi squared or Fisher’s Exact test. Kaplan-Meier curves show clinical progression or death and log-rank test was used for group comparisons. A P value < 0.05 was considered as statistically significant.A total of 96 patients were diagnosed with acute HIV infection in the HIV clinic of the Medical University of Vienna between 1995–2013. Twelve of these patients met exclusion criteria and were thus excluded from this study. Of the remaining 84 patients, 57 (68%) received ART within 3 (group A) and 27 (32%) did not start ART within 3 months (group B) . The decThe mean age at the time of diagnosis was 41.1 ± 9.8 years. The majority  of participants were male and 12% (10/84) were female. Eighty-two percent (69/84) of individuals were born in Western Europe, 13% (11/84) in Eastern Europe and 2% (2/84) in Africa. Transmission occurred in 18% (15/84) via heterosexual intercourse, in 69% (58/84) via homosexual intercourse and in 13% (13/84) via intravenous drug use. The majority of subjects  presented with clinical symptoms, i.e. 61% (51/84) had a maculo-papular rash, 11% (9/84) of subjects presented with pharyngitis, 32% (27/84) with lymphadenopathy and 37% (31/84) with fever. At the time of diagnosis, the median CD4+ T cell count was 427 (IQR 361) cells/μl. The median CD8+ T cell count was 1028 (IQR 816) cells/μl and the median CD4+/CD8+ ratio was 0.4 (IQR 0.43). The mean HIV viral load of the study population was 5.45 ± 1.12 log10 copies/mL .P = 0.002 (P = 0.035 (The median follow-up time was 38.8 (70.3) months. Among 84 patients, 8 patients (10%) developed CDC B or C manifestations within 5 years after diagnosis. Early ART initiation was associated with a lower frequency of clinical progression . In gro = 0.035 ).The characteristics of the 8 cases of CDC stage B or C-defining illness during the observational time are shown in At the time of clinical progression, 4 of the 8 individuals had measurable HIV RNA levels. Two of the 8 individuals with clinical progression had interrupted treatment while one had not started ART during the follow-up time.All 84 study participants were included in this analysis in order to compare the immunological course of patients who received ART within 3 months (group A) with patients who did not receive ART within 3 months (group B). There was no difference between the groups in terms of age and transmission risk. Eighty-two per cent (47/57) of the patients in group A were male, whereas all patients (27/27) in group B were male (P = 0.026). All female individuals (n = 10) started ART within 3 months (group A) .Baseline median CD4+ T cell counts (520 (IQR 421) vs. 414 (IQR 267) cells/μl, P = 0.292) and mean HIV RNA-levels  were comparable among group A and B. Median baseline CD8+ T cell count was significantly lower and median CD4+/CD8+ ratio higher in group A as compared to group B (982 (IQR 745) vs. 1199 (IQR 1660) cells/μl, P = 0.048; and 0.465 (IQR 0.47) vs. 0.3 (IQR 0.31), P = 0.006) .After one year group A showed significantly higher mean CD4+ T cell counts , lower median CD8+ T cell counts (623 (513) vs. 1014 (484) cells/μl, P < 0.001) and a higher median CD4+/CD8+ ratio (1 (IQR 0.7) vs. 0.4 (IQR 0.4), P < 0.001). Median HIV RNA-levels were significantly lower in group A vs. B (1.69 (IQR 0.41) vs. 4.17 (IQR 3.1) copies/mL, P < 0.001). ART within 3 months was associated with a significantly higher increase in number of CD4+ T cells compared to deferred/no therapy (225 ± 266 vs. 87 (IQR 225) cells/μl, P = 0.002). While the changes in CD8+ T cell counts were not significantly different between the two groups (-274 (IQR 888) vs. -426 (IQR 1378), P = 0.436), the CD4+/CD8+ ratio was significantly higher in the early treatment group (0.44 (IQR 0.84) vs. 0.145 (IQR 0.33), P = 0.003) .Two years after diagnosis group A still showed significantly higher CD4+ T cell counts (774 (400) vs. 518 (302) cells/μl, P = 0.001), whereas the viral load was (not significantly) lower (1.43 (1.27) vs. 3 (3.22) log10 copies/ml, P = 0.061). The mean increase from baseline of CD4+ T cells was significantly higher in group A compared to group B . The median CD4+/CD8+ ratio was higher in group A as compared to group B (0.97 (IQR 0.64) vs. 0.56  .The results of our study indicate that ART during acute HIV infection leads to a significant reduction of the frequency of clinical progression to a CDC stage B or C manifestation and an enhanced increase of CD4+ T cell counts in the first 2 years. Our findings suggest, that the initiation of ART during acute infection may decrease the risk of clinical progression and preserve the immune function.The international trend of ever-earlier treatment initiation in chronic HIV infection has recently been reinforced by the unambiguous results of the START trial and the TEMPRANO trial , 4. HoweSuppression of viral replication during acute HIV infection was shown to limit viral reservoirs  and viraData regarding clinical progression of HIV infection when ART is started during acute infection is limited. In our study, individuals with early treatment less frequently developed CDC B or C manifestations. Thus, our real-life data suggests, that early ART initiation during acute HIV infection might have beneficial effects on disease progression when compared to delayed ART initiation or no ART. At the time of clinical progression to CDC B or C manifestation, 4 of the 8 individuals displayed high HIV viral loads. Thus, high viral load might be associated with clinical progression of those individuals and explained by either treatment interruption or treatment failure. Therefore, a subsequent analysis was performed in order to take significant treatment interruptions into account. Interestingly, we still observed a beneficial effect of early ART.Interestingly, all our female study participants received early ART, although it has been described that women tend to prefer a delay of ART initiation due to personal reasons . A totalThis study had several limitations resulting mostly from its retrospective study design: First, the follow-up time differs between individuals with 48% of the study population having less than 5 years of follow-up which makes the interpretation of clinical progression after five years difficult. Thus, we assessed clinical progression to CDC B and C manifestations only within 5 years after the diagnosis. Secondly, the groups were heterogeneous after two and five years of follow-up, as some initially untreated patients had started therapy and some “early treatment” patients may have stopped or changed their ART regimen. To investigate the long-term benefit of early treatment, the study population was too small and inhomogeneous after 5 years. As subjects with incomplete follow-up or missing data were excluded, selection bias might have been introduced towards more healthy or adherent subjects. Nevertheless, our study provides interesting information for physicians in routine clinical practice, as it compares the ‘real-life’ clinical and immunological outcome of early and delayed ART initiation in individuals treated outside of clinical trials.In conclusion, our retrospective observational study shows that in patients who received ART within three months after being diagnosed with acute HIV infection clinical progression to CDC B or C manifestations occurred less frequently in the early treatment group during follow-up. In addition, the early treatment group showed an improved immunological course 12 and 24 months after diagnosis. However, further randomized-controlled clinical trials are required to determine the clinical benefits and disadvantages of ART initiation during acute HIV infection.S1 File(DOC)Click here for additional data file.