Lymphoma was a common complication of HIV infection in the pre-antiretroviral era, and the incidence of HIV-associated lymphoma has dropped dramatically since the introduction of combination antiretroviral therapy (cART) in resource-rich regions. Conversely, lymphoma is an increasingly common complication of HIV infection in resource-limited settings where the prevalence of HIV infection is high. Relatively little is known, however, about the true incidence and optimal treatment regimens for HIV-associated lymphoma in resource-poor regions. We review the epidemiology, diagnosis, and treatment of HIV-associated non-Hodgkin lymphoma in developing nations and highlight areas for further research that may benefit care in both settings. Examples include risk modification and dose modification of chemotherapy based on HIV risk factors, improving our understanding of the current burden of disease through national cancer registries, and developing cost-effective hematopathological diagnostic strategies to optimize care delivery and maximize use of available chemotherapy. An association between the acquired immunodeficiency syndrome (AIDS) and lymphoma was first suggested in 1982 after four young men in San Francisco with severe immunodeficiency were diagnosed with a “Burkitt-like lymphoma” . While mThe incidence of the three AIDS-defining NHLs, diffuse large B-cell lymphoma (DLBCL), primary CNS lymphoma, and Burkitt lymphoma (BL), increased steadily in the United States between 1981 and 1990, at which time the incidence rate leveled off and began declining with the widespread availability of cART in 1996 . Over 25In Africa, the AIDS epidemic was first reported by Clumeck et al. and Van De Perre et al. in 1984 when they described a group of Africans cared for in Belgium with profound immunosuppression and a series of patients in Kigali, Rwanda with infectious complications or generalized Kaposi sarcoma, respectively . Nearly On average, patients in Africa present with HIV-associated complications at a higher CD4 count compared to those in resource-rich nations. With current supportive care, the burden of HIV-associated NHL is currently estimated at about 15,000 per year in the equatorial belt of Africa alone , 18. TheThe Kampala Cancer Registry is one of the oldest continually operating cancer registries in Africa and one of two which are WHO-certified. This registry was created in 1954 and enables an estimation of the impact of HIV infection on rates of malignancy in the area and serves as a tool for ongoing research . LinkingComprehensive data on survival after a diagnosis of NHL in HIV-positive persons are lacking in both resource-rich and resource-poor regions. However, two recent studies highlight the discrepancies in survival between patients in these two settings. In the USA, 47% of HIV-positive persons diagnosed with non-CNS NHL were alive 2 years after their diagnosis , which wIncreasing the number of such registries and the quality of data collected will contribute significantly to improving our understanding of the epidemiology of lymphoma in Africa. Collecting information on HIV-associated malignancies at clinics that distribute antiretrovirals is one potential way to increase the available data.A necessary complement to expanded cancer registry data in resource-poor nations is continued improvement in diagnostic accuracy, especially of hematological neoplasms. The accurate diagnosis of lymphomas can be challenging, even for pathologists in developed nations without hematopathological specialization. Diagnostic modifications were made in 20% of a series of submitted lymphoma cases in the United Kingdom after central review. After evaluation of associated clinical data in each of the cases, the authors concluded that clinical management likely would have differed in about half of the cases with diagnostic discrepancies . SimilarAs optimal therapies become more varied for each lymphoma subtype, it is likely that the clinical significance of diagnostic accuracy will increase. An initial attempt to improve this diagnostic accuracy in a cost-effective manner was recently reported by Naresh and colleagues through a description of a diagnostic algorithm for Burkitt lymphoma. They described a three-tiered method for diagnosis that involved increasing numbers of immunohistochemical tests in each tier if the diagnosis remained unclear. They were able to confirm a diagnosis of BL versus DLBCL in 82% of the cases using the first phase of studies  and in 92% of cases with the addition of testing for Ki-67, CD38, and CD44 . This tyThe benefit of immunohistochemistry, not routinely available in resource-limited regions at present, extends beyond its assistance in confirming a diagnosis in this age of increasing numbers of targeted therapies. Discovering immunophenotypic differences of lymphomas in varying patient populations may promote discovery of novel targeted agents as well as further evaluation of current agents in clinical trials, even at the present time. For example, Tumwine and authors described the immunohistochemical features of 119 cases of lymphoma in Kampala, Uganda. 37% of the Burkitt lymphoma cases were CD30 positive , twice tAt the present time, standard therapy for HIV-associated lymphoma in Africa does not include targeted therapy, such as rituximab, as current medication costs are prohibitive. Therefore, treatment is delivered with standard cytotoxic agents alone. Because of the similarities between the current patient population in resource-limited nations and patients in resource-rich nations in the pre-cART era, a historical review of chemotherapy for HIV-associated lymphomas is helpful for identifying potential areas of further study.Initially, the treatment of AIDS-associated lymphoma in the United States achieved complete response (CR) rates of 53% with combination chemotherapy usually involving CHOP , though these responses were tempered by a rate of relapse of 54%. Additionally, significant infectious complications were noted in 42% of the cohort, which contributed to a mortality rate of 85% during a three-year study by Ziegler and colleagues reported in 1984 .The next generation of chemotherapy trials in AIDS-related lymphoma studied more aggressive chemotherapy combinations in recognition of the fact that such cases typically presented at a more advanced stage, had a higher grade at presentation, an increased risk of relapse, and an increased frequency of extranodal disease compared with non-AIDS-related lymphomas. For example, Gill and authors compared M-BACOD  with an even more intensive regimen using high-dose cytarabine and high-dose methotrexate in combination with other agents. Rates of complete remission were 54% and 33% in the two groups, respectively, and the overall survival was 11 months in the M-BACOD group compared to 6 months in the cytarabine/methotrexate arm. This trend towards shorter survival was attributed to a higher rate of opportunistic infections in the cytarabine/methotrexate arm, with more than 75% developing this complication . SimilarμL. Patients with none of these risk factors received one of two aggressive chemotherapy regimens and no differences in overall survival were noted between 4 cycles of CHOP  and 3 cycles of ACVBP . Patients with one risk factor received either standard-dose or low-dose CHOP, again without any difference in overall survival. The third group, with either 2 or 3 risk factors, received either 4 cycles of low-dose CHOP or 12 cycles of vincristine and prednisolone. There were no differences in overall survival between regimens in any of the risk groups, though lymphoma-specific outcomes were improved in the more aggressive arms of each subset. It should be noted that after 1996 most patients were started on cART, and this subset composed about one-third of the entire study cohort. While cART did decrease the number of patients with 2-3 risk factors and improve overall survival, it did not lead to any significant differences between chemotherapy regimens in risk-stratified patients [A 1997 study by the AIDS Clinical Trials Group (ACTG 142) therefore compared lower-dose m-BACOD to standard dose m-BACOD with GM-CSF support. The lower-dose regimen was associated with decreased hematological toxicity and similar rates of response. CR rate in the low-dose arm was 39%, compared to 52% in the standard-dose arm while median overall survival was 35 weeks compared to 31 weeks, respectively. Neither of these differences was statistically significant . The surThe balance of minimizing myelotoxicity and infectious risk while optimizing lymphoma therapy has an even narrower therapeutic window in resource-limited nations due to the decreased availability of supportive care measures such as broad-spectrum antibiotics and the high rates of baseline cytopenias. Concurrent use of other supportive medications may be a major contributor to the high rates of cytopenias in African patients with HIV infection. For example, in a study of 498 patients started on antiretroviral therapy in Cote d'Ivoire, the observed 24% rate of grade 3-4 neutropenia was ascribed to the combined administration of trimethoprim/sulfamethoxazole and zidovudine (AZT). While the neutropenia usually resolved with discontinuation of the TMP/SMX, the omission of this prophylactic therapy increased the risk of infectious complications, a risk that would likely increase further in the setting of cytotoxic chemotherapy . This inμL. This finding supports the importance of risk stratification by CD4 count, even in patients on cART at the start of chemotherapy [After the discovery and widespread use of cART in resource-rich countries, overall survival in HIV-associated lymphoma improved, in one study from an average of 6 months to 20 months [otherapy .For a time, this report led to decreased use of rituximab therapy in patients with HIV-associated lymphoma. However, additional data was recently provided by Dunleavy and colleagues  and Spar2 day 1, cycle 1 only), etoposide (100 mg/m2 days 1–3), cyclophosphamide (100 mg/m2 days 22–26), and procarbazine (100 mg/m2 days 22–26). As the initial regimen required G-CSF support, doses were decreased in the protocol to prevent this requirement. Additional modifications during therapy were also outlined, in a manner similar to the infusional EPOCH regimen. These adjustments led to a 50% dose reduction in all medications for an absolute WBC count less than 3,000 cells/μL or a platelet count under 100,000 cells/μL. For WBC count less than 1,500 cells/μL or platelets under 50,000 cells/μL doses were held until counts improved. If counts did not improve within three weeks, subjects were removed from the protocol—though this did not occur in any subjects on protocol. Median CD4 count in the 49-patient cohort was 198 cells/μL, 37% of patients were on antiretroviral therapy, and most had a history of previous opportunistic infection. 65% of the patients completed the two cycles determined by the protocol and a 6% treatment-related mortality was noted during the study, a significant improvement from previous studies. The reported CR rate was 58% with 78% having an objective response, numbers that are comparable to pre-cART studies in resource-rich nations. Median overall survival was 12 months, though a large variance was noted in patients on cART compared to no retroviral therapy with a median overall survival in the latter group of about 6 months. Even with these limitations, however, several principles can be incorporated to improve care in resource-poor settings. Dose adjustment has been investigated in trials of chemotherapy in sub-Saharan Africa with some success. One such study, and the first prospective trial investigating chemotherapy for HIV-associated lymphomas in Africa, was performed by Mwanda and colleagues, reported in 2009 . This stThis study serves as an example that prospective chemotherapy trials can be completed in resource-limited settings. It also identifies additional benefits from such studies, which may aid the management of HIV-associated lymphoma in resource-rich nations. First, this study by Mwanda and colleagues in East Africa is notable for its inclusion of female participants. In contrast to the >85% male composition of many of the other major trials in the field , 39, 40 Since platelet transfusions are currently not routinely available in most resource-limited nations , conditiM. tuberculosis is a consideration when balancing the risks and benefits of corticosteroids in high prevalence regions [Another aspect of the regimen used by Mwanda that may warrant further study is the avoidance of corticosteroids, even though they are known to be active lympholytics. The rationale for not including corticosteroids in the study regimen is avoidance of potential exacerbation of concurrent Kaposi sarcoma (KS) and HHV-8 infection, an important consideration as the prevalence of KS is highest in East Africa . Similar regions . Hepatit regions  and is w regions . There i regions  which coWhile a large portion of the improvements in treatment of HIV-associated lymphomas in resource-limited nations will occur as a result of earlier diagnosis, increased access to cART, and optimal treatment of concurrent infectious disease, significant opportunities to improve the hematological management of such cases also exist. Some of these advances may also benefit patients with HIV-associated lymphoma in resource-rich nations. Examples include improved risk modification and dose modification of chemotherapy, improved diagnostic capabilities with eventual implementation of targeted therapies based on the immunophenotypic profile, and an increased understanding of optimal supportive care for patients with infectious comorbidities.The cost of cancer care is often raised as a barrier to increasing access in resource-limited settings. On the contrary, however, it is the cost of inaction that is estimated to be much more significant. The Global Task Force on Expanded Access to Cancer Care and Control estimated that the world could have saved $131 billion in 2010 by investing in cancer treatment and prevention to limit the associated disability-adjusted life years . Similar


To evaluate the influence of HIV-1 tropism on virologic and immunologic responses in antiretroviral-naïve HIV-1-infected patients enrolled in the ArTEN trial .Baseline plasma samples from patients enrolled in the ArTEN trial were tested genotypically for HIV tropism using geno2pheno (5.75% FPR) and PSSM . Univariate and multivariate analyses were performed to find variables associated with virologic/immunological outcome. Parameters examined included gender, Hepatitis coinfection, HIV subtype, treatment arm, viral tropism, baseline CD4 counts and VL.428 out of 569 randomized and treated patients could be analyzed, 146 on ATZ/r and 282 on NVP. Overall, 332 (76.9%) subjects were infected with subtype B variants and 45 (10.4%) were HCV coinfected. The V3 successful amplification rate was 92.1% (394/428). X4 variants were found in 14% (55/394) by geno2pheno and 29.2% (115/394) by PSSM, with no significant differences between treatment arms or HIV clade. See Table At baseline, patients with X4 viruses by geno2pheno had higher VL  and lower CD4 counts  than those with R5 viruses. At weeks 24 and 48, the proportion of patients with VL <50 copies/mL was similar in both treatment arms, but lower in those with X4 than R5 viruses. The multivariate analysis confirmed HIV tropism as independent predictor of virologic response at week 24, along with baseline VL and CD4 count. In contrast, the extent of CD4 gains was not significantly determined by HIV tropism, but it was by baseline VL, CD4 count and treatment arm.HIV-1 tropism is an independent predictor of virologic response at week 24 in ARV-naïve patients treated with NVP or ATZ/r plus TDF/FTC. In contrast, CD4 gains are not determined by viral tropism. This observation may have important clinical implications, as it may be worthwhile testing for viral tropism, besides VL, CD4 counts and resistance before beginning any HAART regimen.


Adefovir Dipivoxil (ADV) is an important agent to suppress hepatitis B virus (HBV) replication with suboptimal effect on virological and serological response. To optimize Adefovir therapy in chronic hepatitis B (CHB) patients with hepatitis B e antigen (HBeAg) positive, we studied the baseline parameters and on-treatment HBV DNA for favorable outcomes.48 patients were enrolled in the study and followed up for 5 years prospectively. Baseline characteristics, virological, serological and biochemical parameters as well as on treatment HBV DNA were assessed in prediction of favorable outcomes.9 copies/ml and ALT ≥3 × ULN had more chance of HBeAg seroconversion , while in patients with HBeAg < 800 s/co or HBsAg < 5000 IU/ml higher rates of HBeAg loss were achieved. 2. HBV DNA level < 104 copies/ml at week 24 was predictive for VR , HBeAg loss  and HBeAg seroconversion .1. The patients with baseline alanine aminotransferase (ALT) ≥5 × the upper limit of normal  had higher rates of viral response (VR), HBeAg loss and HBeAg seroconversion at year 5 compared to the patients with ALT < 5 × ULN ; Patients with baseline HBV DNA < 109 copies/ml. Lower level of HBeAg(< 800 s/co) and HBsAg(< 5000 IU/ml) may be regarded as referenced factors. In patients with serum HBV DNA < 104 copies/ml at week 24 the therapy should continue, and a favorable outcome may be achieved in 5 years or longer.ADV treatment should be started for patients with baseline ALT≥5 × ULN or patients with ALT≥3 × ULN and HBV DNA < 10 Adefovir Dipivoxil (ADV) is a nucleotide analogue for treatment of hepatitis B. Long term treatment with ADV is well tolerated and may produce long-term virological, biochemical, serological and histological improvement . CompareThe aim of this study is to assess baseline and on-treatment serum markers in prediction of long term response in the early phase of treatment with ADV among HBeAg-positive CHB patients so as to identify the most beneficial patients from ADV treatment and optimize the therapy.6 copies/ml before treatment. Criteria for exclusion included serum creatinine greater than 1.5 mg/dl (130μmol/L); seropositivity for hepatitis C or D virus or human immunodeficiency virus. No patients received LAM or any other anti-HBV therapy within 6 months prior to treatment. Other treatments were not used during the therapy. Written informed consent was obtained from all patients and the study was approved by the Ethical Committee of Jinan Infectious Disease Hospital.48 HBeAg-positive CHB patients who enrolled in the study were treated with ADV (provided by GlaxoSmithKline) and followed up for 5 years. All patients were seropositive for hepatitis B surface antigen (HBsAg) and HBeAg for more than 6 months and with baseline ALT ≥1.2 × the upper limit of normal  and HBV DNA ≥1010 copies/ml or more than the treatment nadir) were assessed for the development of ADV-associated mutations (rtA181V and rtN236T) in the HBV polymerase.All patients were followed up at weeks 4, 12, 24, 52 and every 12-16 weeks after week 52 for detection of serum biochemical parameters, serum viral load  and HBV markers (micro particle enzyme immunoassay with ABBOTT reagents). DNA sequencing and phylogenetic analysis of HBV genome were evaluated at baseline. Serum samples at first time point from subjects who experienced a breakthrough of HBV DNA (HBV DNA level increased by 1 logThe primary efficacy endpoints in this study were HBeAg seroconversion defined as combination of HBeAg loss and development of hepatitis B e antibody accompanied by HBV DNA negative(< 300 copies/ml). The secondary efficacy endpoints are HBeAg loss and viral response (VR) defined as HBV DNA negative.Descriptive statistics such as the mean, median, and standard deviation for each continuous variable and frequencies for each categorical variable were used to summarize the data as well as detect outliers and missing values. The associations of baseline and on-treatment parameters with virological, serological and biochemical responses were assessed using Chi-square tests or Fisher's exact tests. All p values were calculated with two-sided significance level of 0.05. Data analyses were performed using SAS 9.2 .Except for 1 woman who withdrew because of pregnance at week 104, 47 patients completed 5 years' follow up. All patients were ethnically Chinese and HBV genotype C positive. The baseline demographic, clinical and virological data are shown in Table Of 47 patients, the rates of VR, accumulative HBeAg loss, HBeAg seroconversion and ALT normalization in the end of the fifth year were 66.0%, 36.2%, 23.4% and 70.2%, respectively. The rates of HBeAg loss increased over time, and the proportion of patients with ALT normalization and HBV DNA < 300 copies/ml achieved maximal values after 2 and 4 years respectively Figure . Virus bWe evaluated baseline characteristics such as ALT, HBV DNA, HBsAg and HBeAg level in prediction of 5-year response and found baseline ALT was a potential predictor of outcome. Patients with baseline ALT ≥5 × ULN were more likely to have HBeAg seroconversion, HBeAg loss and VR than patients with ALT < 5 × ULN Table , while i9 copies/ml, ALT was positively associated with VR and HBeAg seroconversion. The rate of HBeAg seroconversion was significantly higher in patients with ALT ≥3 × ULN when compared to the patients with ALT < 3 × ULN .Even so, there was a trend that the rate of VR in the 5 years decreased with the higher levels of baseline viral load Figure . In subg10 copies/ml at week 24 had higher rates of HBeAg seroconversion, HBeAg loss and VR compared to the patients with serum HBV DNA ≥4 log10 copies/ml. The drop of the serum HBV DNA ≥3 log10 copies/ml at week 4 and HBV DNA undetectable at week 52 can predict VR and HBeAg loss while the drop of the serum HBV DNA ≥4 log10 copies/ml at week 12 was significantly associated with the increased rates of HBeAg loss and HBeAg seroconversion.The relationships between on-treatment HBV DNA levels and 5-year outcomes were presented in Table 4- 6.5 × 107 copies/ml, and ALT flares were found in 3 patients but none of them developped liver decompensation. ADV correlated mutations were detected in 3 of the 4 patients (1 of them with N236T and another 2 with combination of A181T/V and N236T mutations in HBV DNA polymerase). None of the patients who achieved HBV DNA < 4 log copies/ml at week 24 experienced viral breakthrough. All four patients were then given additional LAM for combination therapy.Four patients experienced viral breakthrough at week 104, 184, 208, 260 respectively. HBV DNA rebounded to 2.2 × 10Four patients had an increase in serum creatinine of more than the peak value of normal (1.5 mg/dl), but the abnormality was not confirmed by a consecutive sample test. Three patients had slightly elevated serum uric acid in incontinuous samples. No action was taken regarding study medication dosing.7 and 108 copies/ml [9 copies/ml had more chance of VR, HBeAg seroconversion and ALT nomalization at year 2 [9 copies/ml and ALT ≥3 × ULN had more favorable outcomes. An elevated ALT level indicates increased clearance to HBV infected hepatocytes. It was reported that Chinese patients with ALT > 5 × ULN had high rate of spontaneous HBeAg seroconversion even without treatment [The response of ADV monotherapy for HBeAg positive CHB patients is less satisfying comparing with that of other oral NAs, but in many Asian countries like China, tenofovir is unavailable, ADV is still the only nucleotide analogue without cross resistance to other NAs to date -14. The opies/ml . Subgrout year 2 . There wreatment , but trereatment -20. Simireatment ,22. The reatment ,24. More10 copies/ml at week 24 was predictive for VR, HBeAg loss and HBeAg seroconversion after 5-year treatment, The drop of HBV DNA from baseline ≥3 log10 copies/ml at week 4, ≥ 4 log10 copies/ml at week 12 and HBV DNA turning negative at week 52 can also predict favorable outcomes although not as optimal as HBV DNA < 4 log10 copies/ml at week 24. None of the patients who achieved HBV DNA < 4 log10 copies/ml at week 24 experienced viral breakthrough. Accordingly we recommend serum HBV DNA level < 4 log10copies/ml at week 24 as one of the major predictors for long term outcomes in patients with ADV therapy.Early HBV DNA reduction may also contribute to VR and HBeAg seroconversion in some studies ,15,25. IOur study has some limitations because of its small sample size and lack of a control group. However, in our study most patients completed 5 years' follow-up, and the detection method was advanced. The findings may give some evidence to manage HBeAg positive patients who intend to accept or have already accepted ADV therapy.9 copies/ml, lower level of HBeAg(< 800 s/co) or HBsAg (< 5000 IU/ml) may be regarded as referenced factors. Patients will be followed up regularly and long term outcome may be predicted according to on-treatment HBV DNA. For patients with HBV DNA level < 104 copies/ml at week 24 therapy should continue and favorable outcomes may be achieved in 5 years or longer. For others with HBV DNA ≥104 copies/ml at week 24, some modifications for the therapeutic regimen such as addition or switch to another agent should be considered to enhance the long term response.ADV treatment may be initiated to patients with baseline ALT≥5 × ULN or patients with ALT≥3 × ULN and HBV DNA < 10ADV: Adefovir Dipivoxil; ALT: alanine aminotransferase; CHB: chronic hepatitis B; HBeAg: hepatitis B e antigen; HBV: hepatitis B virus; LAM: lamivudine; NAs: nucleos(t)ide analogues; ULN: upper limit of normal; VR: viral response.The authors declare that they have no competing interests.HL conceived of the study, participated the design, carried out the study and drafted the manuscript. DYG carried out laboratory work, FS and JYZ participated in following up of patients and data collecting. BL participated in the design of the study and performed the statistical analysis. LXM participated in the design and coordination and helped to draft the manuscript. All authors read and approved the final manuscript.


Limited information is available on the relationship between nevirapine plasma concentrations and virologic response or liver toxicity in Chinese patients with HIV infection. The objective of this prospective study was to test this relationship and to determine the minimal therapeutic trough concentration of nevirapine for Chinese patients.trough (12 hr postdose) and C2 (2 hr postdose) for measurement of nevirapine concentrations 6 months after treatment initiation. Therapeutic outcomes, viral load and CD4 cell count, were assessed at 3 and 6 months after starting therapy, while the evaluation of hepatotoxicity was undertaken 12 months after nevirapine treatment.A total of 227 HIV-infected, treatment naïve patients were enrolled into this study. Blood samples were taken at Ctrough of nevirapine for Chinese patients was determined to be 3.9 µg/ml using the receiver operating characteristic curve. Virologic failure was observed in 21% (6/29) of patients with low nevirapine concentrations (<3.9 µg/ml) versus 5% (4/87) in patients with concentrations higher than 3.9 µg/ml (p = 0.015). Hepatotoxicity was significantly associated with the median nevirapine trough concentrations among male patients  and hepatitis C virus co-infection (p = 0.039).A significant correlation between nevirapine trough concentrations and viral load was noticed after 6 months of treatment, particularly in patients with partial response and viral failure (p<0.01). The therapeutic Ctrough of nevirapine was 3.9 µg/ml, higher than the recommended 3.0 µg/ml. The correlation between nevirapine concentrations, efficacy and hepatotoxicity suggests the benefit of dosage adjustment based on therapeutic drug monitoring among Chinese HIV-infected patients to optimize nevirapine containing antiretroviral therapy.Among Chinese patients with HIV infection, the therapeutic C Highly active antiretroviral therapy is considered an effective approach for the management of HIV/AIDS. Due to its low cost and high efficacy, nevirapine -containing regimens are often preferable to others in resource-limited countries As the majority of the previous studies were performed among Caucasian subjects, there is generally a lack of information regarding the efficacy and safety of nevirapine in Chinese HIV-infected patients. A number of studies exploring the association of exposure to nevirapine with virologic response yielded a target trough concentration of ∼3.0 mg/l trough (n = 116) and C2 (n = 49).Of 227 HIV-positive antiretroviral-naive patients screened, 173 were treated by a fixed combination antiretroviral therapy containing nevirapine for at least 24 weeks and included in the virologic response analysis . Demogratrough and C2 in the three groups are summarized in trough in patients with virologic failure was significantly lower than that in partial response and complete response groups , whereas no significant differences were noted between partial and complete response groups. In contrast, no significant difference in median C2 was noted among these groups (p = 0.608). A relatively large inter-patient variability in nevirapine Ctrough was noted  for all patients, particularly when limited to patients with a partial response or viral failure .The overall incidence of virologic failure was 10% (18/173). Nevirapine Cas noted , Table 2trough threshold for therapeutic drug monitoring in Chinese HIV-infected patients, the receiver operating characteristic curve  and an acceptable specificity of 78% (p = 0.06). Virologic failure was observed in 21% of patients with concentrations <3.9 µg/ml versus 5% with concentrations higher than 3.9 µg/ml (p = 0.015) (In order to determine the nevirapine C= 0.015) .Of the 227 patients screened, 191 patients were qualified for the liver toxicity analysis . The inctrough and C2 in different groups are summarized in trough between these groups . Previous studies suggest that gender, hepatitis B or C virus co-infection and baseline liver function are independent risk factors for nevirapine related liver toxicity. Thus, the impact of gender, baseline liver function and presence of hepatitis C virus antibody on Ctrough were evaluated. A similar analysis for C2 was not possible due to the small number of C2 samples. A significantly higher median Ctrough was noted in males with severe liver toxicity in comparison to those without severe toxicity . No significant differences were observed in Ctrough medians in other subgroups with and without severe hepatotoxicity . The hepatitis C virus co-infection rate was 29% (56/191) in our study population. Active HCV co-infection, defined as HCV RNA >103copies/µl, led to a significantly higher incidence of liver toxicity, 44% (10/23) compared to 18% (6/33) among patients without active HCV co-infection  and 16% (10/63) in the patients with the baseline CD4+ T count >250/mmtrough have a significantly higher risk of virologic failure, those with a high Ctrough are at greater risk of severe liver toxicity, especially male patients. Our data suggest that for the optimal virologic outcomes, a trough nevirapine concentration of ≥3.9 µg/ml should be sustained throughout the treatment course for Chinese patients with HIV infection. To our knowledge, this is the first report of an association between nevirapine concentration and clinical outcomes in Chinese patient population. This adds to the evidence supporting the usefulness of therapeutic drug monitoring in optimizing treatment of this population.This study found a significant correlation between nevirapine trough concentrations, virologic response and liver toxicity among Chinese HIV-infected patients. While patients with low nevirapine Ctrough among Chinese patients with partial and complete response after a 6-month treatment were significantly higher than that among patients with viral failure . Another study of 178 patients identified a mean plasma concentration of 4.3 µg/ml to be an independent factor for virologic failure trough (3 µg/ml) had an unfavorable sensitivity (40%) and may lead to a high incidence of virologic failure. The sensitivity would be improved to 60% without a marked decrease of specificity using 3.9 µg/ml. Therefore, to minimize the risk of virologic failure, we believe a more suitable nevirapine Ctrough threshold is 3.9 µg/ml in Chinese patients, a 30% increase from the current nevirapine Ctrough recommendation (3 µg/ml).No target trough concentration of nevirapine has been established for treatment success in Chinese patients. Although treatment guidelines recommend various target thresholds for nevirapine trough concentrations, these data are predominately from studies in Caucasian and African American patients, which may not be applicable to patients of Asian descent. Additionally, the current recommendations for nevirapine Ctrough and liver toxicity are not in agreement. González de Requena et altrough at week 24 was an independent predictor for liver enzyme elevations. However, a prospective population pharmacokinetic study Liver toxicity is the most common adverse effect associated with nevirapine treatment while results from previous studies on the relationship of nevirapine Ctrough or C2 between patients with and without severe liver toxicity. Several confounding factors such as gender, HCV co-infection and baseline liver function have been suggested for nevirapine exposure and liver toxicity trough was significantly higher in Chinese male patients with severe liver toxicity. However, such relationship was not observed in females and other subgroups, suggesting the nevirapine-related liver toxicity might be gender dependent. While previous studies 3) . This may be due to the relatively small sample size, along with racial and ethnic factors.Our data confirmed no significant differences in nevirapine COur data confirmed that hepatitis C virus co-infection was significantly associated with an increased risk of severe liver toxicity in Chinese HIV+ patients 2 was chosen to represent nevirapine peak concentration, based on previous pharmacokinetic results that indicate the mean time to reach nevirapine peak concentration was 2.01 hours 2 had no correlation with any clinical outcomes evaluated in this study. This may be due to inter-patient variability, i.e. the exact peak time for nevirapine is different from patient to patient. Thus, it is difficult to collect samples that truly represent peak concentrations. Our data suggest that the clinical use of nevirapine peak concentrations may not be practical. Future studies using other metrics, such as area under the time-concentration curve derived from population analysis, are warranted to explore the relationship between pharmacokinetics of nevirapine and clinical outcomes in Chinese HIV+ patients.The use of nevirapine peak concentration as a monitoring parameter was explored in this study, as limited information is available on this topic to date. Nevirapine Ce.g. dosing in relation to food, concurrent medications, or genetic polymorphisms of CYP2B6, which significantly influenced nevirapine metabolism in HIV-infected patients in Uganda There were several limitations to this multi-centre prospective study in patients receiving nevirapine-containing therapy. The cohort was relatively small and heterogeneous, including patients with various underlying medical conditions. However, our patients reflected a typical Chinese HIV+ clinical cohort In conclusion, this study supports the association between nevirapine concentrations and treatment outcomes in Chinese HIV+ patients. For patients with low trough concentrations, dose adjustments should be considered to achieve and sustain a median nevirapine trough concentration greater than 3.9 µg/ml. Given the inter-patient variability and the lack of an upper pharmacokinetic threshold for nevirapine associated hepatotoxicity, dose modification should be considered only in symptomatic patients. Finally, further studies are warranted, as a therapeutic range for nevirapine in Chinese HIV+ patients remains elusive.th Hospital of Guangzhou, HIV/AIDS Care Center of Yunnan, and Zhejiang Medical University. Written consent was obtained from each patient. Eligible patients were aged from18 to 65 years, and received a standard regimen that included nevirapine and two nucleoside reverse transcriptase inhibitors between January 2002 and November 2008 from thirteen HIV/AIDS Clinical Centers in China. A total of 227 patients were enrolled in this study  was administered at 200 mg once daily for 2 weeks and 200 mg twice daily thereafter. The bioequivalence of nevirapine in reference to Viramune® from Boehringer Ingelheim was demonstrated in the previous studies The primary efficacy outcome was virologic failure, defined as a single plasma HIV-1 RNA concentration  >400 copies/ml at week 24. Complete virologic response was defined as a viral load <50 copies/ml at week 24, whereas partial virologic response was defined as a viral load between 50 and 400 copies/ml at week 24. The QUANTIPLEX HIV-1 RNA assay was used to measure the plasma HIV-1 RNA concentrations. The limits of detection of the assay, as indicated by the manufacturer, was 50∼500,000 copies/ml.All clinical adverse events and laboratory abnormal results were documented. Severe liver toxicity was defined as laboratory abnormalities greater than grade 3 , including a significant increase  of aspartate aminotransferase (AST), alanine aminotransferase (ALT) or total bilirubin, severe clinical symptoms consistent with liver toxicity, or a therapy change caused by liver toxicity during the first 12 months of treatment.2) during DOT or prior to the morning dose for the detection of trough concentration . The nevirapine concentration in plasma was determined by a validated HPLC assay modified from a previous study th month of nevirapine treatment were assayed for concentrations. Additional plasma samples were collected for concentration assessment if severe liver toxicity presented. For patients without severe liver toxicity, the nevirapine plasma concentrations were determined during the 12-month follow-up visit.A plasma sample was collected at 2 h after oral administration of nevirapine . For all tests, p<0.05 was considered to be statistically significant.All statistical analyses were performed using the SPSS 11.5 statistical package. Categorical variables were tested with Chi-Square or Fisher's exact test, and continuous variables were tested with Kruskal-Wallis or student


Data regarding the outcomes of HIV-infected adults with baseline renal dysfunction who start antiretroviral therapy are conflicting.+ T-cell count measured at the time of antiretroviral therapy initiation and at follow-up. We used the adjusted Cockroft-Gault equation to calculate estimated glomerular filtration rates (eGFRs).We followed up a previously-published cohort of HIV-infected adult outpatients in northwest Tanzania who had high prevalence of renal dysfunction at the time of starting antiretroviral therapy (between November 2009 and February 2010). Patients had serum creatinine, proteinuria, microalbuminuria, and CD42) decreased from 131/171 (76.6%) at the time of ART initiation to 50/171 (29.2%) at the time of follow-up (p<0.001). Moderate dysfunction (eGFR<60 mL/min/1.73 m2) decreased from 21.1% at antiretroviral therapy initiation to 1.1% at follow-up (p<0.001), as did the prevalence of microalbuminuria . Use of tenofovir was not associated with renal dysfunction at follow-up.In this cohort of 171 adults who had taken antiretroviral therapy for a median of two years, the prevalence of renal dysfunction (eGFR <90 mL/min/1.73 mMild and moderate renal dysfunction were common in this cohort of HIV-infected adults initiating antiretroviral therapy, and both significantly improved after a median follow-up time of 2 years. Our work supports the renal safety of antiretroviral therapy in African adults with mild-moderate renal dysfunction, suggesting that these regimens do not lead to renal damage in the majority of patients and that they may even improve renal function in patients with mild to moderate renal dysfunction. Major advances in HIV care, particularly the widespread implementation of antiretroviral therapy (ART), have improved survival and decreased the incidence of opportunistic infections worldwide 22 and were therefore at increased risk for ART-related side effects. These findings were concerning given reports that renal dysfunction is associated with increased hazard of death among HIV-infected patients initiating ART Studies from several countries in sub-Saharan Africa have demonstrated a high prevalence of renal dysfunction in HIV-infected individuals, reporting that 34% to 77% of patients have estimated glomerular filtration rates (eGFRs) <90 ml/min/1.73 mAlthough renal dysfunction is known to be common in this population, data regarding the progression of renal dysfunction after the initiation of ART are conflicting. Several studies have followed patients for up to 12 years and demonstrated that baseline renal dysfunction improves after ART initiation in HIV-infected patients, regardless of which ART regimen is used Patients had consented for initial participation in the study done at the time of ART initiation and provided a second written informed consent prior to enrollment in this follow-up study. This study was approved by the institutional review boards of both the Catholic University of Health and Allied Sciences (CUHAS)/BMC and Weill Cornell Medical College.This study was conducted among adults receiving care at the HIV outpatient clinic at Bugando Medical Centre (BMC). BMC is the referral hospital for 13 million people in northwest Tanzania. It is located on the shore of Lake Victoria where the prevalence of HIV is over 6% + T-cell count (CD4 count), body mass index (BMI), serum creatinine, proteinuria, and microalbuminuria were obtained from the HIV clinic database. These measurements were repeated at the time of follow-up using the same reagents and laboratory instruments used at baseline. Serum creatinine was measured using a Cobas 400 clinical chemistry machine , calibrated by the IDMS-traceable Creatinine Jaffe 2 method. Spot proteinuria and microalbuminuria were measured in urine specimens using rapid test strips  and Micral-TestB , respectively.A structured questionnaire was used to collect demographic information. Baseline data (at the time of ART initiation) including CD4Continuous variables were summarized by medians and interquartile ranges (IQRs) and categorical variables were summarized by frequencies and percentages. We used.2 using the Mostellar formula 2.Pearson’s Chi square to compare categorical variables and paired t-tests and Wilcoxon signed-rank tests to compare continuous variables at ART initiation and at follow-up. Wilcoxon rank-sum tests were used to compare eGFRs between groups of patients with different outcomes. Univariable followed by multivariable logistic regression were used to determine the association between baseline characteristics and outcomes , and were summarized with odds ratios (ORs) and 95% confidence intervals (CIs) with associated p-values. Two-way hypotheses/confidence intervals were used for all calculations. Data were analyzed using StataIC/11.1 . Estimated glomerular filtration rates (eGFRs) were calculated by the Cockroft-Gault (CG) equation as a primary outcome since the CG formula had been used in analysis of the baseline cohort. We adjusted the creatinine clearance by CG for a body surface area of 1.73 mTwo hundred thirty-eight patients were enrolled from November 2009 to February 2010 and followed for a median of two years. The median age was 38  years and ∼70% were female. Over 90% of patients had no more than primary schooling, and over 80% were either unemployed or self-employed. Nearly two-thirds of patients lived with their partners (either married or cohabiting).Median baseline CD4 count at the time of starting ART was 143 (78–187) cells/µL, and median eGFR was 72.7 (55.1–100.7) by CG and 93.0 (66.0–129.0) by MDRD. Among these 238 patients, 153 (64.3%) had baseline decreased eGFR <90 by CG and 116 (48.7%) by MDRD. The most common ART regimens used were zidovudine/lamivudine/efavirenz (30%), stavudine/lamivudine/nevirapine (25%), tenofovir/emtricitabine/efavirenz (23%), and zidovudine/lamivudine/nevirapine (22%), and 169/171 patients were taking cotrimoxazole at the time of follow-up. Of note, 8 of the 40 patients who were treated with a tenofovir-containing regimen had a baseline eGFR <60 by CG.2. Nine patients met criteria for World Health Organization (WHO) immunological failure with CD4 counts either persistently <100 (3 patients) and/or below baseline (8 patients).At the time of follow-up, 17 patients had died, 32 were lost to follow-up, and 18 did not consent to additional testing. Among the remaining 171 patients, the median time on ART was 2.0 (1.8–2.4) years. All except two patients were currently receiving ART. Most patients experienced increases in both CD4 count and BMI, with the median CD4 count rising from 143 to 396 cells/µl and the BMI rising from 21 to 24.3 kg/m2 [0.80–0.99], p = 0.033). These factors remained significant when analyzed for death alone (n = 17) without the other 32 patients who were lost to follow-up.The baseline median eGFR among the 49 patients who ultimately died or were lost to follow-up was 65.6 (51.8–96.6), which was not statistically different from the baseline eGFRs of the 171 who participated or the 18 who declined to participate (eGFR = 74.1 (55.8–100.1), p = 0.20 and eGFR = 70.7 (58.5–112.3), p = 0.29 respectively, by Wilcoxon rank-sum). On multivariable logistic regression analysis, factors that were significantly associated with death or loss to follow-up included less education , living with one’s partner , and lower baseline BMI (OR = 0.89 for each increasing kg/mBaseline decreased eGFR (<90 by CG) demonstrated a borderline trend towards association with death  though not loss to follow-up . Baseline decreased eGFR by MDRD was not associated with death or loss to follow-up. Neither baseline nor current low eGFR (<90 by CG) was associated with immunological treatment failure . Among the 54 patients who were originally treated with tenofovir, 5 died (9.3%) compared with 12 of the 184 patients (6.5%) who were not treated with tenofovir (p = 0.55).). At follow-up, 36 of 171 (21.1%) had decreased eGFRs of <90, and only 2 (1.2%) had eGFRs <60 compared to 107/171 (62.6%) and 36/171 (21.1%) respectively at baseline (p<0.001 for each). By MDRD, 23 of 171 (13.5%) had eGFRs <90, and the same two patients had eGFRs <60. The prevalence of microalbuminuria decreased from 72.1% to 43.9% (p<0.001), and the prevalence of proteinuria decreased from 35.7% to 8.8% (p<0.001) at follow-up. All eight patients who had had initial eGFRs <60 and were treated with tenofovir had follow-up eGFRs >60 and stable (n = 3) or improved (n = 5) microalbuminuria and proteinuria.At the time of follow-up, patients’ eGFRs by CG equation had improved, from a median of 74.1 (55.8–100.1) at baseline to 103.4 (85.3–135.6) at follow-up (p<0.001) Table 1By univariable logistic regression analysis, decreased eGFR (<90 by CG) after an average of two years on ART was significantly associated with following baseline characteristics: lower CD4 count , lower BMI , and older age . When subjected to multivariable analysis, age, baseline CD4 count and baseline BMI remained significantly associated with decreased eGFR Table 2.Of note, neither baseline decreased eGFR nor tenofovir use was associated with decreased eGFR at follow-up. In fact, we observed a trend towards renal improvement in those who received tenofovir-containing regimens . In addition, each subsequent year on ART was associated with a trend towards protection against decreased eGFR (OR = 0.6 [0.4–1.1]. p = 0.13).This study, which followed a cohort HIV-infected patients in whom nearly two-thirds had renal dysfunction at the time of initiating ART, revealed substantial renal improvement in the majority of patients after a median of two years. The prevalence of renal dysfunction dropped from 77% pre-ART to 29% at follow-up, and the prevalence of moderate renal dysfunction (eGFR <60) dropped from 21% to 1%. We additionally noted significant decreases in the prevalence of microalbuminuria and proteinuria . In the face of conflicting reports on the utility of ART for reversing renal dysfunction, our findings provide reassurance that, even in the setting of mild-moderate renal dysfunction, ART is safe and is more likely to improve than to worsen renal function.These findings have particular import in sub-Saharan Africa, where the burden of renal disease among HIV-infected patients is high Our work extends the findings of other studies conducted in sub-Saharan Africa. A study in rural Uganda similarly reported improvement in renal dysfunction of most HIV-infected patients after ART initiation Furthermore, our data supports the safety of tenofovir use in sub-Saharan Africa. A 2010 meta-analysis found that tenofovir was associated with a significant, though clinically-modest, loss of renal function Our study has several limitations. First, like the other studies of renal function and tenofovir safety in sub-Saharan Africa, this is an observational cohort study and not a randomized clinical trial. An additional limitation of our study, as with many studies of HIV in sub-Saharan Africa, is that we were not able to measure viral loads. These limitations highlight the salient role that a rigorously-conducted randomized controlled trial in this setting would play in clarifying this issue.In conclusion, the remarkably high prevalence of renal dysfunction in this cohort of HIV-infected adults who began ART in Tanzania in 2009 had improved in the large majority of patients when reassessed after ∼2 years of ART. Our data also provide some additional support for the WHO’s recommendation for tenofovir-based regimens in sub-Saharan Africa. Though our sample size was small, we found that patients given tenofovir-containing regimens experienced renal stability or improvement, even if they had pre-existing mild to moderate renal dysfunction. We cautiously support use of tenofovir without routine renal monitoring in patients initiating ART in resource-limited settings such as sub-Saharan Africa, although larger studies are needed to confirm our findings.


Viral load monitoring (VLM) to identify individuals failing antiretroviral therapy (ART) is not widely available in resource-limited settings. We compared the genotypic resistance patterns between clients with VLM versus immunological monitoring (IM).Between 2004–2008, 559 ART naïve clients were enrolled in a prospective cohort, initiated on ART, and monitored with viral load (VL) and CD4+ cell counts every 6 months (VLM group). From February 2008 through June 2009, 998 clients on ART for 36–40 months (corresponding to the follow-up time of the VLM group) at the same clinic and monitored with CD4+ cell counts every 6 months were recruited into a cross sectional study (IM group). Samples from VLM clients at 12, 24 and 36 months and IM clients at 36–40 months with VL > 2000 copies/ml underwent genotypic drug resistance testing.P < 0.0001) had at least 1 non-nucleoside reverse transcriptase mutation. 19/39 (49%) of VLM clients had an M184V mutation compared to 61/70 (87%) in the IM group (P < 0.0001). Only 2/39 (5%) of VLM clients developed thymidine analogue mutations compared to 34/70 (49%) of IM clients (P < 0.0001).Baseline characteristics were similar. Virologic failure (VL > 400 copies/ml) at 12, 24 and 36 months in the VLM group were 12%, 6% and 8% respectively, and in the IM group 10% at 36–40 months. Samples from 39 VLM and 70 IM clients were genotyped. 23/39 (59%) clients in the VLM group  compared to 63/70 (90%) in the IM group, (Routine VL monitoring reduced the rate of accumulated genotypic resistance to commonly used ART in Uganda. Antiretroviral treatment (ART) programs have scaled up to reach over 5.2 million HIV-infected individuals in need of life-saving treatment in low and middle income countries by the end of 2009 . Most ofFailure to achieve or maintain virologic suppression for prolonged periods of time may lead to the sequential development of thymidine analogue mutations (TAMs) in clients taking nucleoside reverse transcriptase inhibitors (NRTIs) such as zidovudine (ZDV) or stavudine (d4T) as part of their ART regimens -12. The The objective of our study was to compare genotypic resistance patterns (with particular attention to TAMs) among a group of clients on first-line ART at an urban clinic in Kampala, Uganda, who were monitored both clinically, immunologically and virologically as part of a research cohort study to a similar group of clients attending the same clinic who were monitored only clinically and immunologically.The Infectious Diseases Institute (IDI) of Makerere University College of Health Sciences  is a center of excellence in the delivery of HIV clinical care, research and training, with over 10,000 active clients registered including over 6,500 receiving ART. Eligibility criteria for ART at the time of this study (February 2008 through June 2009) were CD4 < =200 cells/ul or WHO stage IV disease; first-line regimens included stavudine or zidovudine plus lamivudine and nevirapine or efavirenz.Clients attending the routine care clinic who become eligible for ART are offered adherence counseling prior to ART and also during follow-up if deemed necessary by clinicians. Clients are seen monthly for follow-up assessments, drug refills and monitored through prospective CD4+ cell counts every 6 months. Treatment failure was assessed according to the WHO immunologic or clinical criteria for treatment failure . A more A nested research cohort within the routine care clinic was established in 2004, with a consecutive prospective enrollment of 559 ART-naïve clients who initiated ART from April 2004 through April 2005; clients enrolled in this cohort are monitored through both CD4+ counts and viral load measurement , every 6 months; plasma is also stored for future investigations. A more detailed description of the study procedures and data collection has been presented elsewhere . In brieFrom February 2008 through June 2009, a cross sectional study was conducted in the IDI routine care clinic population recruiting a convenience sample of clients who were on first-line ART regimens for 36–40 months (corresponding to the length of follow-up time reached by IDI research cohort clients). Clients still on first-line ART were consecutively recruited during their monthly follow-up visits. After providing written informed consent, blood was drawn for HIV viral load (VL), CD4+ cell count and plasma was stored for genotyping. Genotyping was done on all clients found to have an HIV VL > 2,000 copies/ml (corresponding to the sensitivity threshold of the assay). Results of the viral load and genotyping test were made available to the physicians for clinic management of their clients.In the research cohort clients, those alive and in care at 12 months were considered eligible for this analysis. We included any research cohort client having a HIV VL of >2000 copies/ml while still on first-line at months 12, 24 or 36 of follow-up; however, clients who had a detectable VL above 2,000 copies/ml up to month 12 but subsequently (months 24 or beyond) became virologically suppressed without regimen change were not included in the genotyping analysis as these were considered to have early adherence problems rather than drug resistance . All cliP values are two-sided. All analyses were performed using SAS version 9.2  or Stata version 11.1 .Baseline characteristics for both monitoring groups were compared using the Fisher exact test for categorical variables  and Mann–Whitney U test for continuous variables . We used the Mann–Whitney U test to compare median CD4+ count increase at follow-up. We used the t-test for proportions to assess differences in mutation rates across monitoring groups. All Plasma was separated within 2 hours from blood draw and stored immediately at −80°C. HIV-1 RNA was tested with the Roche Amplicor MONITOR v1.5 assay . HIV-1 RNA was extracted from plasma samples using a Qiagen RNA extraction method . Polymerase gene-specific primers were used for reverse transcriptase, followed by 750 base pair pol gene encompassing amino acids 1–242 of reverse transcriptase. The PCR products was then purified using the QIAquick PCR purification kit  and sequenced using Beckman Coulter sequencing kit . The obtained sequences were then edited using BioEdit sequence editor version 7.0.4. The cleaned sequences were then uploaded into the Stanford University HIV Drug resistance database to obtain the drug resistance profile. Genotyping assays were performed at the Joint Clinical Research Center laboratory in Kampala. For genotype analysis, mutations were generally categorized according to the International AIDS Society-USA recommendations .All study participants from the IDI routine care clinic provided written informed consent, while the participants from the IDI research cohort had already provided consent at study enrollment for future use of stored plasma. The study was approved by the National AIDS Research Council Ethics Board, the Uganda National Council for Science and Technology, and the National Institute of Allergy and Infectious Diseases Intramural Institutional Review Board.Genbank accession numbers: KC008609 to KC008711.Four hundred forty one of the 559 research cohort clients (VLM group) were alive and in care at 12 months and included in this analysis. Nine hundred ninety-eight clients on ART for 36–40 months were recruited from the routine clinic population (IM group). Table Samples from 39 VLM and 70 IM clients were successfully amplified and genotyped Figure  &1b. SomComparing the 39 first genotypes from VLM clients to the 70 IM clients, 23/39 (59%) of VLM clients as opposed to 63/70 (90%) in the IM group had at least 1 NNRTI mutation (p < 0.0001)  of VLM clients as opposed to 63/70 (90%) in the IM group had at least 1 NNRTI mutation (p = 0.1034). Four out of ten (40%) of VLM clients had an M184V mutation compared to 61/70 (87%) of IM clients (P = 0.0185). None of the VLM clients developed TAMS whereas 34/70 (49%) of IM clients developed TAMS (p < 0.0001).A total of 26 clients in the VLM cohort were switched from first to second-line ART in the first 36 months of follow-up, while all patients in the IM group reached 36 months on first-line ART without clinicians suspecting treatment failure. The median number of VL measurements before switch was 4 and median VL prior to switch was 21,773 .Although the proportion of clients failing ART at 36 months was comparable between those monitored with VL and compared to those monitored with CD4+ cell counts only, the proportion of the clients with multiple resistance mutations especially TAMS was significantly higher in the IM clients. This is the first observational study directly comparing genotypic resistance profiles to commonly used antiretroviral drugs between individuals monitored with virologic compared to immunologic monitoring alone. Several studies have documented the lack of sensitivity of immunologic and clinical criteria to identify individuals failing ART raising concern regarding the potential for increased genotypic resistance to ART, which could result ,11,18. IThe participants enrolled in the IM cohort in this study were clients who had not been identified as having any evidence of treatment failure by clinicians. In contrast to most studies looking at resistance among clients in RLS, this was not a selected group of individuals failing by immunologic or clinical criteria and would have been left on first-line ART if VL testing was not done as part of this study. The significant degree of resistance observed in this group raises concern about the need for periodic VL monitoring in settings where none is currently available in routine care. A moderate proportion of clients had multiple TAMS possibly resulting in compromised efficacy of commonly used second-line ART regimens available in RLS.Our study has limitations; it is not a randomized clinical trial and therefore unmeasured bias between the VLM and IM groups remains a possibility. Because the IM group was cross-sectional, we have no data on lost to follow-up or number of deaths before study enrollment; however, we would expect clients lost to care to do as poorly or worse with respect to rates of virologic failure. Clients enrolled in the VLM group followed certain inclusion criteria including living within 20 km of the clinic and willingness to attend to visit schedules which could also select for a more adherent population compared to the IM group. The use of stored specimens resulted in some amplification failures among the VLM group, which could possibly affect our overall results. Finally, we have no information on duration of virologic failure among the IM group to allow us to control for duration of failure which could influence the mutation patterns observed.Despite the limitations mentioned pertaining to study design, baseline characteristics, treatment setting and study staff were all similar. Virologic and immunologic characteristics at 36 months of follow-up were also similar between the two groups. . We believe the reduced rate of resistance, particularly to NRTIs, observed among VLM clients is explained by the frequent VL monitoring and ability to detect and allow caregivers to discuss adherence and possibly switch to second-line regimens prior to the development of extensive drug resistance. Our results support ongoing efforts to improve adherence counseling strategies as treatment programs continue to scale up access. Our study was not designed to look at longer term mortality benefits between our VLM and IM clients, however, a recent multi-country study conducted in Malawi, Zambia and South Africa suggested that the lower rate of mortality observed among South African ART programs could be explained in part by the presence of VL monitoring and timely switch to second-line regimens . As ART Access to viral load monitoring remains a priority for countries continuing to scale up ART in order to limit the emergence of drug resistance. Further studies are warranted to evaluate novel monitoring strategies that minimize resistance, maximize positive clinical outcomes, recognizing cost constraints faced by programs challenged by ever increasing numbers needing HIV treatment.The authors declared that they have no competing interests.SJR, HK, TCQ and AK contributed to study design, participant recruitment and follow-up, and final analysis. KN contributed to study conduct and statistical analysis. YCM, MK and BC contributed to participant recruitment, study conduct and analysis. In performed laboratory assays and contributed to analysis. All authors contributed to manuscript writing. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/12/381/prepub


The incidence of Hodgkin lymphoma (HL) among HIV-infected individuals remains unchanged since the introduction of combination antiretroviral therapy (cART). Recent epidemiological data suggest that CD4 count decline over a year is associated with subsequent diagnosis of HL. In an era of economic austerity monitoring the efficacy of cART by CD4 counts may no longer be required where CD4 count>350 cells/µl and viral load is suppressed (<50 copies/ml).We sought to establish among our HIV outpatient cohort whether a CD4 count decline prior to diagnosis of HL, whether any decline was greater than in patients without the diagnosis, and also whether other clinical or biochemical indices were reliably associated with the diagnosis.Twenty-nine patients with a diagnosis of HL were identified. Among 15 individuals on cART with viral load <50 copies/ml the change in CD4 over 12 months preceding diagnosis of HL was −82 cells/µl . Among 18 matched controls the mean change was +5 cells/µl, 95% CI −70 to 80, p = 0.89). The decline in CD4 over the previous 6–12 months was somewhat greater in cases than controls . In 26 (90%) patients B symptoms had been present for a median of three months (range one–12) before diagnosis of HL.The CD4 count decline in the 12 months prior to diagnosis of Hodgkin lymphoma among HIV-infected individuals with VL<50 copies/ml on cART was not significantly different from that seen in other fully virologically suppressed individuals in receipt of cART and who did not develop HL. All those who developed HL had B symptoms and/or new palpable lymphadenopathy, suggesting that CD4 count monitoring if performed less frequently, or not at all, among those virologically suppressed individuals with CD4 counts >350 may not have delayed diagnosis. While the incidence of AIDS-defining malignancies such as Kaposi sarcoma and non-Hodgkin lymphoma has fallen since the introduction of highly active antiretroviral therapy (HAART) 3 among virologically suppressed patients is common An association between a falling CD4 cell count, not explained by virological failure of HAART, and a diagnosis of Hodgkin lymphoma has been described by the COHERE collaboration We reviewed the CD4 dynamics, HAART history and clinical features in virologically suppressed patients with HIV-associated Hodgkin lymphoma and among matched controls to assess whether a CD4 count decline in virologically suppressed patients was indicative of development of Hodgkin lymphoma, and to identify if such a decline, if present, was associated with any clinical or laboratory markers suggestive of Hodgkin lymphoma.We undertook a retrospective cohort study of all HIV-associated Hodgkin lymphoma diagnoses at our University-affiliated hospital-based service in London, between 1996 and 2012. Mortimer Market Centre and University College London Hospitals provide HIV care to over 4,000 individuals in North central London, United Kingdom (UK). Patients were managed according to UK National Guidelines, with clinical review and CD4 monitoring every three to six months 3) at the earliest date  prior to the ‘diagnosis’ date for which there was a value available for both cases and controls. Where possible two controls were matched to each case.For each individual with Hodgkin lymphoma data were extracted from paper case note review and interrogation of electronic patient records, including viral load, antecedent CD4 dynamics (absolute CD4 count) prior to diagnosis of Hodgkin lymphoma, as well as clinical and laboratory parameters. All patients in the cohort who received HAART did so with two nucleoside reverse transcriptase inhibitors and one non-nucleoside reverse transcriptase inhibitor, a boosted protease inhibitor, or an integrase inhibitor. Individuals with a fully suppressed viral load (<50 copies/ml) and in receipt of HAART at diagnosis of Hodgkin lymphoma were matched with controls who were attending the outpatient clinic at Mortimer Market Centre, over the same time interval and who were also in receipt of HAART and had a fully suppressed viral load, and who did not subsequently develop Hodgkin lymphoma. For each of these control patients equivalent data was abstracted from case notes and electronic patient records, relating to a ‘diagnosis date’ close to diagnosis in the matched case and 12 months prior. Controls were matched to cases on the basis of age (±6 months), gender, and CD4 lymphocyte count (±100 cells/mmThe Fisher’s exact test (two-tailed) was used to compare proportions; the matched pairs Students’ T-test was used to compare CD4 counts at baseline and at diagnosis for cases and controls separately. These tests were carried out in GraphPad Prism v4.01 . To compare the change in CD4 over time in cases with their matched controls, linear regression with the change in CD4 as outcome variable and case or control status as predictor was used, and generalised estimating equations in Stata 12  provided robust standard errors that recognised the matching. Analysis of change in CD4 count in cases was based on the change from the earliest date  prior to diagnosis for which the CD4 count was measured to diagnosis, and for comparison of cases to controls change from the earliest date where the CD4 was measured for both case and matched control(s) was analysed. A p-value of <0.05 was considered significant.Between January1996 and May 2012 a histologically-confirmed diagnosis of Hodgkin lymphoma was made in 29 HIV-infected patients: 27 (93%) were male and six (21%) were Black African. Eighteen were men who have sex with men and two were intravenous drug users. Three patients were co-infected with Hepatitis B and two were co-infected with Hepatitis C. Their median age was 41 years (range 26–61) and median time from diagnosis of HIV infection to diagnosis of Hodgkin lymphoma was 67 months (range 0–320). No patient received interferon-γ and none started co-trimoxazole. Fifteen patients were receiving HAART and were fully suppressed (VL<50), fourteen patients were not in receipt of HAART and had detectable viral loads. Fifteen patients, fully suppressed (VL<50) were identified. These cases were matched to 18 control patients .18FDG PET-CT scan. Three patients with histologically-confirmed bone marrow involvement had 18FDG PET-CT scans suggestive of bone marrow infiltration. Of the other ten patients with no evidence of bone marrow involvement on 18FDG PET-CT, five had Hodgkin lymphoma on bone marrow biopsy.At diagnosis of Hodgkin lymphoma, eighteen individuals had stage IVB, two IVA, four IIIB, three IIB, one 1A and one stage 1B disease. Seventeen (59%) had bone marrow involvement; one patient did not undergo bone marrow examination, and this was the only site of positive histology in 7/29 (24%) episodes of Hodgkin lymphoma. At diagnosis of Hodgkin lymphoma 13 patients had a Among patients with advanced disease  the median lymphoma prognostic score (IPS) Seventeen (59%) individuals had started HAART prior to diagnosis of Hodgkin lymphoma . Fifteen (52%) individuals had a plasma HIV RNA <50 copies/ml at diagnosis of Hodgkin lymphoma; HIV RNA was >50 copies/ml  in 12; plasma HIV RNA was not recorded in two individuals. Median CD4 count at diagnosis of Hodgkin lymphoma was 270 cells/µl (IQR 153–368). Median CD4 count in those with plasma HIV RNA <50 copies/ml was 320 cells/µl (IQR 188–368), and 240 cells/µl (IQR 150–330) in those with plasma HIV RNA >50 copies/ml.3 , There was a significant fall in CD4 count over the 6–12 months prior to diagnosis of Hodgkin lymphoma , In 26 (90%) patients B symptoms had been present for a median of 3 months (range 1–12). Three patients did not have B symptoms ; one had Stage IA disease and symptoms of less than one month duration, one had Stage IVA disease and no change in CD4 count, and one had a fall in CD4 lymphocyte count without B symptoms and multiple hematological and biochemical abnormalities prior to diagnosis: all three had new palpable peripheral lymphadenopathy. No controls developed B symptoms or new palpable lymphadenopathy.Nineteen patients had anaemia and or thrombocytopenia prior to diagnosis of Hodgkin lymphoma. Cytopenias at diagnosis were not associated with bone marrow involvement (p = 0.47). One of the controls (6%) developed new cytopenias, which were transient.The incidence of Hodgkin lymphoma has not fallen in HIV infected patients in the era of HAART Data from high income settings suggest that CD4 monitoring is not required in addition to routine viral load measurement when CD4 counts are above 350 cells/µl and viral suppression has been achieved Our study is limited by the relatively small sample size and its retrospective nature. Larger prospective studies of patients with suppressed viral loads are indicated to evaluate the utility of monitoring for classical symptoms and signs of lymphoma  compared with the utility of CD4 count monitoring for early detection of patients with Hodgkin lymphoma.In summary, this study showed that there was a CD4 count decline in the 12 months prior to diagnosis of Hodgkin lymphoma among HIV-infected individuals who were fully virologically suppressed and in receipt of HAART. All those who developed Hodgkin lymphoma had B symptoms and/or new palpable lymphadenopathy.


We investigated gender differences in treatment outcome during first line antiretroviral treatment (ART) in a hospital setting in Tanzania, assessing clinical, social demographic, virological and immunological factors.We conducted a cohort study involving HIV infected patients scheduled to start ART and followed up to 1 year on ART. Structured questionnaires and patients file review were used to collect information and blood was collected for CD4 and viral load testing. Gender differences were assessed using Kruskal-Wallis test and chi-square test for continuous and categorical data respectively. Survival distributions for male and female patients were estimated using the Kaplan-Meier method and compared using Cox proportional hazards models.Of 234 patients recruited in this study, 70% were females. At baseline, women had significantly lower education level; lower monthly income, lower knowledge on ARV, less advanced HIV disease , higher CD4 cell count  and higher BMI (p = 0.002). After 1 year of standard ART, a higher proportion of females survived although this was not significant, a significantly higher proportion of females had undetectable plasma viral load , however females ended at a comparable CD4 cell count  signifying a worse CD4 cell increase (p = 0.05), even though they still had a higher BMI (p = 0.02). The unadjusted relative hazard for death for men compared to women was 1.94. After correcting for confounding factors, the Cox proportional hazards showed no significant difference in the survival rate (relative hazard 1.02).We observed women were starting treatment at a less advanced disease stage, but they had a lower socioeconomical status. After one year, both men and women had similar clinical and immunological conditions. It is not clear why women lose their immunological advantage over men despite a better virological treatment response. We recommend continuous follow up of this and more cohorts of patients to better understand the underlying causes for these differences and whether this will translate also in longer term differences. The widespread use of combination Antiretroviral Therapy (ART) has improved the lives of people living with HIV through reducing morbidity and mortality . An infe2 is associated with a significantly higher mortality after starting treatment [Currently, in resource limited settings, physicians start antiretroviral therapy based on the appearance of symptoms, CD4 + T-cell count and the progression of loss of CD4+ T-cells  or BMI breatment . Within reatment .The progression rates to AIDS and clinical manifestations of diseases associated with HIV infection might differ between women and men because of biological and socioeconomic factors . PreviouIn resource-limited settings, men are more likely to have more advanced disease at HIV diagnosis, which is thought to put them at higher risk of adverse outcomes and less likely to respond well to ART. Some studies found that women had higher CD4 cell count at ART initiation than men . In seveTanzania is among the countries where ART is currently been scaled up . The maiBased on this we conducted a study to examine the gender difference in the disease progression and outcomes among HIV patients on ART attending a Care and Treatment Centre (CTC) in Dar es Salaam Tanzania from 2010 to 2011.The study was conducted at the CTC in Temeke Municipal Hospital of Dar es Salaam region. Temeke is one of the three administrative districts of Dar es Salaam region, with an area of 656 square kilometres and is the largest district with a population of 927,310 (growth rate of 4.3% per year) . Since 2We conducted a cohort study in which we followed up HIV-infected ARV naïve patients for one year. All patients who were HIV positive, above 18 years of age, ARV naïve but were due to start ART were enrolled in this study upon receipt of their informed consent. We excluded patients whose medical records for the previous year could not be obtained in the clinic. Patient enrolment was done for 4 months (September to December 2010). The sample size was calculated using OpenEpi with the following assumptions, 95% significance level, 80% power, female to male ratio of 2.7:1  7.6% of A structured questionnaire translated in Swahili was used to collect all the detailed information on social demographic variables and anthropometrics information. Data with respect to HIV diagnosis, clinical and ARV treatment was collected from the patient record files and the CTC database. Patients were categorized according to the clinical and performance scale of the staging system for patients infected with HIV-1 proposed by WHO . The difEthical clearance to conduct the study was obtained from the National Institute for Medical Research in Tanzania and permission to conduct the study was granted by the Hospital authority. Written Informed consent was obtained from all study participants by signing the provided consent form. Patient identifying information was de-linked from the collected data.Blood was collected from all the participants in EDTA collection tubes, CD4 level was estimated using Becton Dickinson FACSCalibur, and viral load using TaqMan Viral-Load Assay COBAS® AmpliPrep at the National Health Laboratory in Tanzania.Epi Info version 3.5.1 and STATA 11. Gender differences were assessed using the Kruskal-Wallis test for continuous variables and the chi-square test for categorical data. Descriptive analysis was done for the basic demographic, clinical and immunological characteristics of patients as well as continuous variables like CD4 counts, age, plasma viral load levels and BMI for both males and females. The criterion for significance for all analyses was a two-sided p-value of less than 0.05. Survival distributions for male and female patients were estimated using the Kaplan-Meier method. Patients who were lost to follow up were censored at the date when they were last seen. Patients who were still alive at the date when the study ended were censored at this date. Survival times were expressed in days. Cox’s proportional hazards regression models were used to assess the associations between patient characteristics and outcomes. All other variables were included in multivariable models to assess their impact on the association between gender and outcomes.Data were analyzed using A total of 234 patients were recruited in this study, 164 (70%) females and 70 (30%) males with a refusal rate of 6% and 25% respectively. Not all patients eligible to start ART were enrolled in this study because not all met the inclusion criteria. Significantly more males attended secondary schools than females; had a higher income and a better knowledge on ARV use   and males (62.9%) , which appears after starting ART at advanced HIV disease (WHO stage IV), CD4 count below 50 cells/ul and BMI below 16 kg/m2 and thisDespite the facts that all the patients were prepared to start ART, there were still a significant proportion of patients who were using traditional medicine, alcohol and injection drug abuse. The history of using traditional medicine and alcohol was high among our study participants, particularly among males. This may also be a reason of delaying medical treatment until late at WHO stage III and stage IV when the patients had already developed opportunistic infections. Injection drug use (IDU) is also associated with both, non-adherence to ART and HIV disease progression, and many IDU live in unstable housing, have undiagnosed mental illness, high rates of incarceration, and street-involved survival-lifestyles, which may all complicate delivery of HIV-related treatments .Overall, females were found to start ART at a less advanced disease stage, with higher CD4 count and higher BMI, and with lower viral loads than males. Similar findings are reported by other studies . Given tThe differences that we found will need further evaluation as this may need redefining the time to initiate ART in the two groups and the methods to monitor treatment response. The possibility of initiating ART at lower viral loads in women, especially during the early stages of infection, merits further study. Although the relative viral load has a similar predictive value for progression to AIDS for men and women, the same absolute viral load seems to confer different risks for AIDS between the sexes . BecauseOur study findings are limited by the following issues: our cohort was rather small and may not necessarily represent all HIV-infected patients in need of treatment. We also missed some of the clinical information that may be useful on comparing the differences between females and males HIV patients. Due to the high number of Lost to follow-up (LTF), mortality is likely underestimated.We assessed the gender differences on HIV disease progression and outcomes after one year of ART among HIV infected patients and whether this potential difference is influenced by socio-demographic, clinical, immunological and virological differences among patients starting ART in a hospital in Dar es Salaam. Male HIV patients delay seeking treatment and enter into treatment at a significantly more advanced stage of HIV infection, which predisposes them to increased mortality and worse treatment outcome. However, we observed that after one year of ART, males and females had similar clinical and immunological conditions. It is not clear why women lose their immunological advantage over men already at 1 year of treatment despite a better virological treatment response. It may be related to the study design, to the fact that women had a lower socio-economical status or to biological differences. We recommend continuous follow up of this and more cohort of patients to understand responses to ART and the differences between males and females, together with advocating early HIV diagnosis and treatment.AIDS: Acquired immunodeficiency syndrome; ART: Antiretroviral treatment; ARV: Antiretroviral; BMI: Body mass index; CTC: Care and treatment centre; HAART: Highly active antiretroviral therapy; HIV: Human immunodeficiency virus; IDU: Injection drug users; LTF: Lost to follow up; PMTCT: Prevention of mother to child transmission; WHO: World Health Organization.The authors declare that they have no competing interest.FM designed the study, performed data analysis and wrote the first draft of the manuscript, VM conducted the interviews and supervised laboratory work together with manuscript review, MIM assisted study design and supervised interviews and clinical examination and manuscript review, RZS assisted in supervising laboratory work and manuscript review, JV and PN assisted data analysis and manuscript review, EL and AV supervised the overall study implementation and manuscript development process. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/13/38/prepub


First line HAART with tenofovir DF (TDF) and emtricitabine (FTC) in pivotal trials has been associated with high efficacy and good tolerability. However, real-life clinical practice often differs from clinical trials due to co-morbidities, co-infections, and less intensive clinical monitoring.+ antiretroviral naïve patients (pts) from 50 German centres enrolled in this non-interventional cohort. All patients were to be followed for three years every three months to monitor and document efficacy , renal safety, tolerability, regimen changes and resistance profile. All patients received TDF+FTC as a single tablet fixed-combination  mostly in combination with either NNRTI or PI/r as their first regimen.Between July 2005 and August 2006, 534 HIV3. TVD was combined with NNRTI (efavirenz (EFV)27%, nevirapine 16%), PI/r (54%) or other (3%). In an as treated analysis after 36 months, 91% of pts achieved VL<50 copies/mL . Median CD4 cell count increased to 472 cells/mm3 (IQR: 341-631). Regimen with TVD showed a good safety profile and 36 pts were switched to a single tablet regimen with EFV/TDF/FTC (Atripla); 113 adverse events (AEs) of any grade were reported in 73/534 pts (13.7%); 15 of these were rated serious. 21 (3.9%) pts discontinued the TVD regimen due to AEs. Most of them (n=13) discontinued within the first six months. Renal abnormalities of any grade were reported in 10 pts . Median creatinine clearance was 109.0 mL/min (n=444) at baseline and 103.3 mL/min (n=287) after 36 months. Virological failure as a reason for discontinuation was documented in 12 pts; in 11 failing pts genotyping was performed and detected M184V (n=2) or K65R (n=2) among other NRTI, PI or NNRTI mutations. One failing patient had shown M184V at baseline.As of April 2010, three years of therapy have been documented for 330/534 (61.8%) pts; 81% male; median age was 39 years. Clinical AIDS diagnosis was documented in 22% pts; 46% pts started therapy with median 211 (IQR: 111-297) CD4 cells/mmDuring three years of follow-up, overall safety of TVD was good. Virological failure was rare (12 pts) and K65R was detected in only 2 failing patients. First line HAART with Truvada (TDF/FTC) plus an NNRTI or PI/r in clinical practice showed comparable efficacy to that observed in controlled clinical trials.


Although being considered as a rarely observed HIV-1 protease mutation in clinical isolates, the L76V-prevalence increased 1998-2008 in some European countries most likely due to the approval of Lopinavir, Amprenavir and Darunavir which can select L76V. Beside an enhancement of resistance, L76V is also discussed to confer hypersusceptibility to the drugs Atazanavir and Saquinavir which might enable new treatment strategies by trying to take advantage of particular mutations.Based on a cohort of 47 L76V-positive patients, we examined if there might exist a clinical advantage for L76V-positive patients concerning long-term success of PI-containing regimens in patients with limited therapy options.Genotypic- and phenotypic HIV-resistance tests from 47 mostly multi-resistant, L76V-positive patients throughout Germany were accomplished retrospectively 1999-2009. Five genotype-based drug-susceptibility predictions received from online interpretation-tools for Atazanavir, Saquinavir, Amprenavir and Lopinavir, were compared to phenotype-based predictions that were determined by using a recombinant virus assay along with a Virtual Phenotype™(Virco). The clinical outcome of the L76V-adapted follow-up therapy was determined by monitoring viral load for 96 weeks.In this analysis, the mostly used interpretation systems overestimated the L76V-mutation concerning Atazanavir- and SQV resistance. In fact, a clear benefit in drug susceptibility for these drugs was observed in phenotype analysis after establishment of L76V. More importantly, long-term therapy success was significantly higher in patients receiving Atazanavir and/or Saquinavir plus one L76V-selecting drug compared to patients without L76V-selecting agents (p = 0.002).In case of L76V-occurrence ATV and/or SQV may represent encouraging options for patients in deep salvage situations. The reduced susceptibility to certain antiretrovirals is often accompanied with a gradual loss of viral fitness, indicating that mutations with high fitness costs are less able to persist in the absence of drug pressure . There hAs example, M184V/I, the most prevalent NRTI-mutations selected under 3TC or FTC in the reverse transcriptase, do for instance revert partially the effect of thymidine-analogue mutation- (TAM) on resistance . K65R anThis article reports about possible clinical advantages of a valine substitution, instead of leucine, at position 76 in the HIV-1 protease. This mutation generally disappears quickly in replicating viruses in absence of selection pressure mediated by LPV, APV or DRV treatment. Thus, for deep salvage therapy situations in patients with strongly limited therapy options, it might be of advantage to maintain these drugs in treatment regimens to preserve L76V in the current replicating virus in combination with a "resensitized" drug ATV or SQV.At first, the impact of L76V on ATV- and SQV-resistance characteristics was assessed before and after establishment of the mutation. Due to the manifestation of the L76V mutation as well as other minor mutations at resistance-relevant sites in the course of treatment, genotype-based interpretation tools predicted intermediate or mostly complete resistance against all PIs including ATV and SQV and the majority of NRTIs and NNRTIs resulting in an active drug score (ADS) of ≤ 1.0 for the failing regimen Figure  and 1.1 In a further aspect, genotypic and phenotypic resistance data of 10 patients, all L76V positive, was assessed in order to analyze if these observed resensitizing effects represent ubiquitous drug resistance patterns. Figure Despite a general concordance in genotype- and phenotype-based resistance predictions for LPV and APV, there were wide discrepancies in the weighting of resistance for ATV and SQV, mostly overestimation of resistance in genotype-based predictions Figure . HoweverConsidering the effect of L76V on susceptibility for ATV and SQV, the big question was obviously, how this mutation might affect the therapeutic option and strategy for patients with a narrow margin of remaining active drugs. A considerable issue remained to generalize data from a small cohort of patients with diverse optimized backbone therapies. Thus, this work focused on the amount of active drugs in the treatment of each patient. Table 2 test)  and 67% of group B (ATV and/or SQV plus L76V-selecting drug LPV or APV) within the first weeks of follow-up therapy. Despite similar response rates at first, a sustained therapy success with virus suppression still below 50 copies/mL at week 96 and longer was predominantly achieved in group B patients where the selection pressure on L76V was constantly maintained by the drugs LPV or APV Table  test (Tat) Table . PatientInterestingly, despite a successful virus suppression <50 copies/mL, the majority of group B therapies were expected to have an ADS below 2.0 after genotypic resistance predictions, indicating a very likely event of therapy failure (bold numbers in square brackets) Table .Most of the cases where therapies were predicted to have active drug scores of ≥2.0 turned out to be successful. Only few experienced virological failure despite an ADS of more than 2.0 (indicated in round brackets).A major question remained obviously, why patients of group A display earlier therapy failures than patients of group B. After two years of follow-up therapy, only one patient of group A, who additionally received a fusion-inhibitor containing treatment, showed a viral load still below 50 copies/mL. The median viral load increased after 24 weeks of follow-up in group A Figure . More inThese results additionally indicate benefits for patients with L76V-selecting drugs in combination with L76V-"resensitized" drugs. A major issue remains the establishment of additional protease gene mutations i.e. L90 M and further compensatory changes over the time  and another drug which gains efficiency when L76V develops. This article reports about a significant clinical benefit of the protease mutation L76V on drug susceptibility to ATV and SQV due to resensitizing effects in multi-resistant patients resulting in a significantly higher long-term therapy success. These results may be in line with explanations from molecular dynamics- and free energy studies recently reported by Alcaro et al. who found that in the presence of the L76V substitution, ATV reveals a more productive binding affinity, in agreement with hypersusceptibily data .The strategy of combining mutation-selecting drugs with "resensitized" drugs has already been discussed for the reverse transcriptase mutation M184V in NRTI-containing therapies ,13,16 anDespite initially adequate therapy response rates in 50% (group A) - 67.7% (group B) of cases, it remains a major issue that virological failure under these therapies often occur due to compensatory changes in the virus genotype over the time mostly due to an additional establishment of further mutations in the respective gene ,14. As sNevertheless, since there are still distinct discrepancies, mostly overestimation of resistance, in the prediction of the resistance level for Atazanavir and Saquinavir in five of the most common genotypic interpretation systems, there is still a need for further evaluation in the case of L76V occurrence.HIV strains of 46 intensely pretreated (34 showed NRTI/NNRTI/PI resistance/12 showed NRTI/PI resistance) and one naïve with transmitted mutation, L76V-positive patients derived from 24 centres throughout Germany between 1999-2009 were retrospectively analysed for HIV-resistance patterns and success of follow-up therapy. The inclusion criterion is provided in Figure All patient data was categorized in three groups concerning the follow-up therapy:Group A: ATV and/or SQV (no selection pressure on L76V)Group B: LPV or APV plus ATV or SQV (maintained selection pressure on L76V)Group C: LPV or APV plus other drugs (maintained selection pressure on L76V)All patients received an optimized backbone therapy.Plasma of patients was analysed at baseline and week 12, 24, 48 until end of investigation at week 96 to monitor efficiency of therapy. Plasma RNA was measured by using the COBAS AMPLICOR HIV-1 Monitor system and the Abbott m2000sp/rt system according to the manufacturer's recommendations.Plasma samples of all 47 patients were collected and stored at -20°C until time of RNA extraction. All specimens were processed by using the FDA-approved Siemens HIV TruGene system as well as the Abbott HIV-1 Genotyping System on the Applied Biosystems' 3100 capillary electrophoresis platform according to the manufacturer's recommendations. HIV-1 genotypes were processed and analyzed by using the wildtype LAV-1 sequence as reference. The sensitivity for detecting minor quasispecies variants was 15%. In this cohort, only patients with major L76V positive population were included. Minor wildtype variants were not detected at this position.Phenotypic resistance analysis of the complete protease gene and the first 900bp of the RT were performed according to an earlier described recombinant virus assay by determining a virus specific resistance factor . In addiSeveral algorithms are available worldwide, both in public and private domains. The concordance of resistance predictions was analysed between the five most commonly used algorithms [REGA v7.1.1  HIVGradeThe authors declare that they have no competing interests.FW has made substantive intellectual contribution to the study including acquisition-, analysis- and interpretation of data and finally drafting the manuscript. JV assisted as consultant in patient-specific aspects and was involved in manuscript revision. GN was responsible with genotyping processes as described in the manuscript. RE was responsible for genotypic resistance interpretation and manuscript revision. HW realized the phenotypic resistance analysis. PB and AT assissted in concept and design aspects and directed sample- and data acquisition. HK, RK, MS and TB were significantly involved in data acquisition, provision of samples and manuscript revision. All authors read and approved the final manuscript.