The principal goal of HAART is sustained viral load (VL) suppression resulting in immune reconstitution and improved HIV outcomes. We studied the factors associated with 10 years of continuous VL suppression on HAART in the US Military HIV Natural History Study.n = 149) were compared to those who did not have continuous viral load suppression  for ≥10 years on HAART. Factors associated with >10 years of VL suppression were evaluated by multivariate logistic regression. Additionally, association between CS and CD4 reconstitution was analyzed with a mixed effects model.Participants with continuous VL suppression  and had less antiretroviral use prior to HAART . At initial HAART, the median CD4 cell count was higher and VL was lower for CS compared to NCS participants . New AIDS events were lower during HAART  and post-HAART CD4 trajectories were greater for the CS compared to NCS group. Factors negatively associated with ≥10 years of VL suppression included log10 VL at first HAART  and antiretroviral use prior to HAART .Compared to NCS participants, a lower proportion of CS participants started HAART in the early HAART era (66 vs 90 %, for years 1996–1999; Sustained VL suppression is a key to long-term health in HIV-infected patients, as demonstrated by the lower proportion of AIDS events observed 10 years after HAART initiation. The current use of more potent and well-tolerated regimens may mitigate the negative factors of pre-HAART VL and prior ARV use encountered by treatment initiated in the early HAART era. The primary goal of highly active antiretroviral therapy (HAART) in HIV-infected individuals is sustained viral load (VL) suppression which, in turn, leads to several benefits. Immune recovery is evidenced by CD4 cell gains, a reduction in activated CD8 cells, decreased immune activation, and enhanced responsiveness to vaccines –3. EffecUnfortunately, not all patients are able to maintain VL suppression on HAART. In the US, approximately 40 % of HIV-infected persons have a suppressed VL . Recent Sustained VL suppression is essential to achieve the best possible treatment outcomes. Because a significant proportion of patients do not achieve this goal, we examined factors associated with ≥10 years of VL suppression in the US Military HIV Natural History Study (NHS). We hypothesize that both patient and treatment-related factors will be associated with long-term VL suppression, and analyses included medication adherence and characteristics of the early HAART era such as prior therapy with single or dual agents. Longitudinal treatment outcomes spanning the entire HAART era were also analyzed to evaluate CD4 trajectories and development of new AIDS events during long-term HAART.The NHS is a large prospective multicenter cohort of HIV-infected individuals. The study population is comprised of active duty military, retired military, and their beneficiaries from the Army, Navy/Marines, and Air Force. Participants are evaluated approximately every 6–12 months at military treatment facilities throughout the United States. Data between study visits are systematically collected, including demographic characteristics, laboratory data, information on medication use, and reports of clinical events with medical record confirmation. The NHS has been enrolling since 1986 and consists of more than 5800 participants. Self-reported adherence (SRA) data has been systematically collected since 2006. All participants provided informed written consent and this study protocol was approved by the Uniformed Services University of the Health Sciences central IRB.NHS participants initiating HAART on or after January 1, 1996 with ≥10 years of continuous treatment were included. Participants were required to have ≥1 VL and CD4 count determinations per year during follow-up, with data collected through December 31, 2013. Treatment interruptions <6 months in duration were permitted. HAART was defined as two or more nucleoside reverse transcriptase inhibitors (NRTIs) in combination with at least one protease inhibitor (PI), one nonnucleoside reverse transcriptase inhibitor (NNRTI), or one integrase strand transfer inhibitor (INSTI). Regimens comprised of one NRTI with at least one PI and one NNRTI or an abacavir or tenofovir containing regimen of 3 or more NRTIs in the absence of both PIs and NNRTIs were also considered HAART. Non-HAART antiretroviral (ARV) use was defined as treatment not meeting HAART criteria above and typically consisted of mono- or dual-therapy prior to the availability of HAART. The total number of HAART regimens, defined as changes to any or all ARV components, were also captured during the study period.VL suppression was defined as achieving a VL ≤400 copies/mL within the first year of HAART. Virologic failure was defined as not achieving suppression or two consecutive VL determinations ≥400 copies/mL after initial suppression. The threshold of 400 copies/mL was chosen in order to compare outcomes during the entire HAART era given the differences in VL assay detection limits over time. Participants were divided into two separate groups for analysis. The continuous VL suppression (CS) group was defined as those with all VL values ≤400 copies/mL for ≥10 years. The non-continuous VL suppression (NCS) group was defined as having 1 or more episodes of virologic failure during the study period. Since more sensitive VL assays with limits of detection <50 copies/mL became clinically available during the later HAART era, we also analyzed the proportion with VL suppression <50 copies/mL in both groups. CD4 count trajectories and development of AIDS events after HAART initiation were also analyzed. SRA data was obtained via voluntary participant questionnaire with adherence defined by the overall percentage of HAART doses taken in the prior 6 months.Cohort demographics and other characteristics associated with HIV were described separately for participants in the CS and NCS groups. For continuous variables, t-tests were used for normally distributed variables or by Wilcoxon tests when appropriate. For categorical variables, chi-squared tests or Fisher’s exact tests were used. From the clinically relevant baseline characteristics, logistic regression was used to analyze the impact of factors on continuous VL suppression during 10 years of HAART. SRA data was calculated as the average and minimum percent adherence and evaluated by t-tests. Adherence was also evaluated as a categorical variable (report of 100 % adherence yes/no) and analyzed by chi-squared test.Mixed effects models were used to analyze the factors associated with longitudinal CD4 cell reconstitution. The square root of the CD4 count was used to normalize the data. An interaction term between the years from HAART initiation to VL suppression was used to quantify the difference in the rate of CD4 cell increase between groups. From this data subset, a locally-weighted scatter plot smoothing (LOWESS) was created to visualize trends in CD4 cell reconstitution over 10 years on HAART.p = 0.065). A greater proportion of NCS participants (90 %) were treated in the early HAART era (1996–1999) compared with the CS group . The median CD4 count at first HAART was higher in the CS compared with the NCS group  and the median VL at first HAART was 4.4 log10 copies/mL and 4.5 log10 copies/mL, respectively (p = 0.048). First HAART regimens differed among the groups (p < 0.001), with NCS having a higher proportion of unboosted PI use compared with CS participants (76 % vs 51 %). AIDS outcomes prior to first HAART were similar for CS (8 %) and NCS participants . During longitudinal follow-up, groups had a median of 1 treatment interruption , with a higher proportion of any treatment interruption observed in NCS (57 %) compared to CS (17 %) participants (p < 0.001). NCS participants also had a greater median number of HAART regimens (7 [p < .001) and a higher proportion of new AIDS events by 10 years of HAART  compared with CS participants. In a subgroup analysis of participants with VL data using assays with a limit of detection <50 copies/mL during HAART, the proportion with a suppressed VL <50 copies/mL was higher in the CS group  compared to the NCS group .A total of 276 participants met the inclusion criteria Table . Particiicipants 0 % were p = 0.341). A similar proportion of participants reported always having 100 % adherence in the CS (26 %) and NCS  groups.SRA was high in both groups Fig. , with anp = 0.984, Table p < 0.001) and log10 VL at first HAART  were both negatively associated with ≥10 years of VL suppression. A negative trend for long-term VL suppression was observed for African Americans compared with Caucasians, but this association was marginal . No association was observed for the time from HIV diagnosis to first HAART, CD4 count at first HAART, or type of first HAART regimen. For factors after initiation of first HAART, the total number of HAART regimens used during the study period was negatively associated with long-term VL suppression  due to virologic failures, while no association was observed for SRA .Analysis of demographic factors showed no association between age at first HAART and VL suppression for ≥10 years , longer time from HIV diagnosis to first HAART , and higher log10 VL at first HAART  and marginal rate of increase in √CD4 during follow-up , whereas no association was observed for demographic factors and SRA.Longitudinal CD4 cell trends during the first 10 years of HAART showed that the CS group had a greater upward trajectory of CD4 cell gains compared with the NCS group Fig. . AnalysiOver the past 20 years, the availability of HAART has effectively transformed HIV from a uniformly fatal condition to that of a chronic disease. Contemporary treatment is associated with improved life expectancy, with one study finding no elevated mortality risk in patients with CD4 counts above 500 cells/uL who maintained VL suppression . Since lThe inability of many patients to maintain VL suppression can be explained in part by the era in which participants began HAART. A previous study in our cohort reported VL suppression during the early HAART era (1996–2000) compared to the late HAART era (2000–2007), with 58 and 85 % VL suppression at 5 years for those treated in the early versus late HAART era, respectively . SimilarThe use of ARVs prior to HAART, typically mono- or dual-therapy, is an important characteristic of the early HAART era. We observed that ARV use prior to HAART negatively impacted both the ability to achieve long-term VL suppression and the magnitude of CD4 cell gains during HAART. Although non-HAART ARV use was likely a major reason for suboptimal treatment outcomes, other features of the early HAART era other factors likely contributed to the lower rate of treatment success during that period. For example, the early HAART era is also characterized by less potent, unboosted PI regimens, which were more commonly used for first HAART in the NCS group, and other HAART regimens associated with greater adverse effects and reduced tolerability compared to more contemporary regimens , 20. In Advanced HIV disease, as evidenced by low CD4 cell count and AIDS events, is associated with lower rates of VL suppression on HAART , 23, 24.Suboptimal treatment outcomes involve both clinical and non-clinical factors. For example, access and engagement in care have been identified as key areas along the HIV care continuum . Some ofDiscordant HIV treatment outcomes have been observed in different racial/ethnic groups. A study of non-white participants found a VL suppression rate of 31 % compared to 54 % in white participants at 7–14 months in an urban setting . Non-whiAdherence is a cornerstone of successful HIV treatment. We found no difference in those reporting 100 % SRA in CS and NCS participants and the overall adherence was 98 % or greater in both groups. This high degree of SRA may be somewhat explained by free access to care and medications, or possibly by other characteristics of our population such as level of education, socioeconomic status, or very low rate of injection drug use . Other eThe strengths of this study include long-term follow-up spanning the entire HAART era in a diverse cohort of patients with free access to care and medications. Limitations included the inability to assess adherence in the early HAART era since SRA data was not systematically captured until 2006. The high level of SRA in our study likely limited the ability to detect an association between adherence and VL suppression, since >95 % adherence is associated with optimal and sustained VL suppression . HoweverSustained VL suppression is essential to reduce long-term morbidity in HIV-infected patients, as demonstrated by the lower proportion of AIDS events and improved CD4 cell reconstitution after ≥10 years of continuous VL suppression. We identified factors negatively associated with ≥10 years of VL suppression, including high VL at first HAART, prior ARV use, HIV diagnosis in the pre-HAART era, and number of HAART regimens used. It is likely that treatment in the current era, characterized by regimens that are more potent, more convenient, and less toxic, may promote higher success rates and more durable VL suppression in the future.AIDS, acquired immune deficiency syndrome; ARV, antiretroviral therapy; CS, continuous viral load suppression; HAART, highly active antiretroviral therapy; HIV, human immunodeficiency virus; INSTI, integrase strand transfer inhibitor; LOWESS, locally-weighted scatter plot smoothing; NCS, non-continuous viral load suppression; NHS, natural history study; NNRTI, non-nucleoside reverse transcriptase inhibitor; NRTI, nucleoside reverse transcriptase inhibitors; PI, protease inhibitor; SRA, self-reported adherence; VL, viral load


Worldwide, chronic infection with HBV and HDV occurs in more than 10 million people with higher rates of developing cirrhosis, hepatic decompensation and hepatocellular carcinoma. Peginterferon (pegIFN) for 48 weeks is one of the current therapies, with poor response rates; prolonging therapy beyond 12 months might be of benefit for the patients.In order to assess the response to a prolonged pegIFN therapy, we present 2 patients with chronic B/D coinfection, treated with pegIFN alpha 2a, 180 mcg weekly for 96 weeks and monitored, at least, every three months with a complete medical evaluation.Patient 1: Female age 30, diagnosed at age 19 with chronic B/D coinfection; treated the first year with oral azathioprine for 12 weeks, then one week every three months; the second year she started interferon alpha 2a for 48 weeks, achieving biochemical and virologic response. At age 23, she became pregnant, gave birth to a healthy baby girl with no viral infection; after pregnancy, she had an ALT 10 times the upper normal limit, HBV-DNA 1,000,000 IU/mL. For two years, she received support therapy: ursodeoxycholic acid, vitamins, silymarin until we decided to start peginterferon alpha 2a 180 mcg weekly for 48 weeks. Well tolerated, we obtained undetectable HBsAg, HBV-DNA and HDV-RNA in the serum and normal ALT. For a sustained response, we decided to continue this treatment for another 48 weeks. Until present she maintained undetectable HBsAg, HBV-DNA and HDV-RNA; anti HBs < 2.00 (limits 2-10 IU/L), anti-HBe: 0.012 COI (reactive).Patient 2: Male, 40 years old, diagnosed at age 36 with chronic B/D coinfection; we started standard peginterferon alpha 2a therapy for 48 weeks; with a major side-effect: Hashimoto thyroiditis in month 3, successfully resolved. We continued the treatment, then – also based on a second-opinion from a French hospital – we indicated another 48 weeks of treatment that resulted in sustained biochemical and virologic response with viral eradication, until present.A long-term peginterferon therapy could be a chance for cure in patients coinfected with HBV/HDV, with permanent and rigorous monitoring and medical evaluation. This approach needs further studies, for the benefit of patients, considering the higher rates of mortality among them.


In previous studies, protease inhibitor (PI) monotherapy has shown trends for higher low-level elevations in HIV-1 RNA compared to triple therapy, but no increase in the risk of drug resistance.n=137) or with 2NRTIs (nucleoside reverse-transcriptase inhibitors) (n=136), after a 4 week run-in phase with DRV/r + 2NRTI. Treatment failure was defined as HIV-1 RNA levels above 50 copies/mL (FDA Snapshot method) by Week 48, or switches off study treatment. Patients with elevations in HIV-1 RNA on DRV/r monotherapy could be re-intensified with NRTIs. The trial had 80% power to show non-inferiority for the monotherapy arm (delta = − 12%).A total of 273 patients with HIV-1 RNA <50 copies/mL for over 24 weeks on current antiretrovirals switched to DRV/r (darunavir/ritonavir) 800/100 mg once-daily, either as monotherapy . In the primary efficacy analysis, HIV-1 RNA <50 copies/mL by Week 48 (intent-to-treat (ITT)) was 118/137 (86.1%) in the DRV/r monotherapy arm versus 129/136 (94.9%) in the triple therapy arm; DRV/r monotherapy did not show non-inferiority versus triple therapy in the primary analysis . In the multivariate analysis, the main predictor of treatment failure was nadir CD4 count. For patients with nadir CD4 counts <200 cells/µL, HIV-1 RNA suppression rates at Week 48 were 27/41 (66%) in the DRV/r monotherapy arm and 29/30 (97%) in the triple therapy arm; for patients with CD4 nadir at least 200 cells/µL, HIV-1 RNA suppression rates were 91/96 (95%) in the DRV/r monotherapy arm and 100/106 (94%) in the triple therapy arm. In the overall population, by a switch included analysis, efficacy was 92.0% versus 96.3%, showing non-inferiority . No treatment-emergent primary PI mutations were detected in three patients with sustained elevations in HIV-1 RNA at least 400 copies/mL . CD4 counts remained stable during the trial in both arms.In this study for patients with HIV-1 RNA < 50 copies/mL at baseline, switching to DRV/r monotherapy showed lower efficacy versus triple antiretroviral therapy at Week 48 in the primary switch equals failure analysis (86% versus 95%). However, this lower efficacy was seen mainly in patients with CD4 nadir levels below 200 cells/µL. There was no development of PI resistance.


Although injection drug use drives antiretroviral drug resistance, the prevalence of protease inhibitor (PI) resistance among Kenyan IDUs remains undetermined. We, therefore, explored PI resistance mutations and their association with viral load and CD4+ T cell counts in HIV-1 infected IDUs  and non-drug users  naive for PI treatment from coastal Kenya.P < 0.05).Only IDUs harboured major PI resistance mutations consisting of L90M, M46I and D30 N among 3 (6.4 %) ART-experienced and 1 (3.1 %) -naive individuals. Minor PI mutations including A71T, G48E, G48R, I13V, K20I, K20R, L10I, L10V, L33F, L63P, T74S, V11I, and V32L were detected among the ART-experienced (36.2 vs. 46.9 %) and -naive (43.8 vs. 66.7 %) IDUs and non-drug users, respectively. All the four IDUs possessing major mutations had high viral load while three presented with CD4+ T cell counts of <500 cells/ml. Among the ART-naive non-drug users, CD4+ T cell counts were significantly lower in carriers of minor mutations compared to non-carriers (Transmitted drug resistance may occur in IDUs underscoring the need for genotyping resistance before initiating PI treatment. Despite up-scaling of antiretroviral drugs for treatment and prevention, HIV-1 remains an important cause of infectious disease burden in the world. In the year 2013, an estimated 35 million people globally were infected with HIV of whom 24.7 million reside in Sub-Saharan Africa . As suchThe current standard regimen for first-line HIV treatment in Kenya consists of two nucleoside reverse transcriptase inhibitors (NRTI) mainly tenofovir disoproxil fumarate (TDF) or azidovudine (AZT), lamuvudine (3TC) and one non-nucleoside reverse transcriptase inhibitor (NNRTI) efevirenz (EFV) or nevirapine (NVP) . ProteasSeveral studies across Kenya show widespread resistance to NRTIs and non-NNRTIs in ART-naive and -experienced adults and children, breastfeeding infants and IDUs –31. MoreThis cross-sectional study was conducted in HIV-1 infected IDUs and non-drug using controls at Bomu Hospital, a social enterprise facility in Mombasa City, coastal Kenya. Injection drug users were recruited via respondent-driven, snowball and makeshift-outreach sampling methods. In the context of the current study, IDUs comprised of individuals exhibiting injection needle-stick scars and reporting a history of injecting any illicit drug classified by UNODC at least once in the previous month . Those y® 903 cards  for preparing dry blood spots (DBS) that were stored at −20 °C until used for pro-viral DNA extraction. For enumerating CD4+ T cell counts, 5.0 μl of blood were stained with CD3/CD4/CD45 monoclonal antibody reagent (BD Tritest) and analysed on BD FACSCalibur™ according to the manufacturer’s protocols. HIV-1 viral load was determined in 0.2 ml plasma samples using the Abbott Molecular m2000sp sample preparation and m2000rt real-time amplification and detection systems  according to the manufacturer’s methods.In brief, about, 3.0 ml venous blood was collected from study participants in ethylenediaminetetraacetic acid vacutainer tubes  and used for enumerating CD4+ T cells, and plasma harvesting for HIV-1 viral load quantification. A drop of whole blood was applied on Whatman-FTA2, 1 U/µL Taq polymerase (KemTaq®), 200 µM of each dNTP , and 0.5 µM of each first or second round primers. Amplification consisted of initial denaturation at 94 °C for 4 min, followed by 40 cycles of 94 °C for 15 s, 50 °C for 30 s, and 72 °C for 1 min, with a final extension of 72 °C for 5 min. PCR products were electrophoresed in 1 % ethidium bromide-stained agarose gel, and visualized under ultraviolet light. PCR product sizes of approximately 330 bp were diagnostic for HIV-1 pro-viral DNA.HIV-1 pro-viral DNA was extracted from DBS using QIAamp™ DNA blood mini kit  according to the manufacturer’s recommendations. HIV-1 pro-viral DNA encoding protease gene was amplified by nested PCR with primers; Nyupol_7 (5′-GGGAATTTTCTTCAGAGCAG-3′) HXB2 nucleotide position 2125–2144, and Nyupol_8 (5′-TCTTCTGTCAATGGCCATTGT-3′) HXB2 nucleotide position 2635–2615 in the first round. Nyupol_9 (5′-TCCTTAACTTCCCTCAAATCACT-3′) HXB2 nucleotide position 2241–2264 and Nyupol_10 (5′-CTGGCACGGTTTCAATAG GACT-3′) HXB2 nucleotide position 2577–2556 were used in the second round. First and second round PCR was conducted in a 25 µl volume containing 5 µL DNA, 1× PCR buffer, 1.5 mM MgCl®, Foster City, USA) on an ABI PRISM® 3100 Genetic Analyzer  as per the manufacturer’s protocols. Primer pair Nyupol_9 and Nyupol_10 was used for forward and reverse sequencing reactions, respectively. Forward and reverse chromatograms were visually inspected and edited for base mis-calls using MEGA version 6.0 [http://www.DnaBaser.com). Protease inhibitor drug resistance mutations were identified and interpreted using Stanford web-based HIV drug resistance database [PCR amplicons were purified with QIAquick™ PCR purification kit  according to the manufacturer’s protocol. Direct sequencing was performed using BigDye™ sequencing chemistry . Age and CD4+ T cell counts and viral load were compared across study groups using Kruskal–Wallis test and Dunn’s post hoc correction for multiple comparisons. Differences in distribution of gender were compared across the study groups using Chi-square test. Rates of resistance mutations in each study group were summarised as numbers and proportions. Statistical significance was set at P < 0.05.Data analysis was conducted using IBMThis study was conducted following ethical approval obtained from Kenyatta University Ethical Review Committee, approval number PKU019/116 of 2012 in accordance with Helsinki declaration . WrittenP = 0.531). Age was significantly different across the groups (P = 0.009) with ART-naive IDUs  having younger individuals relative to ART-naive non-drug users . In addition, 20 (42.5 %), 24 (51.1 %) and 3 (6.4 %) ART-experienced IDUs while 3 (9.3 %), 7 (21.9 %) and 22 (68.8 %) ART-experienced non-drug users were on antiretroviral therapy for <1, 1–3, and >3 years, respectively. The CD4+ T cell counts were similar across the study groups (P = 0.379). The HIV-1 viral load was significantly different across the study groups (P = 0.004) with ART-naive  and -experienced  IDUs presenting with lower levels compared to ART-naive non-drug users .Baseline characteristics of the study participants are presented in Table Major and minor HIV-1 protease drug resistance mutations detected in the study participants are shown in Table In non-drug users, 15 (46.9 %) ART-experienced individuals had minor mutations consisting of 5 (15.6 %) K20R, 2 (6.3 %) L10V, 2 (6.3 %) L33F, 1 (3.1 %) I13V + L63P, 1 (3.1 %) L10V + K20R, 3 (9.4 %) L10V + T74S and 1 (3.1 %) L33F + A71T. In addition, 14 (66.7 %) ART-naive non-drug users harboured minor mutations comprising of 1 (7.1 %) K20I, 8 (38.1 %) K20R, 2 (9.5 %) L10I, 1 (7.1 %) L101 + K20R, and 2 (9.5 %) L10V + V11I.P > 0.05), but among ART-naive non-drug users, CD4+ T cell counts were significantly lower in carriers of minor mutations compared to non-carriers .Viral load and CD4+ T cell counts of individuals with major and minor mutations are presented in Tables Effective use of protease inhibitors in HIV-1 treatment and prevention is largely impeded by the increasing development and spread of acquired and transmitted resistance . AntiretIn the current study, major PI mutations were detected only in IDUs with the antiretroviral treatment-experienced  individuals having higher rates than -naive (D30N) individuals. Most importantly, major mutations, D30N and M46I co-existed with minor mutations, G48E, K20I and T74S, suggesting that these mutations mediate evolution of major drug resistance . Our finOverall, higher rates of minor mutations were found in IDUs relative to non-drug users, suggesting heterogeneity of HIV-1 strains in IDUs. The detection of A71T, G48E/R, I13V, K20I/R, L10I/V, L33F, L63P, T74S, V11I, and V32L minor mutations in this study is, in part, consistent with previous studies that reported K20R, L10I/V, L33F/I, and L63P minor mutations among HIV-positive women attending antenatal clinics in a large HIV treatment study in western Kenya . HoweverThe high viral load among individuals carrying major PI mutations is consistent with phenotypic and clinical studies showing absence or low virologic response in patients having these major mutations . It is ienv [While a prospective design would have been important in examining the emergence of PI resistance in treatment-naive and -experienced IDUs, this cross-sectional study provides the first baseline evidence of occurrence of PI resistance in IDUs from Kenya. Although specific antiretroviral regimens used by the ART-experienced individuals were not evaluated in this study, poor adherence to ART by injection drug users, generate sub-optimal antiretroviral drug levels that exert selective pressure on the viral genome leading to resistance . Since ienv  that conProtease inhibitor transmitted drug resistance is likely to occur among Kenyan IDUs. Therefore, performing HIV-1 drug resistance analyses prior to initiating PI treatment in HIV patients from high-risk population groups is critical in achieving better treatment outcomes and prolonging the effectiveness of these drugs in the country.The 125 sequences described in this study were submitted to the GenBank under accession numbers: KP791995, KP791996, KP791997, KP791998, KP791999, KP792000, KP792001, KP792002, KP792003, KP792004, KP792005, KP792006, KP792007, KP792008, KP792009, KP792010, KP792011, KP792012, KP792013, KP792014, KP792015, KP792016, KP792017, KP792018, KP792019, KP792020, KP792021, KP792022, KP792023, KP792024, KP792025, KP792026, KP792027, KP792028, KP792029, KP792030, KP792031, KP792032, KP792033, KP792034, KP792035, KP792036, KP792037, KP792038, KP792039, KP792040, KP792041, KP792042, KP792043, KP792044, KP792045, KP792046, KP792047, KP792048, KP792049, KP792050, KP792051, KP792052, KP792053, KP792054, KP792055, KP792056, KP792057, KP792058, KP792059, KP792060, KP792061, KP792062, KP792063, KP792064, KP792065, KP792066, KP792067, KP792068, KP792069, KP792070, KP792071, KP792072, KP792073, KP792074, KP792075, KP792076, KP792077, KP792078, KP792079, KP792080, KP792081, KP792082, KP792083, KP792084, KP792085, KP792086, KP792087, KP792088, KP792089, KP792090, KP792091, KP792092, KP792093, KP792094, KP792095, KP792096, KP792097, KP792098, KP792099, KP792100, KP792101, KP792102, KP792103, KP792104, KP792105, KP792106, KP792107, KP792108, KP792109, KP792110, KP792111, KP792112, KP792113, KP792114, KP792115, KP792116, KP792117, KP792118, KP792119, KT033003, KT033004, KT033005, KT033006, KT033007, KT033008, and KT033009.


Where available, antiretrovirals (ARVs) and antenatal HIV testing and care have significantly reduced mother to child transmission (MTCT). Higher maternal viral load (VL) is linked with higher risk of MTCT, increasing risk of MTCT for women starting ARVs during pregnancy compared to those already suppressed.A single-centre, retrospective cohort of women starting ARVs during pregnancy from 2004 till 2013. Demographic, obstetric and virological data, and neonatal outcomes were collected where available.60 pregnancies were recorded (in 56 women) in which ARVs were started or restarted from a total of 129 recorded pregnancies. 48% (27/56) were new antenatal HIV diagnoses and in these median gestational age (GA) at diagnosis was 16.1 weeks (range 5.3-37.6). Median GA at ARV commencement was 22.4 weeks (range 8-37.7) with 63% (35/56) starting before 24 weeks and 91% (51/56) before 28 weeks. HIV diagnosis during pregnancy was associated with a later commencement of ARVs . The ARV regimen was available for 58 pregnancies. Treatment was with two NRTIs plus NNRTI (3), or PI (54) or raltegravir (1). Raltegravir was added as a forth agent in 7 patients.87% (52/60) had resistance genotyping before (14) or during (38) pregnancy, 81% (22/27) for new diagnoses in pregnancy. The rate of any ARV resistance was 12% (6/52): 4 patients had NNRTI and 2 NRTI resistance mutations, 4 were treatment-naïve. This was not associated with treatment failure.HIV VL at delivery was available in 57 pregnancies with detectable VL in 16% (9/57). Pre-treatment VL >100,000 copies/mL during pregnancy was associated with higher risk of detectable VL at delivery (p=0.016). 69% babies were delivered by Caesarean section, 32% as an emergency. There was one late miscarriage at 17 weeks. Median GA at birth was 38 weeks (range 17-42) with 21% born at <37 weeks (10/48). There was one HIV MTCT  in a woman who was poorly adherent with ARVs throughout pregnancy with a VL of 216 copies/mL at delivery following a period of directly observed therapy.Over 10 years of integrated HIV and antenatal care, there was only one case of MTCT. Initiating ART for prevention of MTCT is complex, requires a multi-disciplinary approach and importantly patient engagement. Antenatal practices and guidelines have changed over the period of this dataset, allowing normalisation of pregnancy when HIV is diagnosed and treated early.


The outcomes from an antiretroviral treatment (ART) program within the public sector in Myanmar have not been reported. This study documents retention and the risk factors for attrition in a large ART public health program in Myanmar.A retrospective analysis of a cohort of adult patients enrolled in the Integrated HIV Care (IHC) Program between June 2005 and October 2011 and followed up until April 2012 is presented. The primary outcome was attrition (death or loss-follow up); a total of 10,223 patients were included in the 5-year cumulative survival analysis. Overall 5,718 patients were analyzed for the risk factors for attrition using both logistic regression and flexible parametric survival models.The mean age was 36 years, 61% of patients were male, and the median follow up was 13.7 months. Overall 8,564 (84%) patients were retained in ART program: 750 (7%) were lost to follow-up and 909 (9%) died. During the 3 years follow-up, 1,542 attritions occurred over 17,524 person years at risk, giving an incidence density of 8.8% per year. The retention rates of participants at 12, 24, 36, 48 and 60 months were 86, 82, 80, 77 and 74% respectively. In multivariate analysis, being male, having high WHO staging, a low CD4 count, being anaemic or having low BMI at baseline were independent risk factors for attrition; tuberculosis (TB) treatment at ART initiation, a prior ART course before program enrollment and literacy were predictors for retention in the program.High retention rate of IHC program was documented within the public sector in Myanmar. Early diagnosis of HIV, nutritional support, proper investigation and treatment for patients with low CD4 counts and for those presenting with anaemia are crucial issues towards improvement of HIV program outcomes in resource-limited settings. Myanmar has a concentrated HIV epidemic and the global HIV prevalence in adults has been estimated at 0.53% in a recent modelling study There has been a very significant increase in the number of patients receiving ART worldwide, and by the end of 2011, it had reached 20 times the 2003 levels As antiretroviral treatment becomes more readily available Determinants of treatment outcomes have been documented within the private sector in an ART cohort administered by Médecins Sans Frontières (MSF)-Holland in Myanmar; in this study the reported retention in care at 60 months reached 72% [95% CI: 70–74] Oral inform consent was obtained from all patients enrolled in the cohort; written informed consent was not collected as it was inadvisable to collect written documentation during the time of the military regime in Myanmar. The oral consent was obtained by marking a tick-box on the patient case form at enrollment after full discussion with a trained peer counselor, and kept in the patient's file. The protocol was approved by the Ethical Advisory Group (EAG) committee of the International Union Against Tuberculosis and Lung Disease (hereafter “The Union”) (EAG number 4/14). All data were treated confidentially and stored as anonymized data. Biological assays were performed as part of routine follow up and all tests results were anonymized.The Union has been implementing an Integrated HIV Care (IHC) program within the public sector in collaboration with the Department of Health, the National TB Program (NTP) and the National AIDS Program (NAP) since 2005. Initially, it was implemented at a single ART clinic in Mandalay. From that starting point, there was a steady expansion of the program so that by mid-2013, more than 15,000 patients were receiving ART in a total of 14 ART centers and 12 ART decentralized sites in 6 regions. The entry points for enrollment in this IHC program include TB clinics, pre-ART clinics run by the NAP, antenatal clinics, and hospitals located in the project area. The IHC program also accepts patients referred from other ART programs. There are no geographical limitations for enrollment in the IHC program (i.e. patients from the entire country have access to the program).After enrolment, patients went through a standardized process including registration , baseline clinical assessment and laboratory testing, confirmation of eligibility by a selection committee and ART adherence counseling before ART initiation. Once patients are “stabilized”, generally 6 to 12 months after ART initiation at district or tertiary hospitals, they are transferred out to the nearest decentralization sites for chronic HIV care. Staff of the Ministry of Health provides clinical care for ART initiation and follow- up. The Union provides support including additional human resources  comprehensive laboratory investigations , drug procurement and supply management, data entry, and program monitoring. Self-management support from the People Living with HIV and AIDS (PLHA) network are deployed in all ART sites and were actively involved in the triage and registration, adherence counseling, and defaulter tracing. They also play an important role in providing financial assistance and social support for patients in distress.The IHC program follows the national guideline for ART initiation, and uses AZT/3TC or D4T/3TC plus an NNRTI as first-line regimen, and protease inhibitor based regimens for second line treatment. In 2013, the national guidelines were updated to WHO recommendations and adopted TDF/3TC (FTC) as the preferred reverse transcriptase inhibitors. TB/HIV collaborative programs have been well established, and there is a cross-referral system between TB clinics and ART clinics for patients diagnosed at either of these sites. The enrolled patients also get support for necessary drugs for treatment of opportunistic infections (OI) and for required investigations if they are admitted to the hospital.We retrospectively analyzed a total of 10,413 patients who were enrolled in our program between June 2005 and October 2011 and were followed up until April 2012 when censoring for this analysis occurred. After removing patients with data inconsistencies a total of 10,223 patients were considered for the 5-year cumulative survival analysis. For the logistic regression and survival analyses, patients with missing covariate data (primarily CD4 at initiation) were removed, leaving a final total of 5,718 patients for estimation of risk factors for attrition . The demThe primary outcome of this study was attrition, which included death  and loss to follow-up (LTF). Loss to follow-up was defined as patients who did not return to clinic within three months from their last scheduled appointment and who could not be traced by the PLHA network. A system was in place to extract the patient cohort code if they failed to come to the clinic and to allow the PLHA network to trace the patients back within two weeks. A small number of patients have been classified as LTF after referral to non-IHC ART clinics, as we are unable to investigate the continuum of care for these patients. The primary survival outcome was defined as those patients who were both alive and still in active follow-up at the end of April 2012. Survival time was measured from date of enrollment to date of death, last recorded clinical visit, or study censoring date.Routine patient medical data are recorded on paper forms by attending clinicians and Union staff. These forms are computerized in a password-protected database. All patient information was entered into the database using a unique coding system and the database is accessible only to data team members. We will make freely available any materials and data described in this publication that may be reasonably requested for the purpose of academic, non-commercial research.In this analysis, the models for attrition utilized recommendations for low-income settings which include CD4 count at baseline, sex, age, ART regimen (NNRTI vs. PI-based) and clinical stage (WHO stage I/II vs. III/IV) as independent predictors 3 for HIV to AIDS progression We included in the multivariate models all variables associated with attrition from the univariate analysis (at p<0.20 level). Age was grouped as 18–30, 31–40, 41–50 and 51–60+ years; baseline CD4 cell count was dichotomized using the standard clinical cut-off of 100 cells per mmFor both analyses the predictors examined were: patient characteristics , and baseline clinical and laboratory markers , prior OIs, and TB, hepatitis B and C serological status).Proportion surviving was calculated using Kaplan-Meir methods; preliminary survival models used Cox proportional hazard methods. Due to extensive proportional hazard violations in multiple variables , Royston-Parmer flexible parametric survival models were used Data management, exploratory data analyses and logistic regressions models were fit using the software R 2.15; survival analyses were performed using Stata 12.1, ; all tests were two-tailed with α = 0.95.A comprehensive sensitivity analysis of the missing variables was performed and complete case analysis was performed for estimation of risk factors for attrition. The characteristics of the omitted and complete cases were similar with the exception of two variables- those with missing data were more likely to have a history of ART and less likely to have tuberculosis at baseline. As such, we are unable to assume the data are missing completely at random, which may introduce some bias in the estimates.Our sensitivity analyses had two components. The first used simulated data, whereby data were randomly generated for missing values to assess the potential impact of ‘worst-case’ scenarios. The simulated data for each missing variable was assigned to one category and then used to compute adjusted odds ratios; this process was then repeated, and re-run with the opposite . The resulting sets of adjusted odds ratios were then compared.To complement this analysis, the univariate odds ratios for the primary outcome were also compared between full case data and those with missing data (table S2 in The mean (±SD) for age was 36 (±8) years, and 61% of patients were male among a total of 10,413 patients. The demographic characteristics of study population at baseline such as age, sex, literacy, use of alcohol and HIV risk factors are shown in The cumulative outcomes were death 909 (9%), loss to follow up 750 (7%) and in active follow up 8,564 (84%) for the cohort used for survival analysis  with the median follow up duration of 13.7 months (interquartile range [IQR] 5.5–28.7). The corresponding retention rates and 95% CI of participants were 12 months ; 24 months ; 36 months ; 48 months ; 60 months  .Among 10,223 patients, 1,542 attrition [death or LTF] events occurred over 17,524 person-years at risk, with an annual incidence density of 8.8% (95% CI: 8.4–9.3) in our study. In comparison, 1,061 attrition [death or LTF] events occurred among 5,963 patients over 14,854 person years at risk with an incident density of 7.0% (95% CI: 6.7 to 7.6) per year in the private setting Two complementary analyses were performed to investigate risk factors for attrition. The risk factors identified in logistic regression analysis are shown in 2 ; CD4 less than 100 cells/µl at baseline ; anaemia at baseline  and protease inhibitor based regimen .After adjustment in a multivariate model, the significant factors identified were male sex ; illiteracy ; prior history of ART ; WHO stage III or IV at baseline ; BMI<18.5 kg/mIn the adjusted multivariate flexible parametric model, the independent risk factors for attrition were: BMI<18.5 ; WHO stage III or IV at baseline ; anaemia at baseline , and baseline CD4 count <100 cells/µl .Two factors showed marginally significant increased hazard: Cotrimoxazole treatment at baseline , and male gender .Several factors showed a protective effect: previous ART at baseline , literacy  and TB treatment at baseline  .The comparison of baseline demographics between full-data cases and those with missing data are presented in table S1 in The comparison of the univariate odds ratios between cases with full data and those with missing values , to maximize the comparability to studies in similar settings that have appeared in the literature. While this has the potential for introducing biases if the nature of missing data has an influence on the primary outcome, the multiple sets of complementary sensitivity analyses we have performed suggest these effects are likely small. Moreover, the demographics  of the patients with missing data are remarkably similar to the included patients, with two exceptions. A higher proportion of patients with missing data have history of prior ART, while a lower proportion have TB treatment at ART initiation. The broad agreement of our results with prior studies suggests that any biases in our data analysis are likely minor.Many factors have been linked to attrition in various settings, including the type of ART regimen at initiation Our findings are similar to the results of the MSF cohort analysis. In The MSF cohort, high WHO staging, low BMI, male sex and age were found to be independent risk factors for attrition. Our study did not find a strong impact of age, but also identified that a low CD4 count and anaemia were risk factors for attrition; conversely, TB treatment at ART initiation, ART history and literacy were found to be predictors for the retention in care. The observed differences are likely to be due to differences in program structure, and potentially to some differences between the study populations.One of the main risk factors for attrition is low CD4 count at enrollment; this is a common feature which has been found in many other cohort studies However, pooled data from 13 research cohorts from five sub-Saharan African  and two Asian (Cambodia and Laos) countries reported a lower survival not only in those patients with low CD4 but also for patients with a high CD4 count Several studies exploring HIV attrition found independent associations between attrition and low BMI Although the association is weak, male gender is an independent risk factor for attrition. This is in line with the results from other studies In contrast to a report from Thailand A review of 18 cohorts in Europe and North America concluded that patients on protease inhibitor had higher probability of treatment interruption or modification; this review also highlighted that those patients receiving tenofovir/emtricitabine based regimens had lower probability of treatment substitutions compared to non-standard regimens Like other resource-limited settings, IHC programs in Myanmar used d4T as the main NRTI (67%) followed by AZT (31.2%) and TDF (2.3%) for ART initiation. A recent study from South Africa evaluated the effectiveness of TDF and reported that the adjusted hazard ratio for loss-from-care, when compared to TDF, was 1.5 (95% CI: 1.1–1.9) for d4T and 1.2 (95% CI: 1.1–1.4) for AZT The protective factors for attrition include the administration of a TB treatment at ART initiation and a prior ART history ; the betA cluster randomized control trial in Vietnam reported that there was no significant difference in mortality rate between groups who received enhanced adherence versus a control groups without intervention The modifiable risk factors for attrition we found could motivate attending clinicians to provide more comprehensive care to achieve both increased individual benefit and greater impact at the population level.We found that the attrition remains quite low (3%) in the initial decentralized sites. Patients might have less constraint to come to these sites and better efforts might have been allocated to “stabilize” these patients (including the treatment of co-morbidities) before the transfer.One of the main strengths of this study is the sample size, which allowed us to investigate the retention in care and the risk factors for attrition in a large cohort of patients followed in the public sector in Myanmar. However, there are also some limitations. First, it should be acknowledged that a significant number of patients with missing data were excluded from the analysis, potentially introducing bias. Secondly, the study assessed a limited number of socio-demographic factors; we were not able to include in our analysis other important parameters such as the distance between the patients’ residence and the service delivery point Our study, conducted in a resource-limited setting, provides evidence about the quality and the effectiveness of a large ART program from the public sector in Myanmar. It also advocate for the feasibility of the long-term retention of a large cohort of patients on ART within an Integrated HIV Care program in Myanmar. Our result suggests that key improvements for future programs are early diagnosis of HIV and initiation of ART, comprehensive nutritional support to increase BMI to normal levels, and targeting those patients with low CD4 count and/or haemoglobin for intensive investigation and clinical management. Finally, a comprehensive study of patients in second-line therapy settings would be an important next step in addressing these programs gaps.File S1Table S1. Baseline demographics between cases with full data and those with missing predictors . Table S2. Comparison of unadjusted OR for primary outcome between full data and missing case patients. Table S3. Comparison of full-case date and data with simulated outcomes to assess the potential impact of missing data.Contains Tables S1–S3. (DOCX)Click here for additional data file.


Standard-of-care antiretroviral therapy (ART) uses a combination of drugs deemed essential to minimise treatment failure and drug resistance. Protease inhibitors are potent, with a high genetic barrier to resistance, and have potential use as monotherapy after viral load suppression is achieved with combination treatment. We aimed to assess clinical risks and benefits of protease inhibitor monotherapy in long-term clinical use: in particular, the effect on drug resistance and future treatment options.In this pragmatic, parallel-group, randomised, controlled, open-label, non-inferiority trial, we enrolled adults (≥18 years of age) positive for HIV attending 43 public sector treatment centres in the UK who had suppressed viral load (<50 copies per mL) for at least 24 weeks on combination ART with no change in the previous 12 weeks and a CD4 count of more than 100 cells per μL. Participants were randomly allocated (1:1) to maintain ongoing triple therapy (OT) or to switch to a strategy of physician-selected ritonavir-boosted protease inhibitor monotherapy (PI-mono); we recommended ritonavir (100 mg)-boosted darunavir (800 mg) once daily or ritonavir (100 mg)-boosted lopinavir (400 mg) twice daily, with prompt return to combination treatment if viral load rebounded. All treatments were oral. Randomisation was with permuted blocks of varying size and stratified by centre and baseline ART; we used a computer-generated, sequentially numbered randomisation list. The primary outcome was loss of future drug options, defined as new intermediate-level or high-level resistance to one or more drugs to which the patient's virus was deemed sensitive at trial entry . We estimated probability of rebound and resistance with Kaplan-Meier analysis. Analyses were by intention to treat. This trial is registered with the International Standard Randomised Controlled Trial Number registry, number ISRCTN04857074.Between Nov 4, 2008, and July 28, 2010, we randomly allocated 587 participants to OT (291) or PI-mono (296). At 3 years, one or more future drug options had been lost in two participants (Kaplan-Meier estimate 0·7%) in the OT group and six (2·1%) in the PI-mono group: difference 1·4% (−0·4 to 3·4); non-inferiority shown. 49 (16·8%) participants in the OT group and 65 (22·0%) in the PI-mono group had grade 3 or 4 clinical adverse events ; 45 (six treatment related) and 56 (three treatment related) had serious adverse events.Protease inhibitor monotherapy, with regular viral load monitoring and prompt reintroduction of combination treatment for rebound, preserved future treatment options and did not change overall clinical outcomes or frequency of toxic effects. Protease inhibitor monotherapy is an acceptable alternative for long-term clinical management of HIV infection.National Institute for Health Research. Current HIV treatment guidelines recommend a combination of two drug classes for initiation and maintenance of antiretroviral therapy (ART).Protease inhibitors are potent, with a high genetic barrier to resistance, and are the only drugs that act at many steps of the HIV lifecycle, thus having potential for use alone as monotherapy.Evidence before this studyWe searched PubMed for reports published between Jan 1, 1998, and Jan 1, 2008, with no language restrictions, using terms including “protease inhibitors”, “monotherapy”, and the individual drug names, and reviewed relevant HIV conference abstracts to identify randomised controlled trials that compared protease inhibitor monotherapy with triple antiretroviral therapy (ART) in patients who had previously achieved viral load suppression. We identified three trials, all investigating lopinavir monotherapy, and, overall, these trials supported the hypothesis of virological non-inferiority of monotherapy to triple therapy. Since then, authors of a meta-analysis of ten trials noted an overall risk ratio of 0·94 for viral load suppression at 48 weeks with protease inhibitor monotherapy compared with triple ART, with, at most, a 13% increase in the absolute risk of virological failure with protease inhibitor monotherapy.Added value of this studyTo our knowledge, this trial is the largest and longest-duration protease inhibitor monotherapy trial done so far, with more than three times the randomly allocated person follow-up time of previous trials, and thus it provides more precise estimates of important but uncommon efficacy and safety outcomes than did previous trials. By contrast with previous studies that restricted the choice of drugs in both the monotherapy (single specified protease inhibitor) and combination ART  groups, this trial used a pragmatic design representative of routine clinical care, with flexibility of drug selection in both treatment groups. Also, whereas previous trials compared predefined regimens with short-term viral load endpoints, this trial compared treatment strategies with a primary efficacy endpoint (preservation of drug options) relevant to long-term clinical management. In this trial we noted an increase of about 32% in absolute risk of virological failure with protease inhibitor monotherapy (much greater than that previously reported), but all patients with rebound resuppressed spontaneously or with reintroduction of combination ART. Findings from this trial showed that the protease inhibitor monotherapy strategy was non-inferior to triple ART in preservation of future treatment options and did not change overall clinical outcomes or frequency of toxic effects.Implications of all the available evidenceProtease inhibitor monotherapy does not increase the risk of drug resistance and is an acceptable alternative for long-term clinical management of HIV infection. Clinical benefits, if any, seem slight, and some patients might need to switch back to combination ART. Nevertheless, this approach could appeal to patients who are stable on treatment but who wish to minimise their exposure to specific drugs or more than one drug class.We did a pragmatic randomised controlled trial comparing a protease inhibitor monotherapy treatment strategy with clinician-selected standard combination treatment, aiming to assess effects on drug resistance, future treatment options, and other, long-term, clinically relevant outcomes.In this pragmatic, parallel-group, randomised, controlled, open-label, non-inferiority trial, we enrolled participants attending 43 public sector hospital-based HIV treatment centres in the UK. Eligible participants were adults aged 18 years or older who were HIV positive, had been on ART consisting of two nucleoside reverse transcriptase inhibitors (NRTIs) and one non-NRTI (NNRTI) or protease inhibitor for at least 24 weeks with no change in the previous 12 weeks, had a viral load of less than 50 copies per mL at screening and for at least 24 weeks before screening , had a CD4 count of more than 100 cells per μL at screening, and who were willing to continue current ART or change according to the randomised allocation. Exclusion criteria were known major protease inhibitor resistance mutations at previous resistance testing , previous ART change for unsatisfactory virological response , protease inhibitor allergy, concomitant drugs with protease inhibitor interactions, present or anticipated need for radiotherapy or cytotoxic chemotherapy, treatment for acute opportunistic infection within the previous 3 months, present or planned pregnancy, active substance misuse or psychiatric illness, history of HIV encephalopathy with a present deficit of more than 1 in any domain of the Neuropsychiatric AIDS Rating Scale,The protocol was approved by the Cambridgeshire 4 Research Ethics Committee and Medicines and Healthcare Products Regulatory Agency. All participants provided written informed consent.Participants were randomly assigned (1:1) to maintain ongoing triple therapy (OT) or switch to a protease inhibitor monotherapy strategy (PI-mono). Randomisation was stratified by centre  and baseline ART regimen (protease inhibitor or NNRTI). The computer-generated, sequentially numbered randomisation list (random permuted blocks of varying size) was preprepared by WS. Sites faxed screening forms to the trial coordinating centre, where trial staff confirmed eligibility and did the randomisation . Treatment allocation was open label.In the OT group, we managed patients using triple combination treatment. In the PI-mono group, we switched patients to a single ritonavir-boosted protease inhibitor selected by the physician: we recommended darunavir (800 mg) boosted with ritonavir (100 mg) once daily or lopinavir (400 mg) boosted with ritonavir (100 mg) twice daily. Drugs were taken orally. Patients switching from NNRTI-based regimens continued NRTIs for the first 2 weeks. Protease inhibitor substitution was allowed in the event of toxic effects or for convenience. The strategy required prompt reintroduction of NRTIs  for protocol-defined confirmed viral load rebound and management with combination treatment for the remainder of the trial .Study visits at baseline, weeks 4 and 8 (PI-mono group only), week 12, and every 12 weeks thereafter included assessment of clinical status, drug adherence (standardised questions), viral load, CD4 cell count, and safety blood tests (measured at site laboratory). Visits at baseline, week 12, week 48, and every 48 weeks thereafter included additional assessments of cardiovascular disease risk (Framingham equation),If viral load was detectable at 50 copies per mL or higher at any visit, we repeated the test (on the same sample if available or a fresh sample draw if not). If viral load was less than 50 copies per mL on the repeat test, we continued routine follow-up, but if higher, we did adherence counselling and patients returned for a confirmatory test at least 4 weeks from the date that the first sample was taken. If viral load was less than 50 copies per mL with the confirmatory test, we resumed routine follow-up, but if higher , this result met the protocol definition of confirmed rebound and so the patient was required to change treatment, and we did a repeat test 4 weeks later.Stanford algorithm for drug susceptibility prediction. If we identified resistance mutations, we compared them with any genotypic testing reports from before the trial.We did genotypic resistance testing on all viral load rebound samples that were confirmed or preceded treatment switch. We did genotypic testing at site laboratories, repeated at the central laboratory if local sequencing was unsuccessful. We used the The primary outcome was loss of future drug options, defined as new intermediate-level or high-level resistance to one or more drugs in contemporary use to which we deemed patient's virus to be sensitive at trial entry (assessed at 3 years). We defined contemporary use on the basis of inclusion in present UK treatment guidelines,Secondary outcomes were occurrence of serious drug-related or disease-related complications, including death or serious AIDS-defining  or non-AIDS-defining illness; total number of grade 3 and 4 adverse events; confirmed virological rebound; CD4 cell count change from baseline; neurocognitive function change from baseline; cardiovascular risk change from baseline; and health-related quality of life change from baseline . Additional specified safety outcomes were facial lipoatrophy, abdominal fat accumulation, peripheral neuropathy, and estimated glomerular filtration rate.We defined non-inferiority of the PI-mono group by the upper limit of the two-sided 95% CI for the difference in proportions of patients who maintain all future drug options during 3 years (OT group minus the PI-mono group) being less than 10%. We chose the 10% non-inferiority margin on the basis of US Food and Drug Administration guidance All comparisons were as randomised (intention to treat). We deemed a per-protocol analysis not relevant for this pragmatic trial in view of the fact that a switch back to combination treatment in the PI-mono group was an intrinsic element of the clinical strategy being assessed. Statistical tests are two-sided and test the hypotheses of no difference between randomised groups. We estimated the absolute difference between groups in reduction of future drug options using Kaplan-Meier analysis, with the 95% CI (two-sided) derived with bootstrap methods. In this analysis and other time-to-event analyses, we censored participants at the time of death, loss to follow-up, or withdrawal. The primary analysis included all new resistance mutations noted that conferred intermediate-level or high-level drug resistance. We predefined a sensitivity analysis in which we restricted loss of drug options to classes to which the patient was exposed during the trial, thus excluding mutations that were probably archived .2 or Fisher's exact tests, with conventional or Agresti-Caffo 95% CIs for the risk difference and logistic regression models for adjusted analyses. For continuous variables, we compared groups by use of mean change from baseline and t tests or linear regression; we estimated change from baseline to the last available visit at which a measurement was done at or after week 144 (we did not include patients without such data). We estimated the proportion of patients who had viral load rebound with Kaplan-Meier analysis and compared groups by use of a log-rank test. We compared incidence rates with Poisson regression. We compared adherence during the entire follow-up period between groups with generalised estimating equations .For secondary endpoints, we compared binary outcome variables between groups using χWe used Stata version 12.1 for all analyses. A data monitoring committee reviewed interim data annually. This trial is registered with the International Standard Randomised Controlled Trial Number registry, number ISRCTN04857074.The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.Between Nov 4, 2008, and July 28, 2010, we randomly allocated 587 participants to OT (291) or PI-mono 296; . One <1.In the PI-mono group, initial drug choices were darunavir in 233 (80%) of patients, lopinavir in 40 (14%), atazanavir in 16 (6%), and saquinavir in 1 (<1%); 58% were still taking monotherapy at trial end. Combination treatment was reintroduced for the following reasons: 69 (23%) for protocol-defined confirmed viral rebound , 11 (4%)The number of patients with loss of future drug options at 3 years (the primary outcome) was two patients (Kaplan-Meier estimate 0·7%) in the OT group and six (2·1%) in the PI-mono group (difference 1·4% [95% CI −0·4 to 3·4]), therefore meeting the non-inferiority criterion. PI-mono was also non-inferior with prespecified analyses of loss of future drug options during the full trial follow-up period  and loss of future drug options during the full trial period but excluding mutations that were probably archived . One (<1%) participant on atazanavir monotherapy developed the Ile50Leu mutation (as a mixture with wild-type), conferring predicted high-level atazanavir resistance. We detected an isolated Leu90Met mutation in two (<1%) patients on darunavir monotherapy; both resuppressed with reintroduction of NRTIs. This mutation, possibly archived, does not affect darunavir sensitivity, but confers resistance to saquinavir and thus meets the endpoint definition. Three (1%) patients in the PI-mono group had NRTI or NNRTI mutations detected, probably archived from previous treatment. In the OT group, three (1%) patients had loss of future drug options to drug classes that they were taking and one (<1%) taking a protease-inhibitor-based regimen had NNRTI mutations that were probably archived .We noted one or more episodes of confirmed viral load rebound in eight (Kaplan-Meier estimate 3·2%) patients in the OT group and 95 (35·0%) in the PI-mono group during all follow-up: absolute risk difference 31·8% . Rebound while actually on monotherapy (occurred in 93 patients) was more common in the first year (24 per 100 person-years) than in subsequent years  between groups . Causes ollow-up . Howeverollow-up , and onlollow-up .In patients who have achieved viral load suppression with combination treatment, a maintenance strategy of protease inhibitor monotherapy, with reintroduction of combination treatment in the event of viral load rebound, was non-inferior to continuous combination treatment for preservation of future treatment options during 3–5 years. Furthermore, and perhaps more relevant than is non-inferiority for understanding of the clinical implications of this approach, the findings showed that the absolute number of patients who lost future drug options with protease inhibitor monotherapy was very low. Only one patient developed clinically significant resistance to a protease inhibitor taken as monotherapy, an Ile50Leu mutation with atazanavir monotherapy; clinical negative effects are mitigated by an increase in sensitivity to other protease inhibitors conferred by this mutation.gag or env genes, or in minority species that are not detected by population assays,We sought resistance fastidiously, testing confirmed viral rebound samples irrespective of level of viraemia with standard population sequence genotypic testing. Although protease inhibitor resistance could occur in other regions of the virus, such as A higher proportion of patients in the PI-mono group had viral rebound, as expected, although the difference was much greater than the 10–13% noted in a previous systematic review.We noted fewer episodes of renal impairment in the PI-mono group as expected in view of the well-recognised renal toxic effects of NRTIs . However, the risk of serious drug toxic effects can be minimised by close laboratory monitoring and pre-emptive treatment changes, and no patients in the OT group developed end-stage renal disease.A concern with protease inhibitor monotherapy is that suboptimum drug penetration into the CNS might lead to harm.The strengths of this trial are its size and duration ; low withdrawal and loss-to-follow-up; pragmatic design set in routine clinical care, with flexibility in drug selection in both treatment groups; and use of a primary efficacy endpoint relevant to long-term management. The open-label design, a possible limitation, is unlikely to have affected detection of viral rebound or resistance (and hence the primary endpoint) because the protocol-mandated frequency of viral load testing was identical in the two groups (apart from two extra tests at weeks 4 and 8 in the monotherapy group), and we did resistance testing in everyone with viral rebound. Likewise, the open-label design is unlikely to have affected adverse event detection because the frequency of laboratory safety monitoring was standardised and adverse events were graded with standardised diagnostic criteria. Another possible limitation is the absence of before-treatment resistance tests that would help rule out resistance acquired before the trial. Although entry criteria were broad, patients entering this trial were established for years on a stable effective regimen, yet needed to be willing to change to an alternative regimen (in some cases adding new drugs with risk of side-effects or increased pill burden) if randomly allocated to do so. In view of the absence of any certainty of benefit, only a few eligible patients would therefore have been likely to be prepared to participate. Such motivated patients might have better outcomes (perhaps mediated by adherence) than the general clinic population would have, and this notion is consistent with the very low amount of rebound and resistance noted in the OT group. The main study finding that, despite high levels of viral load rebound, protease inhibitor monotherapy does not jeopardise future treatment options is likely to be generalisable internationally to settings where treatment is individualised and regular viral load monitoring done. However, protease inhibitor monotherapy is not appropriate for resource-limited settings delivering treatment without regular viral load monitoring.Protease inhibitor monotherapy is an acceptable alternative to standard combination ART for long-term HIV management, with a slight benefit in terms of a reduction of renal toxic effects. The need for regular viral load monitoring and a possible switch back to combination treatment might be perceived as drawbacks, but this approach could nevertheless appeal to patients who are stable on treatment but wish to minimise their exposure to specific drugs or more than one drug class. Broadly, the trial challenges the notion that combination treatment is essential for management of chronic HIV infection.


The once-a-day ETV treatment was as effective as the twice daily dosing regimen. Grade 1–2 adverse events were observed motivating a treatment switch in 4.2% of the subjects. In conclusion, ETV (once- or twice daily) plus two analogs is a suitable, well-tolerated combination both as a switching strategy and after failure with first generation NNRTIs, ensuring full drug activity.Etravirine (ETV) is recommended in combination with a boosted protease inhibitor plus an optimized background regimen for salvage therapy, but there is limited experience with its use in combination with two nucleos(t)ide reverse-transcriptase inhibitors (NRTIs). This multicenter study aimed to assess the efficacy of this combination in two scenarios: group A) subjects without virologic failure on or no experience with non-nucleoside reverse-transcriptase inhibitors (NNRTIs) switched due to adverse events and group B) subjects switched after a virologic failure on an efavirenz- or nevirapine-based regimen. The primary endpoint was efficacy at 52 weeks analysed by intention-to-treat. Virologic failure was defined as the inability to suppress plasma HIV-RNA to <50 copies/mL after 24 weeks on treatment, or a confirmed viral load >200 copies/mL in patients who had previously achieved a viral suppression or had an undetectable viral load at inclusion. Two hundred eighty seven patients were included. Treatment efficacy rates in group A and B were 88.0% (CINCT01437241ClinicalTrials.gov  Etravirine (ETV), a second-generation non-nucleoside reverse transcriptase inhibitor (NNRTI), was designed to overcome common first-line NNRTI resistance mutations; it has demonstrated a potent activity in vitro and in vivo in short-term monotherapy trials both in naïve subjects and in patients with high levels of phenotypic resistance to efavirenz and nevirapine ETV is not recommended to be administered with nucleos(t)ide reverse-transcriptase inhibitors (NRTIs). This recommendation is based mostly on the results of a phase II trial, which compared the efficacy of ETV against that of a protease inhibitor, where both treatments were administered in combination with two NRTIs after a first-line virologic failure in an NNRTI-based regimen. Nevertheless, the high rate of at least two baseline resistance mutations to the NRTIs and NNRTIs in the previous trial did not allow the researchers to obtain accurate conclusions In spite of its antiviral activity, its favorable pharmacokinetics for once-daily administration, its safety and drug interactions profile In this study, we aim to evaluate the efficacy of an ETV plus 2 NRTIs regimen out of the context of advanced salvage therapy, where ETV is usually administered in combination with PI/rtv. Moreover, we have assessed if the efficacy of this regimen is independent of the once- or two-daily administration of ETV.Adult HIV-infected subjects attending several HIV clinics from Andalusia (Spain) and switching to a regimen of ETV plus 2 NRTIs due to adverse events (AEs) or virologic failure (VF) on a preceding regimen were consecutively enrolled in this ambispective observational study from January 2009 (marketing authorization date for ETV in Spain) to September 2011 and followed up during 52 weeks. Patients were classified as group A (subjects without virologic failure on or no experience with NNRTIs switched due to AEs) and group B (subjects switched after a VF on an efavirenz- or nevirapine-based regimen). The NRTIs prescribed as part of HAART were selected by the responsible physicians on the basis of previous antiretroviral treatments (ART) and/or genotypic resistance testing. In the cases of a previous VF, the genotypic resistance tests had to demonstrate susceptibility or low-level resistance both to NRTIs  and the Spanish Agency for Medicine and Healthcare Products which approved this consent procedure, and registered at ClinicalTrials.gov (NCT01437241).+ T cell count was measured by flow cytometry, and the plasma HIV-RNA was measured using the Roche Amplicor HIV-1 Monitor assay . The primary endpoint was efficacy at 52 weeks assessed by -intention-to-treat analysis; regimen failure was defined as treatment interruption for any reason or VF. VF was defined as the inability to suppress plasma HIV-RNA to <50 copies/mL after 24 weeks of treatment, or a confirmed viral load >200 copies/mL in patients who had previously achieved a viral suppression or had an undetectable viral load at inclusion. The secondary outcomes included efficacy according to on-treatment analysis, changes in CD4+ cell counts, the incidence of AEs and lipid profiles. Hepatotoxicity was classified according to the highest aminotransferases level observed during therapy with respect to the upper limit of normal (ULN) (grade 0 (<1.25 ULN), grade 1 (1.25–2.5×ULN), grade 2 (2.6–5×ULN), grade 3 (5.1–10×ULN), and grade 4 (>10×ULN) or relative to baseline values in patients with chronic viral hepatitis or cirrhosis (grade 0 (<1.25×baseline), grade 1 (1.25–2.5×baseline), grade 2 (2.6–3.5×baseline), grade 3 (3.6–5×baseline), and grade 4 (>5×baseline)). Patients missing two consecutive scheduled visits were considered to be lost to follow-up.Patient assessments were performed at baseline and every three months thereafter, including AEs, biochemical and hematologic profiles; the CD4Descriptive statistics were used for demographic, epidemiological and clinical data, prior ARTs, CD4 cell count and viral load. Kaplan–Meier plots were produced for the ‘time to event’ analyses, and comparisons between the treatment groups were made using the log-rank test. Chi-square tests and Spearman’s rank-correlation coefficients were used to assess the relationship between VF and qualitative and quantitative variables, respectively. Statistical calculations were performed with Statistical Product and Service Solutions software .A total of 346 patients started a regimen of ETV plus two NRTIs in the study period. Fifty nine of them were excluded from the analysis to homogenize the analysis population . The baseline characteristics of the 287 analyzed subjects are shown in 95, 83.9–92.1%) for the intention-to-treat analysis and 97.2%  for the on-treatment analysis. Thirty subjects (12.4%) had treatment failures, out of whom only 8 (3.3%) were due to VF; the remaining failures were due to AEs , treatment dropout , loss to follow-up , death , AEs attributable to concomitant peginterferon plus ribavirin therapy  and imprisonment  (+ cell counts from baseline to week 52 was 58 cells/µL (IQR: –15 to 198) and was inversely proportional to baseline CD4+ counts .In this group, 242 subjects (84.3%) without experience with or VF on NNRTIs were switched to an ETV-based regimen due to AEs during their previous regimen . ETV was dosed at 400 mg once daily in 88.8% of the patients. Most patients received tenofovir plus emtricitabine (60.3%) or abacavir plus lamivudine (34.3%). Seventy four per cent (n = 179) showed an undetectable HIV viral load at the time of switching to an ETV-based regimen. The remaining 63 subjects had a median viral load of 720 copies/mL  as treatment switches occurred before achieving an undetectable viral load with the previous regimens. The Kaplan–Meyer estimates for efficacy at 52 weeks were 88.0%  . The medForty five patients (15.6%) were included in this group after failing an efavirenz- or nevirapine-based regimen. Before switching, genotypic resistance tests showed the following results: i) a wild-type strain in 17 subjects, ii) an isolated K103N mutation in 14, iii) the K103N plus one other NNRTI mutation in 7 , and iv) other NNRTI mutations (without the K103N) in another 7 subjects . Thus, no subjects showed an ETV score >2 at baseline. Additionally, 5 patients had NRTI mutations conferring low-level resistance to one of the NRTIs included in the regimen. ETV was dosed at 400 mg once daily in 64.4% of the subjects.95, 65.0–89.7%) for the intention-to-treat and 90.5%  for the on-treatment analysis, being slightly lower than the efficacy found in group A . The reasons for treatment failure were as follows: VF , treatment drop-out or loss to follow-up , AEs  and ETV interaction with rifampin  (+ cell count increase from baseline to week 52 was 61 cells/µL (IQR: –6 to 156), inversely proportional to baseline CD4+ counts .In group B, the Kaplan–Meyer estimates for efficacy at 52 weeks were 77.4%  . The medThe VF episodes were more frequent in group B (4/45) than in group A (8/242), although the difference was not statistically significant . No relationships were found between a poor virologic outcome and the baseline ETV score, the presence of mutations conferring low-level resistance to the NRTIs or the NRTIs combination used. Among the patients from group A, the VF rates for a once- and twice-daily administration were 2.8 vs. 6.9%, respectively (p = 0.243); for the subjects in group B, these values were 3.4 vs. 21.4%, respectively (p = 0.094).Plasma HIV-RNA amplification was achieved in 11 out of these 12 patients with VF. Four of these 11 patients exhibited a wild-type virus while the remaining 7 subjects showed 1 or more new NNRTI mutations. Additionally, 4 out of these 7 subjects with new NNRTI mutations also showed new NRTI mutations .Forty one patients (14.3%) reported AEs . Although these AEs were grade 1–2 in all cases, they motivated a treatment switch in 12 subjects (4.2%) . However, 90, 36; p = 0.341), 0 mg/dL , –2 mg/dL  and –3 mg/dL , respectively  or abnormal baseline lipid levels to avoid skewing the results. Thereby, the 151 subjects with normal baseline lipid profiles completed 52 weeks on therapy with median changes in total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) and triglycerides (TG) levels of –3 mg/dL , –1 mg/dL , –19 mg/dL  and –68 mg/dL , respectively . A lipid profile was available in 91 of the subjects after 52 weeks on therapy, with the corresponding changes in TC, LDL-C, HDL-C and TG levels of –32 mg/dL  subjects without resistance to NNRTIs who experienced AEs during an NNRTIs- or a PI/rtv-based regimen, and 2) as a rescue regimen after a VF on a first-generation NNRTI-based regimen.In the first setting, the efficacy at 52 weeks was striking; the AEs that motivated switching from the preceding regimen were resolved in most cases, and the virological success rate (97.2%) was comparable to the best results of the clinical trials on ART. This figure is also remarkable when taking into account that these results were based on routine clinical practice. It seems reasonable to assume that the high genetic barrier of ETV to the development of resistance may have contributed to these favorable results. In the second scenario, we observed a VF rate of only 8.9%.min in both healthy volunteers and HIV-infected patients who were administered ETV 400 mg once daily, as compared to 200 mg twice daily; nevertheless, the ETV Cmin in the once daily patients was still well above the protein binding adjusted EC50 for wild type HIV. Moreover, similar intracellular ETV levels were observed in HIV-infected patients with both dosing regimens ETV was administered as a once-daily dosing regimen in most subjects. Three pharmacokinetic studies have shown a lower ETV CRegarding the genotypic resistance tests of the 11 patients with VF, resistance-associated mutations which significantly decrease ETV susceptibility appeared in 5 out of the 11 patients (45%); wild-type strain or minor resistance mutations, which do not significantly decrease ETV susceptibility, were observed in the remaining subjects. New NRTI mutations only appeared in four out of the 11 subjects. The high viral load levels observed in some VF may suggests a low adherence.Regarding the safety profile of this combination, no clinical grade 3 or 4 AEs were recorded. In fact, most of the treatment changes due to AEs, some of which were questionably related to either of the study drugs, would reflect the current widespread availability of antiretroviral drugs rather than the patient’s AE severity. The incidence of mild-to-moderate rash (2.0%) was lower than previously reported We believe that our study has two main limitations. Firstly, there were a limited number of subjects included in group B; however, given that minimal data are available for this scenario, our results may allow clinicians to consider this therapeutic option after a VF on a first-generation NNRTI-based regimen with limited resistance mutations. Secondly, adherence was not objectively measured. A low compliance might have negatively influenced the treatment efficacy rate, particularly in those subjects with a previous VF for whom poor medication adherence might have been the cause of both the previous and the actual failures. However, we believe that our work accurately reflects the efficacy of treatment with ETV plus 2 NRTIs in routine clinical practice in two scenarios where the treatment options are not well-defined.In summary, ETV plus two analogs is a suitable, well-tolerated combination both as a switching strategy due to the toxicity of NNRTIs or PI/rtv-based regimens and after failing with first-generation NNRTIs, ensuring full drug activity. In these scenarios, a once daily administration of ETV is as effective as a twice daily regimen and would enhance regimen compliance.In summary, ETV plus two analogs is a suitable, well-tolerated combination both as a switching strategy due to the toxicity of NNRTIs or PI/rtv-based regimens and after failing with first-generation NNRTIs, ensuring full drug activity. In these scenarios, a once daily administration of ETV is as effective as a twice daily regimen and would enhance regimen compliance.


HIV/ AIDS clinics in resource limited settings (RLS) face increasing numbers of patients and workforce shortage . To address these challenges, efficient models of care like pharmacy only visits (POV) and nurse only visits (NOV) are recommended [3]. The Makerere University Joint AIDS Program (MJAP), a PEPFAR funded program providing care to over 42,000 HIV infected adults has implemented the POV model since 2009. In this model, stable patients on antiretroviral therapy (ART) with adherence to ART >95% and Karnofsky score >90% are reviewed by a doctor every four months but visit pharmacy for ART re-fills every two months. A study conducted in August 2011 showed low retention on the POV program with symptomatic diseases, pending CD4 count, complete blood count results, and poor adherence to ART as the major reasons for the non-retention in the POV program. To improve retention on POV, the TAT (Turnaround Time) for laboratory results (the main reason for non-retention in the previous study) was reduced from one month to one week. In August 2012, the study was repeated to assess the effect of reducing TAT on improving retention one year after patients were placed on POV.A cohort analysis of data from patients in August 2011 and in August 2012 on POV was done. We compared retention of POV before and after reducing the TAT for laboratory results.Retention on POV was 12.0% (95% CI 9.50–14.7) among 619 patients in 2011, , mean age was 33 years, Standard Deviation (SD) 8.5 compared to 11.1% (95% CI 9.15–13.4) among 888 patients , mean age 38.3 years, SD 8.9 in 2012 (p=0.59). The main reasons for non-retention on the POV program in 2012 were poor adherence to ART (23%) and missed clinic appointments (14%).Reducing TAT for laboratory test results did not improve retention of stable HIV-infected adults on POV in our clinic. Strategies for improving adherence to ART and keeping clinic appointments need to be employed to balance workload and management of patients without compromising quality of care, patients’ clinical, immunological and adherence outcome.


Nucleoside reverse transcriptase inhibitor (NRTI) is associated with endothelial dysfunction and proinflammatory effects. Maraviroc (MVC) is an antagonist of CCR5 receptor. CCR5 is the receptor of RANTES , a mediator of chronic inflammation and endothelial function. Our aim was to evaluate the maintenance of viral suppression and improvement of endothelial function in virologically suppressed HIV-infected patients switched to an NRTI-sparing combined antiretroviral therapy (cART) with MVC.This observational, non-interventional, multicenter study was performed at the Infectious Diseases Service of Santa Lucia, Morales Meseguer, Virgen de la Arrixaca and Reina Sofía University Hospital . The selection criteria were to be asymptomatic on a regimen with undetectable viral load (<50 HIV-RNA copies/mL) for at least six months, no previous treatment with R5 antagonists, no evidence of previous protease inhibitor (PI) failure and available R5 tropism test. Twenty-one HIV-infected patients were selected after the treatment regimen was changed to Maraviroc 150 mg/once daily plus ritonavir-boosted PI therapy. Endothelial function was prospectively evaluated through flow-mediated dilatation (FMD) of the brachial artery at baseline and at weeks 24.We included 21 patients on treatment with PI in combination with 2 NRTI. The mean cART exposition was 133±68.9 months. Fourteen (66.6%) were males, aged 49±9 years, 15 (71.4%) smokers, 4 (19.04%) family history of coronary heart disease, 1 (5.76%) type 2 diabetes and 3 (14.28%) hypertensive, mean total cholesterol was 185.5±35 mg/dL, c-LDL 100.2±37 mg/dL, tryglicerides 170.42±92.03 mg/dL, cHDL 52.6±15.5 mg/dL, CD4 779,5±383.28 cells/mL, nadir CD4 187,96±96 cells/mL. After 24 weeks of follow-up of a switch to an NRTI-sparing regimen, 95.2% of HIV-patients on viral suppressive cART maintained viral suppression and CD4+ T cell count. This cART switch improve endothelial function in patients with lower baseline FMD levels after 24 weeks .The results of our study show that a switch to an NRTI-sparing bi-therapy with MVC improves endothelial function and maintained the immune-virologic efficacy. This regimen emphasizes the needs for further clinical studies to associate these achievements with the incidence of non-AIDS-defining illnesses.


Antiretroviral treatment (ART) has been scaled up over the last decade but compared to adults, children living with HIV are less likely to receive ART. Moreover, children and adolescents are more vulnerable than adults to virological failure (VF) and emergence of drug resistance. In this study we determined virological outcome in perinatally HIV-1-infected children and adolescents receiving ART in Togo.HIV viral load (VL) testing was consecutively proposed to all children and adolescents who were on ART for at least 12 months when attending HIV healthcare services for their routine follow-up visit (June to September 2014). Plasma HIV-1 VL was measured using the m2000 RealTime HIV-1 assay . Genotypic drug resistance was done for all samples with VL>1000 copies/ml.Among 283 perinatally HIV-1-infected children and adolescents included, 167 (59%) were adolescents and 116 (41%) were children. The median duration on ART was 48 months (interquartile range: 28 to 68 months). For 228 (80.6%), the current ART combination consisted of two nucleoside reverse transcriptase inhibitors (NRTIs) (zidovudine and lamivudine) and one non-nucleoside reverse transcriptase inhibitor (NNRTI) (nevirapine or efavirenz). Only 28 (9.9%) were on a protease inhibitor (PI)-based regimen. VL was below the detection limit (i.e. 40 copies/ml) for 102 (36%), between 40 and 1000 copies/ml for 35 (12.4%) and above 1000 copies/ml for 146 (51.6%). Genotypic drug-resistance testing was successful for 125/146 (85.6%); 110/125 (88.0%) were resistant to both NRTIs and NNRTIs, 1/125 (0.8%) to NRTIs only, 4/125 (3.2%) to NNRTIs only and three harboured viruses resistant to reverse transcriptase and PIs. Overall, 86% (108/125) of children and adolescents experiencing VF and successfully genotyped, corresponding thus to at least 38% of the study population, had either no effective ART or had only a single effective drug in their current ART regimen.Our study provided important information on virological outcome on lifelong ART in perinatally HIV-1-infected children and adolescents who were still on ART and continued to attend antiretroviral (ARV) clinics for follow-up visits. Actual conditions for scaling up and monitoring lifelong ART in children in resource-limited countries can have dramatic long-term outcomes and illustrate that paediatric ART receives inadequate attention. Of the more than three million children infected with HIV, 90% live in sub-Saharan Africa . Over thIn resource-limited settings, in addition to the risk of acquired HIV resistance during PMTCT, the limited number of available paediatric-formulated antiretroviral drugs for the different age classes, the frequently observed poor adherence, the social environment, psychosocial factors and the absence of biological monitoring compromise ART efficacy in HIV-infected children and adolescents. These factors all make children and adolescents more vulnerable than adults to virological failure (VF) and the emergence of drug resistance –10. Seve3). ART has also been scaled up among children, but only 2800 (23.3%) of the 12,000 children (<14 years) infected with HIV in Togo were receiving ART in 2013 [In Togo, scaling up and free access to ART started in 2007 in the capital city; they were expanded to semi-rural areas in 2008. The country adopted the WHO public health approach, and in 2013 at least 31,000 HIV-positive adults were receiving ART, which corresponds to almost 50% of those in need for ART according to the WHO guidelines from 2010  test was consecutively proposed for the purpose of the study to all perinatally HIV-1-infected children (aged<10 years) and adolescents (aged between 10 and 19 years) who were on ART for at least 12 months when attending private or public HIV healthcare services for their routine follow-up visit. HIV care centres were in the urban region of Lomé, the capital city, and in three semi-rural areas: the Maritime, Plateaux and Kara regions.Demographic information was collected using a standardized questionnaire by the interviewer during sampling, and information on ART history was collected retrospectively on site from medical records. Whole blood was drawn by venepuncture on EDTA tubes  and sent within four hours to the national reference laboratory ) in Lomé and its satellite in Kara, especially for samples collected in the Kara sanitary region. Upon reception, five spots of 50 µL of whole blood were prepared for each patient onto  Whatman 903 filter paper and dried at room temperature for three hours. Dried blood spots (DBS) were then placed individually in plastic bags and stored in a hermetic box containing silica desiccant at −20° until genotypic resistance testing in a WHO-accredited laboratory . The remaining whole blood samples were centrifuged, and plasma was aliquoted and stored at −80°C for further HIV-1 RNA quantification. For the Maritime and Plateaux regions, DBS and plasma aliquots were prepared on site, stored at −20°C for a maximum of one week and subsequently transported by road in a cool box to the BIOLIM/FSS-UL laboratory in Lomé, where they were stored at −80°C for plasma and −20°C for DBS.The study was approved by the National Ethics Committee (CBRS/Togo) and Ministry of Health (N°752/2014/MS/CAB/DGS/DPLET/CBRS). Patients were recruited on a voluntary basis and, for all children, parents or legal guardians provided consent to participate in the study and were informed of the study objectives and procedures. A unique identifier was assigned to each sample and used throughout the study, ascertaining anonymity. Only physicians could establish the correspondence between this identifier and the patient.10 copies/ml). Nucleic acids were extracted with the NucliSENS easyMAG method  from two entire spots of 50 µl whole blood as previously described [in-house protocol from the Agence Nationale de Recherche sur le Sida et les Hépatites en France (ANRS) (www.hivfrenchresistance.org/ANRS-procedures.pdf). PCR products were purified and directly sequenced using the BigDye Terminator v3.1 Cycle Sequencing Kit . The quality of all sequences was tested with the calibrated population resistance tool (www.cpr.stanford.edu/cpr.cgi). We used the ANRS interpretation algorithm, version 24 (www.hivfrenchresistance.org/2014/Algo-2014.pdf), to identify relevant drug resistance mutations (DRMs) and to predict drug resistance or possible resistance to antiretroviral drugs. We constructed phylogenetic trees with maximum likelihood methods implemented in PhyML to identify HIV-1 subtypes and circulating recombinant forms and to evaluate eventual epidemiologic links between samples [Plasma HIV-1 VL was measured using the m2000rt Real Time HIV-1 assay  in the national reference laboratory (BIOLIM/FSS-UL) in Lomé. The lower limit of detection for the assay is 40 copies/ml (1.6 log copies/ml). Genotypic drug resistance testing was performed on all samples with plasma HIV-1 RNA load above 1000 copies/ml , Plateaux (n=15) and Kara (n=70) regions. The male/female ratio was 141/142; 167 (59.1%) were adolescents and 116 (40.9%) were children. Twenty (7.1%) were less than five years old and among them only two were less than three years old. The median duration on ART for the entire study population was 48 months (interquartile range (IQR): 28 to 68 months). Median duration on ART increased with age categories: 21 months (IQR: 15 to 27) for children less than five years old and reaching 64 months (IQR: 52 to 86) for adolescents aged between 15 and 19 years. Mean duration on ART was only slightly lower in the semi-rural areas: 46 months (IQR: 26 to 68) versus 50 (IQR: 30 to 73) in Lomé.A total of 283 perinatally HIV-1-infected children and adolescents aged 2 to 19 years who had been receiving ART for at least 12 months were consecutively included between June and September 2014. Patient characteristics are shown in 3 (IQR: 347 to 977). VL was not done in routine follow-up and data on adherence were only occasionally noted in patient records. Only 10 (3.5%) patients had been exposed to PMTCT, for 165 (58.3%) no exposure was reported and information was lacking in the patient records for the remaining. For 159 (56.2%), breastfeeding at a young age was reported, but information on the ART status of the mothers was absent from patient records.For 228 (80.6%) patients, the current ART combination consisted of two nucleoside reverse transcriptase inhibitors (NRTIs), zidovudine (AZT) plus lamivudine, and one non-nucleoside reverse transcriptase inhibitor (NNRTI), nevirapine (NVP) or efavirenz (EFV). Only 28 (9.9%) were on a protease inhibitor (PI)-based regimen when included in the study, and the remaining 27 patients were on other Reverse transcriptase inhibitor (RTI) combinations . The proRetrospective data collection on ART history showed that a change in ART regimen occurred for 135 (47.7%) patients, mainly related to a change in the national guidelines (replacement of stavudine in 2010 by AZT) or replacement of NVP by EFV related to age . SwitcheFor only 102 (36%) patients, VL was below the detection limit of the VL assay used (i.e. 40 copies/ml), for 35 (12.4%) VL was between 40 and 1000 copies/ml and for 146  VL was above 1000 copies/ml .p>0.05) (p=0.003).According to the WHO criteria for resource-limited countries, patients are considered to have VF when VL is above 1000 copies/mL . VF incrp>0.05) . Althougp>0.05). VF rates were slightly lower in Lomé than in the semi-rural clinics: 93/189 (49.2%) versus 53/94 (56.4%), respectively (p>0.05)  versus 54.6% (53/97), respectively ((p>0.05) .The overall VF rates observed among perinatally HIV-1-infected children in Togo are in general higher than those observed in previous reports in African countries. However, in these previous studies the median time on ART was often lower or fewer children were studied; for example 6% VF was observed after 3.3 years (IQR: 2.5 to 4.4) on ART in Kwazulu-Natal (South Africa) ; 16.7% wGenotypic drug resistance testing was successful for 125/146 (85.6%) patients with VL >1000 copies/ml; 110 were sequenced on both reverse transcriptase and protease regions, and for 15 only reverse transcriptase sequences were obtained. Among the 125 patients with genotypes in RT, only seven were not predicted to be resistant in RT  and onlyn=49) and K103N (n=47).The pattern of DRMs found in this study is consistent with the reports from several studies conducted in Africa ,8,9. TheEliminating new paediatric HIV infections and improving the health and survival of mothers and their children in the context of HIV are part of the overall objectives of UNAIDS in 2015. Our study shows that 51.6% of perinatally infected children attending routine HIV care centres in Togo who had been on ART for more than 12 months (median 48 months) were experiencing VF and that 38% of the studied population were infected with multidrug-resistant strains. Despite certain limitations such as absence of information on how many children died of HIV or were lost to follow-up, our study provided important information on virological outcomes of lifelong ART in perinatally infected children and adolescents and illustrates that paediatric ART still receives inadequate attention. In addition, with scale-up of PMTCT programmes and implementation of lifelong ART for HIV-positive mothers, national programmes should make sure to use more robust first-line regimens, including PIs as recommended by the WHO . More ef