The primary analysis of the STAT study demonstrated the feasibility, efficacy, and safety of using DTG/3TC as a first-line regimen in a test-and-treat setting through 24 weeks, with therapy adjustments for baseline resistance or hepatitis B virus (HBV) co-infection. Here we present secondary analyses through Week 48 of virologic outcomes in participants by baseline viral load (VL). 2, then antiretroviral therapy (ART) was potentially adjusted and participants remained on study. Efficacy analyses included proportion of participants with HIV-1 RNA < 50 c/mL regardless of ART regimen at Week 48, among all participants  and among participants with available HIV-1 RNA data at Week 48 . STAT is a single-arm study of treatment-naive adults with HIV-1 infection who initiated DTG/3TC ≤ 14 days after HIV-1 diagnosis without availability of screening/baseline laboratory results. If baseline testing indicated DTG or 3TC resistance, HBV co-infection, or creatinine clearance < 30 mL/min/1.73 mOf 131 enrolled, DTG/3TC treatment was adjusted in 10 participants, and of those with available data (n=7), all (100%) achieved HIV-1 RNA < 50 c/mL at Week 48. At Week 48, 82% (107/131) of all participants  and 97% (107/110) of those with available data  achieved HIV-1 RNA < 50 c/mL. Of participants with baseline VL ≥ 500,000 c/mL, 89% (17/19) achieved HIV-1 RNA < 50 c/mL at Week 48; the remaining 2 withdrew from study. Of participants with baseline VL ≥ 1,000,000 c/mL, 90% (9/10) achieved HIV-1 RNA < 50 c/mL at Week 48 (Table); the remaining participant withdrew consent. Of the 17 participants with baseline VL ≥ 500,000 c/mL with available data through Week 48, 76% (13/17) achieved virologic suppression by Week 24. One participant with baseline VL ≥ 500,000 c/mL switched from DTG/3TC before the Week 48 assessment. Of the 9 participants with baseline VL ≥ 1,000,000 c/mL with available data through Week 48, most participants  were suppressed by Week 24.Figure 1. Virologic outcomes at Week 48, overall and by baseline VL and CD4+ cell count: ITT-E missing = failure analysis.Figure 2. Virologic outcomes at Week 48, overall and by baseline VL and CD4+ cell count: observed analysis.Table. Viral Load by Study Visit Among Participants with Baseline HIV-1 RNA ≥1,000,000 c/mLThese data provide evidence for the efficacy and feasibility of using DTG/3TC as a first-line regimen in a test-and-treat setting, including among participants with very high baseline VL.Charlotte-Paige M. Rolle, MD MPH, Gilead Sciences Janssen Infectious Disease ViiV Healthcare  Tulika Singh, MD MS AAHIVS, Gilead ViiV  Moti Ramgopal, MD FIDSA, Abbvie Gilead Janssen Merck ViiV  Dushyantha Jayaweera, MD, mrcog(uk), face, Gilead (Research Grant or Support)Janssen (Research Grant or Support)viiv (Research Grant or Support) Peter Leone, MD, viiv healthcare (Employee) Jessica Matthews, BS, ViiV Healthcare (Employee) Michael Cupo, Ph.D., GlaxoSmithKline (Employee) Mark Underwood, PhD, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee) Kostas Angelis, PhD, GSK  Brian Wynne, MD, ViiV Healthcare  Deanna Merrill, PharmD, MBA, AAHIVP, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee) Christopher T. Nguyen, MD, ViiV Healthcare (Employee) Jean A. van Wyk, MB,ChB, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee) Andrew Zolopa, MD, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee)


At multivariate binary logistic regression (including age and sex) nadir CD4 cell count (p = 0.034), presence of central nervous system (CNS) opportunistic infections (p = 0.024) and cerebrospinal fluid (CSF) HIV RNA (p = 0.002) in naïve participants and male sex (p = 0.021), a history of CNS opportunistic infections (p = 0.001) and CSF HIV RNA (p = 0.034) in treated patients were independently associated with BBBi. CSF cells and neopterin were significantly higher in participants with BBBi. BBBi was prevalent in naïve and treated PLWH and it was associated with CSF HIV RNA and neopterin. Systemic control of viral replication seems to be essential for BBB integrity while sex and treatment influence need further studies.Despite the substantial changes resulting from the introduction of combination antiretroviral therapy (cART), the prevalence of HIV-associated neurocognitive disorders (HAND) remains substantial. Blood–brain barrier impairment (BBBi) is a frequent feature in people living with HIV (PLWH) and it may persist despite effective antiretroviral treatment. A cross-sectional study was performed in PLWH who underwent lumbar puncture for clinical reasons or research protocols and several cerebrospinal fluid biomarkers were studied. BBBi was defined as cerebrospinal fluid-to-serum albumin ratio (CSAR) >6.5 (<40 years) or >8 (>40 years). We included 464 participants: 147 cART-naïve and 317 on cART. Male sex was prevalent in both groups (72.1% and 72.2% respectively); median age was 44 (38–52) years in naïve and 49 (43–57) years in treated subjects. BBBi was observed in 35.4% naïve and in 22.7% treated participants; the use of integrase inhibitors was associated with a lower prevalence (18.3 vs. 30.9%,  There are approximately 38 million people living with HIV worldwide , out of Monocyte transit across the BBB is a pivotal process in HIV central nervous system (CNS) infection  and seveA number of neurodegenerative disorders, such as Alzheimer’s disease (AD), are associated with BBBi, microvascular and neurovascular degeneration . MoreoveBBBi has been observed despite cART and it has been associated with neuronal damage biomarkers, such as increased levels of total tau and phosphorylated tau . SeveralThe aim of this study was to describe demographic, clinical and therapeutic characteristics, risk factors, comorbidities, as well as CSF and plasma biomarkers in both naïve and treated PLWH, potentially associated with BBBi.A cross-sectional study was performed involving patients with confirmed HIV infection, who underwent lumbar puncture for clinical reasons or research protocols and who were capable to sign the informed consent. The trial was approved by Ethics Committee of the University of Turin .Demographic data, risk factors, co-infections, psychiatric comorbidities, therapeutic and immunovirological data were recorded. The cerebrospinal fluid-to-serum albumin ratio (CSAR), calculated as CSF albumin (mg/L)/serum albumin (g/L), was used to evaluate BBB integrity.Blood–brain barrier damage definition was derived from age-adjusted Reibergrams  .CSF total tau (t–tau), phosphorylated tau (p–tau), and beta–amyloid1–42 (Abeta1–42) were measured by immunoenzymatic methods  with limits of detection, respectively, of 87, 15, and 87 pg/mL. Neopterin was measured through validated ELISA methods . Reference values were as follows: t–tau < 300 pg/mL (in patients aged 21–50), <450 pg/mL (in patients aged 51–70), and <500 pg/mL in older patients; p–tau < 61 pg/mL; 1–42 beta-amyloid > 500 pg/mL; neopterin < 1.5 ng/mL HIV–RNA was quantified by the Roche Amplicor assay v2.0  with a lower limit of quantification of 20 copies/mL.HAND was diagnosed according to the Frascati criteria ; the neu2 test for categorical ones. A multivariate analysis was performed to select the determinants independently associated with BBBi: we used a binary logistic regression analysis using variables with a p-value <0.05 at bivariate comparisons. Data analysis was performed using SPSS software for Mac .Data were analyzed using nonparametric statistical methods: variables were described with medians , absolute values (proportion) or ranges (minimum–maximum). Then, the associations between these variables with BBBi were assessed using Spearman’s test for continuous numerical variables, Mann–Whitney and Fisher’s exact/ChiFour hundred sixty-four patients were included, of which 147 were cART-naïve (median age of 44 years) and 317 were cART-treated (median age of 49 years); their demographic features, risk factors and comorbidities are shown in Both groups of patients consisted mostly of male subjects (72.1% of naïve and 72.2% of ART-treated subjects). With regard to the co-infections, HCV, past syphilis and toxoplasmosis were prevalent among ART-treated subjects .Clinical and cART-related features of the study participants are shown in 3 versus 49 cell/mm3 of naïve patients), as well as current CD4+ T cell count (366 cell/mm3 in ART-treated subjects versus 57 CD4+/mm3 in naïve). With regard to CSF biomarkers, naïve subjects had higher neopterin , but lower tau  and p–tau levels ; Beta42  and S100Beta  were similar between the two groups.Plasma and CSF characteristics and bivariate comparisons among naïve and treated subjects are shown in BBBi was observed in 35.4% of naïve patients and in 22.7% of ART-treated people; clinical, demographic, and therapeutic variables stratified according to treatment group and presence/absence of BBBi are shown in Given the potentially different mechanisms underlying BBBi in naïve and cART receiving participants, we stratified analysis on predictors and biomarkers according to treatment status.p = 0.034), higher CSF HIV RNA  and with the presence of CNS opportunistic infections . In treated participants BBBi was associated with male sex , higher CSF HIV RNA , a history of CNS opportunistic infections  and with non INSTI based regimens .In naïve participants we observed that BBBi was associated with younger age  in INSTI–receivers.Of note, demographic, clinical and immunovirological features were not statistically different among INSTI and other-ARV recipients with the exception of a longer time since first positive HIV serology  and EBV DNA  .Besides higher CSF HIV RNA, we observed significantly higher levels of CSF neopterin in participants with BBBi .p = 0.034, for 100 cells/uL increase aOR 1.401, 95% CI 1.026–1.912), presence of CNS opportunistic infections  and CSF HIV RNA  in naïve participants.At multivariate binary logistic regression (including age and sex) we identified nadir CD4 cell count , a history of CNS opportunistic infections  and CSF HIV RNA  were independently associated with BBBi.Aside from the aforementioned factors, we included the use of INSTI in the multivariate model for cART-treated participants: male sex , whose rate of infection is higher in men than in women in all Mediterranean countries . FurtherIt is worth noting that a major problem of the literature is the clear inequality of female representation in the study populations. Women constitute 51% of HIV-positive subjects worldwide and sex differences in HIV infection have been highlighted in several studies conducted both before and after the introduction of cART . NeverthIn this study cART therapy resulted as an independent protective factor of BBBi. Interestingly, the effect of antiretroviral therapy on BBB has not been clearly demonstrated in literature despite similar analytical methods. Indeed, in their study, Abdulle and colleagues did not find a significant correlation between cART treatment and the reduction of BBB permeability . FurtherOur univariate analysis shows a lower prevalence of BBB alteration among participants treated with integrase inhibitors (INSTI), compared with patients treated with other classes of antiviral drugs (protease inhibitors or non–nucleoside reverse transcriptase inhibitors). Integrase inhibitors  are commonly used as first-line cART regimen, in association with other classes of antivirals, such as two nucleoside reverse transcriptase inhibitors . MoreoveThe association found between BBBi and CSF viral load, both among ART-naïve and treated patients, confirms the evidence observing an increase in CSF HIV–RNA among patients affected by neurological symptoms which were associated with BBBi : a direcIn our analysis, EBV and CMV infections were more common among ART-naïve patients. The incidence of CMV infection has significantly decreased with cART introduction , despiteEBV infects more than 90% of the worldwide population and it is associated with several cancers in PLWH, including Hodgkin lymphomas, non-Hodgkin lymphomas and Burkitt lymphomas . Dehee aFinally, the mechanism that underlies BBB impairment and HAND is not totally clear. HAND could be a direct consequence of the BBB breakdown by different mechanisms, such as an increased permeability, that allow an increasing entry of virus to CNS , or a hiBBB impairment is a common finding in PLWH affected by neurological or neurocognitive disorders either with or without suppressive cART. Indeed, BBB plays a critical role in CNS physiology and in neurological disorders, such as neurodegenerative disorders.We observed higher levels of HIV RNA and neopterin in the CSF of study participants with BBBi, highlighting the significant role of inflammation in the pathogenesis of BBBi. Aside from virological control, female sex was found to be protective: further studies are needed to confirm this finding and to understand thelong–term consequences of an impaired BBB in PLWH.


Progress toward the global target for 95% virological suppression among those on antiretroviral treatment (ART) is still suboptimal. We describe the viral load (VL) cascade, the incidence of virological failure and associated risk factors among people living with HIV receiving first-line ART in an HIV cohort in Myanmar treated by the Médecins Sans Frontières in collaboration with the Ministry of Health and Sports Myanmar.We conducted a retrospective cohort study, including adult patients with at least one HIV viral load test result and having received of at least 6 months’ standard first-line ART. The incidence rate of virological failure  was calculated. Multivariable Cox’s regression was performed to identify risk factors for virological failure.p < 0.001), baseline tuberculosis , a history of low-level viremia , or a history of loss-to-follow-up  and being on the same regimen . Cumulative appointment delay was not significantly associated with failure after controlling for covariates.We included 25,260 patients with a median age of 33.1 years  and a median observation time of 5.4 years (IQR 3.7–7.9). Virological failure was documented in 3,579 (14.2%) participants, resulting in an overall incidence rate for failure of 2.5 per 100 person-years of follow-up. Among those who had a follow-up viral load result, 1,258 (57.1%) had confirmed virological failure, of which 836 (66.5%) were switched to second-line treatment. An increased hazard for failure was associated with age ≤ 19 years (adjusted hazard ratio, aHR 1.51; 95% confidence intervals, CI 1.20–1.89; VL monitoring is an important tool to improve programme outcomes, however limited coverage of VL testing and acting on test results hampers its full potential. In our cohort children and adolescents, PLHIV with history of loss-to-follow-up or those with low-viremia are at the highest risk of virological failure and might require more frequent virological monitoring than is currently recommended.The online version contains supplementary material available at 10.1186/s12981-021-00336-0. There is a global commitment to end the AIDS epidemic by 2030  and the In 2017, less than 5% of those globally receiving ART were thought to be receiving second-line ART . A studyMyanmar has the second highest HIV prevalence in Southeast Asia with an estimated 0.57% of the general population being HIV-positive . In 2018Previous studies identified poor adherence –16, advaSince 2003 Médecins Sans Frontières (MSF) has been providing HIV care in Yangon, Kachin and Shan States. VL monitoring was introduced in 2009, initially as a targeted approach for those most at risk of failure. Since 2016 all patients were eligible for routine HIV VL monitoring once per year. In this study we describe the VL cascade, the incidence of virological failure and associated risk factors, including the cumulative appointment delay, among PLHIV receiving first-line ART in the HIV cohort treated by MSF in Myanmar.We conducted a retrospective cohort study of patients enrolled on ART in the MSF HIV programme in Myanmar between 01 January 2001 and 31 October 2017. The study included patients who had at least one HIV VL test available after receiving at least 6 months of standard first-line ART  with a non-nucleoside reverse transcriptase inhibitor (efavirenz or nevirapine) was used. Second-line regimen was composed of two nucleoside/nucleotide reverse transcriptase inhibitors, ideally not used in the first-line regimen and one protease inhibitor (atazanavir/ritonavir or lopinavir/ritonavir).2,  ≥ 18 kg/m2) and values > 40 kg/m2 were considered errors and defined as missing. Yearly coverage of viral load was defined as the proportion of patients active and in care at the end of the year, who had at least one VL measurement in that year. Virological failure was defined as a patient with a VL ≥ 1000 copies at a visit ≥ 183 days after ART initiation. Those with a follow-up VL ≥ 1000 copies/ml, within 183 days of a previous VL showing virological failure, had confirmed virological failure. Low-level viremia was defined as a VL between 200 and 999 copies, occurring ≥ 183 days after ART initiation, and prior to a first episode of virological failure. Starting dates were defined for each patient based on the earliest visit date at which ART was prescribed. If this date was before 2009, then the start date was set to 1st January 2009 for regression analyses. The reason for this is that VL testing only started to become widely available after 2009; thus, the need to avoid overweighting those who started treatment before 2009 but had no chance of having VL tests. For calculation of operational indicators in the cascade analysis, the original ART start date was used, regardless of whether this was before 2009 or not. End dates were defined based on the earliest occurring visit date at which there was either a virological failure, death, switch to second line ART or reached the maximum visit for that patient without event. For the definition of LFU, each visit had an expected next visit date. We calculated the difference between expected and actual next visit date in days. If this difference was greater than 60 days then the earlier visit was marked as LFU. Using this, the following variables were created: number of times a patient was LFU, total days patient was LFU . Cumulative appointment delay was calculated as the number of days of delay between the dates of appointment and the actual dates visits took place. Time under observation was calculated as the time between starting and ending dates in years. Time on ART was calculated as time under observation minus time LFU.The study used routine programme data collected from standardized patient forms and encoded in the MSF HIV programme database, FUCHIA (Follow-up and Care of HIV Infection and AIDS). Values recorded during the ART initiation visit were considered baseline for: age, marital status, gender, World Health Organization (WHO) stage, body mass index (BMI), risk group, and tuberculosis co-infection. We defined CD4 at ART initiation as the measurement taken closest to the date of ART initiation, within 92 days before or after initiation. BMI was used as a binary variable  for continuous variables. We compared proportions for categorical variables using a chi-squared test (with Holm correction) and differences in distribution for continuous variables using a Kruskal–Wallis test. The purpose of this was to both describe the cohort and to roughly estimate selection bias. The incidence rate for virological failure was calculated as the number of patients with a first VL ≥ 1000 copies over the total observation time. Using Cox proportional hazard regressions, we computed hazard ratios (HR) and respective 95% confidence intervals (CI). Significant variables from the bivariable analyses were investigated for confounding and effect modification using Mantel–Haenszel statistics and Woolf’s tests, as well as testing for co-linearity. Only dichotomized versions of variables were included in multivariable analyses. Variables were selected for multivariable analysis based on results from bivariable and stratified analyses. Where effect modification was identified in stratified analysis, we tested whether the addition of interaction terms significantly improved the model fit based on Akaike information criterion and analysis of variance. Only complete cases, thus without missing information for any of the variables selected in the univariate analysis, were considered for multivariable analysis. The final multivariable model was selected based on step-wise forward and backward Cox proportional hazards regression using the Akaike information criterion and likelihood ratio tests. The model proportional hazards assumption was tested using scaled Schoenfeld residuals. Assumptions of non-linearity was assessed visually. All analyses were two-tailed, with a significance level of 0.05, and carried out using R statistical software version 3.6.0 .As illustrated in the Fig. Patients may have had multiple visits and multiple tests in one year however only the first result in a specific year was considered. A patient is included in the total count of each year they were receiving ART for at least part of the year.Baseline characteristics of the first-line cohort, stratified by having received an HIV VL test, are presented in Table p < 0.001), and tended to have lower CD4 counts at ART initiation . Baseline tuberculosis was diagnosed more frequently among those who received HIV VL testing  and a lower proportion of them had a history of LFU . History of injecting drug use was less frequently reported among those with access to viral load testing . Those who had access to HIV VL testing had more episodes of late appointments, but a lower cumulative number of days late, and only 25% of them accumulated ≥ 60 days late for appointments, in comparison with 28.2% of those who had never received a HIV VL test (p < 0.001).Comparison between patients who did or did not have at least one HIV VL test showed that those who had HIV VL test results tended to be younger , had been on ART after 2009 for a longer time  had documented virological failure, with a calculated incidence of failure of 2.5 per 100 person-years . Among those with virological failure, 2202 (61.5%) had a consecutive VL test within six months of the first test that showed virological failure , who were economic migrants , those with baseline BMI < 18.5 kg/m2 , CD4 > 500 cells/mL , or WHO stage two  were more likely to have virological failure (Table p < 0.001), were LFU at least once , or had a cumulative appointment delay over 60 days  were more likely to experience virological failure. Females  or those with age > 19 years at ART initiation  had lower hazards of virological failure.Using univariate regression, patients whose marital status was single , with a history of low-level viremia , a history of LFU , or being on the same treatment regimen since the start of treatment  were associated with an increased hazard of failure, while controlling for other covariates. Starting ART at the age > 19 years was associated with 34% lower hazard of failure . Cumulative appointment delay was not significantly associated with failure after controlling for other covariates. We observed an interaction between sex work and gender  and between gender and being single . The differences between the characteristics of the population included in the final regression model and the entire population on first-line ART in this cohort, are presented in the Additional file The multivariable analysis was conducted on 8,308 patients (32.9%) with complete information for all the variables required  PLHIV received at least one VL test and 14.2% experienced virological failure (2.5 per 100 person-years). Our results are comparable with previous reports from resource-limited settings, where virological failure occurred in 4.3–34.0% PLHIV on first-line ART , 29–32. We showed that the risk of virological failure was lower among those initiating ART if they were aged > 19 years (90% of the study cohort) compared to those with or younger than 19 years. This finding is similar to that reported in other studies. The higher risk of failure among children and adolescents may be explained by suboptimal adherence, lack of paediatric drug formulations, and lack of care models responsive to the specific needs of these subgroups , 35–37. A systematic review reported that history of treatment change was associated with an approximately 2.5-fold higher risk of virological failure in cohorts in Myanmar and Malawi . In our p < 0.0001) than in PLHIV who did not experience low-level viremia [Increasing evidence shows that low-level viremia is associated with unfavorable treatment outcomes. A large multicentre cohort in South Africa detected low-level viremia in 23% of PLHIV, with risk of subsequent failure in this group observed as 2.6 times higher (95% CI 2.5–2.6;  viremia . In our  viremia .There is an effective and life-saving second-line ART regimen, but delayed switch is particularly problematic in patients with advanced HIV disease. Current recommendations for the management of virological failure rely on a public health approach. Programmes in resource-limited settings use a threshold of ≥ 1000 copies/mL to identify failure and recommend switching to second-line ART when virological failure is confirmed in a second sample . Some haGuidelines on virological monitoring and the management of treatment failure have been changing over time –44. In oIn short, routine VL monitoring reduces mortality when used together with adherence support  and a tiOur study evaluated a large cohort with a long study period. It used real-life programme data with complete data on appointment delays, including LFU. However, 28.6% of the cohort had no VL during the observation period and data for various baseline characteristics were incomplete, which resulted in only a part of our cohort being included in the final multivariable model. The resulting selection bias might lower the internal validity of our study results and reduce the generalizability of our study findings. The burden of virological failure was assessed by looking at the first episode of virological failure only, despite knowing that PLHIV transit from suppressed to unsuppressed state multiple times during their time on ART. This might underestimate the total burden of failure in a cohort and multistate analysis of virological outcomes would be more appropriate. We did not investigate the reason why patients did not access VL, were delayed or LFU, or why switching to second-line ART was delayed. Further research on these topics is needed.VL monitoring is an important tool to improve programme outcomes. Suboptimal viral load cascade in resource-limited settings hampers the full potential of VL monitoring and it reduces its cost-effectiveness. Our study observed higher rates of virological failure among children and adolescents, in PLHIV with tuberculosis co-infection and those with history of LFU or who remain on one treatment regimen. Those subgroups might need more frequent virological and more intensive clinical monitoring. Growing evidence on the risk factors for unfavourable virological and clinical outcomes, may suggest the refinement of a differentiated approach to VL monitoring in growing and aging HIV cohorts in resource-limited settings.Additional file 1:Table S1. Characteristics of patients included in multivariable analysis compared to the total population on first line ART.


The incidence of metabolic disorders in human immunodeficiency virus (HIV) endemic settings is a prevailing burden in developing countries. Cholesterol homeostasis and fat metabolism are altered by HIV and antiretroviral therapy (ART), thereby possibly contributing to complications such as gallstone formation.The aim of this study was to evaluate established risk factors for the formation of cholesterol gallstones in black South African women living with HIV (WLHIV).t-tests. For non-normally distributed data, the Mann–Whitney U test was used. Statistical tests were two-sided, and p-values of less than 0.05 were considered statistically significant.A case series study was conducted of all black South African women undergoing cholecystectomy for gallstone disease over a 1-year period at King Edward VIII Hospital, Durban, South Africa. Age, body mass index (BMI), family history of gallstones, oestrogen exposure and lipograms were compared between WLHIV and uninfected women. Categorical variables were tested using either the Fisher’s exact test or Pearson’s chi-square test. Means were compared using independent p = 0.015). A statistically significant number of uninfected women were in the overweight/obese category (BMI > 25 kg/m2) compared to the normal weight category (BMI < 25 kg/m2) (p < 0.001). The number of obese WLHIV did not reach statistical significance.A total of 52 patients were assessed, 34 HIV-uninfected and 18 WLHIV. The median age of WLHIV versus the uninfected women was 35 and 50 years, respectively, (The age of occurrence of gallstone disease amongst black South African WLHIV was significantly lower and fewer women were obese compared with the uninfected women with gallstone disease. These findings differ from known gallstone risk factors in other populations and in uninfected black South African women. This could be attributed to the metabolic alterations caused by HIV infection itself and/or to the long-term use of ART. Larger cohort studies are required to elucidate the role of HIV and ART in cholestatic disease. Of South African PLWH, 3.9 million (52%) are on antiretroviral therapy (ART).1 Most gallstone research is performed in Europe and South America. A paucity of data comes from Africa. This oversight may, in part, be because of the historically low incidence of gallstone disease (GD) amongst black South Africans,3 and/or a focus on other concurrent health crises, such as HIV, maternal death, malnutrition and other non-communicable diseases.4South Africa (SA) has a population of 57.7 million. It is estimated that 7.52 million (13.1%) are people living with human immunodeficiency virus .5 Gallstone disease occurs in up to 20% of the population of developed countries, but reportedly, only 5% in sub-Saharan Africa (SSA).6 Local reports suggest the incidence is low, but is outdated (1987).Gallstone disease presents in a variety of ways: biliary colic, cholecystitis, gallstone pancreatitis, obstructive jaundice and as a risk for gallbladder cancer. The actual cost of GD to the already overburdened healthcare system in SA is not known. However, in developed countries, it is rated as the second highest gastrointestinal ‘cost-driver’ of the healthcare system.7 The urbanisation of black South Africans and lifestyle changes such as the consumption of high-fat, low-fibre foods, and the general rise in body mass index (BMI) have been contributory factors.8 This rise in GD (stones) incidence amongst black South Africans comes at a time when HIV infection has affected many and large numbers are on ART.Historically, GD was predominantly observed in South Africans of European descent. But an increase in GD in black South Africans has been noted in recent years.9 Whilst there appears to be a variety of pathological processes at play, the underlying process is not identical in PLWH and the uninfected. Increased waist circumference, for instance, is less frequent in PLWH.9 Factors contributing to these metabolic outcomes are the host response to HIV infection, specific ART drugs, HIV-associated lipodystrophy and alcohol consumption.10 Genetic factors are likely to prime some in the absence of environmental factors such as smoking.9Human immunodeficiency virus is now a chronic, manageable disease. People living with HIV have an extended life-span. But this has come at a cost: metabolic changes in PLWH include the metabolic syndrome, type 2 diabetes mellitus, serum lipid perturbations, cardiovascular disease and changes in the distribution of body fat.11 The pathogenesis of pigment stones is a result of infection (brown) or haemolysis (black), whereas the pathogenesis of cholesterol stones is a result of the supersaturation of cholesterol in bile.12As determined by cholesterol concentration, gallstones are classified into two main categories: cholesterol stones (including pure cholesterol and mixed stones) and pigment stones (black and brown stones). Cholesterol stones are the most usual and account for up to 80% of all gallstones.13 People living with HIV have altered circulating lipid levels. Some changes are independent of ART and follow ongoing viral activity and the consequent inflammatory milieu within the individual, instead. In ART naïve patients with HIV-1 subtype B, very low-density lipoprotein (VLDL), cholesterol (TC) and triglycerides (TG) increase with rising HIV viral load. High-density lipoprotein (HDL) and low-density lipoprotein (LDL) decrease.14This supersaturation has been attributed to risks commonly referred to as the 5 ‘F’s .15 yet HDL levels in ART-naïve PLWH in SA (HIV-1 subtype C) are low, suggesting a possible risk of CVD and possibly cholesterol-related GD.16African people generally display higher fasting HDL and lower TG levels than people of European descentAntiretroviral therapy also alters lipid (cholesterol) metabolism. Protease inhibitors (PIs) generally have the greatest dyslipidaemic effect. Nucleoside reverse transcriptase inhibitors (NRTIs) and the non-nucleoside reverse transcriptase inhibitors (NNRTIs) exhibit less effect and the integrase strand transfer inhibitors (InSTIs) appear to be ‘neutral’ in this regard.17 In Japan, studies report an increased rate of cholelithiasis in 9.8% of PLWH possibly related to PI treatment.18 Lin et al. report that cumulative exposure to atazanavir/ritonavir, over a 2-year period in particular, is associated with a 6.29-fold increase in the incident-risk of cholelithiasis.19Advancing age is a risk for gallstone formation. Aging results in greater intestinal absorption of cholesterol, greater biliary excretion of cholesterol and reduced hepatic synthesis and biliary excretion of bile salts.20 With ageing also comes a relative hypoperfusion of the gallbladder wall resulting in gallbladder dysfunction, together with decreased gallbladder wall contraction.20 All contribute to cholesterol-related GD.Increased weight: The amount of cholesterol synthesised and secreted into bile is directly proportionate to weight (BMI). Overweight and the level of the BMI are directly proportional to the incidence of symptomatic gallstone per year.21Oestrogen: Women of childbearing age, pregnant women, women on hormone replacement therapy or those with a history of high-dose oestrogen (> 50 mcg), unopposed contraception, have a 2–3 times higher risk of gallstones.22Genes: The hypothesis of family history and GD dates back to as early as the mid-1900s.23 There is also growing evidence of a genetic influence.24 Much of the genetic studies have been undertaken in mice in which 25 lithogenic or Lith-genes have been identified.257 Whether or not they conform to the same risk factors described above as in white populations is unknown. We compared well-known risk factors for cholesterol gallstone formation to validate if black South African women living with HIV (WLHIV) share the same risks as uninfected black South African women with GD. To our knowledge, this report is the first to address this issue.To date, there have been no studies investigating the risk factors of gallstone formation in black South African women since the early 1990s.This case series study was conducted by comparing known risk factors for gallstone disease amongst black WLHIV and uninfected black South African women presenting with symptomatic gallstones requiring surgery. All patients over the age of 18 years undergoing a cholecystectomy for GD  at the King Edward VIII Hospital, Durban, SA, during January to December 2017 were included in this study.Written informed consent was received from all study participants with a standard consent form in two of the official main languages of SA (English and Zulu). The informed consent included voluntary HIV counselling and testing if this had not been assessed prior to cholecystectomy.+ lymphocyte (CD4+) counts were measured in all PLWH. Lipograms  were performed on all patients in a fasting state and were measured directly.Clinical demographic data as per the self-identified questionnaire included sex, age, ethnicity, first degree family history of gallstones, HIV status, including the use or non-use of ART. Co-morbidity data included hypertension, diabetes mellitus and previous tuberculosis. Oestrogen exposure was defined based on pregnancies and history of contraception use and was assessed as a binary variable. Body mass index was measured by the main author using the same stadiometer for all patients in order to avoid measurement error. Patients undergoing cholecystectomy for reasons other than gallstones but where gallstones were an incidental finding were excluded from the study. Patients whose HIV status was unknown or who refused testing after voluntary counselling were also excluded. All patients had stones that macroscopically met the description of cholesterol stones. None of the patients had pigment stones. None of the patients were on any lipid-lowering medication such as fibrates which predispose to gallstones. Current viral loads (VLs) and CD4t-tests; for non-normally distributed data, the Mann–Whitney U test was used. Statistical tests were two-sided, and p-values of less than 0.05 were considered as statistically significant.Statistical analyses were performed using R Project for Statistical Computing. Descriptive statistics such as frequencies and percentages were used to summarise categorical variables. Central tendency and dispersion of data was measured using means and standard deviations for normally distributed variables and medians and interquartile ranges (IQRs) for skewed variables. Associations between categorical variables were tested using either the Fisher’s exact test where 80% of expected cell counts < 5 or Pearson’s chi-square test where 80% of expected cell counts > 5. Similarly, with regard to the testing of associations between continuous variables: for normally distributed data, means were compared using independent Ethics approval was granted by the University of KwaZulu-Natal’s Biomedical Research Ethics Committee (BREC), reference number BE276/16. Permission to conduct the research was granted by King Edward VIII Hospital management.N = 52). Median age of all women was 43 years (IQR 30–54). Patient demographic and clinical parameters are presented in A total of 55 black South African women underwent a cholecystectomy during the study year. Three patients refused HIV testing after voluntary counselling and were excluded   were on ART for an average of 4.9 years, 4 were ART naïve and 1 had missing data for ART. All patients on ART had undetectable VL, with an average CD4= 0.015) .2 (IQR 28–39), and 30 kg/m2 (IQR 24–35), p = 0.231. However, when comparing BMI within the groups stratified by HIV status, the HIV-uninfected group had a statistically significant number of patients in the overweight/obese category (BMI > 25 kg/m2) compared to the normal weight category, BMI > 25 kg/m2, p < 0.001. However, in the WLHIV group, differences between the weight groups were not statistically significant (The median BMI of the HIV-uninfected and WLHIV was 33 kg/mnificant .Seven per cent (1/14) of WLHIV compared with 26% (8/31) of HIV-uninfected women had a positive family history of gallstones .Oestrogen exposure was marginally higher, 94% (29/31) amongst HIV-uninfected women compared with WLHIV, 86% (12/14) . The aveLipogram results of patients are shown in The median values of LDL were higher in the WLHIV group compared with the HIV-uninfected group; HDL levels were lower amongst WLHIV. These results did not reach statistical significance .The proportion of abnormal HDL and LDL levels was higher amongst WLHIV as compared with uninfected women. Differences in the groups were not statistically significant .3 A study from the Kalafong Hospital, Pretoria, from 1988 to 2007, found the overall incidence of gallstone pancreatitis increased by 9.7% and in black South Africans by 3.4%.26 A further study from the King Edward VIII Hospital, Durban, SA, recorded an increase in the hospital prevalence of calculous disease in black South Africans in the 2 years after 1992 as compared with the preceding 2 years.7 Since 2000 however, there has been a paucity of data in the field, and perhaps, more importantly, very little that assesses the effect of the HIV epidemic and ART, on GD in PLWH.The largest analysis of gallstone pathology in black South Africans dates to 1987, when 100 cholecystectomies were performed over a 3-year period at the Baragwanath Hospital, Johannesburg. This study demonstrated a large increase in cholecystectomies in black South Africans during the period 1967–1987. Analysis of stone and bile composition between black South Africans and people of European descent was similar.27 In our study, HIV-uninfected women were more likely to be older than WLHIV. Previous reports of GD in people < 30 years attribute this age-shift to teenage pregnancy, sedentary lifestyle and a raised BMI. Of 507 patients in Rawalpindi, 48% with GD presented < 30 years. A high BMI and an elevated socioeconomic status were associated with cholelithiasis in these patients.28 In a large study in the United States of America, there was a comparison of patients presenting with GD in the Bronx area compared with other counties. People living with HIV and pregnant patients were excluded. Although the incidence of gallstones in patients < 20 years did not increase over the 15-year study period in counties other than the Bronx, GD in the latter increased with time. Most patients were female. The assumption at the time was that the increase was because of rising rates of teenage pregnancy and obesity in the Bronx area.29 The reason for young patients presenting with GD in these studies differs from our study of PLWH. The youths in these studies conformed to known risk factors. Many WLHIV in our study had normal BMIs. Oestrogen exposure from multiple pregnancies and prolonged contraception was infrequent. An alternative explanation of GB disease in our South African WLHIV is that HIV infection, its treatment or both, may be implicated.The Swedish multigenerational registry study assessed 660 732 patients with symptomatic gallstones. The incidence per 100 000 people peaked between the ages of 30–34 years but continued to rise to ≥ 75 years confirming an increase in the incidence of gallstones with increasing age.2 The BMIs of these women were significantly higher in those with gallstones. This was attributed to urbanisation and diets high in fats and low in fibre. This mirrors our findings in HIV-uninfected black South African women where a statistically significant number (88%) had a BMI > 25 kg/m2. There were few overweight/obese patients, BMI > 25 kg/m2, in the WLHIV. Rapid weight loss, as well as rapid weight gain after ART initiation in PLWH, is well documented.30 This is akin to weight cycling. Weight cycling is the phenomenon of intentional weight loss and regaining that weight. In patients where BMI is adjusted for, weight cycling increases the risk of gallstone formation, with larger fluctuation and more weight cycles being associated with the highest risks.31Up to the late 1980s GD was a condition almost exclusive to people of European descent. A 1989 screening study of 100 black South African women without any gastrointestinal symptoms in Soweto, Johannesburg, nevertheless demonstrated a 10% prevalence of gallstones in the group.32 Therefore, overall BMI may not be an accurate risk stratifying tool in the development of gallstones in PLWH who may well be going through weight cycling type of phenomenon.Whilst normalisation of weight results in normal concentrations of cholesterol in bile, rapid weight loss, either non-operatively or operatively in the form of gastric bypass surgery, results in gallstone formation in more than 50% of patients. Mechanisms involved are increased biliary saturation secondary to increased cholesterol mobilisation, increased nucleation because of changes in bile arachidonate and glycoprotein concentrations, and elevated levels of mucin and calcium in bile.2–24.9 kg/m2) and the overweight BMI group (25.0 kg/m2–29.9 kg/m2) relative to control subjects, but not amongst those in the obese category (≥ 30.0 kg/m2).33 There could be a link with the increase in visceral adiposity rather than to an increase in BMI to the development of gallstones in PLWH compared with uninfected patients. Furthermore, this visceral adipose tissue results in accelerated lipolysis and is what contributes to the high prevalence of non-alcoholic fatty liver disease reported in up to 30%–35% of mono-infected patients, that is, PLWH without hepatitis B or C.34In a study looking at the fat distribution in PLWH at different BMIs, visceral adiposity was increased in the normal BMI group -based therapies as the preferred first-line ART therapy. InSTIs have been touted as not affecting cholesterol metabolism which may have a big impact on preventing CVD and GD in these subsets of patients. However, there are growing reports of weight gain with the use of InSTIs,39 especially in black African women.40 One study showed a greater increase in abdominal fat compared with PIs.41 This is of concern considering that a large proportion of patients with CVD and GD are linked to obesity and, in particular, abdominal fat.In the longest follow-up of body composition following ART, it was found that continued fat gain after 96 weeks of treatment was associated with the greatest risk of metabolic disorders.27 The familial risk of developing gallstones is 2–4 times normal. Our HIV-uninfected group with a first degree family history of GD was 26% compared with our PLWH group which only revealed a first degree family history in 7%. This low prevalence of first degree family history of gallstones in PLWH is another risk that deviates from known risk factors of gallstone formation.Familial cases account for 36% of all gallstones according to the largest family history study of GD. There is a parental family history of 50.9%, a sibling history of 35.1% and a combined parental and sibling history of 14%.22 Males with cirrhosis of the liver have an increased incidence of gallstones because of the higher oestrogen levels.42 In this observational study, the overall combined oestrogen exposure rates of those patients presenting with symptomatic gallstones were 94% and 86% in the HIV-uninfected and WLHIV groups, respectively. The pregnancy rates indicated by the number of children in the WLHIV group (61%) were also lower than the HIV-uninfected group (79%). Although not statistically significant, this may point to oestrogen being less important in the WLHIV. However, the HIV-uninfected cohort would have had a longer time of oestrogen exposure and time to fall pregnant by virtue of being older compared with the WLHIV.The high oestrogen levels in pregnancy are associated with increase cholesterol secretion in bile, whilst the high progesterone levels cause a decrease in bile salts and decreased contractility of the gallbladder wall resulting in precipitation of cholesterol.44 This indicates that serum cholesterol and LDL may be a contributing factor to gallstone formation, whilst serum HDL might be protective, both of the former were markedly abnormal in our study population.There is a correlation between serum total cholesterol, apolipoprotein B, C2, C3 and the amount of cholesterol saturation in bile. Also, there is a correlation with the levels of serum HDL with the amount of lecithin and bile acids in bile.The study is limited by its small sample size, especially with respect to WLHIV. Although we provide weight, BMI and serum lipid data, we have been unable to provide a more comprehensive evaluation of visceral adiposity. A future study will need to include abdominal fat and waist circumference measurement in the assessment. Furthermore, specific detail on antiretroviral drugs (ARVs), the regimen used and its duration, was not collected and thus linkage to an individual drug or regimen cannot be made. The case series nature of the study excludes a comparator population without GD. The lack of chemical analyses of the stones is a limitation. But pigment stones are rare, and are fairly distinctive. We believe it unlikely that these would have been missed during the pathological assessment. Nonetheless, stone analysis, particularly the exclusion of pigment stones in PLWH, may have a role in future studies.The formation of cholesterol gallstones is complex; involving genetic and environmental factors, including lifestyle. Most research into the actual cause and risk factors of gallstones has been performed in the West with a paucity of data from Africa. Whilst this has been because of the lower incidence of GD in our region, this is changing. Most black South Africans are now exposed to a Western lifestyle: urbanised diets and obesity. The patients in this study share these risks with the community. Do these risks apply equally to PLWH? From these observations, there are differences. Black South African WLHIV with GD were younger than HIV-uninfected peers. And whilst obesity and an elevated BMI were important with regard to GD in the HIV-uninfected, this was less so in WLHIV. And suggestive of a greater role of environment than genes in the development of GD in WLHIV is the relative absence of first degree relatives with the condition.


After the introduction of antiretroviral treatment (ART) back in 1996, the lifespan of people living with HIV (PLWH) has been substantially increased, while the major causes of morbidity and mortality have switched from opportunistic infections and AIDS-related neoplasms to cardiovascular and liver diseases. HIV itself may lead to liver damage and subsequent liver fibrosis (LF) through multiple pathways. Apart from HIV, viral hepatitis, alcoholic and especially non-alcoholic liver diseases have been implicated in liver involvement among PLWH. Another well known cause of hepatotoxicity is ART, raising clinically significant concerns about LF in long-term treatment. In this review we present the existing data and analyze the association of LF with all ART drug classes. Published data derived from many studies are to some extent controversial and therefore remain inconclusive. Among all the antiretroviral drugs, nucleoside reverse transcriptase inhibitors, especially didanosine and zidovudine, seem to carry the greatest risk for LF, with integrase strand transfer inhibitors and entry inhibitors having minimal risk. Surprisingly, even though protease inhibitors often lead to insulin resistance, they do not seem to be associated with a significant risk of LF. In conclusion, most ART drugs are safe in long-term treatment and seldom lead to severe LF when no liver-related co-morbidities exist. The human immunodeficiency virus (HIV) infection constitutes a major global public health issue, affecting 37 million people worldwide, of whom 34 million are adults . In the Following the efficacious control of the HIV infection, the causes of liver involvement in PLWH have changed from opportunistic infections and lymphomas to hepatitis C (HCV) and hepatitis B (HBV) co-infections, drug-induced liver injury (DILI), as well as alcoholic (AFLD) and non-alcoholic fatty liver disease (NAFLD) ,16,17,18Several studies have explored the possible causes of liver fibrosis in HIV-infected patients, with most of them pointing out viral hepatitis co-infections, age, and alcohol abuse as the major risk factors ,39,40,41Apart from those already mentioned, other factors associated with significant LF appear to be chronically elevated serum alanine aminotransferase (ALT) and gamma glutamyl-aminotransferase (γGT) levels, while findings concerning body-mass index and the presence of hypertriglyceridemia or diabetes mellitus (common predisposing factors for NAFLD) are inconsistent ,45,46,47The most interesting finding in all the recent studies is the association between HIV itself and LF. Even though HIV is primarily found in liver macrophages, it may also infect hepatocytes, leading to low-level intrahepatic replication and possibly hepatocyte cell death and inflammation ,49,50. IHIV may also lead to LF through high amounts of circulating lipopolysaccharides (LPS) ,59. MoreSimilarly, several studies have shown that HIV seropositivity per se and a low CD4 + cell count among PLWH have been associated with a higher degree of LF, irrespective of the presence or absence of viral hepatitis co-infection ,65,66,67Assessing the contribution of various ART drugs to LF among PLWH has proven a difficult task through the years, even though the risk of hepatotoxicity and the pathophysiological pathways associated with LF for each ART drug class are largely known . As alreNRTIs were the first anti-HIV drug class; zidovudine (AZT) was the first FDA approved medicine for HIV treatment back in 1987 . After AMitochondrial toxicity and hypersensitivity reactions are the main mechanisms of NRTIs-induced liver damage. Mitochondrial toxicity is caused by the inhibition of mitochondrial DNA (mtDNA) replication due to the binding of NRTIs to the mitochondrial DNA polymerase gamma. This leads to an impairment of oxidative phosphorylation and promotes the formation of reactive oxygen species which in turn damage mtDNA, resulting in mitochondrial dysfunction . NRTIs aNRTIs are the best studied drugs as far as LF is concerned . In two However, not all NRTIs carry the same risk for LF; DDI and AZT have the greatest risk. In a large study of 1785 PLWH with a 2-year follow up, higher FIB-4 values were correlated with DDI use, older age, male gender, a low CD4 + cell count, and an unsuppressed HIV viral load . In anotBoyd A et al. also showed a progression of LF under AZT treatment in 167 HIV/HBV co-infected patients . InteresAlthough many studies have focused on DDI, AZT and TDF, there is insufficient data for the rest of the NRTIs regarding their potential to induce LF. In a study of 112 HIV/HCV co-infected patients undergoing a liver biopsy, it was shown that the use of d4T led to liver steatosis and that patients with steatosis were more prone to develop worse LF. A combination of ABC and lamivudine (3TC) as backbone therapies were shown to increase the APRI score in a cohort of 314 HCV/HIV co-infected Canadian patients while exposure to ABC alone was found to have a negative impact on liver stiffness in a cohort of PLWH without co-infections ,96,97. FNNRTIs are non-competitive inhibitors of reverse transcriptase affecting the catalytic function of the enzyme by binding to specific tyrosine residues located near the active site . The mosRegarding the association of NNRTIs with LF, data are scarce . In a crPIs are peptidomimetic molecules that target the active site of HIV aspartic protease, the enzyme responsible for cleaving the precursor viral polyprotein, gagpol, into its constituent proteins. The inhibition of viral polyprotein cleavage results in the production of immature non-infectious viral particles. All FDA-approved PIs have been associated with cases of hepatitis even though the exact mechanism is largely unknown . HoweverFirst generation PIs—e.g., indinavir and ritonavir—are known to induce IR, mainly through dramatically increasing the central adiposity and altering the plasma lipid profile via lipogenesis inhibition, decreasing the hepatic clearance of very-low-density lipoproteins (VLDL), and increasing the production of hepatic triglyceride ,118,119.No cases of severe PI-related LF have been reported in the literature, even though IR seems to be a common adverse effect in clinical practice and cases of indinavir-induced hepatitis have been described ,125,126.INSTIs target the integration process of the HIV viral DNA into the host DNA, a process achieved through a series of DNA cutting and joining reactions, mediated by the retroviral enzyme integrase ,133. CurOverall, INSTIs are considered safe and potent ART drugs; severe transaminitis is a rare event ,139. WeiGiven the lack of data in the literature relating the use of INSTIs to significant LF, and that hepatotoxicity is a rare adverse event of INSTIs, it appears that INSTIs are a safe therapeutic option for patients with liver diseases.Entry inhibitors act by preventing HIV from entering into the host cell . So far,All entry inhibitors have proven to be liver-friendly, even in cirrhotic patients; transaminitis or the deterioration of the liver function are rather rare adverse events ,148,149.Data regarding entry inhibitors and liver fibrosis are few and mainly concern MVC. In an experimental study by Coppola et al., the addition of MVC in the hepatic stellate cell line blocked the accumulation of fibrillar collagens and the production of extracellular matrix proteins along with a down-regulation of metalloproteinases 2 and 9  and their inhibitors  . In anotART has changed the landscape of HIV infection, increasing the lifespan of PLWH and changing the major causes of morbidity and mortality. However, concern has risen regarding the short and long-term hepatotoxicity of ART. Several studies have attempted to address this issue, but many controversies still exist, since the same drugs have been found to carry a significant risk for LF in one study, and minimal or no risk in another.According to most studies, ‘first generation’ NRTIs, mainly DDI and AZT, may lead to significant LF after long-term treatment, a possibility that is decreasing with ‘new generation’ NRTIs, such as TDF or FTC. On the other hand, NNRTIs have not been implicated into fibrogenesis, with the exception of NVR, while the same applies for INSTIs. Surprisingly, even though PIs are known to cause insulin resistance and weight gain, data are controversial with some studies showing an improvement while others showing a worsening of LF under PI-containing ART regimens. Lastly, entry inhibitors seem to carry a minimal risk for hepatotoxicity or significant LF.In conclusion, a reasonable therapeutic strategy is to avoid using ‘first generation’ NRTIs in PLWH with predisposing factors for LF or established, significant LF, and choose ‘new generation’ NRTIs or other ART-class drugs instead.


Changes in HIV treatment guidelines over the last two decades reflect the evolving challenges in this field. Our study examined treatment change patterns throughout a 7-year period in a large Italian cohort of HIV patients as well as the reasons and direction of changes. Treatment-naïve and -experienced HIV patients managed by Cotugno Hospital of Naples between 2014 and 2020 were analyzed. During the period, the proportion of single-tablet regimen treatment sharply increased for the naïve and experienced patients. Regimens containing integrase strand transfer inhibitors rapidly replaced those containing protease inhibitor and non-nucleoside reverse transcriptase inhibitors. The use of the tenofovir alafenamide fumarate/emtricitabine backbone increased rapidly after its introduction in the Italian pharmaceutical market, making up 63.7 and 54.9% of all treatments in naïve and experienced patients, respectively, in 2020. The main reason for treatment changes was optimization and/or simplification  followed by adverse effects and virological failure. Our real-world analysis revealed that the majority of treatment-naïve and treatment-experienced patients received antiretroviral drugs listed as preferred/recommended in current recommendations. Regimen optimization and/or simplification is a leading cause of treatment modification, while virologic failure or adverse effects are less likely reasons for modification in the current treatment landscape. The human immunodeficiency virus (HIV) pandemic continues to be a major global public health issue. In 2020, there were approximately 37.7 million people living with HIV (PLWH), and around 1.5 million people acquired HIV worldwide ,5. ChangOver the past few years, several new drugs with improved efficacy, better tolerability and toxicity profiles, and more convenient formulations have become available . For treIn Italy, approximately 90% of PLWH starting HIV treatment achieve and maintain viral suppression ,11 PeoplThe purpose of this study is to examine the change in ART regimens for treatment-naive and treatment-experienced patients over the last seven years (2014–2020), which includes the COVID-19 pandemic era, through the analysis of pharmacy data from Cotugno Hospital of Naples . The secondary aim is to explore the reason and direction of treatment changes after the introduction of new drugs and recommendations.This observational, non-interventional, descriptive study was carried out after approval from the institutional ethics committee of Cotugno Hospital. The article does not contain clinical studies, and all patients’ data were fully anonymized and were analyzed retrospectively. For this type of study, formal consent is not required according to current national law from Italian Medicines Agency.http://www.fda.gov/Safety/MedWatch/HowToReport/ucm053087.htm, accessed on 16 November 2021). Furthermore, since 2018 the Cotugno Hospital pharmacy staff have collected the reasons for every ART regimen change  before dispensing medications following a structured interview with patients and clinician. For each ART modification, the following information was collected: anonymous patient code, date of dispensation, Anatomical Therapeutic Chemical (ATC) code, quantity dispensed, dose, and formulation. Data related to adverse drug reactions were collected through standard-of-care operating procedures utilized in specialty pharmacy setting. This information was also extracted and analyzed.Cotugno Hospital is one of the largest hospitals in Italy. It provides care to ~2500 PLWH per year . For this retrospective study, data were retrieved from the hospital pharmacy databases containing outpatient medications dispensed by the hospital pharmacy and reimbursed by local health authorities. For each dispensed medication the following information was collected: anonymous patient code, patient sex and date of birth, origin, date of dispensation, Anatomical Therapeutic Chemical (ATC) code, quantity dispensed, dose, and formulation. Data related to adverse drug reactions were collected through standard-of-care operating procedures utilized in a specialty pharmacy setting. This procedure utilized prescription claims software and a clinical assessment management program according to the national network for pharmacovigilance  . AdverseThe study population comprised all HIV patients 18 years or older who had at least one pharmacy claim for ART between 1 January 2014 and 31 December 2020. We excluded patients who had ≤2 ART claims during that period in order to exclude HIV prophylaxis treatment. For each calendar year, the date of the first ART claim was set as the index date. Further, patients were considered treatment-naïve if they had no ART dispensed by Cotugno Hospital pharmacy during 1 year before the index date, while treatment-experienced had ≥1 claim for ART during that period. The Italian health care service provides ART to all the individuals in need and has recommended universal HIV treatment since 2015 regardless of the initial CD4 count [Finally, switching ART regimens was defined as a treatment change in at least one antiretroviral drug in the regimen excluding dose modifications. Reasons for switching were classified as follows: adverse events, virologic failure, drug–drug interactions, treatment optimization and/or simplification.p < 0.05 indicating statistical significance.Chi-square statistics for trend and analysis of variance (ANOVA) were used to compare distributions of categorical variables and continuous variables, respectively. The proportions of ART regimens and nucleoside backbones dispensed on the index date were calculated by year. Switching patterns between drug class or within NRTI backbones were examined by a matrix analysis to show switches ‘from’  and switches ‘to’  for each drug class  or NRTI backbones . Statistical descriptive analysis was performed using SPSS software version 23 SPSS Inc., Chicago, IL, USA with Treatment-naivepatients. The baseline characteristics of patients and the most common ART regimens chosen within the study period are shown in p < 0.0001). TDF/FTC has been the predominant backbone until 2017. After this treatment initiation with TDF/FTC dropped below 10% in 2020, while the use of TAF/FTC increased accounting for 68.4% of all treatment initiations in the last year. The use of ABC/3TC doubled from 10.3 to 27.1% in the early period (2014–2018) but decreased after 2019. With respect to the third antiretroviral agents, the use of PI and NNRTI decreased throughout the period , while the use of INSTI rose sharply, accounting for two-thirds of all third agents prescribed in 2020. Finally, DTG-based two-drug regimens accounted below 3% in 2020, for DTG + 3TC and DTG/3TC.The proportion of STRs used increased from 48.4 to 81.2% over the study period (Treatment-experienced patients. During the 7-year observation period the number of treatment-experienced patients increased from 1779 (2014) to 2137 (2020). A full description of baseline characteristics and ART used can be found in p < 0.0001). The proportion of STR increased constantly over time, amounting to 77.3% in 2020. TDF/FTC was the most commonly prescribed NRTI backbone in the early period. After 2018, there was a sharp decline , while the use of TAF/FTC increased in the same period (30.1–60.1%). With respect to the third agent, PI were the most commonly prescribed in the first two years, followed by NNRTI. Since 2016, PI and NNRTI prescribing decreased, while there was an increase in use of INSTI (from 13.0 to 50.8% during 2016–2020). The use of DTG-based two-drug regimens increased over time, amounting to 2.3% for DTG + RPV or DTG + 3TC in 2020, whereas the proportion of FDC dual therapy was 2.6%.The number of treatment changes totaled 1855 from 2018 to 2020. The main reason reported for modification of treatment regimen was optimization and/or simplification in each year  followed by adverse effects and virological failure .Over 3 years, 29.8% of all switching involved changes between drug class and 40.8% within NRTI backbones.With regard to changes between drug class, 48.6 and 24.0% of treatment changes were to INSTI-based three-drug regimens and DTG-based two-drug regimens, respectively. Specifically, 80.1 and 55.2% switched from PIs and NNRTIs to INSTIs; 44.1% on INSTIs switched to dual therapy (13.7% to DTG/RPV or DTG/3TC and 30.4% to DTG + RPV or DTG + 3TC); 43.3 and 13.4% from others to INSTIs and dual therapy, respectively .Regards to changes within NRTI backbones, 91.8% of these was to TAF/FTC: 648 switched from TDF/FTC  and 72 from ABC/3TC  .This study is a detailed examination of 7 years of temporal trends (2014–2020) in the prescribing pattern of antiretroviral drugs and reasons for ART switches in a large Italian cohort of HIV patients. The dynamic treatment landscape in which an increased number of co-formulated and STR options became available, with evolution of guidelines over the study period, is evident in the changing prescribing trends and reason for switching. Broadly, our real-world analysis of ART patterns reveals that the majority of treatment-naïve and treatment-experienced patients received regimens that were listed as recommended in current guidelines. Regimen optimization and/or simplification is a leading cause of regimen modification; virologic failure or adverse effects are less likely causes in the current treatment landscape. First, we found a rapid increase in the use of STRs throughout the study period, amounting to over three-quarters of all ART regimens prescribed in 2020. These findings confirm that one of the most important challenges for clinicians managing HIV infection remains to encourage patients to take antiretroviral drugs correctly for a lifetime. Indeed, the advent of STRs has allowed a significant simplification of ART regimens in most treatment-naïve and -experienced patients. Results of previous surveys show that patients prefer to take fewer daily pills and look for compact easy-to-use regimens; observational and controlled studies indicate that virological and clinical outcomes are better in individuals treated with STRs versus MPRs, even among difficult-to-treat populations . In our Second, we observed a dramatic shift in prescribing patterns over time, with INSTI-based regimens rapidly replacing PI and NNRTI-based regimens during the later period.The switching matrix between drug class showed that 80 and 55% of all changes from PIs and NNRTIs (between 2018 and 2020) were towards INSTI-based regimens. The above findings are in accordance with international and national guidelines for ART, which recommend INSTI-based regimens in treatment-naïve and treatment-experienced patients ,4,5,18. The appeal of INSTIs mainly increased after the AIFA’ s approval of additional once-daily STR containing elvitegravir (EVG), dolutegravir (DTG), and the new INSTI bictegravir (BIC), especially in combination with TAF/FTC.Regarding the NRTI backbones, TDF/FTC was the most commonly used backbone until 2017. After TAF entered in the Italian pharmaceutical market on March 2017, we found that prescribers were more likely to prescribe TAF than TDF, both in treatment-naïve and treatment-experienced PLWH. This may be reflecting the preference among clinicians for TAF, especially in an aging population with comorbidities. In several clinical trials and cohort studies, TAF, given in combination with other antiretroviral agents, has been associated with high efficacy and lower risk of renal and bone toxicities compared with TDF both in treatment-naïve and treatment-experienced patients . A systeIn addition, our study also explores prescribing of dual therapy in real-world setting, DTG plus 3TC and DTG plus RPV, recently approved also as FDC by AIFA. Since 2017, Italian guidelines recommend DTG based 2-drug regimens, underlying the efficacy of these regimens in patients harboring variants bearing reverse transcriptase inhibitor resistance mutations or in patients with a history of virological failure to reverse transcriptase inhibitors . In 2019Finally, we observed that the number of treatment-experienced patients remained stable in the pandemic era, suggesting that retention in HIV care has been assured despite COVID-19 restrictions. Hospitals in Italy are to dispense antiviral drugs in 3–6-month doses to meet the needs of people living with HIV and reduce facility visits . Since tOur study has several limitations. First, this is a retrospective study without follow-up; therefore, it is not possible to ascertain the consequences and the efficacy of prescribing strategies. Second, the viral load and CD4+ count were not reported in this study. Third, no data were available on clinical and psychosocial factors that could have affected ART prescribing. Finally, this analysis was limited to one site, and prescribing patterns in this clinic may not reflect decision-making and management elsewhere in Italy. As most of the physicians at Cotugno Hospital have a specific interest and expertise in HIV care and are involved in the evaluation of new agents through clinical trials or as opinion leaders, they will generally be knowledgeable about new treatments and are more likely to be early adopters of new therapeutic approaches.In conclusion, the overarching goal of ART is still to achieve and maintain virologic suppression in all patients, but regimen simplification, especially with potent STRs, and optimization of ART to reduce toxicities and ensure long-term tolerability has become an increasingly important goal in HIV management, particularly in the context of an aging population. Taken together, these findings suggest that in the contemporary ART era treatment changes are more likely to occur for optimization rather than as a result of adverse effects and virologic failure.


In Nigeria, private for-profit health facilities present an opportunity to achieve the UNAIDS 95-95-95 HIV targets because of their reach and patronage. However, little is known about determinants of outcomes in these facilities. This study describes patient outcomes and the patient and health facility characteristics associated with these outcomes in adults receiving HIV treatment in private facilities in the Federal Capital Territory (FCT), Benue and Nasarawa states in north-central Nigeria.A retrospective longitudinal analysis of program data collected between 2013 and 2019 was done. Patient attributes and outcomes were compared across the two states and FCT. Incidence rates were determined for all cause exit, mortality and loss to follow up (LTFU). Cox proportional hazard models were used to identify associations between patient and facility attributes and these outcomes. Bivariate and multivariate logistic regression models were used to determine the factors associated with viral suppression among the study participants.p < 0.001), Zidovudine (AZT)-based regimens , and lowest quartile baseline CD4 + count  were associated with regimen switch. 75.6% of subjects were viral suppressed. Male gender ; AZT-based regimen , age in the bottom quartile  were associated with virally suppression.Of the 22,010 study subjects, 42.7%, 22.2% and 35.1%, respectively, were in Benue, FCT and Nasarawa. Almost a third (31.8%) had received antiretroviral treatment (ART) for less than a year at censoring. Incidence rates for all-cause exit, mortality and loss to follow up (LTFU) were 17.2 , 2.1 , and 11.2  per 100 person years respectively. Males had higher risks of death , and LTFU . Age at ART start showed a dose–response association with both mortality and LTFU. Care at model facilities (OR = 2.16, Private for-profit facilities are a major provider of HIV and other health services in Nigeria. With appropriate technical support and engagement, they can help accelerate efforts to achieve epidemic control of HIV in Nigeria, and contribute to achievement of UNAIDS 95-95-95 target by 2030. The 2018 Nigerian National AIDS Indicator and Impact Survey (NAIIS), the largest ever population-based HIV impact assessment (PHIA) globally, showed a prevalence of 1.4% among people aged 15–69 years , 6–10.th largest contributor to the global burden of HIV [With its estimated 1.9 million people living with HIV, Nigeria remains the 4n of HIV . It alson of HIV . Nigerian of HIV . The natn of HIV . Only 7 n of HIV . These dn of HIV , 12, 14.The HIV response in Nigeria is government-led but largely donor-funded, with many programs initially focusing on supporting the public sector’s capacity to provide comprehensive HIV prevention, care and treatment services in secondary and tertiary health facilities , 15, 16.Solina Center for International Development and Research (SCIDaR), with sub-grant funding from the Institute of Human Virology, Nigeria (IHVN), designed and began implementing a model to support private for-profit facilities to provide HIV prevention, care and treatment services in Nigeria in 2013. This paper aims to determine the patient and health facility factors that are associated with patient retention and virologic suppression in adult patients receiving ART in private health facilities supported by the SCIDaR-IHVN program in Benue and Nasarawa states, and the Federal Capital Territory (FCT) between 2013 and 2019. Benue, Nasarawa and the FCT are all in the north-central zone of the country, with HIV prevalence rates of 5.3%, 2.0% and 1.6% respectively, compared to a national average of 1.4% [This study is a retrospective analysis of routinely collected longitudinal data for patients enrolled in the SCIDaR-IHVN private sector HIV care and treatment program in Benue, Nasarawa, and the FCT between January 2013 and November 2019. All adult patients (aged 18 years and above), who received ART for at least one month in any of the 221 private health facilities supported by the program  were included in this study. Patients on ART for less than a month were excluded as they are unlikely to have demonstrated treatment effects. Also, because medication usage was not directly observed in most patients, only those who returned for the first follow up visit at one month could be presumed to have commenced treatment. Routinely collected patient-level demographic and clinical data was extracted from the PEPFAR Retention and Audit Determination Tool (RADET) database. The data was cleaned, organized and analyzed using Stata® 13 SE .The outcomes of interest were viral suppression (< 1000 copies/ml) in most recent viral load test , all-cauTreating time on ART, in months, at point of exit as the analysis time, overall and state-specific incidence rates with 95% confidence intervals were calculated for all-cause exit, mortality, LTFU, treatment stoppage and transfers out. In addition, state-specific and overall incidence rates of regimen switch from 1st to 2nd line were determined. Hazard ratios  were computed using Cox proportional hazards models to identify demographic, clinical and patient care characteristics that were associated with all-cause exit, mortality, and LTFU in the study population. In addition, odds ratios, with 95% confidence intervals) were computed with a logistic regression model to identify patient characteristics that were associated with regimen switch to 2nd line.Viral suppression rates  were calculated for each state and for the overall study population. The state-specific rates were compared using a Pearson chi squared test. Factors associated with viral suppression in the study population were determined using multivariate logistic regression models. Patient characteristics assessed for relationship with viral suppression included gender, age at ART start , state of residence, pregnancy status, host health facility support type, ART enrolment year, duration on ART in years, months of ARV refill , baseline CD4+ count (categorized into quartiles), current regimen base, and contact testing status. Adjusted ORs for viral suppression by ART enrolment year and by duration on ART in years from the best fit multivariate logistic regression model were charted to identify any trends over time.p < 0.001). Among the female study subjects, 3.9% were pregnant and 3.6% breastfeeding at time of data recording. Mean age at start of ART was 33.8 years (SD 9.9 years). Overall, almost 1 in 6 (17.3%) patients commenced ART in 2013 or earlier, with Benue contributing more to this group (19.9%) compared to FCT (12.7%) or Nasarawa (16.9%). Annual enrolment increased gradually to peak at 24.0% in 2016, after which enrolment began to decline as shown in Fig. p < 0.001). The majority (81.5%) of patients were started on tenofovir (TDF)-based treatment regimens and few (1.0%) had switched to second line regimens as of time of analysis. As Table A total of 22010 patients meeting the inclusion criteria were included in this analysis. This number included 9392 participants (42.7%) in Benue, 4890 (22.2%) in the FCT, and 7728 (35.1%) in Nasarawa. The means and standard deviations of patient numbers per facility were 116 (SD 219.8) in Benue, 65.2 (SD 60.4) in FCT, and 118.9 (90.6) in Nasarawa. Two percent (442) of patients had commenced ART prior to joining the program in 2013. As shown in Table Table Results of multivariate Cox proportional hazard models showing associations of patient attributes with the different types of program exit are shown in Table nd line are presented in Table The results of unadjusted and adjusted logistic regression modeling of factors associated with regimen switch to 2Overall viral suppression rate on the program was 75.6% . As shown in Fig. Few reports on patient level HIV treatment outcomes from Nigeria have been published, and there is no large-scale outcomes data from private for-profit health facilities. The potential to improve equity and access to health services in low and middle income countries (LMICs) through better private sector engagement is widely recognized in the literature, yet very little empirical information on their effectiveness and quality of service exists , 28–33. Population estimates for viral suppression among PLHIV in Nigeria vary widely between geo-political zones, ranging from 33.7% in the south-south zone to 65.7% in the north-central . We founFemales had better outcomes, including retention in care and viral suppression, which is in keeping with other studies from Nigeria and elsewhere –37. BettDespite the potential that private for-profit health facilities hold, engaging them in public and social services like HIV prevention, care and treatment services is fraught with challenges –30, 32. Nonetheless, our study showed that intensified technical support for these facilities (model facility support) yielded significant improvements in quality of care and patient outcomes. Furthermore, performance improved with experience, and outcomes have continued on an upward trajectory Fig. . The scaThis study was limited by the non-availability of some data for analysis. Trends in repeat viral load and CD4+ testing records could be informative in understanding determinants of disease progression in the study population but repeat test measures were unavailable for analysis. Also, because viral load testing was not universally accessible during the earlier years of program implementation, testing was prioritized for patients in whom it was specifically indicated, such as those with signs of clinical failure or evidence of poor adherence. This may have resulted in an under-estimate of viral suppression rates and may affect the overall generalizability of our findings.Private for-profit facilities are a major provider of HIV and other health services in Nigeria and other LMICs. Our study shows that despite limited support, they are able to provide quality care for PLHIV. With appropriate technical support and engagement, private for-profit health facilities can help accelerate the achievement of UNAIDS 95-95-95 target by 2030.