HIV-1C has been shown to have a greater risk of virological failure and reduced susceptibility towards boosted protease inhibitors (bPIs), a component of second-line combination antiretroviral therapy (cART) in South Africa. This study entailed an evaluation of HIV-1 drug resistance-associated mutations (RAMs) among minor viral populations through high-throughput sequencing genotypic resistance testing (HTS-GRT) in patients on the South African national second-line cART regimen receiving bPIs.pol genes were amplified and sequenced using Illumina HiSeq2500, followed by bioinformatics analysis to quantify the RAMs according to the Stanford HIV Drug Resistance Database.During 2017 and 2018, 67 patient samples were sequenced using high-throughput sequencing (HTS), of which 56 samples were included in the final analysis because the patient’s treatment regimen was available at the time of sampling. All patients were receiving bPIs as part of their cART. Viral RNA was extracted, and complete p = 0.042) and integrase inhibitor RAM . The majority of the drug resistance mutations in the minor viral quasispecies were observed in the V82A mutation (n = 13) in protease and K65R (n = 5), K103N (n = 7) and M184V (n = 5) in reverse transcriptase.Statistically significantly higher PI RAMs were observed in minor viral quasispecies  compared to non-nucleoside reverse transcriptase inhibitors  RAMs in second-line cART patients from South Africa compared to the conventional GRT with ≥20% used in Sanger-based sequencing. Several RTI RAMs, such as K65R, M184V or K103N and PI RAM V82A, were identified in < 20% of the population. Deep sequencing could be of greater value in detecting acquired resistance mutations early.The online version contains supplementary material available at 10.1186/s12879-021-05905-2. High-throughput sequencing (HTS) has unique advantages and significantly improves sensitivity in quantifying the minority HIV drug-resistant variants within HIV quasispecies . IncreasStudies have shown that even in adherent patients, those with pre-existing Y181C mutants have a triple higher risk of virological failure on an efavirenz-based cART regimen . SeveralIn sub-Saharan Africa, South Africa has 23.6% pre-treatment drug resistance to efavirenz or NVP, followed by Namibia with 13.8%, while Zimbabwe has 10.9% resistance to NVP . EarlierStudies have reported that the rates of virological failure on second-line cART are high in resource-limited settings, including South Africa, and are associated with the duration of exposure to previous drug regimens and poor adherence , mostly The study was approved by the Faculty of Medicine and Health Sciences, Health Research Ethics Committee (HREC) Stellenbosch University, South Africa (N15/08/071). The investigations also complies with the South Africa National Health Act No 612003 and abides by the ethical norms and principles for research as established by the Declaration of Helsinki, the South African Medical Research Council Guidelines as well as the Department of Health Guidelines. A waiver of written informed consent was awarded to conduct sequence analyses on these samples by the Health Research Ethics Committee of Stellenbosch University, South Africa.For HIV-1 viral load testing, we used the Abbott m2000sp and the Abbott m2000rt analyzers . Viral RNA was isolated from patient samples according to the manufacturer’s instructions using the Abbott RealTime HIV-1 Amplification Reagent Kit.Convenient plasma samples were obtained from patients receiving bPIs as part of their treatment regimen (as referred by the clinician) with viral load > 900 copies/mL at the time of sampling from the diagnostic section at the Division of Medical Virology, Stellenbosch University, and the South African National Health Laboratory Services (NHLS), and were collected between March 2017 and February 2018 . We exclReverse transcriptase PCR (RT-PCR), which consists of cDNA synthesis followed by first-round PCR, was performed using the SuperScript™ III One-Step RT-PCR System with Platinum™ Taq DNA Polymerase  using the primers 1810F (5′-GCTACACTAGAAGAAATGATGACAGCATG-3′) and 5220R (5′-CCCTAGTGGGATGTGTACTTCTGA-3′). The second-round nested PCR was performed with 2001F (5′-TGCAGGGCCCCTAGGAAAAAGGGCTGTT-3′) and 5087R (5′- ATCCTGTCTACYTGCCACACAAYC-3′) primers using the KAPA HiFi HotStart ReadyMix PCR kit. The amplified products were purified using the QIAamp gel extraction kit . For HTS, the purified amplicons were fragmented, and the library was prepared using NEBNext® Ultra™ DNA Library Prep Kit for Illumina®  with multiplexed NEB next adaptors. The samples were then pooled together with other unrelated non-viral indexed libraries. Paired end sequences of read length 250 bp were carried out on the Illumina HiSeq2500. The sequences are available in SRA (submission ID: SUB5871663).pol gene sequences in very sensitive local mode using Bowtie2 in order to select reads originated from pol genes and create a consensus gene. The subtyping was performed using REGA version 3. The selected reads were then aligned against pol protein sequences using the BLASTX program from the BLAST package. The best BLASTX hit was chosen for each read for the amino acid counting, which was performed by in-house script. The resistance was interpreted as per the mutation lists provided in the Stanford HIVDB, accessed on 6 January 2019 .Among the 67 samples sequenced, current treatment regimen data were not available for 11 samples, and therefore they were excluded from further analyses. Among the 56 patients, 5.3% (n = 13) in protease and K65R (n = 5), K103N (n = 7) and M184V (n = 5) in reverse transcriptase  and major (≥20% of the population) viral quasispecies and identified increased PI RAM in minor viral populations. Our study also indicated very low levels of transmitted INI RAMs in patients failing on a bPI-based regimen.Earlier study have indicated that PI RAMs were uncommon in patients failing on second-line cART, with only 7% of patients on bPIs showing PI RAMs . A studyEarlier studies indicated that HIV-1C has reduced susceptibility towards PIs without the emergence of major PI RAM  and thatEven though there is no indication of the patients being administered RAL, three of the patients in our study harbored Y143R mutation in > 20% of the population. Previous studies on HIV-1C have shown major INI mutations at baseline in less than 5% of patients from Ethiopia  and South Africa  . HoweverWe show that the use of high-throughput resistance testing for GRT can greatly improve the identification of acquired PI RAMs in bPI-failing patients. Using HTS-GRT, PI RAMs (V82A) and RTI RAMs  were identified in < 20% of the population that Sanger-based sequencing failed to identify, strengthening their role in detecting the acquired mutations early. In resource-limited settings, the use of these high-throughput resistance-testing assays might help in the early detection of minor variants before evolving as a majority variant. Acquired drug resistance poses a significant threat to achieving the WHO/UNAIDS 90–90-90 targets for 2020. A recent WHO report also indicated an alarming surge in drug resistance across Africa . ContinuAll authors declare no conflicts of interest.Additional file 1 Table S1. Individual patient wise mutation profiling.


Results: Patients (99%) at Lancers and Chesterville PHCs were positive about POC CD4 testing, identifying benefits: No loss/delay of test results (6.4%), cost/time saving (19.5%), and no anxiety (5.1%), and 58.2% were ready to initiate treatment. Significantly more patients at Chesterville than Lancers Road PHC felt POC would provide rapid clinical decision making  and better clinic accessibility  respectively. Healthcare providers thought same-day CD4 results would impact: Clinical management (46.2%), patient readiness (46.2%), and adherence (23.0%), and would reduce follow-up visits (7.7%), while 38.5% were concerned that further tests and training (15.4%) were required before antiretroviral therapy (ART) initiation. Conclusion: The high acceptability of POC CD4 testing and the immediate health, structural, and clinical management benefits necessitates POC implementation studies.Background: The high burden of disease in South Africa presents challenges to public health services. Point-of-care (POC) technologies have the potential to address these gaps and improve healthcare systems. This study ascertained the acceptability and impact of POC CD4 testing on patients’ health and clinical management. Methods: We conducted a qualitative survey study with patients ( South Africa has an estimated population of 58.78 million with 7.97 million living with Human Immunodeficiency Virus (HIV), of whom 20% are women of reproductive age 15–49 years) , resulti9 years ,Conventional HIV treatment and care services provided at primary healthcare (PHC) clinics in the public service in South Africa are largely unable to cope with the volume of patients entering the system, resulting in delayed and missed opportunities for treatment and ultimately unacceptably high levels of morbidity and mortality .Risk of losing patients who may not return due to cost and distance; delays in diagnosis and treatment initiation;Patients who seek healthcare elsewhere become nontraceable, giving wrong addresses to clinics further away for eligibility resulting in unnecessary repeat testing and higher workloads in some PHC clinics ;Incomplete or incorrect completion of request forms or labelling of test tubes;The rejection of sample quality (insufficient or clotted specimen);Specimen damage or loss through transport;Misplacing of printed laboratory results at the clinic ,8.Diagnostic CD4 testing performed by conventional flow cytometry is centralized and offsite, provided by the National Health Laboratory Service (NHLS), serving >80% of the population . There aInstituting point-of-care (POC) CD4 testing in PHC clinics with the availability of same day results has the potential to address a number of these challenges for both patients and the health system. Additionally, POC testing brings with it greater patient satisfaction and helps with the morale of healthcare providers doing away with the “frustration” associated with conventional testing . Daneau Implementation of POC studies has demonstrated the reduction of pretreatment loss to follow-up in Mozambique ,13, acceBarriers to POC implementation have also been documented ,18 whereSeveral studies have assessed the acceptability of POC assays, such as CD4 testing  and the TM CD4, [At the time of undertaking this qualitative survey study, several POC technologies , were bThis was a qualitative survey study determining the acceptability, understanding, and perceptions from the client and healthcare provider perspective of the impact of the provision of POC CD4 testing in a PHC clinic setting. A qualitative survey utilises open-ended questions (rather than closed yes/no or agree/disagree questions) and delivers this to a larger sample of participants than is typical in a qualitative study . This alThe study population consisted of a convenience sample of clients presenting at the Lancers Road and Chesterville PHC clinics under the eThekwini Health Unit from 25 September 2015 to 30 June 2016. Individuals (>18 years old) who were referred to the “blood room” for phlebotomy (both HIV-1 negative and HIV-1 positive) and were willing to provide informed consent were included in the study.Lancers Road PHC clinic is a busy primary health clinic (PHC) facility under the eThekwini Health Unit, situated in the centre of the convergence of the taxi rank from all the outlying areas into the city of Durban. Chesterville PHC is situated within the Chesterville community, serving a population of 15,840  and situLancers Road PHC was considered a POC research “experienced” site as different studies were being undertaken evaluating several POC tests including POC CD4, whereas Chesterville PHC was a research “naïve” site as far as POC testing was concerned.Chronic care ;Antenatal ;Cancer (breast and ovarian);HIV education.Both PHCs offered all PHC services seeing 250–400 patients per day. This included HIV Counselling and Testing (HCT) for walk-in patients, with both clinics performing on average 600–700 HCT/month. Both PHC clinics provided basic education sessions every morning in the waiting room covering different topics:The PHC clinic procedures with respect to HIV Counselling and Testing (HCT) are depicted in Patients’ requiring phlebotomy (both HIV-1 positive and HIV-1 negative) who were seen in the “blood room” by the counsellor/phlebotomist were approached by a study research assistant to participate in the study. Hence, there was no stigmatization for those that were HIV-1 infected as only the counsellor/phlebotomist and the patient knew what blood draw/s were required. They provided written informed consent, and then completed face-to-face questionnaires. If during enrollment patients asked what a POC test was, they were told, “It is a test you get back on the same day”.n = 642)Are you happy to receive a CD4 test result on the same day? , we initially asked participants a yes/no closed question. We specifically asked five questions:After each closed item, we asked a single open-ended question, probing their answer. Participants had three lines to answer on, however most just recorded short answers.Do you think it is beneficial for the patient to get their CD4 result on the same day?What was the impact on your workload in giving CD4 results to the patient on the same day?Does having a CD4 result on the same day help you with patient management?Do you know what a CD4 test result means?Were you able to administer antiretrovirals (ARVs) to the patient on the same day you had the CD4 test result?For healthcare providers, we approached all within the PHC and requested their participation. Questionnaires were also administered to the healthcare providers. Healthcare provider questionnaires mainly focused on their perception of the usefulness of same-day CD4 results to patients and their interpretation of the meaning of a CD4 test result, as well as the impact that same-day CD4 results would have on their workload, patient clinical management, and administration of ART initiation. Similarly, for each question , we asked healthcare providers initially a yes/no closed question. We specifically asked 5 questions:After each closed item, we asked a single open-ended question probing their answer. Nurses had 5 lines to answer on.Study records were maintained safely in a locked cabinet on-site for the entire study period. The risks of participation were minimal. Confidentiality was maintained by assigning each patient/healthcare provider a unique study number and using the study number as the sole patient/healthcare provider identifier. Patient responses were entered into a specific database, which was secured using password-protected access systems.The study was approved by the Medical Research Council Research Ethics Committee (EC017-6/2015) as well as the eThekwini Research Ethics Committee (No. M.1/1/2 2 September 2015).The study was powered on patient acceptance of POC testing, which was assessed from the response to question 3.1 (Do you think it is a good idea to have a point of care laboratory in the clinic?). To detect a 90% POC test acceptance rate within a 7% margin of error at an alpha of 5%, 71 consenting patients were required. Assuming that 10% of HIV positive patients refused to consent to the study, approximately 80 HIV positive patients were required to reach the required sample size. Under the assumption that 25% of patients who were present for HIV testing were HIV positive, our sample size target was 320 patients in total at each PHC clinic, to be screened for entry into the study.The analysis of categorical outcomes is presented as frequencies and percentages.As this was a qualitative survey study, data from the questionnaires from patients from each PHC clinic and healthcare provider  were computed using coding. The binomial test with normal approximation was used to test whether proportions observed differed significantly between clinics. A 5% level of significance was used. Data were analyzed using Stata version 13.To understand the variation qualitatively in people’s responses, we did an open coding on participants’ written answers to each question. We then organized the different small codes into larger themes, which connected codes together to understand the responses of participants. Once we had done this, we allocated each participant a response code and calculated the percentage and number who provided each reason for their answer.There were 642 patients interviewed, 322 at Lancers Road PHC and 320 at Chesterville PHC, of whom 272/322 (85%) and 233/320 (72.8%) were women with a median age of 32 and 34 years at Lancers Road and Chesterville PHC, respectively. No one refused to participate.n = 2) participants reported that they would not want this, because they needed time to consider the results.The overwhelming majority (99.5%) of patients in both the research “experienced” ) and “naïve” ) PHC clinics welcomed the receipt of same-day CD4 test results ((a) in p < 0.0001) reported this. Clinic accessibility was also a challenge, but this varied by clinic with significantly more patients at the Lancers Road (40.4%) than Chesterville PHC (24.7%) having difficulty with clinic accessibility (p < 0.0001). One in twenty (5.9%) at Lancers clinic reported they would not have the anxiety of waiting for their results if they received them within the day. An overall minority (3.4%) at both PHC clinics preferred CD4 test results on a different day.Similarly, (b) in Responses to whether participants knew what CD4 results meant are presented in (c) of Participants were asked if they had a CD4 test and were eligible for ART initiation, if they felt they were ready ((d) in There were 13 nurses interviewed, 5 at Lancers Road and 8 at Chesterville PHC, of whom 4/5 (80%) and 6/8 (80%) were females with a median age of 31 and 45.5 years, respectively. There were 3/5 (60%) and 1/8 (12.5%%) enrolled and 1/5 (20%) and 6/8 (75%) professional nurses at Lancers Road and Chesterville PHC, respectively, while 1/5 (20%) and 1/8 (12.5%) were staff nurses at each site.Almost half of the nurses (46.2%) ((a) in Nurses also reflected on the impact on their workload of providing the CD4 results on the same day ((b) in In contrast, over half (53.8%) of nurses felt that it would increase the workload and not be beneficial; 30.8% described how this would increase their workload, as it would entail major administrative burdens, which would slow them down. Similarly, nearly a quarter (23.0%) were concerned that the other procedures to be completed before starting a person on ART would also lead to an increased workload.Despite concerns about increased workload, the overwhelming majority of nurses emphasized that providing the CD4 results on the same day would help with clinical management of patients ((c) in The majority of nurses (92.3%) correctly interpreted a CD4 test result either as an indication of initiating treatment (46.2%), level of “soldier cells” (38.5%), or staging of HIV infection (7.7%), while 7.7% did not know the meaning of a CD4 test result ((d) in Nurses reported that they were able to administer ARVs. on the same day as giving a CD4 test ((e) in Overall, patients and nurses were positive about the CD4 POC testing and receiving CD4 results on the same day, with both practical benefits and medical benefits being described by both groups of people. Concerns expressed about receiving CD4 results on the same day were related to worry around the “shock” of tests results, and closely related to this, the need for counselling for new patients, and further tests, before ART initiation. Understanding this more broadly, POC testing was about providing important health information and enabling improved clinical management, as well as patients being able to understand their own health and start to take charge of it.The majority of patients were happy to receive a same-day CD4 result and would rather wait for a short period of time for results. As they would receive medical intervention immediately, there would be no loss or delay of test results, saving them time, money, and clinic accessibility, and reducing anxiety. In the current study, among those who had received CD4 test results, the length of time was from 4 days to 4 weeks, through normal laboratory systems. Two-thirds of patients had a good understanding of the meaning of a CD4 test result and were ready to start ART if eligible.Most nurses felt that a same-day CD4 test result was beneficial to the patient, would facilitate better clinical management, and would have an impact on either reducing or increasing their workload, including initiating ART, and most gave the correct explanation of the meaning of a CD4 test result.Regardless of POC testing exposure or not, the high acceptability by patients and clinic staff of a same-day CD4 test result confirms findings from a feasibility and acceptability study of POC EID testing , finger-A small minority preferred CD4 test results on a different day, most of whom were from the Chesterville PHC, reiterating that they were not ready to receive such information immediately. As has been described , they waIn this study, patients expressed several practical benefits of same-day POC CD4 testing: It would save time and days off work, cause less anxiety, and be a cost saver, which have been found to be important factors resulting in loss of linkage to care if not addressed . Again, One of the barriers was clinic inaccessibility, particularly for patients attending the Lancers Road PHC. A significantly higher percentage of patients from the Chesterville PHC clinic received routine CD4 test results within 1–7 days due to the close proximity of the clinic facility, within walking distance in the community, compared to Lancers Road of 1–4 weeks where transport was required (data not shown).Most (80%) patients correctly explained CD4 count results related to treatment initiation due to their immune status and facilitating decrease in viral load, while 20% of patients still did not understand the meaning of CD4 count results. Our study did not provide any education; however, in South Africa, there is a long history of CD4 count testing , particuThe acceptability of ART initiation if eligible was high, with patients expressing the impact of life-saving ARVs. on making them feel better in order to take care of their family, longevity, and their action on their immune system and HIV virus, while a few gave no explanation. A minority felt they had no choice and were not ready.Both professional and enrolled nurses felt that a same-day CD4 count result was beneficial to patients as it helped determine their disease progression in order to ascertain treatment initiation and patient convenience. However, one-third felt that some patients were not ready for same-day results to start treatment or would have to take time off work due to the turnaround of results.With respect to workload, the opinions were divided. Half of the healthcare professionals felt that it would decrease their workload as patients would be treated early whereas the remainder felt this would increase their workload as all other tests would have to be completed before ART initiation, particularly at Lancers Road PHC, the reason being that it is an extremely busy clinic with a heavy patient load .With respect to clinical management, professional nurses felt that a same-day CD4 test result would facilitate patient readiness, adherence to ART, and fewer follow-up visits. We concur with findings from two qualitative studies, one from South Africa  and the Although current programmes could be enhanced by the introduction of POC testing ,42 to adThe strength of this study is the large patient sample size, collection of both quantitative and qualitative data from the general PHC population, its being undertaken in two different geographic settings, and the POC testing experience.The limitations are the small sample size of healthcare professionals and the lack of inclusion of other stakeholders for their insights into the advantages and disadvantages of POC testing from their perspective. The qualitative data were from a closed-caption set of questions, and few respondents wrote more than a short sentence as an answer to any question. While in-depth qualitative interviews and focus-group discussions can generate more detailed information and understanding of a topic under consideration, the qualitative survey did allow for a large number of views to be generated from patients and some form of quantification to be done to describe the overall perceptions of patients.The high patient and nurse acceptability of POC CD4 testing and their grasp of the immediate health and structural benefits  in the former and clinical management in the latter lends itself to undertaking implementation studies in the future in order to address barriers . This is


A substantial number of persons living with HIV (PLWH) in Nigeria do not experience durable viral suppression on first-line antiretroviral therapy (ART). Understanding risk factors for first-line treatment failure informs patient monitoring practices and distribution of limited resources for second-line regimens. We determined predictors of immunologic and virologic failures in a large ART delivery program in Abuja, Nigeria.3 after 6 months on ART. Virologic failure (VF) was defined as two consecutive HIV-1 RNA levels > 1000 copies/mL after at least 6 months of ART and enhanced adherence counselling. HIV drug resistance (Sanger sequences) was analyzed using the Stanford HIV database algorithm and scored for resistance to common nucleoside reverse transcriptase inhibitors (NRTIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs). Univariate and multivariate log binomial regression models were used to estimate relative risks (RRs) and 95% confidence intervals (CIs).A retrospective cohort study was conducted at the University of Abuja Teaching Hospital, a tertiary health care facility, using data from February 2005 to December 2014 in Abuja, Nigeria. All PLWH aged ≥ 15 years who initiated ART with at least 6-month follow-up and one CD4 measurement were included. Immunologic failure was defined as a CD4 decrease to or below pre-ART level or persistent CD4 < 100 cells per mm3, and the mean HIV-1 RNA was 3.3 ± 1.3.log10 copies/mL. A total of 3468 (80.5%) received nevirapine (NVP) and 2260 (19.5%) received efavirenz (EFV)—based regimens. A total of 2140 (36.1%) received tenofovir (TDF); 2662 (44.9%) zidovudine (AZT); and 1126 (19.0%) stavudine (d4T). Among those receiving TDF, 45.0% also received emtricitabine (FTC). In a multivariate model, immunologic failure was more common among PLWH with female gender as compared to male [RR (95% CI) 1.22 (1.07–1.40)] and less common among those who entered care at the program’s VCT center as compared to other entry points [0.79 (0.64–0.91)], WHO stage 3/4 as compared to 1/2 [0.19 (0.16–0.22)], or CD4 200 + cells per mm3 as compared to lower [0.19 (0.16–0.22)]. Virologic failure was more common among PLWH who entered care at the program’s VCT center as compared to other entry points [RR (95% CI) 1.45 (1.11–1.91) and those with CD4 < 200 cells per mm3 at entry into care as compared to higher [1.71 (1.36–2.16)]. Of 198 patient-derived samples sequenced during virologic failure, 42 (21%) were wild-type; 145 (73%) carried NNRTI drug resistance mutations; 151 (76.3%) M184I/V; 29 (14.6%) had ≥ 3 TAMs, and 37 (18.7%) had K65R, of whom all were on TDF-containing first-line regimens.Of 12,452 patients followed, a total of 5928 initiated ART with at least 6 months of follow-up and one CD4 measurement. The entry point for 3924 (66.2%) was through the program’s own voluntary counseling and testing (VCT) center, while 1310 (22.1%) were referred from an outside clinic/program, 332 (5.6%) in-patients, and 373 (6.3%) through other entry points including prevention of mother to child transmission (PMTCT) and transferred from other programs. The mean CD4 at enrollment in care was 268 ± 23.7 cells per mmIn this cohort of Nigerian PLWH followed for a period of 9 years, immunologic criteria poorly predicted virologic failure. Furthermore, a subset of samples showed that patients failing ART for extended periods of time had HIV-1 strains harboring drug resistance mutations. In 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) released the ambitious 95–95–95 targets to end the HIV epidemic globally by 2030, which included mandates that 95% of all diagnosed persons living with HIV (PLWH) should be on antiretroviral therapy (ART) and 95% of those should have plasma HIV-1 RNA suppression   1.21 (0.99–1.45)] and of female gender [RR (95% CI) 1.22 (1.07–1.40)]. Immunologic failure was less likely among patients identified and enrolled either through VCT [RR (95% CI) 0.79 (0.64–0.91)], at WHO stage 1 or 2 [RR (95% CI) 0.76 (0.60–0.96)] and CD4 < 200, cells/mm3 at ART initiation [1.71 (1.36–2.16)] and HIV care enrollment via UATH VCT [RR (95% CI): 1.45 (1.11–1.91)] versus other service entry points , followed by subtype G n = 83, 42%) and other subtypes or CRFs  (Fig. , 42% and8.5%, folOur study evaluated immunologic and virologic failure in a large African HIV treatment program. We found that predictors of immunologic failure included female gender, entry into care via VCT, and low CD4. Predictors of virologic failure included young age, unmarried status, entry into care via VCT, WHO stage 3/4, and low CD4. Immunologic criteria poorly predicted virologic failure.Although some studies have examined predictors of immunologic failure among patients failing first-line regimens, there is a paucity of data from sub-Saharan Africa –25. In a3 at entry into care. This may be related to patient-level factors such as lack of awareness of their HIV status or barriers to accessing care such as stigma [Many PLWH in sub-Saharan Africa are diagnosed late in the disease course, with low CD4 counts . In thiss stigma , 28, higs stigma .Consistent with our findings, data from a large cohort study conducted in East Africa and Nigeria showed that younger age, single marital status and female gender were independently associated with virologic failure and immunologic failure . In addiSimilar to previous studies , 30–33, Based on the reported high virological responses to d4T-containing first-line ARV regimens, it is expected that the majority of adherent adult patients receiving a first-line d4T-containing regimen will be virologically suppressed at the time of d4T switched. Because of its favorable toxicity profile, TDF will usually be preferable to AZT in these patients. TDF will retain residual activity against emerging drug-resistant variants.In this cohort of Nigerian PLWH, there was a high burden of drug resistance among patients failing ART for extended periods of time. Proactive identification of participants at risk for virologic failure is needed to optimize HIV care outcomes and decrease the risk of acquired drug resistance. Immunologic criteria poorly predicted virologic failure, underscoring the need for consistent resources to support routine viral load monitoring in Nigeria and other resource-limited settings. As ART coverage increases globally, HIV drug resistance remains one of the main obstacles to achieving the 95–95–95 treatment targets.


Cytopenia is a frequent hematological disorder in patients with human immunodeficiency virus (HIV) infection. However, the distribution and risk factors of cytopenia in patients starting highly active anti-retrovirus treatment (HAART) and the effect of HAART on cytopenia were not fully investigated.  From November 2004 to August 2016, a retrospective study was conducted to evaluate the prevalence of cytopenia in 4325 HAART-naïve patients. Risk factors of cytopenia at baseline and on recovery from cytopenia were analyzed using logistic regression analysis after 24 months of HAART in Beijing Ditan Hospital. μL, femaleness, WHO stage IV, coinfection with hepatitis B virus (HBV), BMI <18.5 kg/m2, a viral load ≥100,000 copies/ml, and age ≥40 years. In total, 70.2% and 76.4% of patients with cytopenia recovered after 6 and 24 months of HAART, respectively. The predictors of patients without normal blood cells after 24 months HAART were a CD4 cell count of <200 cells/μL, femaleness, WHO stage IV, coinfection with hepatitis B virus (HBV), BMI <18.5 kg/m2, a viral load ≥100,000 copies/ml, and age ≥40 years. In total, 70.2% and 76.4% of patients with cytopenia recovered after 6 and 24 months of HAART, respectively. The predictors of patients without normal blood cells after 24 months HAART were a CD4 cell count of <200 cells/ The prevalence of cytopenia was 19.1% in HIV-naïve patients. Risk factors for cytopenia in HAART-naïve patients were a CD4 cell count<200 cells/ Early detection could decrease the prevalence of HIV-related cytopenia, while starting HAART as early as possible seems to be effective for normalization of the blood cells in HIV-infected patients. The most common manifestation is reduction of any of the blood cell lines, leading to neutropenia, anemia, and thrombocytopenia. Previous studies have reported prevalence rates of anemia, neutropenia, and thrombocytopenia of 1.3%–95% , 3, and In HIV-infected patients, cytopenia has been associated with the progression to AIDS (anemia), high mortality (anemia), hospitalization , and secondary infections caused by bacterial and fungal pathogens (neutropenia) or drugs used for HIV –11. HighIn China, Dai et al. found that the prevalence of anemia was 9.76% . Shen ren = 108) or incomplete information (n = 613). Finally, a total of 4325 patients were included. The demographic and clinical data for the HAART-naïve patients including sex, age, height, weight, route of transmission, the initial time of HAART treatment, and WHO stage were collected. Laboratory data such as absolute neutrophil numbers, hemoglobin concentration, absolute platelet count, and absolute CD4+ T-cell count were collected at baseline.In total, 5047 HIV-infected patients who were on follow-up after HAART at the Department of Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, from November, 2004 to August, 2016, were included in this study. This study was approved by the ethics committees of Beijing Ditan Hospital, Capital Medical University, and the study conformed to the Declaration of Helsinki. The profiles of 722 participants were excluded because of neutrophilia  n = 69. In total, 213 patients were excluded and 611 HIV-infected patients with cytopenia were included. The number of neutrophils, the platelet count, the CD4+ T-cell count, and the hemoglobin concentration at 6, 12 and 24 months after the initiation of HAART were recorded. The flow chart is shown in To investigate the effect of HAART on cytopenia, 824 HIV-infected patients with cytopenia were followed up to 24 months after the initiation of HAART. The exclusion criteria were all patients without cytopenia μL; thrombocytopenia: platelet count <100,000 cells/μL. Patients with isolated anemia, thrombocytopenia or neutropenia were defined as patients with unicytopenia. Bicytopenia was defined as a patient in whom any two of the three lineage cell counts  were below the levels designated above. Pancytopenia was defined as having three lineage cell counts  below the levels designated above.Conditions were defined based on the following parameters. Anemia: hemoglobin <11 g/dL in women or <12 g/dL in men ; neutropμl and over 200 cells/μl [2 and overweight and obesity was >24.0 kg/m2 [Retrospective data were collected from medical records, including demographic, clinical, and laboratory characteristics. Variables include age, sex, HIV transmission route, coinfection with HBV, coinfection with HCV, WHO staging, HIV viral load, the use of AZT and stavudine (D4T), and body mass index (BMI). Age was categorized as <40 and over 40 years. Based on Chinese guidelines for diagnosis and treatment of HIV/AIDS, CD4 T-cell count was categorized as <200 cells/cells/μl . Based ocells/μl . The cut.0 kg/m2 , 24. HIV.0 kg/m2 .U test (nonparametric). A Pearson's test was used to evaluate differences in categorical variables. Binary logistic regression analysis or ordinal logistic regression analysis was used to evaluate risk factors associated with cytopenias and persistent cytopenia after 24 months of HAART. Demographic variables (sex and age) and clinical/laboratory characteristics  were included to investigate for the risk factor of cytopenia. The risk factors of persistent cytopenia investigated included demographic variables (sex and age) and clinical/laboratory variables . Statistical significance was set at a level of p < 0.05.All statistical analyses were performed using SPSS 22.0 software  and GraphPad 7 . Data were presented as the medians with interquartile ranges (IQR) due to skewed statistical distributions, while categorical variables were presented by percentages. The differences between two groups were analyzed using the Mann–Whitney μL. The median age was 36 years, the ratio of males to females was 15 : 1, the median BMI was 21.5  kg/m2, and the median CD4+ T-cell count was 249  cells/μL. Sexual transmission was mainly via the transmission route, which accounted for 91% of cases. According to WHO staging, stages II and III were present in 2541 (81.9%) individuals  patients in our cohort, of which 662 (15.3%) patients had unicytopenia, 144 (3.3%) had bicytopenia, and 18 (0.4%) had pancytopenia. Among the unicytopenia cases, 287 (6.63%) patients had isolated anemia, 306 (7.7%) had isolated neutropenia, and 69 (1.6%) had isolated thrombocytopenia. Among the bicytopenia cases, 96 (2.2%) had anemia and neutropenia, 26 (0.6%) had anemia and thrombocytopenia, and 22 (0.5%) had thrombocytopenia and neutropenia. The prevalence and distribution of cytopenia are shown in μL , femaleness , WHO stage IV , coinfection with hepatitis B virus (HBV) , BMI <18.5 kg/m2 , a viral load >100,000 , and age ≥40 years  were all risk factors of cytopenia , femaleness , WHO stage IV , coinfection with hepatitis B virus (HBV) , BMI <18.5 kg/m2 , a viral load >100,000 , and age ≥40 years  were all risk factors of cytopenias , femaleness , coinfection with HBV , and treatment with AZT  were all risk factors for unrecoverable hematological parameters after 24 months of antiviral therapy  were also increased. Femaleness, the lower CD4+ T-cell count at baseline, an advance stage at baseline, and coinfection with HBV were risk factors for persistent cytopenia after HAART, which suggested the importance of starting HAART early in cytopenia patients with HIV infection.In the present study, we found that HAART was an effective treatment for cytopenia patients before the initiation of HAART. Along with the recovery of the CD4There have been a large number of studies about the prevalence of anemia, thrombocytopenia, leucopenia, and neutropenia –30, and μl, advanced WHO clinical stage, higher HIV viral load, age ≥40 years, and coinfection with HBV at baseline was identified as the risk factors for cytopenia in the multivariate analysis, a finding consistent with that of the previous studies [In this study, CD4 <200 cells/ studies . The ass studies .+ T-cell count, which indicated that HIV-related cytopenia was caused by HIV-1 and immunosuppression and that virus suppression and immunological reconstitution could prompt the normalization of blood cells.Previous studies have reported that HAART is an effective treatment for anemia, thrombocytopenia, and neutropenia , 28, 34 + T-cell count and advanced staging before the initiation of HAART were predictors of patients with persistent cytopenia after 24 months of HAART. Levine et al. found that HAART use and higher CD4+ T-cell counts were associated with the resolution of neutropenia [μL, HIV RNA >5000 copies/mL, and erythrocyte mean corpuscular volume <80 fl were independent predictors of anemia after 12 months of HAART [+ T-cell count was associated with HAART-naïve patients with cytopenias, which suggested the advanced stage before initiation of HAART was associated with the risk of cytopenia and the recovery ratio of cytopenia after treatment. More importantly, early detection of HIV could decrease the prevalence of cytopenias, while early initiation of HAART was very important for HIV-1 infected patients with cytopenia.In accordance with a previous study, we also found that a low CD4tropenia . Berhaneof HAART . O'Bryanof HAART . In the A previous study found that the incidence of cytopenia was 63.2% in HIV-infected patients in South Africa . KyeyuneThe present study found that the ratio of recovery was 68.2% in patients with cytopenia after 6 months HAART, and 76.4% of patients with cytopenia returned to normal blood cell levels after 24 months HAART. After 6 months of antiviral therapy, the increase in blood cells obviously slowed down. The main reasons for this were that viral replication was suppressed and immunity was improved by 6 months of HAART, and HIV-1 related cytopenia caused by myelosuppression was relieved. Other factors such as malnutrition and a patient's economic situation may play a role in persistent cytopenia after 6 months of HAART.It is not only HIV-1, but also HAART such as AZT, that can lead to persistent hematopoietic suppression and resulting cytopenia , 17. In There are some limitations to our study. First, there was potential inherent bias in a retrospective observational study. Second, most of the participants in the present study were urban residents of Beijing, who are not necessarily representative of all HIV-infected patients in China.+ T-cell count, a higher viral load, WHO stage IV, and coinfection with HBV. HAART was an effective treatment for cytopenia, and along with the CD4+ T-cell count, the blood cell count was also increased. Persistent cytopenia after 24 months of HAART was associated with femaleness, coinfection with HBV, a CD4+ T-cell count at baseline, and WHO stage IV at baseline. Early initiation of HAART and combination antiretroviral therapy without AZT seems to promote the recovery of HIV-infected patients with cytopenia.The prevalence of cytopenia in patients before the initiation of HAART was 19.1%, of which the prevalence of unicytopenia, bicytopenia, and pancytopenia was 15.3%, 3.3%, and 0.4%, respectively. Cytopenia was associated with femaleness, a lower BMI, a lower CD4