We developed and validated a new and simple metric, the Programmatic Compliance Score (PCS), based on the IAS-USA antiretroviral therapy management guidelines for HIV-infected adults, as a predictor of all-cause mortality, at a program-wide level. We hypothesized that non-compliance would be associated with the highest probability of mortality.3; and (6) not achieving viral suppression within 6 months since antiretroviral therapy initiation. The sum of these six indicators was used to develop the PCS score - higher score indicates poorer performance. The main outcome was all-cause mortality. Each PCS component was independently associated with mortality. In the mortality analysis, the odds ratio (OR) for PCS ≥4 versus 0 was 22.37 (95% CI 10.46–47.84).3543 antiretroviral-naive HIV-infected patients aged ≥19 years who initiated antiretroviral therapy between January 1, 2000 and August 31, 2009 in British Columbia (BC), Canada, were followed until August 31, 2010. The PCS is composed by six non-performance indicators based on the IAS-USA guidelines: (1) having <3 CD4 count tests in the first year after starting antiretroviral therapy; (2) having <3 plasma viral load tests in the first year after starting antiretroviral therapy; (3) not having drug resistance testing done prior to starting antiretroviral therapy; (4) starting on a non-recommended antiretroviral therapy regimen; (5) starting therapy with CD4 <200 cells/mmPCS was strongly associated with all-cause mortality. These results lend independent validation to the IAS-USA treatment guidelines for HIV-infected adults. Further efforts are warranted to enhance the PCS as a means to further improve clinical outcomes. These should be specifically evaluated and targeted at healthcare providers and patients. HIV treatment has evolved tremendously since the advent of highly active antiretroviral therapy (HAART) in 1996 HIV treatment guidelines provide evidence-based standards aimed to optimize the management of HIV infected individuals. However, for a variety of reasons, not all patients are fully adherent to these guidelines. Here, we developed and validated a composite metric, the Programmatic Compliance Score, to assess the impact of non-compliance with HIV treatment guidelines on all-cause mortality, among antiretroviral therapy-treated HIV-infected individuals within a fully subsidized, population-based antiretroviral therapy program. We hypothesized that non-compliance would be associated with the highest chance of dying prematurely.The Centre's HIV/AIDS Drug Treatment program has received ethical approval from the University of British Columbia Ethics Review Committee at its St. Paul's Hospital site. The program also conforms with the province's Freedom of Information and Protection of Privacy Act.This study was conducted using population data from the British Columbia (BC) Centre for Excellence in HIV/AIDS (the Centre) Eligible study participants were ≥19 years old, naïve to antiretroviral therapy when they started treatment between January 1, 2000 and August 31, 2009. These patients were followed until death due to any cause, or if alive, until the last contact date or August 31, 2010, whichever came first. Finally, to be eligible for this analysis, participants were required to have at least one baseline CD4 cell count and a plasma viral load measurement available within six months prior to the antiretroviral starting date.All plasma viral load measurements in BC are centrally done at the St Paul's Hospital virology laboratory. The quantification range of plasma viral load assays has evolved over time, as previously described. Thus, for analytical purposes, we truncated our measurements to range from <50 to >100,000 copies/mL. CD4 cell counts are measured by flow cytometry, followed by fluorescent monoclonal antibody analysis . The CD4 data come from different laboratories across BC, and, in our database, we capture >80% of all CD4 tests done in the province. HIV genotypic resistance testing is performed centrally at the Centre's laboratory. Samples have been assigned to one of four resistance categories based on a modification of the 2011 IAS-USA list of mutations The recommended antiretroviral therapy regimens have changed since 2000, based on the BC guidelines for treating HIV-positive adults, as in the IAS-USA guidelines 3 (coded as 1) or ≥200 cells/mm3 (coded as 0); (5) Initiating antiretroviral therapy on a combination regimen recommended by contemporary guidelines (coded as 0) or not (coded as 1); and (6) Achieving viral suppression within 6 months of initiating antiretroviral therapy (coded as 0) or not (coded as 1). Viral suppression was defined by two consecutive plasma viral loads <50 copies/mL. Our main measure of exposure, the programmatic compliance score (PCS), was then obtained by adding the values for indicators 1 to 6, which provided a range from 0 (least compliance) to 6 (most non-compliance).We developed six performance indicators based on the IAS-USA guideline recommendations during 2000–2010 The primary outcome in this study was all-cause mortality. Deaths occurring during the follow-up period were identified on a continuous basis through record linkages carried out with the BC Division of Vital Statistics and enhanced by direct physician reports to the program.Further, we considered the following baseline explanatory variables: age, gender, history of injection drug use (IDU), year of antiretroviral therapy initiation, plasma viral load, follow-up time in months and place of residence at the start of antiretroviral therapy. Place of residence was used to control for the heterogeneity in patient treatment access, care and socio-demographic factors not previously defined. We also considered adherence to antiretroviral therapy measured at 12 months from antiretroviral therapy initiation, since the calculation of adherence at 6 months in our database can yield less precise estimates. Adherence was estimated by dividing the number of months of medications dispensed by the number of months of follow-up. We have previously shown that this measure of adherence is independently associated with HIV viral suppression and survival We run two sets of analysis. The first set included data from patients who have started antiretroviral therapy between 2000 and 2009. The second analysis, recognizing that some of the variables were not collected systematically before the year 2006, we restricted our analysis from patients who have started antiretroviral therapy between 2006 and 2009.In bivariable analyses, categorical variables were compared using the Fisher's exact test, and continuous variables were compared using the Wilcoxon rank-sum test. The mortality probability model was built in terms of finding the best predictive probabilistic model of mortality, using logistic regression th to 75th percentile range [Q1–Q3]: 35–48 years), CD4 cell count was 190 cells/mm3 (Q1–Q3: 100–280 cells/mm3), and plasma viral load was 4.9 log10 copies/mL (Q1–Q3: 4.4–5.0 log10 copies/mL). The median follow-up was 44 months (Q1–Q3: 22–77 months). Of these patients, 39% had a history of IDU, 52% started antiretroviral therapy before 2006, and 63% were more than 95% adherent during the first year of follow-up.A total of 3543 antiretroviral naïve adults  were eligible to participate in this study. At baseline, the median age was 42 years  deaths were recorded, producing an overall crude death rate of 33 per 1000 person-years. This analysis was restricted to the individuals who have started antiretroviral therapy between 2006 and 2009. In total, we observed 118 deaths (7%), producing an overall crude death rate of 30 per 1000 person-years. Using various indicators of non-compliance to treatment guidelines, we developed a simple and highly predictive metric, the Programmatic Compliance Score or PCS, to predict the probability of mortality among HIV-positive individuals starting naïve on antiretroviral therapy. We found that individuals who had a PCS score 4 or higher had a mortality probability 22 times higher than those individuals with PCS score 0. The sensitivity analysis also confirmed these results. The PCS, therefore, may serve as a simple but powerful proxy for the performance of the program as a whole in achieving execution of its accepted guidelines. The PCS incorporates the overall effects of the decisions and social situations of patients, physicians and others in whether or not treatment guidelines are actually implemented.It is noteworthy and surprising that indicators associated with plasma viral load and resistance were far more impactful than suboptimal CD4 cell count at the start of therapy with respect to the probability of mortality. Low CD4 cell count at the start of antiretroviral therapy has been shown by our group and by others to be highly predictive of adverse treatment outcomes There are several features of our study that should be highlighted. First, this study was based on patients who were naïve to antiretroviral therapy, thus our results were not confounded by previous therapy use. Secondly, despite the potential limitations of using pharmacy refill-based adherence as a surrogate marker of actual pill taking, we have previously shown that this measure of adherence is independently associated with different disease outcomes In summary, the Programmatic Compliance Score or PCS metric is highly predictive of all-cause mortality, among HIV infected adults starting antiretroviral therapy. Our results show that individuals with sub-optimal PCS compliance are at a very high probability of premature morbidity and mortality. It is important to mention that the requirement for having a baseline genotypic testing before starting antiretroviral therapy was not explicitly stated in the guidelines prior to 2006, and only emphasized in the guidelines after 2006. However, given that the efficacy of antiretroviral therapy is directly related to having a fully functional regimen, there is no reason for failing to order such an important test, given that it is free for anyone starting antiretroviral therapy in BC. Thus, while these results do not allow us to establish a causal relationship regarding the association between our new metric and survival, this metric highlights the importance of adherence to treatment and monitoring guidelines during the first year on antiretroviral therapy. Despite improvement in the PCS within our cohort over time, it is clear that there is still substantial room for improvement. It should be emphasized that minimizing the occurrence of these non-compliance practices is not solely dependent on the healthcare provider. Health administrative bodies can improve compliance outcomes through regular surveillance and ongoing physician training. Further, the individual patient ultimately bears responsibility for his/her own health; the implications of poor compliance to treatment need to be communicated at the time of initiation. Furthermore, our results provide important clues on how to develop effective strategies to improve HIV associated health outcomes not only in BC, but around the world. Finally, our results also lend independent validation to the most recent IAS-USA antiretroviral therapy management guidelines for HIV infected adults.Text S1Appropriate Regimens based on the BC guidelines for treating HIV-positive adults between 2000 and 2010.(DOCX)Click here for additional data file.


The measurement of CD4+ T-cell (CD4) counts is a strong predictor of progression to AIDS and a means of monitoring antiviral therapy (ART). The success or failure of controlling virus levels in untreated patients or those taking ART may be associated with treatment adherence, habits, correlated infections unrelated to HIV, cancer, immunosuppressive drugs; as well as socio-economic and psychosocial aspects and access to healthcare. The aim of the present study was to identify, using a multilevel model, the factors related to the variations of CD4 counts over time, in patients living with HIV.A cohort study was conducted with patients living with HIV, selected from July 2007 to December 2010. Patients were monitored from records of their first CD4 count after being diagnosed with HIV. A multilevel model with 3 levels of aggregation was applied to analyze the associations of predictor variables and the behavior of CD4 over time.3, and there was a mean increase of 1.529 cells/mm3 per month. Patient's age, smoking, use of illicit drugs, hospital treatment, changing doctors and the use of ART, were factors that affected the kinetics of the CD4 count during the follow-up period.A total of 1870 patients were enrolled. The mean number of CD4 at the beginning of the cohort was 393.1 cells/mmThe results of this study indicated increased levels of CD4 over time in a cohort of patients living with HIV/AIDS and identified factors that may influence this increase and are liable to intervention. The measurement of CD4+ T-cell (CD4) counts is a strong predictor of progression to Human Immunodeficiency Syndrome (AIDS), as well as a means of monitoring antiretroviral therapy (ART). Low CD4 counts are associated with a greater risk of patients living with HIV developing opportunistic infections, which may then progress to advanced diseases and death Possible increases or decreases in CD4 counts are directly related to HIV replication. The use of combinations of antiretroviral drugs (ART) generally results in the suppression of virus replication and hence increased levels of CD4. The success or failure in controlling levels in untreated patients or those on antiretroviral therapy may be associated with factors related to treatment adherence, habits, other correlated infections unrelated to HIV, cancer, immunosuppressive drugs (corticosteroids and chemotherapy), as well as socio-economic and psychosocial factors and access to healthcare A number of studies have shown that lower age groups, poor education and low income were all associated with a poorer therapeutic and immune response. The most indicated mediating mechanisms amongst the socioeconomic variables and therapeutic response, are lower rates of treatment adherence et al.et al.The use and duration of ART are important factors in understanding the kinetics of viremia and CD4 counts. The work of Chu Factors related to CD4 variations in patients living with HIV are multiple and complex. There are few longitudinal studies reported in the literature with long observation periods and prospective designs. A model, which is able to indicate independent associations related to CD4, with an appropriate methodology, would provide support for possible therapeutic interventions and, consequently, a better quality of life and survival for patients. Multilevel analysis takes into account the nested data structure (repeated measures of CD4 within subjects) and allows to examine relations between variables at different levels of the multilevel data structure. This study aimed to assess an explanatory model, using the statistical technique of multilevel models for the variations of CD4 counts over time in patients living with HIV.A cohort study was conducted with patients living with HIV, of both sexes, aged 18 years or older, with a minimum of two CD4 cell count, selected during the period from July 2007 to December 2010, treated at 2 referral HIV/AIDS centres: the Correia Picanço Hospital and the Oswaldo Cruz University Hospitals, responsible for the care of about 70% of patients living with HIV in the state of Pernambuco, Brazil. All selected patients were followed and data were obtained from a questionnaire periodically applied and from medical records. The study was approved by the research ethics committee at the University of Pernambuco Oswaldo Cruz University Hospital, and all participants who agreed to participate in this study signed a consent form.To assess the variation of the CD4 cell count over time data was retrieved from medical records starting from the first CD4 cell count, performed at the time of HIV diagnosis. For those participants diagnosed before July 2007, CD4 counts were recorded retrospectively. The CD4 cell count for all patients was performed by flow cytometry using anti-CD4 antibodies labeled with fluorescent dye, at a reference laboratory. To get the information on biological and socioeconomic aspects, habits and disease history, patients were interviewed by previously trained health professionals, using standardized questionnaires. Data regarding the time-dependent variables, use and regimen of antiretroviral therapy, were collected from patient records.Initial data analysis used descriptive statistics to characterize the study population. For the analysis of factors associated with CD4 variations over time, a multilevel modelling The multilevel model was adjusted using GLLAMM , and the estimated parameters of the model obtained by REML (restricted maximum likelihood estimation). Snedecor's F statistics was used to test the significance of the fixed effects model and the likelihood ratio obtained in REML was used to test the significance of the random effects. The assumptions of normality were tested estimating a regression model for each trajectory of each individual of the cohort and observing the distribution of the coefficients (intercept and slope). These assumptions were confirmed and a linear rate of change in CD4 counts over time was assumed, meeting the assumptions of generalized linear models (GLM).In a first step of the statistical analysis, the effect of each independent variable on CD4 variation over time (interaction) and the differences in the mean CD4 count at the beginning of follow-up (intercept) were tested. With this first approach, the variables that presented a statistical significance  of the interaction parameter below 20% (p<0.20) were eligible for the multivariate analysis. In this phase, the model was adjusted following the stepwise method, with the inclusion of the variables in the model through order of significance in the univariate step (forward process). The exclusion criterion for the final multivariate model was a statistical significance below 10% (p<0.10). A residual analysis was performed from the final model. STATA  12.0T was used for the descriptive analysis and construction of graphs, and R Project for Statistical Computing 2.14.2 was used in the application of multilevel models.The study collected 21,601 measurements of CD4 counts, corresponding to 1,870 patients treated by 44 doctors in the two referral hospitals. The mean number of CD4 measurements per patient was 12±7 measurements, with a minimum record of 2 and a maximum of 40 repetitions.A total of 533 patients were treated at the Oswaldo Cruz University Hospital and 1337 at the Correia Picanço Hospital, with a mean follow-up period of 6.0±3.6 years, with a minimum period of 10 days and a maximum of 20 years. The majority of patients surveyed were male (63.4%), with a mean age of 39.1 years, a minimum age of 18 and a maximum of 74 years. With regard to education, the number of years of study was between 1 and 9 years for 53.5% of the patients, and between 10 and 12 for 30.3%. The income of the majority of participants (64.4%) was below the minimum salary. With regard to their habits, 29.6% of patients living with HIV were smokers, 35.6% were drinkers and 27.6% used or had used illicit drugs. Current or past use of marijuana was reported by 26.6% of those surveyed, while the use of cocaine was reported by 9.1%, crack by 6.5% and glue by 5.8% of patients. Diabetes was reported in 4% of patients, cancer or lymphoma in 2.5% and the use of corticosteroids up to 6 months prior to the interview in 5.3% .In an exploratory stage, noting the growth rate of the mean CD4 levels of patients throughout the follow-up period associated with each of the explanatory variables, it was observed that, among the biological variables, male patients presented a lower CD4 baseline and a lower growth rate, although not statistically significant (p = 0.163). According to age, patients aged over 40 years presented a lower increase of CD4 over time. The socioeconomic status of the patients, represented by the variables of education and income, did not discriminate different behaviours in the CD4 kinetics during the follow-up period .With regard to the variables related to habits, a lower increase rate was observed in the mean levels of CD4 in patients with a history of smoking, drinking and illicit drug use. When evaluating each of the illicit drugs, all patients presented a lower increase in CD4 over time, although the difference was only statistically significant for patients who reported marijuana use .With regard to past medical history, patients with diabetes and cancer, presented no statistically significant difference in the behavior of CD4 over time, when compared to individuals without the diseases. Similar results were obtained when comparing those who reported using steroids during the 6-month period prior to the interview with those who had never used this medication .With respect to hospital care, it was observed that patients treated in one of the referral hospitals presented a statistically higher rate of CD4 increase when compared to patients treated in the other. Patients who changed doctors over the period of outpatient treatment, presented a lower increase in CD4 over time, and this difference was statistically significant .Patients on ART had a significantly higher mean rate of CD4 increase during the cohort. For patients on different regimens of ART, all regimens presented a significant increase in CD4 levels, when compared to patients who were not taking ART .3, with a linear increase, irrespective of the variables that make up the model, of 1.529 cells/mm3 per month  were grouped on a higher level, which is the patient, with the obtained associations in the model on two levels, adjusted by a third level of aggregation formed by the groups of patients treated by the same doctor.et al.et al.et al. observed that patients aged 50 years and over presented a poor CD4 response to ART, thus corroborating the present findings, as well as a lower frequency of naive CD4 cells and higher number of memory CD4 cells in the pre-ART treatment assessment period, suggesting that the progression of HIV-infection is associated with a depreciation of naive CD4 cells and a lower response to ART et al.et alIn the present study, patients aged 40 years and over presented lower rates of CD4 increase over the period of the cohort. Two lines of argument may be explored in order to explain this outcome: one is related to treatment adherence, and the other to immune senescence, a term used to describe phenotypic and functional alterations in lymphocytes associated with patient age. With regard to adherence, in the work of Lignani et al., in a cross-section of 64 patients, described the outcome of an association of smoking with poor adherence et al.Among the variables related to patient habits, smoking and illicit drug use were discriminant factors for a lower increase of CD4 over time. However, these two variables did not remain in the same model, possibly because of the concomitance of the two habits. Considering the importance of each in the progression of the disease, two independent explanatory models were presented, to discuss the results. There is certain controversy with regard to smoking and declining levels of CD4. Some studies have corroborated the present findings, by describing lower levels of CD4 progression among smokers et al.An association was observed between illicit drug use and the behavior of CD4 over time, with a lower rate of increase in CD4 counts among patients who used at least one illicit drug, thus corroborating the literature Two variables related to patient care remained in the final model of the behavior of CD4 over time: the referral health service where the patient is treated and a change of doctor during the follow-up period. With regard to the first, patients at Service “A” had a higher rate of CD4 increase over time than those treated at “B”. Differences in the clinical characteristics of the patients, or those related to the quality of care are possible explanations for this result. When comparing the profile of patients in the two referral services, it was observed that patients treated at Service “A” presented a lower mean time of HIV-infection diagnosis (5±2.6 years) when compared to those in Service “B” (6.4±3.8 years), as well as lower initial CD4 counts. Lower CD4 counts favour early therapeutic intervention resulting in a greater acceleration of increased CD4 counts in these patients. A longer period of infection decreases the patient's response to treatment. The proportion of patients using ART was similar in the two services. There was a higher percentage of patients who changed doctors during follow-up in Service “B” (11.1%) than in Service “A” (4.6%), which is one factor in this study that is associated with a lower rate of CD4 increase. Other features of the care provided for these patients were not focused upon in this study.The aims of this study did not include the motives for changing doctors during follow-up, although this aspect constitutes a significant lacuna that needs to be explored in order to fully understand the quality of healthcare provided by health professionals. One of the factors that the World Health Organization indicates as being related to ART adherence is the patient/healthcare-provider relationship, where the object is the doctor-patient relationship. In a meta-analysis, a strong association was observed between doctor and patient communication and adherence to treatment, with the greatest risk of noncompliance (19%) among patients who reported having “poor” communication with their doctors 3 more when compared to patients not on ART, thus confirming the findings of the literature. According to Hoffman, et al. (2010) an appropriate response in CD4 counts of patients initiating ART is an annual growth of 50 to 150 cells/mm3. Considering the present cohort and the multivariate multilevel model proposed for patients on ART (3 per month, which corresponds to a mean annual growth of 38.74 cells/mm3, which is below WHO recommended treatment for an adequate response. This therefore, highlights the importance of further studies into the factors related to changes in CD4 and the adopted intervention strategies.The use of ART has an independent effect on the rate of CD4 increases over time. In the cohort of the present study, the mean CD4 increase in patients on ART was 1.155 cells/mms on ART , the meaThe study has some limitations. Patients were followed under routine conditions and data on CD4 count, viral load and antiretroviral treatment were obtained from medical records. Although patients were required by the attending physician to undertake a CD4 count and viral load determination every four months the time gap between consecutive exams varied among patients. Another point is that the information on these HIV related variables was available from the time of diagnosis; however information on the other variables was only available from enrollment in the cohort. Patients were selected from two different reference centres for the treatment of HIV/AIDS but exams were performed by the same reference laboratory and care is delivered in both services according to standard procedures, following the guidelines of the Brazilian Health Ministry for the whole country; thus the results are comparable.The study pointed out groups that should be monitored more carefully because of their potential to a poorer response to treatment. However further studies will be very helpful to clarify some points. Other studies are necessary to understand to which extent smoking and illicit drug use affect the increase of CD4 through biological mechanisms or through an effect on adherence to antiretroviral treatment. The evidence that the quality of the care provided by health professionals may influence the response to the antiretroviral treatment is another aspect to be explored.


Implication of pharmacogenetic variations and efavirenz pharmacokinetics in concomitant efavirenz based antiviral therapy and anti-tubercular drug induced liver injury (DILI) has not been yet studied. We performed a prospective case-control association study to identify the incidence, pharmacogenetic, pharmacokinetic and biochemical predictors for anti-tubercular and antiretroviral drugs induced liver injury (DILI) in HIV and tuberculosis (TB) co-infected patients.NAT2, CYP2B6, CYP3A5, ABCB1, UGT2B7 and SLCO1B1 genes were done. The incidence of DILI and identification of predictors was evaluated using survival analysis and the Cox Proportional Hazards Model. The incidence of DILI was 30.0%, or 14.5 per 1000 person-week, and that of severe was 18.4%, or 7.49 per 1000 person-week. A statistically significant association of DILI with being of the female sex (p = 0.001), higher plasma efavirenz level (p = 0.009), efavirenz/8-hydroxyefavirenz ratio (p = 0.036), baseline AST (p = 0.022), ALT (p = 0.014), lower hemoglobin (p = 0.008), and serum albumin (p = 0.007), NAT2 slow-acetylator genotype (p = 0.039) and ABCB1 3435TT genotype (p = 0.001).Newly diagnosed treatment naïve TB-HIV co-infected patients (n = 353) were enrolled to receive efavirenz based ART and rifampicin based anti-TB therapy, and assessed clinically and biochemically for DILI up to 56 weeks. Quantification of plasma efavirenz and 8-hydroxyefaviernz levels and genotyping for NAT2, CYP2B6 and ABCB1 genes determines susceptibility to DILI in TB-HIV co-infected patients. Close monitoring of plasma efavirenz level and liver enzymes during early therapy and/or genotyping practice in HIV clinics is recommended for early identification of patients at risk of DILI.We report high incidence of anti-tubercular and antiretroviral DILI in Ethiopian patients. Between patient variability in systemic efavirenz exposure and pharmacogenetic variations in  Tuberculosis (TB) is the most common opportunistic fatal infection in HIV infected patients Among the first-line TB drugs pyrazinamide, isoniazid and rifampicin have all been associated with DILI CYP2B6, to a minor extent by CYP3AUGT2B7ABCB1 genetic variation on efavirenz pharmacokinetics OATP1B1, coded by SLCO1B1, is a liver-specific uptake transporter important in hepatic drug disposition. RIF is both substrate and inhibitor of OATP1B1CYP2B6, CYP3A4, UGT2B7, ABCB1 and SLCO1B1CYP3AMetabolic pathway of efavirenz is complex as being a substrate inducer and/or inhibitor of its own metabolism involving several CYP enzymes with varying activities CYP2B6 and CYP3A5th in the WHO high TB-burden country list. Biochemical variables, efavirenz pharmacokinetics as well as pharmacogenetic variations in six candidate genes relevant for metabolism and transport of ARV and anti-TB drugs; namely; CYP2B6, CYP3A5, UGT2B7, NAT2, ABCB1 and SLCO1B1 (OATP1B1) were investigated.Plasma concentrations of HIV and TB drugs display wide inter-individual variability partly due to genetic variations in the respective drug metabolizing enzymes or transporter proteins. Genetic variation is believed to play an important role in DILI The study protocol was approved by the Regional Ethical Review Board in Stockholm at Karolinska Institutet, Sweden; Institutional Review Board (Faculty. Research and Publication Committee) at Faculty of Medicine, Addis Ababa University; The National Ethics Review Committee at Ethiopian Science and technology Ministry as well as by the Food and Drug Administration and Control Authority of Ethiopia. Written informed consent was obtained from each subject before the start of this study.Newly diagnosed ART and anti-TB treatment naïve adult TB and HIV co-infected patients (n = 373) were recruited and enrolled prospectively and followed up to one year during June 2007 to January 2011. The eligibility criteria were age ≥18 years, CD4 count <200 cells/UL, not pregnant and not on other known hepatotoxic drugs concurrently . None of the participants received isoniazid prophylaxis and treatment for tuberculosis two years before enrolment and during the study period.st, 2nd, 4th, 8th, 12th, 24th, 48th, and 56th weeks after initiation of anti-TB treatment.All study participants received RIF based short-course chemotherapy for TB following the national TB treatment guideline. ART was then initiated with 600 mg efavirenz based HAART containing stavudine/lamivudine/efavirenz (D4T/3TC/EFV) or zidovudine/lamivudine/efavirenz (AZT/3TC/EFV) or tenofovir/lamivudine/efavirenz (TDF/3TC/EFV). A complete history and physical examination were taken before enrolment and at the scheduled and unscheduled visits. Laboratory tests were performed before anti TB initiation included complete and differential blood counts, platelet count, CD4 count, HIV RNA determination, hepatitis B surface antigen, anti-hepatitis C antibody, serum albumin, renal function tests, liver tests including; aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), and direct and total bilirubin. Follow-up for liver enzymes were performed at before and on the 1Blood sample was obtained from 201 patients for genotype analysis. Genomic DNA was isolated from peripheral blood leukocytes using QIAamp DNA Maxi Kit (QIAGEN GmbH. Hilden. Germany). Genotyping was carried out at the division of clinical pharmacology, Department of laboratory medicine. Karolinska University Hospital-Huddinge, Karolinska Institute Stockholm, Sweden.ABCB1 3435C>T rs1045642, C__11711730_20 for CYP2B6 516G>T rs3745274 [CYP2B6*6] , C__30720663_20 for UGT2B7-372G>A rs7662029 , C__26201809_30 for CYP3A5 6986A>G rs776746 [CYP3A5*3], C__30203950_10 for CYP3A5 14690G>A g.14690G>A [CYP3A5*6], C__32287188_10 for CYP3A5 g.27131_27132insT rs241303343 [CYP3A5*7], C___1901697_20 for SLCO1B1 388A>G rs2306283 (*1b) and C__30633906_10 for SLCO1B1 521T>C rs4149056 (*5) on ABI 7500 FAST . The final volume for each reaction was 10 µl, consisting of 2× TaqMan Universal PCR Master Mix® (Applied Biosystems), 20× drug metabolising genotype assay mix and 10 ng genomic DNA. The PCR profile consisted of an initial step at 50°C for 2 min and 50 cycles with 95°C for 10 minutes and 92°C for 15 sec.Allelic discrimination reactions were performed using TaqMan®  genotyping assays: (C__7586657_20 for 5′- GTCACACGAGGAAATCAAATGC-3′) and a reverse primer (5′-GTTTTCTAGCATGAATCACTCTGC-3′) as described previously.5′-GGATGAAAGTATTTGATGTTTAGG-3′). Sequencing reaction was done using the ABI PRISM™ BigDye® terminator cycle sequencing ready reaction kit v3.1 , and analyzed on an ABI Prism 377 DNA sequencer. NAT2 sequence chromatograms were visually inspected and analyzed using software program FinchTV version.1.4.0 (htpp://www.geospiza.com) and aligned with the NAT2 reference sequence  for SNPs identification.The coding regions of NAT2 gene was amplified by PCR using a forward primer  from 212 patients, centrifuged (1700 g for 20 min), and 2 mL plasma aliquot was stored at −80°C for determination of efavirenz and its metabolite concentrations. Plasma samples were sent in dry ice to the Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg. Germany. Plasma efavirenz and 8-hydroxyefavirenz concentration were determined by LC/MS/MS as described previously 2>0.99. Accuracy and precision (within-batch and batch-to-batch) of the assay fulfilled all recommendations of FDA guidelines.On the 4Patients with DILI were identified according to the CIOMS  criteria, which are based on selected laboratory liver parameters (CIOMS laboratory criteria and the exclusion of any disease-related causes of liver injury) Baseline demographic and laboratory parameters were described as median and interquartile range (IQR) for continuous variables and as percentages for categorical variables. Chi-square test was used to compare the observed and expected allele frequencies according to Hardy-Weinberg equilibrium. Haplotype analysis was done using Haploview v.4.1 software. The efavirenz metabolic ratio (EFV MR) was calculated by dividing concentrations of efavirenz by 8-hydroxyefavirenz. Normality of kinetic data was assured by transforming the data to Log 10 values before statistical analysis. Independent t-test was used to compare log transformed plasma efavirenz, 8-hydroxyefavirenz and efavirenz/8-hydroxyefvarinz ratio between patients with and without DILI. Univariate and multivariate Cox proportional Hazards Model were performed to identify potential predictors of DILI and Kaplan-Meier curves was performed to estimate the incidence of DILI over time. Incidence of DILI was calculated as the number of episodes per 1000 persons exposed per week. SPSS version 19.0 for complete data analysis and Statistica version 10 for graphical data presentation were employed. Variables with p<0.05 were considered potential predictors for DILI.A total of 373 newly diagnosed antiretroviral and antitubercular treatment naïve HIV-TB co-infected patients among which 199 (53.4%) women and 174 (46.6%) men were enrolled prospectively and followed up for development of DILI for up to 56 weeks after initiation of antiTB treatment. Twenty patients (20.4%) were excluded from the analysis and put on standard treatment as per the national guideline for they had elevated transaminases (>5×UNL) before starting efavirenz therapy. The remaining 353 patients were initiated with the four fixed dose combination anti TB drugs namely rifampicin, ethambutol, pyrazianmide and isoniazid for the intensive phase (2-month) followed with isoniazid and rifampicin for the continuation phase (4-month). All patients were also initiated with either AZT/3TC/EFV or D4T/3TC/EFV or TDF/3TC/EFV within the first 8 weeks after starting anti-TB treatment.The median age of participants was 35 years (range 18–72) and 49.2% of them had a BMI of <18.5. Seventy eight patients were diagnosed smear positive TB; while 62, 36, and 177 smear negative, disseminated and extra pulmonary TB, respectively. Screening of participants for Hepatitis B and C showed that 33 (9.3%) were positive for Hepatitis B surface antigen, while 5 (1.4%) was positive for Hepatitis C virus antibody. Association of socio demographic parameters, sex and type of HAART with DILI using Cox-regression analysis is presented in From a total of 353 patients, 106 (30.0%) or 14.5 per 1000 person-week developed DILI. The median time for development of DILI was 2 weeks and the majority (91.6%) of the DILI occurred during the first 8 weeks. Severe DILI, i.e., elevation of transaminases >5 times the upper normal limit was observed in 65 participants (18.4%) or 7.49 per 1000 person-week. During the follow up period 12.7% died among which 44.7% had DILI and only 5% had severe DILI before they died but none of the deaths in our cohort were secondary to liver failure. From the total of 65 patients who developed severe DILI 26 (40.4%) were taking D4T30/3TC/EFV , There wAnalysis of baseline biochemical characteristics and efavirenz kinetics with development of DILI is presented in NAT-2, CYP2B6, CYP3A5, ABCB1, UGT2B7*2, and SLCO1B1 genotype was done for 201. Association of each genotype with development of sever DILI is presented in NAT2 haplotypes were determined using Haploview following the nomenclature described in http://louisville.edu/medschool/pharmacology/NAT.html. According to the NAT2 genotypes, all participants were stratified into rapid  and slow . NAT2 genotypic analysis of the different SNPs showed that 138 (68.7%) patients were slow acetylators, while 63 (31.3%) were rapid acetylators. NAT2 rapid acetylator genotype was a significantly reduced the risk of developing DILI. None of the patients who developed DILI were homozygous for functional NAT2 variant allele (p<0.05). Cox-regression analysis showed that there was a statistically significant association DILI with CYP2B6*6 and ABCB1 3435TT genotype  Isoniazid is inactivated by ABCB1 3435TT genotype with increased risk for development of DILI. Interestingly the proportion of patients homozygous for ABCB1 3435TT genotype was three fold higher in the patients who developed DILI compare to those who did not. ABCB1 is responsible for the transport of many antiretroviral and anti tuberculosis drugs including rifampicin and ethambutol. ABCB1 3435T variant allele is reported to lower expression level and protein folding thereby altering the structure of substrate binding sites to and decreased transport activity Several anti TB drugs and antiretroviral drugs and are substrates of P-glycoprotein, coded by ABCB1 gene. We found association of Apart from pharmacogenetic and pharmacokinetic predictors, our result indicates a strong association between development of DILI and baseline elevation in serum aminotransferases as seen in other studies indicating that pretreatment liver enzymes are good predictors for development of DILI. The median time for development of DILI was two weeks, and 91.6% occurred during the first 8 weeks of follow up. This finding has clinical importance in providing information when to frequently assess this group of patients for development of DILI. Five of the patients who discontinued treatment because of severe DILI restarted their anti-TB treatment successfully (none discontinued HAART).CYP2B6*6/*6 and ABCB13435TT genotype, elevated baseline liver aminotransferases, high plasma efavirenz concentration, lower hemoglobin and albumin levels. Our result demonstrates that inter-patient variability in systemic efavirenz exposure and pharmacogenetic variation in NAT2, CYP2B6 and ABCB1 gene determines susceptibility to efavirenz induced liver injury in HIV patients and patients. Close follow up and regular monitoring of plasma efavirenz concentration and liver enzymes during early therapy is recommended, particularly in patients with the described underlying risk factors for early diagnosis and management of efavirenz-based HAART induced liver injury. Therapeutic drug monitoring may not be feasible in resource limited setting. Therefore genotyping practice for common functional variants of NAT2, CYP3A5 and CYP2B6 gene in HIV clinics before initiation of therapy is recommended to identify susceptible individuals and optimize the safety of concomitant rifampicin based anti-TB and efavirenz based antiretroviral therapy in co-infected patients.In summary, we report higher incidence of concomitant anti-tubercular and efavirenz based ARV DILI among Ethiopian TB-HIV co-infected patient The identified predictors include; slow acetylation status,


We continue the previously described prospective cohort study of ritonovir-boosted lopinavir (LPV/r) monotherapy for second-line therapy in HIV-infected patients with prior failure and extensive resistance to nucleoside reverse transcriptase inhibitors (NRTIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs), with the objective being to determine the three-year treatment responses.3 and median (IQR) HIV-1 RNA was 55,800  copies/mL. All patients received twice daily LPV/r 400/100 mg and recycled lamivudine 150 mg. By intend-to-treat analysis at 144 weeks, 26 (65%) and 22 (56%) patients achieved HIV-1 RNA at < 400 and < 50 copies/mL, respectively. In as-treated analysis, the corresponding rates were 26 of 28 (93%) and 22 of 28 (78%), respectively. Low-level viral rebound (HIV-1 RNA 50-400 copies/mL) was found in 6 (15%), 6 (15%), and 4 (10%) patients at week 48, 96 and week 144, respectively. Medians CD4 at week 48, 96, and 144 were 351, 481, and 584 cells/mm3 and significantly changed from baseline . There were increments of mean triglycerides at 48 weeks and 144 weeks from baseline (P < 0.05). No major protease resistance-associated mutations emerged after virologic failure.There were 40 patients with a mean ± SD age of 37 ± 8 years. Median (IQR) baseline CD4 was 123 (37-245) cells/mmLPV/r monotherapy with recycled lamivudine can maintain long-term virologic suppression in a relatively small proportion of patients failing NNRTI-based regimen and having limit option for active NRTI. More antiretroviral classes are needed be accessible in resource-limited countries. There are many concerns raised regarding boosted protease inhibitor monotherapy in HIV treatment include this strategic treatment may not be as effective as other combined antiretroviral therapies (ART), high rate of low-level viremia and may lead to developing treatment failure, and a higher level of adherence is required than with the use of standard combined ART . In addiThe present study was designed as a prospective cohort study involving 40 HIV-1 infected patients who were diagnosed virologic failure at the Bamrasnaradura Infectious Diseases Institute, Ministry of Public Health, Thailand. Virologic failure was defined as having viral load > 1,000 copies/mL after 6 months of treatment or a rebound of viral load to > 1,000 copies/mL in any duration after undetectable viral load. Discontinuation of lopinavir/ritonavir due to any reason was considered to be a treatment failure, i.e. plasma HIV-1 RNA > 1,000 copies/mL. Inclusion criteria were as follows: (1) HIV-1 infected patients > 18 years of age, (2) failed NNRTI-based ART with M184V, thymidine analogue mutations (TAMs) and NNRTI-associated mutations, and (3) had plasma HIV-1 RNA > 1,000 copies/mL. The patients were excluded if they had a history of exposure to protease inhibitor or receipt a medication that has drug-drug interactions with lopinavir or ritonavir. Ritonavir-boosted lopinavir in soft gel formulation at 400/100 mg and lamivudine at 150 mg were given twice daily. Ritonavir-boosted lopinavir soft gel formulation was changed to tablet formulation after 48 weeks of treatment. CD4 cell counts (flow cytometry), plasma HIV-1 RNA , and lipid profiles were measured every 24 weeks. Medication adherence was assessed by pill count. All analyses were performed using SPSS software, version 15.0 . This study was reviewed and approved by ethical committee for research in human subjects of the Department of Diseases Control, Ministry of Public Health and by the institutional review board.3 and median (IQR) plasma HIV-1 RNA was 55,800  copies/mL. Mean ± SD baseline total cholesterol was 165 ± 42 mg/dL and mean ± SD triglycerides was 172 ± 117 mg/dL. The frequencies of each thymidine analogue associated mutation (TAMs) were as follows: D67N, 17 (43%), T215FY, 16 (40%), M41L, 8 (20%), K65R, 6 (15%), L210W, 6 (15%), and K219Q, 2 (5%). M184V, Q151M and L74V were found in 40 (100%), 7 (18%) and 2 (5%), respectively. The prevalence of patients with ≥1 major mutation conferring drug resistance to NNRTIs was 100%.As initial enrollment, there were 40 patients with a mean ± SD age of 37 ± 8 years and 70% were males. Median (IQR) baseline CD4 cell count was 123 (37-245) cells/mm3 and significantly changed from baseline . Compared measures to baseline values, there were increments of mean triglycerides at 48 weeks and 144 weeks from baseline . LDL-cholesterol was not different (P > 0.05). No major protease resistance-associated mutations emerged after virologic failure. Three patients died over the study period. The attributed causes of death were cryptococcal meningitis (1 patient), sepsis (1), and hepatits B virus-associated cirrhosis with fulminant hepatitis (1). Over the study period, 36, 32, and 28 patients continued to follow-up at weeks 48, 96, and 144 weeks.Figure A recent systematic review of lopinavir/ritonavir monotherapy demonstrated that overall response rate is not as effective as either continuing combined ART or giving ART at the beginning with relatively marginal significant magnitude, i.e. 95% confidence interval for this determination was 1.02 to 2.13 . It is cAnother concern is that the efficacy in reservoirs is still uncertain as aforementioned. Previous data showed that most of the patients had undetectable HIV-1 RNA in semen and vaginal compartment with ritonavir-boosted lopinavir monotherapy . NonetheThis study provides evidence that long-term virologic control is possible in the patients failing NNRTI-based regimen and having limited options for active NRTI with receiving ritonavir-boosted lopinavir monotherapy and recycled lamivudine. However, this success is in a relatively small proportion of patients. Ritonavir-boosted lopinavir monotherapy should be prescribed with caution as a second-line option, especially in settings where close viral load monitoring is not available. As a consequence, more antiretroviral classes to assure the potency of the regimen are needed to be accessible in many resource-constrained settings. A further larger study is required to assess the risk and benefit of this proposed strategic treatment.The authors declare that they have no competing interests.WM participated in the design of the study, statistical analysis and draft the manuscript. ST, SN, SM, and SS participated in the design of the study and draft the manuscript. All authors read and approved the final manuscript.


To determine the prevalence and associated factors with chronic kidney disease (CKD) in a cohort of HIV-positive individuals with undetectable viral load on HAART.3, and CD4 ≥ 200 cells/mm3, were consecutively enrolled at the outpatient clinic of Hospital de Clínicas, Porto Alegre, Brazil. Exclusion criteria were obesity, malnourishment, amputee, paraplegic, previous history of renal disease, pregnancy and hepatic insufficiency. Renal function was determined by estimated glomerular filtration rate (eGFR) assessed by the modification of diet in renal disease. CKD was defined as an eGFR less or equal than 60 ml/min/1.73 m2, for a period of at least 3 months. Poisson regression was used to determine factors associated with CKD.From March, 2009 to September 2009, 213 individuals between 18-70 years, period on HAART ≥12 months, viral load < 50 copies/mmCKD was diagnosed in 8.4% of the population, and after adjustment, the risk factors were hypertension , time on HAART  and tenofovir exposure . Higher weight  was associated to normal function.CKD was a common finding in this cohort of patients and was related to hypertension, time on HAART and tenofovir exposure. We suggest a more frequent monitoring of renal function, especially for those with risk factors to early identify renal impairment. The advances of antiretroviral therapy (HAART) had turned HIV/AIDS into a chronic disease In this scenario, kidney disease has been increasingly reported, with a prevalence of chronic kidney disease (CKD), varying from 4.7% to 7.6% according to several studies The first stage of renal impairment is silent and only detectable through laboratory analysis The objectives of our study were to describe the prevalence of CKD and to determine the risk factors associated to the development of renal disease in a cohort of HIV infected individuals on HAART, undetectable viral load, and not severely immunosupressed (CD4 count > 200 cells/mm3), which would better resemble the general population, in Brazil.Two hundred fifty five patients attended in the HIV/AIDS outpatient clinic at Hospital de Clínicas, Porto Alegre, Brazil, were consecutively enrolled from March, 2009 through September, 2009. To be included, patients needed to be on HAART and undetectable viral load (<50 copies/ml) for a period equal or greater than 12 months, CD4 counts higher than 200 cells/mm3 and age between 18 and 70 years. Patients were excluded if were obese or malnourishment 3, measured by flow cytometry); plasma HIV-RNA level ; serum creatinine ; date of HIV diagnosis and other comorbidities.Data were collected at the moment of the appointment and included demographic variables ; diagnosis of DM (according to “The American Diabetes Association”)2 or the presence of proteinuria independent of eGFR in both estimations.The biochemical data was measured in the same laboratory. The main outcome of interest in our study was to eGFR assessed by two measurements, at least, three months apart utilizing the MDRD in its simplified version  and CKD-epi equations. CKD was defined as an eGFR less or equal than 60 ml/min per 1.73 m2; mild decrease, GFR between 60–89 ml/min per 1.73 m2 or presence of proteinuria with normal eGFR; moderate decrease, GFR between 30-59 ml/min per 1.73 m2; severe decrease, GFR between 15–29 ml/min per 1.73 m2; and, renal failure or dialysis, GFR less than 15 ml/min per 1.73 m2Renal function was classified in five stages depending on the level of eGFR, as proposed by the Kidney Disease Outcomes Quality Initiative (KDOQI): normal, GFR equal or higher 90 ml/min per 1.73 mThe study was approved by the Research and Ethic Committee of Hospital de Clinicas and all patients signed the informed consent.Statistical analysis included descriptive (mean and standard deviation), univariate and multivariate analysis. Absolute and relative frequencies were utilized for continuous and categorical variables respectively.To evaluate the association between CKD and categorical variables Chi-square test or Fisher exact were applied as required. Independent T test or one way ANOVA were used to compare means; in case of asymmetry Mann Whitney test or Kruskal-Wallis test were used. Variables significantly associated with renal impairment in univariate analysis (p<0.05) were included in the multivariate model. Those significant in the multivariate model (p<0.1) were included in the final model. Poisson Regression was used to determine the factors associated with CKD in an univariate analysis and in a multivariate model. Pearson coefficient and Bland-Altman graph were used to evaluate the correlation and the concordance between the two equations to eGFR (MDRD and CKD-epi). A p value of less than 0.05 was considered significant. Analysis was performed using the statistical package for the social sciences (SPSS) version 17.0 .The sample size calculation was based on a prevalence of at least 4% of CKD in that population with a confidence level of 95%. A sample size of at least 198 individuals was needed to be representative of the 2,050 individuals on HAART in our site to have a power of 80%3, and mean nadir CD4 count was 169±137 cells/mm3. The prevalence of hypertension and DM was 20.7% (n = 44) and 14.1% (n = 30), respectively. There was no statistical difference between ethnicity characteristics (data not shown).From the initial 255 included patients, there were 42 losses (16.5%): 28 due to incomplete laboratory data; 13 withdrew the informed consent; and, one additional patient died after signing the consent. The characteristics and clinical variables of the remained 213 patients are shown in There was a significant correlation between the CKD-epi and MDRD equations . The prevalence of CKD was 8.4%, which is quite close, albeit higher, to the ones reported by other studies that vary from 4.7% to 7.6% The factors associated were: hypertension, time on HAART and TDF use. As expected, hypertension was found to be a major risk factor associated with CKD ), which is in accordance to other studies Another unique finding was that time on antiretroviral therapy was significantly associated with CKD. In our study, there was a 15% increased prevalence of CKD per year of additional exposure to ARVs . This could be explained by the fact that prolonged use of HAART could be associated with greater long term renal toxicity, meaning the more exposition leading to higher toxicity.Adverse effects of the exposure to individuals ARVs were demonstrated by other studies which described the cumulative association of TDF, ATV, indinavir and RTV to the development of CKD An important finding was related to the body weight (RR = 0.89, 95% CI 0.82–0.96, which was significantly associated as a protection factor. To our knowledge, this is the first study that found this association. Individuals with lower body weight were at greater risk of having CKD. Despite it is known that weight may play an important function in drug metabolism, once it can influence the bioavailability and pharmacokinetics of ARVs 3 and at least one year with undetectable viral load, it is not possible to exclude any influence of HIV infection and related diseases or other nephrotoxic medications in the prevalence of renal impairment The study has several limitations that should be considered when interpreting the results. Although all studies estimate the GFR in HIV individuals, this could be not accurate enough to allow a firm conclusion of kidney function. MDRD equation, generally more accurate and utilized In summary, according to our findings, in HIV population which would most resemble the general population, hypertension, time on HAART, and exposure to tenofovir were associated with a higher prevalence of CKD. On the other hand, individuals with higher body weight appeared to be “protected” from chronic kidney disease. We suggest that an equation to eGFR should be routinely applied to better identify decrease in renal function, and should be performed at the moment of HIV diagnosis and later at regular intervals, depending on the associated risk factors. Further studies are necessary to confirm risks associated to renal disease in HIV-infected individuals.


Cryptococcus neoformans and C. gattii), with eight major molecular types. HIV infection is recognized worldwide as the main underlying disease responsible for the development of cryptococcal meningitis (accounting for 80–90% of cases). In several areas of sub-Saharan Africa with the highest HIV prevalence despite the recent expansion of antiretroviral (ARV) therapy programme, cryptococcal meningitis is the leading cause of community-acquired meningitis with a high mortality burden. Although cryptococcal meningitis should be considered a neglected disease, a large body of knowledge has been developed by several studies performed in recent years. This paper will focus especially on new clinical aspects such as immune reconstitution inflammatory syndrome, advances on management, and strategies for the prevention of clinical disease.Cryptococcal meningitis is a life-threatening opportunistic fungal infection in both HIV-infected and HIV-uninfected patients. According to the most recent taxonomy, the responsible fungus is classified into a complex that contains two species ( Cryptococcus spp., is a major cause of fungal meningitis and meningoencephalitis especially in immunocompromised patients [kryptos (hidden) and kokkos (berry) but a long lists of names and synonyms have been generated until the adoption of the actual nomenclature [The encapsulated yeast, patients , 2. Thispatients –5. The gnclature .C. neoformans has been recognized for more than 100 years, the worldwide spread of HIV infection as well as the increasing number of patients with impaired immunity were responsible for the dramatic surge of this life-threatening infection only in the 80's [However, although the 80's –9. Althothe 80's . This paCryptococcus exist but only two are considered important human pathogens. The fungus is actually classified into the Cryptococcus neoformans complex that consists of two species: C. neoformans and C. gattii [C. neoformans var. grubii (serotype A), C. neoformans var. neoformans (serotype D), and AD hybrids generally cause disease in immunocompromised patients whereas C.gatti (serotype B and C) can cause disease also in immunocompetent patients [More than 30 species of the genus . gattii –19. C. npatients –22.C. neoformans var. grubii), VNIII/AFLP3 (AD hybrid), VNIV/AFLP2 (C. neoformans var. neoformans), and VGI/AFLP4, VGII/AFLP6, VGIII/AFLP5, VGIV/AFLP7 (C. gattii) [Molecular typing has identified eight major molecular types within the 2 species: VNI/AFLP1, VNII/AFLP1A ( gattii) .neoformans cryptococcal infections are rarely encountered and have been recently reviewed [Non-reviewed . C. neoformans var. grubii has a worldwide distribution and is the most prevalent species  [C. gattii strain of the Vancouver outbreak has spread to the Pacific Northwest of the United States [C. gattii has been isolated also in temperate regions of Europe  as well as of Asia  [ species  whereas n Europe –37. Cryp regions –40 but, stralia) , 42. Mord States . Finallyh Korea) –47. C. neoformans is now emerged as the leading cause of meningitis accounting for 26 to 45% of cases in several series [The analysis of the risk factors associated with development of cryptococcosis employed in several studies clearly demonstrates that HIV infection is the major underlying condition predisposing to the development of this disease , 33, 48.l series –57. It has been estimated that in 2006 at least 957,900 cases of CM had occurred worldwide with the highest burden from sub-Saharan Africa   MoreoverCryptococcus is usually through inhalation of spores or desiccated yeast cells from the environment. Deposition in the alveoli produces an asymptomatic infection that is either cleared or controlled by a strong cell-mediated immune response leading to a dormant latent infection with development of granuloma in the lungs or hilar lymph nodes [C. neoformans enters the circulatory system it must survive for dissemination to occur and macrophage can be a vehicle either for dissemination and distribution through the host; crossing the blood brain barrier (BBB) is probably mediated by transcytosis  and there is evidence that the capsule is involved [The portal of entry of ph nodes , 61. In involved , 63.C. neoformans with a mechanism of “Trojan horse”; it has been shown in vitro that active macrophage phagosomal extrusion is a possible escape strategy allowing continued propagation and dissemination of the fungus [Macrophages probably play also an important role in the BBB crossing by e fungus . Recentle fungus .Cryptococcus can infect any organ in the body but showing a predilection for the lung and the central nervous system (CNS). The lung is the usual portal of entry of the microorganism and the infection can run either an asymptomatic course, especially among immunocompetent subjects, or progress to a life-threatening pneumonia with respiratory failure as observed in patients with AIDS [The fungus ith AIDS . Cryptococcus species was found to be the second leading infection (after tuberculosis), and in 43% of all cryptococcal antigen positive, there was no evidence of past or concomitant meningitis nor any alternative etiology was identified [In the pre-HAART era, cryptococcal infection was identified as the only cause of acute respiratory failure in 9% of a cohort of 210 patients with AIDS ; black rentified .C. neoformans shows a predilection to invade the central nervous system causing meningitis or meningoencephalitis in about 77–86% of patients [μL; two-thirds of patients had less than 50 CD4+ cells/μL and the median value reported in several series is below 30/μL [patients , 71–89; patients , 72–90. ow 30/μL .Meningismus or neck stiffness is observed globally in about 61% of cases but more frequently in HIV-positive patients in Africa , 80–85 cC. neoformans are found in 6% of AIDS patients with CM but the frequency is higher in patients infected with serotype D due to the seemingly higher skin tropism of this serotype [Skin lesions due to serotype –98. SkinCryptococcal disease seems to occur less frequently in AIDS children than in adults with a prevalence of 0.8 to 1.4% –101. HowC. neoformans infection than children infected by other routes [Older studies suggested that children with HIV infection acquired by vertical transmission may be less likely to develop r routes , 117. Hor routes , 102. Clinical features in children were similar to those observed in adults but those diagnosed in Africa showed higher frequency of headache (86% versus 53%), nuchal rigidity (69% versus 7%), seizures (38% versus 13%), and focal neurologic signs (23% versus 7%) in comparison with patients observed in USA , 101.Elevated intracranial pressure (ICP) is a common complication of AIDS-associated CM. The pathophysiology of elevated ICP in patients with CM is poorly understood and it is likely caused by several convergent factors. It has been postulated that it may be due to the outflow obstruction precipitated by aggregation of fungal polysaccharide accumulating in arachnoid villi and subarachnoid spaces thus providing the blockage of the channels for CSF drainage . This pi2O, 30% of whom showed an intracranial pressure of ≥350 mm H2O [2O [In an old observational study about 60% of the patients had an intracranial pressure of ≥250 mm H0 mm H2O . Similar H2O [2O , 121. Th H2O [2O , 120. HoA recent autopsy study elegantly demonstrated a correlation between high concentration of viable and dead organisms in the arachnoid granulations and raised cerebrospinal fluid pressure with the consequence of the obstruction of CSF resorption .2O) daily drainage by repeated lumbar puncture or positioning of temporary percutaneous lumbar drains is recommended (with a BIII evidence). However, daily lumbar punctures although associated with immediate relief of headache may be associated with the risk of brain herniation [The optimal management of elevated ICP without hydrocephalus in the setting of CM is still uncertain and debated. The updated guidelines by the Infectious Diseases Society of America on the basis of the study by Graybill and coworkers recommend, after appropriate brain imaging to exclude hydrocephalus or space-occupying lesions, CSF drainage by lumbar puncture (with a BII evidence) ; if symprniation . The placement of lumbar drains has been proposed for control of raised ICP when the more conservative measures have failed; this technique allows the removal of more cerebrospinal fluid than can be safely removed by daily lumbar puncture , 126. ThCryptococcal immune reconstitution inflammatory syndrome (IRIS) can be associated with a clinical deterioration of the disease or with a new presentation of cryptococcal disease after reversal of the immune deficiency state , 130. CrThe incidence of paradoxical IRIS associated with cryptococcosis in AIDS patients was reported to be 15.9 events/100 patient-years of follow-up (95% CI 8.5–22.9) in one study from USA, 4.2/100 person-years(PY) of follow-up (95% CI 2.2–7.8) in another study conducted in France, and 25/100 PY in South Africa –137.On the other hand, the incidence of unmasking (or ART-associated) IRIS is lower ranging from 0.2% to 1.6% as reported in two retrospective and three prospective studies , 137–140A meta-analysis of 54 cohort studies comprising more than 13.000 patients starting HAART indicated that CM was associated with the development of IRIS in 19.5% of cases (95% CrI 6.7–44.8%). It ranked second among the opportunistic infections more frequently associated with IRIS but, more notably, had the highest mortality attributed to the syndrome (20.8%) . HoweverAnother controversial point is the establishment of the period of time during which the patients are at risk of developing cryptococcal IRIS. In fact, the time of appearance of IRIS varied quite widely among the different studies with the shortest interval after the start of HAART reported to be few days and the longest 22–27 months –148. HowIn the case definition elaborated by the experts of INSHI, they proposed a maximum time of 12 months for the development of paradoxical IRIS after ART initiation; although acknowledging that the cut-off chosen was largely arbitrary and would exclude those occasional cases presenting after a longer interval, they believed that it might improve the specificity and its practical usefulness .μL (OR 4.0) and starting HAART within 2 months of diagnosis of cryptococcosis (OR 5.5) were identified in a multivariate model as independent risk factors for development of IRIS [P = .031) [μL, P = 0.01) was the only variable associated with development of IRIS [In a retrospective multicentre study from France, a diagnosis of cryptococcosis revealing HIV-infection (OR 4.8), presence of fungemia at baseline (OR 6.1), CD4 cell count of less than 7/ of IRIS . Another = .031) . On the  = .031) . They sh of IRIS . Finally of IRIS .α, granulocyte colony-stimulating factor (G-CSF), granulocyte-macrophage colony-stimulating factor (GM-CSF), and vascular endothelial growth factor (VEGF) were predictive of IRIS with a receiver operating characteristic (ROC) curve of 0.82. The same group showed that a paucity of inflammation in the cerebrospinal fluid at the time of CM is associated with failure to sterilize CSF at 2 weeks and subsequent risk of developing IRIS [Interestingly in a prospective study conducted in a cohort of ART-naïve Ugandans that aimed to identify serum biomarkers predictive of IRIS development, a 4-fold higher baseline concentrations of cryptococcal antigen was observed among patients who developed IRIS in comparison with those who did not develop IRIS . In the ing IRIS .Clinical presentation of paradoxical IRIS can range from the more frequent picture of relapsing meningitis with raised intracranial pressure and negative CSF culture , 154–158Cryptococcal IRIS, especially when presenting with CNS manifestation, is a potentially lethal disease , 157 witCryptococcus neoformans, however, is able to disseminate and infect most areas of the body  and thus it can be cultured or shown by histopathology as well from different body specimens  using a latex agglutination or an enzyme immunoassay kit. Cryptococcal antigen testing on blood and CSF is a highly reliable and rapid diagnostic technique with excellent sensitivity and specificity . Sensitienomenon –175.HIV-positive patients usually have very high serum and CSF CrAg titres than their HIV-negative counterpart as a reflection of the higher yeast burden and, in the pre-HAART era, both were predictive of mycological failure and poor outcome , 13. In In areas of high prevalence of cryptococcosis, the use of serum CrAg as a screening test is helpful to identify those HIV-infected people with advanced disease at risk of developing cryptococcal meningitis and who might benefit of a preemptive antifungal treatment together with antiretroviral therapy –110, 113μL) was a cost-effective measure showing 71% survival at 30-month of those treated with fluconazole together with HAART compared with 100% deaths within 2 months in those treated only with HAART [Using a cut-off value of >1 : 8 the CrAg assay was 100% sensitive and 96% specific for predicting incident CM during the first year of HAART . Subsequth HAART . Cryptococcus positive blood culture from HIV-positive patients from Thailand, showing sensitive ranging from 96% to 100%, respectively [In 2009, a new lateral flow assay (LFA) characterized by rapidity (5–15 minutes), stability at room temperature, and affordability (1.5 to 2.5 US $) was developed for the detection of cryptococcal antigen on serum, CSF, and urine . All theectively . In anotectively  but a smectively . Based oectively , 203.Aspergillus galactomannan assay and serum from patients with cryptococcal meningitis with positive results ranging from 13.6 to 63.3% [Finally two studies showed cross-reactivity between the Platelia to 63.3% , 205. Left untreated CM is a uniformly fatal disease but even with antifungal treatment the outcome is influenced either by factors associated with the host and the underlying diseases and the fungus . SeveralIn the Antiretroviral Therapy Cohort Collaboration study , cryptococcosis ranked third , as a cause of death overall and within the first 6 months after the beginning of therapy . HoweverP = .02), mortality at 2 and 10 weeks was not statistically different in the two arms [Several clinical trials or cohort studies regarding antifungal therapy for AIDS-associated CM have been performed and published over the last 22 years and are summarized in two arms .However, analyzing combined data of early fungicidal activity collected from different cohorts, Bicanic and coworkers were able to show that the magnitude of this was inversely associated with mortality at 2 and 10 weeks and in a multivariate models , it remained independently associated with mortality . As discIn consideration of the fact that 5-FC is presently unavailable in several resource-limited areas where, on the contrary, fluconazole might be obtained free of charge through the Pfizer program or as a cheap generic drug, a phase II randomized open label trial was conducted in Thailand and USA comparing three arms (AmB at 0.7 mg/kg versus AmB at the same dosage plus fluconazole 400 mg or 800 mg per day) . Using aA very interesting decision analysis study based on the results of cryptococcal trials in resource-limited areas and expected life assumptions, provided some evidence that a short-course (1-week) of AmB (1 mg/kg/d) associated with high-dose fluconazole (1200 mg/d) for 2 weeks is the most cost-effective induction treatment among the 6 regimens evaluated .P < 0.001). Moreover, a 5-FC prescription shorter than 14 days was one of the variables independently associated with treatment failure at 3 months of follow-up confirming the results of the study of van der Horst [The French CryptoA/D prospective observational study performed on both HIV-positive or negative patients with a first episode of CM showed that also in the “real life” the best regimen for induction therapy is the combination of AmB and 5-FC . Treatmeer Horst , 76. Inter Horst . In a muP < .001) and less nephrotoxicity with the lower dosage of L-AMB (P = .004). Thus the results of this study confirmed that the main advantage using L-AMB instead of AmB in the treatment of AIDS-associated cryptococcosis is a better tolerability without any significant improvement in the outcome. Recently the expert committee panel of the British HIV Association recommended the use of L-AMB (4 mg/kg/d) as preferred amphotericin B preparation for the induction therapy of AIDS-associated CM [Although AmB is still recommended as the drug of choice for induction therapy of CM by authoritative guidelines , 214, itiated CM . On the iated CM . Finallyhttp://www.niaid.nih.gov/news/newsreleases/2012/Pages/COAT.aspx). Among HIV-infected patients with advanced disease such as those with a diagnosis of CM, there is general agreement that ARV therapy should be started as soon as possible since its deferral is associated with further HIV-related diseases and increased mortality. However, the risk of severe and potentially fatal IRIS associated with an unsterilized CSF infection is an argument against an early or concomitant  ARV therapy. An open-label randomized strategy study of early (within 2 weeks) versus deferred (after acute therapy for opportunistic infection was completed) ARV therapy among subjects with different opportunistic infections demonstrated that the early strategy was associated with fewer AIDS progression and death . HoweverIt has been supposed but not proved that the fungistatic effect of fluconazole used in one study  as opposμL, a median duration of HAART ranging from 6 to 42.5 months and a median follow-up ranging from 9 to 28.4 months after discontinuation [μL [The question regarding when antifungal maintenance therapy can be safely discontinued in patients responding to ARV therapy and at what threshold of CD4+ lymphocytes it should be done has been so far addressed in five case studies –227, thrinuation . The caltion [μL .In the pre-HAART era, a randomized clinical trial comparing fluconazole 200 mg/day with clotrimazole troches for prevention of fungal infections in AIDS patients demonstrated a sevenfold reduction in the risk of cryptococcosis . SubsequIn contrast with the above mentioned lack of survival benefit a randomized double-blind placebo-controlled study performed in Thailand showed a reduction of overall mortality (HR 4.3) in patients receiving weekly fluconazole (400 mg) compared to placebo although the study had a low statistical power with wide confidence intervals for the mortality benefit (0.9–19.8) . A case-μL with primary prophylaxis better when CD4+ are below 50 cells/μL [Modelling of data from a high endemic region for cryptococcosis in resource-limited settings suggested that screening for cryptococcal antigen with preemptive treatment was more cost-effective in patients with CD4+ lymphocytes between 51–100 cells/cells/μL .Finally, a large double-blind randomized placebo controlled trial conducted in Africa provided evidence that fluconazole (200 mg) three times weekly was effective as primary prophylaxis against cryptococcal disease both before and during the early ARV therapy . MoreoveCryptococcal meningitis remains a major cause of morbidity and mortality among HIV-positive patients especially in resource-poor areas. ART is responsible of a dramatic improvement of outcome but it is associated with the possible onset of IRIS that is potentially fatal. In this regard, the optimal timing of ART beginning after the diagnosis of HIV-associated cryptococcal meningitis is unclear. Screening severe immunocompromised HIV-positive patients with the new lateral flow assay to detect CrAg is highly cost effective.


Current HIV-1 antiretroviral therapy (ART) greatly reduces virus replication but does not significantly affect the viral reservoir. Raltegravir, a recently introduced integrase inhibitor, could, at least theoretically, reduce residual viremia in patients on ART and affect the viral reservoir size. The aim of this study was to assess whether switching therapy in treatment-experienced patients that were virally suppressed to a raltegravir-containing regimen reduces the size of the viral reservoir, and if such treatment leads to a change in levels of HIV 2-LTR circles in this patient group.14 ART experienced individuals with a suppressed viral load (<50 HIV-1 RNA copies/mL plasma) at baseline (for at least 2 months) were switched to a raltegravir-containing regimen. Blood samples were taken at baseline and at ≥2 timepoints up to 48±6 weeks. Levels of total HIV-1 DNA and 2-LTR circles in peripheral blood mononuclear cells (PBMCs) were measured using real-time PCR assays.6 PBMCs at baseline and the other had 34 copies/106 PBMCs at week 51.There was no significant change in HIV-1 total DNA levels over the study duration (p = 0.808), median slope 0.24 . Low levels of 2-LTR circles were detected in 2 patients. One had 16 copies/10The switch to a raltegravir containing regimen was not associated with a significant change in HIV-1 total DNA levels in this cohort. There were no observed changes in the levels of HIV-1 2-LTR circles associated with raltegravir treatment initiation. The human immunodeficiency virus type 1 (HIV-1) viral reservoir is established early in infection Raltegravir is an integrase inhibitor which has been shown to significantly alter viral decay dynamics in treatment naive patients At the time of study conception, there was no information on the effects of raltegravir containing ART regimens on HIV-1 DNA levels. We hypothesized that in a treatment experienced cohort, including patients on salvage therapy regimens with potentially higher levels of residual viraemia, maintenance of the viral reservoir through ongoing replication might be more prevalent. Switching to a raltegravir containing regimen may therefore further suppress ongoing replication in these patients and have an impact on the size of the viral reservoir. We assessed total HIV-1 DNA levels in PBMC as a measure of the viral reservoir from 14 treatment experienced patients with suppressed viral load (<50 HIV-1 RNA copies/mL plasma) at study entry that were switched from their current ART to raltegravir containing regimens. We also assessed levels of HIV-1 2-LTR circles since changes in levels of episomal DNA after therapy switch would be an indicator for the presence of ongoing replication in this cohort.Written informed consent was obtained from all patients who participated in this study. The study was approved by the human research ethics committee, St Vincent's Hospital, Sydney, Australia (file number 08/SVH/58).14 treatment experienced patients with suppressed viral load (<50 HIV-1 RNA copies/mL plasma) at least two months prior to study entry were switched from current ART to raltegravir containing regimens. The decision to switch therapy was primarily based on the treating physician's attempt to achieve an optimised treatment regime. Viral load was assessed using the standard Roche COBAS Amplicor assay version 1.5 . Blood samples were taken at baseline and at approximately twelve-week intervals, with 2 or more subsequent samples for each patient up to 48±6 weeks.PBMCs were extracted from blood samples with Ficoll-Paque gradient density centrifugation gag gene as previously described HIV-1 DNA was quantified using a real-time PCR assay targeting a highly conserved 155 base pair region of the 5′- AGTGGGGGGACATCAAGCAGCCATGCAAAT-3′HIV-gag sense primer SK145: 5′- TACTAGTAGTTCCTGCTATGTCACTTCC-3′HIV-gag antisense primer SKCC1B: Fluorescent locked nucleic acid (LNA) probe SKLNA2–3:5′-6-FAM-AT[C]A[A]T[G]AGGAA[G]CT[G]C-TAMRA-3′Bases in brackets indicate locked nucleic acids (LNAs).7 to 101 copies. The limit of detection for the assay was 10 copies. Cycling conditions for both assays were: 1 cycle −95°C for 3 minutes and 40 cycles −95°C for 15 seconds, 60°C for 1 minute on a Bio-Rad iQ-5 multicolour real-time PCR machine (Bio-Rad Laboratories).Patient samples and standard curve dilutions were run in duplicate in 25 µl reactions with 12.5 µl of iQ Supermix , 800 nM of SK145 and SKCC1B, and 200 nM of SKLNA2–3. A maximum input of 500 ng DNA  input was used per reaction. DNA from one HIV-1+ individual with known HIV-1 DNA copy numbers was used as a reference control. The standard curve was designed using linearised HIV-1 plasmid pNL4-3 in 7 serial 10-fold dilutions from 104 cells = 500 ng of DNA), this was then multiplied by 12.5 and displayed as copies per 106 PBMCs. All samples from the same patient (baseline to 48±6 weeks) were run within the same PCR plate to enable comparison between timepoints without the need to account for run-to-run variation. All assays used non-template negative controls.HIV-1 total DNA copy numbers were normalised with a TaqMan beta-actin assay  to determine copies per 500 ng genomic DNA input . The patients were further sub-grouped by time of virological suppression prior to baseline (<12 mths and ≥12 mths) and by reverse transcriptase inhibitors in the treatment regimen. The Wilcoxon Sign Rank test was then used to assess if the median slopes within these subgroups deviated from 0. Again, a median trendline slope of 0 (null hypothesis) would indicate no change in the HIV-1 DNA levels over the study duration. All statistical analysis was performed using GraphPad Prism version 5.0 c .14 treatment experienced patients with suppressed viral load (<50 HIV-1 RNA copies/mL plasma) at study entry were switched to raltegravir containing regimens. The patients in the study cohort were all male with a median age of 54.0 years (range 31.9–74.0). 6 PBMCs for each patient . A linear trendline was plotted for each patient, and the slope of each trendline was obtained (6 PBMCs per week). A nonparametric one-sample Wilcoxon Sign Rank test of the linear trendline slopes found no significant difference from 0 (p = 0.808) and a median slope of 0.24 , indicating no change in the total DNA levels over the study duration.HIV-1 total DNA was detectable in all patient samples. obtained . Figure When the study cohort was subdivided into patients with <12 months (n = 4) and ≥12 months (n = 10) of virologic suppression prior to the switch to raltegravir , analysi6 PBMCs at baseline and Patient 014 had 34 copies/106 PBMCs at week 51 . This includes those patients that were switched to a simplified raltegravir/atazanavir regimen. Similar results were reported in a recent study by Cordery et al. These findings are in line with other recent studies The persistence of ongoing rounds of viral suppression during ART is currently a matter of debate. Findings that suggest ongoing replication include the detection of HIV-1 RNA in lymphoid and gut tissue as well as evidence of cross-infection between cellular compartments in CD4+ T cells and GALT, despite undetectable HIV-1 RNA in plasma Low levels of 2-LTR circles, a possible surrogate marker of ongoing replication during raltegravir treatment In summary, our results demonstrate that the switch to a raltegravir containing regimen in a cohort of treatment experienced, virologically suppressed patients was not associated with a decay in HIV-1 total DNA over 48±6 weeks, and indicates that this change in treatment regimen did not have a significant impact on the viral reservoir size or mechanisms of maintenance. The inclusion, or as other groups have shown the addition of raltegravir to an ART regimen is thus unlikely to contribute significantly to reservoir clearance without other interventions. Future studies exploring therapeutic approaches to eradication of HIV-1 infection will likely need to attempt to specifically target latently infected cells in addition to the complete reduction of all ongoing replication. Finally, the clinical relevance of changes of cell associated HIV-1 DNA levels in the setting of therapeutic strategies that aim at reducing the HIV reservoir will also need to be more clearly established.


The present paper describes possible connections between antiretroviral therapies (ARTs) used to treat human immunodeficiency virus (HIV) infection and adverse drug reactions (ADRs) encountered predominantly in the liver, including hypersensitivity syndrome reactions, as well as throughout the gastrointestinal system, including the pancreas. Highly active antiretroviral therapy (HAART) has a positive influence on the quality of life and longevity in HIV patients, substantially reducing morbidity and mortality in this population. However, HAART produces a spectrum of ADRs. Alcohol consumption can interact with HAART as well as other pharmaceutical agents used for the prevention of opportunistic infections such as pneumonia and tuberculosis. Other coinfections that occur in HIV, such as hepatitis viruses B or C, cytomegalovirus, or herpes simplex virus, further complicate the etiology of HAART-induced ADRs. The aspect of liver pathology including liver structure and function has received little attention and deserves further evaluation. The materials used provide a data-supported approach. They are based on systematic review and analysis of recently published world literature (MedLine search) and the experience of the authors in the specified topic. We conclude that therapeutic and drug monitoring of ART, using laboratory identification of phenotypic susceptibilities, drug interactions with other medications, drug interactions with herbal medicines, and alcohol intake might enable a safer use of this medication.  Knowledge about indications for antiretroviral therapy (ART) use in chronically human immunodeficiency virus (HIV-) infected patients, relative efficacy of different regimens, patient evaluation, and laboratory monitoring are essential in the success of viral eradication. There are different combination therapies presenting activity against both wild-type and multidrug resistant HIV.Side effects of these therapeutic interventions include adverse drug reactions (ADRs) such as direct hepatocytotoxicity, hypersensitivity syndrome reactions (HSRs), nausea, headache, diarrhea, and pancreatic toxicity. An ADR represents any noxious, unintended, and undesired effect of a drug, which occurs at doses used in humans for prophylaxis, diagnosis, or therapy .Pharmaceutical agents that can be combined to make up highly active antiretroviral therapy (HAART) can be divided into three categories, namely, nucleoside reverse transcriptase inhibitors (NRTIs), nonnucleoside reverse transcriptase inhibitors (NNRTIs), and protease inhibitors (PIs), based on their mechanism of action. Substrates of P-glycoprotein, an ATP-dependent efflux membrane multidrug resistance transporter, comprise one class of molecules that can limit the absorption of most PIs. For example, oral administration of saquinavir, indinavir, or nelfinavir in knockout mice lacking this transporter resulted in two- to fivefold increases in plasma drug concentrations . Higher While drug interactions should be examined closely whenever prescribing medication in combination with PIs, this is a particularly important consideration with ritonavir, given its powerful inhibition of cytochrome p450 (CYP) 3A4 and its effects on several other mechanisms of drug interactions . –27. 6–27 = 0.04) .γ-glutamyl transpeptidase were indicative of cholestasis in one study , 3527, 3Recurrent episodes of acute pancreatitis may also suggest a misuse of alcohol or use of concomitant medication. There is no mention of how many drinkers were in a large study, yet the incidence of symptomatic and asymptomatic cases was similar between alcohol drinkers and abstainers .P < 0.05), especially severe hepatic injury , measured by elevations in transaminase levels [P = 0.01) was associated with a greater risk of severe hepatotoxicity in a sample of 108 patients [Hepatic injury is often more common in individuals with alcohol abuse and in those with HCV coinfection. HAART-induced hepatic injury has the potential to limit the usefulness of this medication in HIV treatment . Twelve e levels . Alcoholpatients .Fourteen (10.6%) patients were alcohol abusers in a small sample of 132 HIV patients coinfected with HCV. Due to the low number of alcohol abusers in this sample, no association between alcohol abuse and hepatotoxicity was observed . AlcoholExcessive alcohol consumption had no effect on the development of mild-to-moderate rash. However, severe rash plus/or hepatotoxicity was observed among 741 patients, of which 163 (22.0%) abused alcohol  [t1/2, with no change in the pharmacokinetic profile of ethanol [Since the primary metabolic pathways of abacavir are mediated by microsomal UDP glucuronyl transferase and cytosolic alcohol dehydrogenase, use and misuse of alcohol can lead to hepatotoxicity. A significant pharmacokinetic interaction was found following the coadministration of abacavir and ethanol. Twenty-four HIV-positive men received either a single 600 mg dose of abacavir, 0.7 g/kg ethanol , or a 600 mg dose of abacavir plus 0.7 g/kg ethanol on separate occasions. With coadministration, there was a 41% increase in abacavir area under the curve and a 26% increase in abacavir  ethanol .While not all studies found an association between alcohol consumption and a greater risk of HAART toxicity, studies where such parameters are investigated often use small population sizes, with a low proportion of alcohol abusers, making it difficult to uncover interactions.The present paper discusses hepatic, GI, and pancreatic ADRs related to various ART drugs and drug combinations. We also introduce a section on HSR, since HSRs encompass many of the clinical entities of hepatic and GI representations. We further describe some of the interactions between ART and other drugs and alcohol. Moreover, we briefly explore the influence of certain comorbidities, such as viral hepatitis, on ART-induced hepatotoxicity.As with all ART medications, many clinically significant interactions are possible with PIs. For example, atazanavir cross-reacts with nevirapine. Atazanavir exposure is significantly lower when combined with this drug, and the risk of nevirapine toxicity may increase due to increased nevirapine exposure. In addition, atazanavir in combination with efavirenz is not recommended in treatment-experienced patients, since efavirenz significantly lowers atazanavir exposure. Concomitant didanosine/lamivudine exposure is not recommended in ART-naive patients receiving unboosted atazanavir due to potential toxicities. In addition, the virological response to abacavir may be diminished significantly by multiple NRTI-associated mutations and/or by reductions in phenotypic susceptibility to abacavir. However, many subjects showing evidence of baseline resistance to NRTIs respond to abacavir.Of particular relevance to the HIV-infected population is coinfection with HCV. Hepatitis with aminotransferase elevations was reported, and it should be appropriately monitored .Hepatocytotoxicity, or drug-induced liver injury, can be classified based upon clinical presentation and laboratory features, the mechanism of toxicity, and/or histological findings. The presence of serum bilirubin raised >3 times over the upper limit of normal along with aminotransferase elevations is associated with a more drastic prognosis than isolated aminotransferase abnormalities , an obseIn addition to these acute hepatic presentations, some drugs are associated with chronic histological inflammatory changes and a clinical syndrome resembling autoimmune hepatitis, while others cause endothelial damage or thrombosis, leading to vascular complications such as venoocclusive disease . Withdraper se may influence the ultrastructural architecture of the liver. In the liver of a patient living with AIDS, Phillips et al. found tubular structures mainly in the cytoplasm of endothelial cells and less frequently in Kupffer cells, macrophages, fibroblasts, and biliary cells. These changes were associated with the endoplasmic reticulum, representing a cellular response to virus-induced injury [HIV d injury .Drug-induced steatohepatitis may also resemble alcoholic liver disease , 107. InSome of the subjects living with HIV that were included in these studies have a history or past or present alcohol consumption. From a histological point of view, alcoholic hepatitis presents enlargement of hepatocytes that may increase the vascular pressure in the acinus . MitochoThe predominant cell in the liver is the hepatocyte, which contains abundant cytoplasm. There are little amounts of carbohydrates and phospholipids in filaments seen in hepatocytes. These cytokeratine filaments represent an abnormal expression of the cytoskeleton. Ultrastructurally, irregular inclusions, which range from small conglomerates of filaments to large inclusions, occupy most of the cytoplasm . A wide 7TAA allele of UGT1A1*28 enzyme receiving atazanavir or indinavir were at increased risk of experiencing hyperbilirubinemia in the jaundice ranges. They studied in parallel a group of patients that have not been genotyped for UGT1A1 allele before prescribing atazanavir or indinavir as first-line agents versus patients that have been genotyped for UGT1A1*28. The “genotype-guided ART” narrowed the use of atazanavir or indinavir to individuals without the UGT1A1*28 allele. The authors conclude that genetic screening would lead to a theoretical 75% reduction in the incidence of hyperbilirubinemia in the jaundice range. The high incidence of the UGT1A1*28 allele might lead to high risk of developing jaundice in the setting of Gilbert syndrome when exposed to specific PIs [7TAA variant was most common among African Americans and least common among subjects of Asian origin [7TAA allele before initiation of antiretroviral therapy is controversial [The genetic value of UGT in PI-induced hyperbilirubinemia is further discussed . Rotger ific PIs . UGT1A1 n origin . Therefooversial .Ideally, genetic testing for this allele, in conjunction with testing for markers of immunotoxicity such as lymphocyte toxicity assay, may be used in the future in the clinical setting to prevent, diagnose, or monitor drug-induced ADRs in people living with HIV .We conclude that antiviral pharmacodynamics is affected by a broad array of factors ranging from individual pharmacokinetic and pharmacogenetic parameters, to medication adherence and drug-drug interactions. Therefore, therapeutic and drug monitoring of HAART plays an important role. Using laboratory techniques to identify phenotypic susceptibilities, as well as knowing the interactions between ART and other drugs or herbal medicines, might enable a safer use of this beneficial type of medication in HIV patients. Adding to the complexity, many HIV-infected patients are unable to keep therapeutic medication safe due to their behavior patterns, such as alcohol misuse. Lack of pharmacovigilance is associated with HIV disease progression as well as toxicities.The major objective of this article is to increase awareness on the possible toxicity of therapeutics prescribed in HIV. Moreover, there are other health products including traditional small molecule drugs, natural health products, biologics, and biotechnology products that are prescribed in HIV. These products may cause not only significant liver direct toxicity but also unpredictable, idiosyncratic hepatotoxicity. Therefore, in the process of achieving pharmacovigilance objectives, the investigational approach used for a particular therapeutic may have to be individualized based on the safety characteristics of the product as well as its proposed clinical application.