Recycling tenofovir and lamivudine/emtricitabine with dolutegravir (TLD) after failure of non-nucleoside transcriptase inhibitor (NNRTI) first-line antiretroviral therapy (ART) is more tolerable and scalable than dolutegravir plus optimized nucleoside reverse transcriptase inhibitors. Studies have demonstrated TLD’s efficacy as second-line, but long term follow-up is limited.ARTIST is a single arm, prospective, interventional study conducted in Khayelitsha, South Africa, which switched 62 adults with two viral loads (VL) >1000 copies/mL from tenofovir, lamivudine/emtricitabine and an NNRTI to TLD. We report efficacy to 72 weeks and, in a post hoc analysis, evaluated VL trajectories of individuals with viraemic episodes.Virologic suppression was 86%  74-93), 74% (95% CI 61-84) and 75% (95% CI 63-86) <50 copies/mL, and 95%, 84% and 77% <400 copies/mL at week 24, 48 and 72 respectively, with 89% (50/56) resistant (Stanford score ≥15) to tenofovir and/or lamivudine pre-switch. No participants developed integrase-inhibitor resistance. Of the 20 participants not suppressed at week 24 and/or 48, two developed virologic failure, one switched regimen (adverse event), two were lost to follow-up, one missed the visit, one transferred out, nine resuppressed <50 copies/mL with enhanced adherence counselling and four remained viraemic (three with <200 copies/mL) at week 72.Recycling NRTIs with dolutegravir was effective for most participants to 72 weeks. Most with viraemia did not develop virologic failure and subsequently suppressed with enhanced adherence counselling or continued to have low-level viraemia. No integrase-inhibitor resistance was detected despite low-level viraemia in a minority of participants. In both arms, the backbone was dual nucleoside reverse transcriptase inhibitors (NRTI) with at least one NRTI fully active on resistance testing1, which led the World Health Organization to recommend a second-line regimen of zidovudine, lamivudine and dolutegravir (ALD) after failing a first-line NNRTI-based regimen with tenofovir plus lamivudine or emtricitabine (XTC) in settings with limited access to antiretroviral resistance testing2. This recommendation for the zidovudine and lamivudine NRTI backbone is based on the rationale that the resistance mutation selected for by tenofovir (K65R), does not compromise the activity of zidovudine3.The DAWNING study showed that dolutegravir was superior to ritonavir-boosted lopinavir after failing first-line non-nucleoside reverse transcriptase inhibitor (NNRTI)-based antiretroviral therapy (ART)5. Such a strategy would be beneficial to both patients and the health system as tenofovir is better tolerated than zidovudine, and TLD is available as a single fixed dose tablet taken once daily while ALD requires twice daily dosing of zidovudine and lamivudine 6.Recent evidence has emerged that recycling tenofovir and XTC with dolutegravir (TLD) in second-line ART, after failure of first-line NNRTI-based ART, is efficacious despite high rates of resistance to both tenofovir and XTCAntiRetroviral Therapy In Second-line: investigating Tenofovir-lamivudine-dolutegravir [ARTIST] trial), with 85% (51/60) achieving the primary end point of VL <50 copies/mL despite substantial baseline resistance to one or both of tenofovir and XTC . No participants developed study-defined virologic failure and no integrase resistance was detected in the one participant meeting criteria for resistance testing4.We have previously reported 24-week results of a single-arm interventional study of TLD as second-line ART , dolutegravir resistance developed in two patients who had virologic failure on second-line TLD14.The efficacy of second-line TLD in the absence of a fully active NRTI is likely due to dolutegravir’s high genetic barrier to resistance coupled with a cost in fitness from NRTI resistance mutations15. Here we report follow-up results of the ARTIST trial participants to 72 weeks to evaluate the maintenance of the virologic suppression on second-line TLD. Additionally, we conducted a post hoc descriptive analysis of the VL trajectories of those who had episodes of viraemia.Emergence of dolutegravir resistance in patients on second-line TLD could jeopardise the public health benefits that the combination potentially offers in lower and middle income country programmes. It is unclear whether the efficacy of TLD in those who have failed first-line NNRTI-based therapy is durable, particularly in those who develop viraemia, making longer follow-up crucial to inform treatment policy decisionsWe conducted a single arm, prospective, interventional study in two primary care clinics in Khayelitsha, South Africa. This study was designed to evaluate the virologic efficacy of TLD in second-line ART.4. The protocol was approved by the University of Cape Town’s Human Research Ethics Committee (039/2019) and is available with the statistical analysis plan on ClinicalTrials.gov (NCT03991013). Adults who had virologic failure  on a first-line regimen consisting of tenofovir, XTC and efavirenz or nevirapine were invited to participate. Exclusion criteria were CD4 cell count less than 100 cells/ml, active or suspected tuberculosis, active AIDS-defining conditions, an estimated glomerular filtration rate less than 50 ml/min per 1.73m2, haemoglobin less than 7.5 g/dl, alanine aminotransferase greater than 100 IU/l, a previous or current diagnosis of malignancy or any condition judged to put the patient at increased risk if participating, a condition judged likely to impact adherence (active psychiatric disease or substance abuse), pregnancy, breastfeeding, intention to fall pregnant or unable to take the study medication . Women of child-bearing potential were required to be on effective contraception.A full description of the study design was published with the week 24 primary endpoint resultsParticipants were enrolled and switched to TLD with additional 50 mg dolutegravir for two weeks to overcome efavirenz induction effects on dolutegravir metabolism and transport. Study visits with clinicians occurred every four weeks to week 24, then at week 36, 48 and 72. VL was assessed at baseline and every subsequent visit, with a repeat VL after two weeks of enhanced adherence counselling if VL was >50 copies/mL after week 12. If the repeat VL was >500 copies/mL, a genotypic resistance test was performed per protocol. Baseline genotypic resistance testing was performed retrospectively for all participants and was not available to inform treatment decisions.16. We used a ± two-week visit window for the first 20 weeks, then a ± six-week visit window from week 24 onwards. The extended window was introduced to accommodate COVID-19 restrictions in accessing health facilities. We conducted a modified intention-to-treat analysis (mITT), excluding those switching study drug due to contraception cessation, wishing to become pregnant, pregnancy, non-clinical transfer out or death from non-HIV and non-drug causes (assessed by the study doctor). Failure included: VL ≥50 copies/mL, missing VL within the visit window or loss to follow up, intolerance or adverse event due to any drug in the regimen requiring switch.The primary outcome was VL suppression (defined as VL <50 copies/mL), evaluated according to the FDA snapshot algorithm17.Virological failure was defined as having two consecutive VL >1000 copies/mL after week 12. Genotypic resistance was classified using the Stanford algorithm (version 8.9-1), with a score ≥15 indicating at least low-level resistance. Results were categorised as two fully active NRTIs (both with a Stanford score <15), resistance to one NRTI (one with a Stanford score <15 and one ≥15) and resistance to both NRTIs (both with a Stanford score ≥15)Virologic outcomes at week 24, 48 and 72 are presented as proportions with the corresponding exact binomial 95% confidence interval (CI). A pre-specified secondary analysis described VL suppression defined as <400 copies/mL. A sensitivity analysis of VL suppression excluded certain participants included in the mITT analysis: those lost to follow-up, missing a VL in the window and those who were changed from the study drug for reasons other than treatment failure. The pre-specified sensitivity analysis for the primary end-point of 24 weeks also excluded those with evidence of poor adherence at the visit (TFV-DP <350 fmol/punch), however these results were not available for the 48 and 72 week visits.In a post hoc descriptive analysis, the VL trajectories of participants who were on TLD and had a VL ≥50 copies/mL at weeks 24 and/or 48 were graphed along with a narrative description of their baseline and follow-up resistance test results, reported adherence (taken from clinician notes) and missed visits (no visit within the window).The baseline characteristics of the 62 participants enrolled between August 2019 and July 2020, are described in The proportion of participants with virologic suppression (VL <50 copies/mL) decreased from week 24 to week 72 but was maintained above 70% across the mITT and sensitivity analyses. In the mITT analysis 75.4% of participants had a VL <50 copies/mL at 72 weeks. A sensitivity analysis examined virologic suppression in those with a VL result who remained on TLD throughout the study; at 72 weeks 83.6% had a VL <50 copies/mL in this analysis .The outcomes of those not suppressed at weeks 24, 48 and 72 are described in Two participants met criteria for virologic failure (two consecutive VL >1000 copies/mL after week 12) during the follow up period: one at 36 weeks and one at 52 weeks. Three participants were eligible for resistance testing and all three had resistance testing conducted , but none were found to have integrase resistance mutations.3) compared to those with two active NRTIs at baseline was 0.84 (95% CI 0.74-0.95) for week 24, 0.91 (95% CI 0.61-1.34) for week 48 and 0.91 (85% CI 0.61-1.34) for week 72  at week 24 . FollowiWe plotted the VL trajectories for participants who were on TLD, had a VL conducted and had a result ≥50 copies/mL at week 24 and/or week 48. Of the nine not suppressed at week 24, four were also not suppressed at week 48. Sixteen participants in total were not suppressed at week 48 . By weekOverall, of the 20 participants who had not been suppressed at week 24 and/or week 48 , six had a VL ≥50 copies/mL, three were missing VL results, one had switched due to an adverse event and ten were suppressed <50 copies/mL at week 72 .Our study demonstrated that virologic suppression is maintained above 70% to 72 weeks, despite almost 90% of participants having resistance to one or more NRTI drugs at baseline. The COVID-19 pandemic restricted access to facilities for many participants over the follow-up period: a sensitivity analysis that accounted for this and included only those on TLD with a VL result, also demonstrated high proportions with sustained virologic suppression: 88%, 79% and 84% with VL <50 copies/mL and 98%, 89% and 85% with VL <400 copies/mL at weeks 24, 48 and 72 respectively. Three quarters of the participants with episodes of viraemia re-suppressed to <50 copies/mL after enhanced adherence counselling, while two participants remained viraemic at low levels and only two went on to meet criteria for virological failure.7. Differences in suppression rates could be due to differences in patterns of adherence between the study populations. NADIA found suppression rates over 90% in those with no predicted NRTI activity5. We found a similar proportion suppressed in those with baseline NRTI resistance, and the Malawian observational study found no evidence for increased risk of viraemia or virological failure for participants with baseline NRTI resistance 14. This supports the conclusion from the NADIA trial that dolutegravir in combination with a recycled NRTI backbone is an effective second-line regimen. Most of our participants who were not suppressed had low-level viraemia (VL <200 copies/mL), and most of these resuppressed at later time points with enhanced adherence counselling. While there was little self-reported poor adherence, this may be due to a social desirability bias. Those with missed visits reflect gaps in medication on hand, leading to poor adherence. The NADIA trial also postulated that poor adherence was prevalent in their population5. We hypothesise that suboptimal adherence resulted in low-level viraemia and subsequent re-suppression with improved adherence.The outcomes we report are similar to the NADIA trial, where 92% were suppressed <400 copies/mL on a second-line regimen of dolutegravir or darunavir with a recycled tenofovir/lamivudine backbone at 48 and 96 weeks, and tenofovir/lamivudine was found to be superior to zidovudine/lamivudine at 96 weeks as a second-line backbone 7 and the Malawian observational study (two cases)14. The relatively low median baseline VL at switching and the small sample size in ARTIST may have contributed to our finding that no patients developed resistance to dolutegravir over 72 weeks. However, as resistance to dolutegravir has been shown in dolutegravir monotherapy trials to generally develop between 24 and 48 weeks11, these results are reassuring. This finding in participants using recycled tenofovir in the NRTI backbone, is important considering the high prevalence of tenofovir resistance in patients failing first-line ART in sub-Saharan Africa18. Cycling in and out of care with periods of viraemia is to be expected over a lifetime of ART 20. Thus, sustaining virologic suppression over time requires a regimen that is robust to the development of resistance despite fluctuating adherence. Dolutegravir has a particularly high barrier to resistance, comparable to protease inhibitors and much higher than efavirenz21. Low level viraemia has also been shown not to be associated with subsequent virologic failure in patients on a dolutegravir regimen, nearly half of whom had previous virologic failure22.Despite the substantial proportion with low-level viraemia, only two participants fulfilled the study definition of virological failure over 72 weeks and neither of these participants  had integrase resistance mutations. Resistance has been identified in NADIA (three cases in the TLD group)23. Low-level viraemia at the primary end-point did not predict later virologic failure in participants on first-line TLD in the ADVANCE study, resulting in a recommendation that the goal of treatment on dolutegravir regimens could be shifted to less stringent targets than a VL <50 copies/mL24. The low proportion of participants meeting criteria for virologic failure on TLD despite ongoing low-level viraemia in our study seems to support this recommendation.Dolutegravir with recycled tenofovir and lamivudine seems to fulfil this need for a tolerable, robust second-line regimen and could help in achieving the third UNAIDS target of 95% of those on treatment being virologically suppressed7 addresses two key concerns facing HIV services in this phase of the HIV pandemic: first, patients on second-line ART are in need of more tolerable regimens than the currently-recommended zidovudine/lamivudine/dolutegravir combination, and the fixed-dose, once-daily TLD provides a safe alternative to make treatment more acceptable and effective for individual patients.The demonstrated efficacy of recycling tenofovir and lamivudine with dolutegravir in patients failing first-line NNRTI regimens in our study and the NADIA trial26. The growing evidence from this study, the NADIA trial, and other studies, suggests that switching all patients on NNRTI-based first line to TLD regardless of VL is effective and safe, with the caveat that monitoring and interventions to reduce the development of dolutegravir resistance should be implemented alongside widespread switching. This approach could facilitate less expensive and simpler strategies for wider TLD use 21.Second, scale up of ART is complicated by resource constraints and many programmes are opting for universal TLD regimens, frequently without VL testing before switching patients due to high cost and low availability27. Effective monitoring and management of adherence issues is required to sustain the population health benefits that TLD promises.Suboptimal adherence in a number of participants in this study did not result in virological failure with the development of integrase-inhibitor resistance mutations. This is compatible with dolutegravir’s high resistance barrier, though larger numbers and longer follow-up are needed to verify this. However, adherence challenges remain an issue regardless of regimen. While TLD represents a tolerable and robust second-line that may be helpful in improving adherence and outcomes in those who have previously failed treatment, individuals on this regimen will still benefit from adherence supportLimitations of this study include the higher proportion of missing VL results at week 48 and 72. COVID-19 reduced access to the primary care facilities where the study took place, and while we widened the visit window and used telephonic follow-up to mitigate this, the pandemic may still be responsible for missing VL data. Interpretation of our study is also limited by the small sample size, not having a control arm and lack of long-term therapeutic drug monitoring. While the frequent VL monitoring is not pragmatic for clinical practice, it allowed exploration of virologic trajectories following episodes of viraemia. A strength of our study is that it was embedded within a primary care ART clinical service, increasing generalisabilityMost of our participants on a regimen of dolutegravir with a recycled tenofovir and lamivudine NRTI backbone were virologically suppressed at 72 weeks, despite substantial baseline NRTI resistance. Most of those who did not suppress had low-level viraemia or missed visits. Only two participants with raised VL developed virologic failure, and no participants were found to have developed dolutegravir resistance. With enhanced adherence counselling most participants re-suppressed or continued to have low-level viraemia. These findings, together with those of the NADIA trial and other studies, support the routine switching of all patients on tenofovir and NNRTI-based first-line therapy to TLD regardless of viral load, alongside measures to mitigate and detect the development of dolutegravir resistance. This would simplify rollout and make this effective, tolerable, and inexpensive regimen available to millions more patients.Supplementary material


Uganda has been making progress towards universal HIV test and treat since 2013 and the 2016 test and treat policy was expanded from the 2013 guidelines. The expanded policy was rolled out in 2017 across the country. The treatment outcomes of this new policy have not yet been assessed at program level. The objective of this study was to determine the treatment outcome of the HIV test and treat policy in TASO Tororo Clinic, Eastern Uganda.This was a retrospective cohort study using secondary data. The study involved 580 clients who were newly diagnosed HIV positive in TASO Tororo clinic between June 2017 and May 2018, who were then followed up for ART initiation, retention in care, viral load monitoring and viral load suppression. The data was analyzed using Stat 14.0 version statistical software application.Of the 580 clients, 93.1%(540) were adults aged ≥20 years. The uptake of test and treat was at 92.4%(536) and 12 months retention was at 78.7% (422). The factors associated with retention in care were a) being counselled before ART initiation, AOR 2.41 , b) having a treatment supporter, AOR 1.57  and having an opportunistic infection, AOR 2.99 (95%CI:1.21–7.41). The viral load coverage was 52.4% (221) and viral load suppression rate was 89.1% (197) of clients monitored. Age <20 years was the only identified factor associated with vial load non suppression, AOR 7.35 (95% CI = 2.23–24.24).This study found high uptake of ART under test and treat policy, with very low viral load coverage, and a high viral load suppression rate among those monitored. The study therefore highlights a need to differentiate viral load testing based on the population needs and ensure each client testing positive receives pre-ART initiation counselling so as to improve retention in care. HIV is still a global burden despite the efforts made to combat it and as per the UNAIDS 2019 report, there are 37.9million people living with the disease globally, with 1.7million new HIV infections and 770,000 AIDS-related deaths [Uganda contributes 1.4million people living with HIV to the global burden . HIV pre+, all children under 15years, HIV positive clients in a sero-discordant relationship, HIV positive clients in the category of key and priority populations, and expanded the CD4 cut off for ART initiation for all the other categories to 500 cells/mm3, up from the 350 cut off [With the high burden of HIV in Uganda, the country has been making progress towards universal HIV treatment since 2013 when it adopted new WHO recommendations. This 2013 guideline expanded eligibility to ART to include test and treat, regardless of WHO clinical stage or CD4 level for all pregnant and lactating women which was started under Option BStudies have demonstrated that prompt ART initiation regardless of CD4 counts or clinical stage is associated with better treatment outcomes and there has been a global shift towards universal test and treat intervention. The uptake of test and treat among children in Uganda was found to be 49.1% with better outcomes among those who initiated ART within seven days reported as death at 8.3% and LTFU at 3.3% compared to 14. 4% and 8.6% respectively in the later initiators . StudiesBarriers to starting ART under test and treat have included cost, poor interactions with Health care workers, feeling healthy, concerns about ART side effects; fear of HIV disclosure and discrimination, limited privacy at health facilities; and fear of long waiting times , 10. MenEarlier studies on ART treatment indicated that there were some poor outcomes among those initiating ART under set criteria as CD4 and WHO clinical stage. These poor outcomes reported include, high death and lost to follow up (LTFU) rates among those initiating ART , 14, delRoutine viral load monitoring improves HIV treatment outcome and helps in understanding of HIV surveillance and epidemic trends. It provides data on HIV service coverage and quality. At community level it provides information on HIV transmission risk . Access There are limited studies conducted on the treatment outcomes of the new policy in Uganda. One study which compared treatment outcomes among children initiated on treatment promptly (within 1 week of HIV diagnosis) and those that delayed treatment; found shorter time to viral suppression among prompt ART initiators than those who delayed (24.9months vs 38.5months) . AnotherThis study explored the outcomes of the implementation of HIV/AIDS test and treat policy in The AIDs Support Organization (TASO) Tororo clinic, Tororo district, Eastern Uganda.The study was conducted in TASO Tororo clinic, one of the 11 TASO Centers in Uganda. The center was founded in 1991 in Tororo district, and currently located in the Eastern Division, COX road of Tororo Municipality Tororo district. By December 2018, it was providing care to 8066 people living with HIV with a catchment area of 75KM radius, and had identified 1130 new HIV positive individuals between June 2017 and May 2018. These individuals were identified and initiated on ART during both facility and community outreach HIV testing by HTS volunteers. The 8066 PLHIV provided with ART at TASO Tororo clinic made up 48.75% of all clients  receiving ART in Tororo district. Besides HIV/AIDS, TB/HIV prevention and treatment services, TASO Tororo provides a comprehensive package such as community sensitization on HIV testing and prevention services, screening and treatment of opportunistic infections (OIs), sexual reproductive health services (SRHs), gender based violence (GBV), and Family Health services such as Nutrition Assessment and Counseling services (NACS), screening and treatment for malaria, maternal neonatal and child health (MNCH) to the HIV positive clients and their exposed children.Tororo district is located about 220km East of Uganda’s Capital city, Kampala and boarders Western Kenya. There are two main urban centres in Tororo, that is Tororo Municipality and Malaba Town council (boarders Kenya), with a number of factories and construction work, thereby making the population very mobile within these town areas, though relatively stable in the rural areas.The study population were all patients who were newly diagnosed HIV positive at TASO Tororo clinic between June 2017 and May 2018. The sample size of 422 was determined using the Cochran equation. However, all the eligible study participants (580) were included in the data analysis.The study used a retrospective cohort design using secondary data. We applied quantitative method of data collection and analysis. We used data abstraction tool designed based on the HIV Testing Services (HTS) register, HIV care card and electronic medical record system which are used for routine monitoring of linkage to care, ART initiation and follow up. A retrospective medical record review was selected because the data required to answer the study objectives was available within the routinely collected data.The data abstraction involved patients who were newly diagnosed HIV positive at TASO Tororo between June 2017 and May 2018 who were followed up from HTS register, to ART register and electronic medical records.The people included in the study were HIV positive clients newly diagnosed at TASO Tororo between June 2017 and May 2018 and those with complete information. While those excluded were clients with incomplete information such as age, sex and date of HIV diagnosis and who missed to be entered into the HTS (HIV Testing Services) register.The main outcome was the uptake of ART under the test and treat policy. This was assessed by determining the number of clients testing positive within the study period and the proportions of those who were initiated on ART within one month of HIV diagnosis. The secondary outcomes assessed were; twelve months retention into care assessed by determining the proportions of clients who were still active in TASO Tororo care 12 months after initiation under test and treat policy, viral load monitoring assessed by the presence of viral load result slip in the client’s file or captured in the electronic medical records done within a 12 month period and viral load suppression measured within 12 months of ART initiation. Plasma Viral loads measurement at TASO Tororo was done by Central Public Health Laboratories (CPHL) through a hub system and a patient with a suppressed viral load was considered as one with RNA Viral load <1000copies/mL.Independent variables included age categorized as <20 years (children and adolescents) or ≥20years (adults), sex, baseline WHO clinical stage, educational level, Counselling before ART initiation assessed by documenting a counselling session on the ART care card on the day of ART initiation (counselled or not counselled), ART regimen at initiation measured as Efavirenze (EFV) based, Nevirapine (NVP) based or Protease Inhibitors (PI) based regimens, nutritional status measured using mid upper arm circumference (MUAC), and reported using color coded tape as Green (Well nourished), yellow  and red  marital status reported as never married/single, married/cohabiting, divorced/separated and widowed, presence of treatment supporter, residence of the client reported as urban for clients residing within the municipality and rural for clients outside the municipality.nd outcome (retention) and those who were inactive were dropped while analyzing viral load coverage, and clients who were not monitored for viral load were dropped while analyzing viral load non-suppression , clients who delayed treatment were dropped while analyzing the 2pression .Quality assurance and validity of data was enhanced through training of research assistants on standardized data collection procedures and strict supervision of data collection and entry.Univariate analysis was done for socio-demographic and baseline clinical characteristics and was presented in form of frequencies, proportions and means. Binary logistic regression was used to determine the association between binary outcomes and the independent variables. Multivariate logistic regression was used to assess the factors associated with uptake of ART under test and treat policy, retention, viral load monitoring and suppression at multivariate level. Variables were selected for inclusion into the multivariate models based on their levels of significance at bivariate level(P≤0.25) and on their biological plausibility to the outcomes of interest. Significance level was set at 5%.The study protocol was reviewed and approved by CURE Children’s Hospital of Uganda Research & Ethics Committee (CCHU-REC/16/019), which also granted consent waiver for this study, given that it was utilizing already collected program data and there was no direct contact with the clients. Permission to utilize TASO Tororo program data was sought from the Executive Director TASO Uganda Limited.There were 580 individuals who were diagnosed HIV positive in TASO Tororo within the study period, found to have complete data and were included in the analysis. Their mean (SD) age was 38.0 ± 13.1 years; 56.5% (n = 328) were females and 93.1% (n = 540) were adults aged ≥20 years, 89.8%(n = 521) of the identified HIV positive were from the community outreach testing site and 61.7% (n = 358) were married/cohabiting .Of the 580 clients tested positive within this period, 92.4% , were initiated on ART under test and treat policy. The reasons for failure to initiate on ART within one month of HIV diagnosis were not indicated in the HTS register, but being tested positive at the outreach site was associated with lower odds of failure to take up test and treat, AOR of 0.36  as compared to those tested at the facility.Twelve month retention for the clients who initiated ART under test and treat policy at TASO Tororo ART program was at 78.7%.Of the 536 clients who initiated ART under test and treat policy, 78.7%  were active in TASO Tororo care by 12 months of ART initiation. The 21.3%  of the clients who were no longer active in TASO Tororo care were either transferred out to other health facilities, 7.3% (n = 39), dead 1.3% (n = 7) or lost to follow up 12.7% (n = 68).The factors positively associated with retention in TASO Tororo care were a) being counselled before ART initiation with AOR of 2.41 , b) availability of treatment supporter at the time of ART initiation with AOR of 1.57  and having an opportunistic infection at the time of ART initiation with AOR of 2.99 (1.21–7.41). Of the 422 clients who were active in TASO Tororo care at 12 months, 52.4%  were monitored for Viral load and 47.6%  were not monitored. The odds of failure to monitor for viral load was lower among clients living in an urban area, AOR 0.46 . The detail is shown in Among the 221 clients monitored for viral load and were having valid viral load results in their files, 89.1%  had suppressed viral load  and 10.9%  had non suppressed viral load . There was a marked difference in viral load non-suppression rates between adults ≥20 years (7.5%) and children and Adolescents <20 years (40.9%) and this difference was significant (P<0.001). The factor which was significantly associated with Viral load Non-suppression was age <20 years with AOR of 7.35 (2.23–24.24). The factors such as presence of opportunistic infections, having a treatment supporter and being counselled before ART initiation which were positively associated with 12 months retention in care did not have any association with viral load non suppression both at bivariate and multivariate levels. The baseline clinical stage, TB status and nutritional Status were equally not associated with viral load non suppression. The detail is shown in In this study, we found a high uptake of HIV test and treat program where 92.4% of all individuals who were tested HIV positive accepted ART initiation within one month of HIV diagnosis. This therefore demonstrates a significant progress in the uptake of test and treat program in Uganda particularly and Africa at large, from 28% among women at risk of HIV infection in Kampala , 49.1%amIn this study, being tested positive at the outreach site was significantly associated with lower odds of failure to take up test and treat. This study finding is contrary to findings from Zimbabwe , and couSocio-demographic characteristics such as younger age and being widowed/separated were earlier identified in Uganda  as beingOn 12 month retention in care, this study found suboptimal retention of 78.7% vs expected 95%. This finding is much lower than earlier reported 12 months retention in care in Uganda which was at 90% among adolescents  and 87.8In this study, the factors that were significantly associated with 12 month retention into care included a) being counselled before ART initiation, b) having a treatment supporter and c) having an opportunistic infection at the time of ART initiation. It is evident in this study that treatment supporters are able to offer significant support to the newly enrolled clients on ART and keep them active in care for longer than their counterparts who did not have treatment supporters. Also, to note of importance is the presence of opportunistic infections at the time of enrollment which enabled that clients were retained in care. This retention could have been due to the resultant benefit at enrollment on ART which was coupled by treatment and resolution of the opportunistic infections in the individual. Our study finding of HIV counselling before ART initiation having a significant effect on retention into care reaffirms earlier findings in Malawi  did not In this study, residing in an urban area as compared to rural was significantly associated with lower odds of failure to monitor for viral load. Residing in an urban area could have facilitated viral load monitoring due to the proximity to the clinic and convenient access to get their viral load monitored. Most of the clients who were enrolled on ART in TASO Tororo clinic under test and treat policy were residents in rural area, distant from the clinic. In order to achieve adequate viral load suppression, clients who have been on ART for six months or more need to be monitored for viral load and check their viral load status. This study found viral load monitoring for clients who initiated ART under test and treat very low at only 52.4% against the expected 100% monitoring. This finding highlights a key weakness in the implementation of test and treat policy and generates further questions as to why clients are not being monitored for viral load despite being on ART for 12 months and active in care. This finding is however not unique to TASO Tororo test and treat policy as a multi-country study of HIV treatment and monitoring pattern found viral load coverage to be only at 35%  and anotOn a positive side, this study found generally high viral load suppression (89.1%) and low non suppression (10.9%) among clients who were monitored for viral load after initiating ART under test and treat policy. This suppression rate though still suboptimal is higher than initial findings of viral load suppression in East Africa during a cluster randomized community trial of test and treat where after one year on ART, only 72.9% of the newly diagnosed HIV positive had viral load suppression . DespiteAmong the few clients monitored, the viral load non-suppression rate found in the study was similar to findings in earlier studies where clients were adequately counselled but took long to be initiated on ART. Initial studies reported viral load non suppression as 11% in Uganda , 10.3% iThis study found age at the time of ART initiation as the only predictor of suppression based on multivariate analysis. This finding of viral load non suppression being higher in children and adolescents is consistent with earlier findings in Uganda where odds of virological non-suppression was decreasing with increasing age, with children aged 0–4 years had AOR 5.3 95%CI; 4.6–6.1) and young adolescents had AOR of 4.1  registering the highest odds  and the –6.1 and The study also had limitations. In this study, only 38% (221) of the clients who were tested positive at the facility were monitored for viral load and as such we were unable to decisively determine the viral load suppression rate under the test and treat policy. The study being retrospective in design, we were unable to assess the health system factors which contributed to low viral load coverage as they were not documented in the records. We were also unable to assess the association between baseline CD4 count and viral load outcomes as with the introduction of test and treat, there was inconsistent CD4 testing at the facility.Since it was a retrospective cohort study basing on data generated from the health facility, there were client records with many missing information which led to only half (580 of 1130) of the clients with complete data being included in the analysis.This study found high uptake of ART under test and treat policy, with very low viral load coverage for those initiated, and a high viral load suppression rate among those who were monitored.The study therefore highlights a need to differentiate viral load testing based on the population needs so as to reach even the clients who initiated ART at community level with viral load services.There is need to ensure that each client who tests positive receives psychosocial support (counselling) before ART initiation so as to improve retention in care.There is need to continuously offer psychosocial support to children and adolescents with a focus on ART adherence so as to improve viral load coverage in this age group.S1 Dataset(CSV)Click here for additional data file.


Current HIV treatment regimens provide sustained virologic suppression, at least partially restore the immune system and have limited side effects; however, they do not allow viral eradication and they are burdened by daily pill intake with a life-long commitment for the people living with HIV (PHIV). Injectable agents might represent a turning point in the care of PHIV, allowing less frequent administration of antiretroviral treatment (ART), more widespread use of pre-exposure prophylaxis (PrEP) and more stable drug levels in the blood, thus increasing the odds to get closer to end the HIV pandemic. The aim of this manuscript is to give a comprehensive review of injectable antiretrovirals that have been used in the past, which are available now, will be available in the future, and their role in the treatment of HIV infection About 40 years have passed since the first cases of Acquired Immune Deficiency Syndrome (AIDS) were observed, and the HIV pandemic is still responsible for roughly 38 million people living with the virus and 1.7 million new infections every year . CurrentWe performed a MEDLINE/PubMed search on 03/03/2019 and the complete search string was as follows: (((injectable) AND antiretroviral) AND HIV) AND  AND (“01/01/1990” (Date-Publication): “03/03/2019” (Date-Publication)). The string was then updated on the 30 June 2020 to enclose more recent papersOf the 361 papers identified, 299 were excluded by title and abstract screening as they were not pertinent to our narrative review. We ultimately selected 36 papers: the full texts and pertinent references were then retrieved and collectively discussed. The decision about inclusion in the present narrative review was ultimately made according to the subjective impression of the authors. Eventually, the review was organized for each drug analyzed in the following paragraphs: (i) “Molecular characteristics”; (ii) “Available formulations”; (iii) “Recommended doses”; and (iv) “Place in therapy”. Finally, a discussion about the future applications of the reviewed drugs is given.Zidovudine (AZT) (3’-azido-2’3’-dideoxythymidine) was the first antiretroviral drug available in the 1980s. Initially studied as an antineoplastic drug, it subsequently showed in vitro and in vivo activity against HIV-1 virus and, in a lesser extent, against HTLV-1 and HIV-2. AZT is a thymidine analogue which intracellularly is phosphorylated to its active 5′-triphosphate metabolite, zidovudine triphosphate (ZDV-TP). The principal mode of action of ZDV-TP is the inhibition of reverse transcriptase (RT) via DNA chain termination after incorporation of the nucleotide analogue. ZDV-TP is a weak inhibitor of the cellular DNA polymerases α and γ and has been reported to be incorporated into the DNA of cells in culture ,11 Figu. AZT is available in both oral and parenteral formulation and, by a pharmacokinetic point of view, it shows good oral bioavailability (64%) with serum concentration peak 30 to 90 min after administration . The AZTAZT is recommended at the dosage of 300 mg every 12 h in oral formulation and 1 mg/kg/dose every 4 h in the prevention of perinatal transmission of HIV (2 mg/kg loading dose followed by continuous infusion of 1 mg/kg until delivery).AZT use is no longer recommended in the treatment of HIV infection; the role is limited to prevent mother-to child transmission: (a) intrapartum in women with HIV-RNA > 50 copies/mL, and (b) in infants of HIV-infected mothers ,14 and aEnfuvirtide (T-20) was the first antiretroviral drug targeting viral entry process; it is a 36-aminoacid polypeptide derived from heptad repeat (HR) 2 that binds the HR-1 region of gp41 preventing the coil–coil zipping reaction and subsequently HIV-1 fusion with cellular membrane . T-20, dThis drug is available only in a subcutaneous compound due to its susceptibility to intestinal peptidases. T-20 has a concentration peak at 4 h and a plasmatic half-life ranging from 2 to 3. 8 h without influence by renal or hepatic function. There are frequent adverse drug reactions, mainly cutaneous in the injection site.The dosage of T-20 is 90 mg every 12 h by subcutaneous administration.T-20 use is no longer recommended and limited to as deep salvage treatment in patients with previous treatment failures. In these individuals, the use is recommended in combination with an optimized background therapy ,18.3 and HIV-1 RNA levels less than 100,000 copies/mL and of ART-experienced patients without resistance mutations to RPV (Rilpivirine (RPV or previously TMC278) is a potent diarylpyrimidine NNRTI currently used for the treatment of ART-naïve patients with a CD4+ T cell count more than 200 cells/mms to RPV . It is available in oral formulation (25 mg once daily) as an individual drug preparation or as a single-tablet regimen (STR) in combination with tenofovir disoproxil fumarate or tenofovir alafenamide and emtricitabine  or with dolutegravir (RPV/DTG).In oral formulation, RPV showed a good tolerability and a good pharmacokinetic (PK) profile. RPV should be taken with a normal caloric meal  or high-fat high-caloric meal  and need careful evaluation of possible drug interactions, in particular with proton pump inhibitors and antiepileptic drugs. In a trial on healthy volunteers that were exposed to intravenous nanosuspension, maximum concentration was achieved in three days and decreased to below 10 ng/mL after 12–26 weeks with a half-life of five weeks ,20,21.In animal models, RPV, formulated as a 200 nm nanosuspension and administrated intramuscularly (IM) or subcutaneously (SC), showed sustained and dose-proportional release over 2–6 months with an absolute bioavailability of 100% in spite of high concentrations at the injection site. IM administration showed a higher peak concentration compared to SC. This study showed that nanoparticles generated a secondary depot of RPV by macrophage in the lymph nodes with an initial concentration 100-fold higher than plasma one month after the administration, which decreased 3–6 folds below plasma concentration beyond three months .Long-acting RPV (RPV-LA) was also evaluated in a phase I study with a single injection of escalating doses and a phase II study with 1200 mg loading dose followed by 600 mg every four weeks. RPV was detected after 4 and 8 h after administration; analysis of plasma concentrations was performed up to 28 days after injection or up to <20 ng/mL. After a 300-, 600- or 1200-mg injection, RPV-LA PK was largely comparable to the 1200-mg loading dose and both 600-mg RPV-LA injections. The mean plasma concentration of RPV when administered every 28 days after the last injection in all dosing groups was 79 ng/mL .1. The LATTE-2 study evaluated cabotegravir and RPV-LA in maintaining HIV-1 viral suppression for 96 weeks. In the randomized, phase 2b, open-label study, HIV-1-treated adults initially received oral cabotegravir (CAB) plus ABC/3TC once daily. The objective of this study was to select an effective, tolerable, and safe intramuscular dosing regimen of the two drugs compared with oral CAB plus ABC/3TC. After a 20-week induction period, patients with HIV-1 RNA <50 copies per mL were randomly assigned (2:2:1) to therapy with CAB LA + RPV-LA at 4-week intervals or at 8-week intervals or to continue oral CAB plus ABC/3TC. The primary endpoints were the proportion of patients with viral suppression at week 32, protocol-defined virologic failures, and safety events for 96 weeks. A total of 309 patients were enrolled, 286 were randomly assigned to the maintenance period . At week 96, viral suppression was maintained in 47 (84%) of 56 patients receiving oral treatment, 100 (87%) of 115 patients in the 4-week group, and 108 (94%) of 115 patients in the 8-week group. Three patients (1%) had virological failure . Injection site reactions were mild (3648 (84%) of 4360 injections) or moderate (673 (15%) of 4360 injections) and rarely led to discontinuation (two (<1%) of 230 patients); injection site pain was most frequently reported. Serious adverse events during maintenance were reported in 22 (10%) of 230 patients in the intramuscular groups (4- and 8-week groups) and in seven (13%) of 56 patients in the oral treatment group; none were drug-related. In this study, the combination of CAB-LA and RPV-LA every four weeks or every eight weeks was as effective as daily three-drug oral therapy in maintaining HIV-1 viral suppression for 96 weeks and was well accepted and tolerated .2. In a phase 3, randomized, open-label trial ART-treatment, naïve patients were given 20 weeks of daily oral induction therapy with DTG-abacavir (ABC)-lamivudine (3TC) (DTG/ABC/3TC). Participants who had an HIV-1 RNA <50 copies/mL after 16 weeks were randomly assigned (1:1) to continue the DTG/ABC/3TC or switch to oral cabotegravir plus RPV for one month followed by monthly injections of long-acting cabotegravir plus RPV. The primary end point was the percentage of participants who had an HIV-1 RNA >50 copies/mL or more at week 48 . At week 48, an HIV-1 RNA >50 copies/mL or more was found in 6 of 283 participants (2.1%) who received LA therapy and in 7 of 283 (2.5%) who received oral therapy. This exciting result met the noninferiority criterion for the primary end point . Regarding adverse reactions, in the group of participants who received LA, 86% reported injection site reactions ; 4 participants withdrew from the trial for injection-related reasons. Treatment satisfaction increased after participants switched to LA therapy; 91% preferred long-acting therapy at week 48 .3. In a phase 3, open-label, multicenter, noninferiority study involving patients with HIV-RNA <50 copies/mL for at least six months while taking oral ART, they were randomized into two groups (1:1) to continue their oral therapy or switch to RPV-LA and cabotegravir-LA. The primary end point was the percentage of participants with an HIV-1 RNA level of 50 copies/mL or greater at week 48.Treatment was initiated in 308 participants per group. At week 48, HIV-1 RNA levels of 50 copies/mL or more were detected in five participants (1.6%) on long-acting therapy and in three (1.0%) on oral therapy , a result that met the noninferiority criterion for the primary end point . Adverse events were more common in the long-acting group and included injection pain, which occurred in 231 patients (75%), however, mild or moderate in most cases; and 1% withdrew because of this event .The combination of RPV-LA and CAB-LA is recommended for maintenance treatment of HIV-infected adults who have HIV-RNA < 50 copies/mL, and when the virus has not developed resistance to NNRTIs and integrase strand transfer inhibitor (INIs).RPV LA IM injections every eight weeks in the HPTN 076 study were safe and acceptable. Overall, despite more injection site reactions and pain in the participants receiving RPV LA, the injections were well tolerated. Data from this study support the further development of injectable PrEP agents .Cabotegravir (CAB) is an integrase strand transfer inhibitor (InSTI) similar to DTG that was initially studied in oral formulation . Then, iSee studies previously described in RPV-LAThe combination of RPV-LA and CAB-LA is recommended for maintenance treatment of HIV-infected adults who have HIV-RNA < 50 copies/mL, and when the virus has not developed resistance to NNRTIs and InSTIs.Recently, the HIV Prevention Trials Network study (HPTN 084) on the safety and efficacy of CAB LA for pre-exposure prophylaxis (PrEP) in HIV-uninfected women, was stopped early by the trial Data and Safety Monitoring Board (DSMB) as results showed CAB LA to be highly effective in preventing HIV acquisition .Ibalizumab (IBA) (Trogarzo™), formerly known as TNX-355, is a humanized IgG4 monoclonal antibody (MAb), which acts as an entry inhibitor. It binds the CD4 receptor, leading to its conformational change and interfering with its binding with HIV gp120 ,31 Figu. IBA is currently available as an intravenous infusion and, given its long half-life (3–3.5 days after both intravenous and subcutaneous administration), it can be administered every two weeks as a single loading dose of 2000 mg, followed by a maintenance dose of 800 mg.This first biologic drug was studied for more than a decade with phase I and II trials demonstrating its efficacy and good tolerability profile.10 copies/mL from baseline (day 14). A total of 31 PLWH completed the study. Of the 40 PLWH in the ITT population, 33 (83%) had a decrease in HIV-RNA load of at least 0.5 log10 copies/mL from baseline. At week 25, a mean VL decrease of 1.6 log10 from baseline was observed. Undetectable VL was observed in 43% of patients, while 50% of patients had a VL < 200 copies/mL. The most common adverse events were diarrhea; 4 patients died from causes related to underlying illnesses while 1 patient developed an immune reconstitution syndrome [In a single-group, open label, phase 3 study, 40 patients with an HIV-RNA higher than 1000 copies/mL, ART-treated for more than six months with a 3-class resistance were enrolled. The primary endpoint was the proportion of PLWH with a decrease in HIV-RNA load of at least 0.5 logIBA was approved by the FDA in 2018 and by the EMA on 26 September 2019  in combiGS-6207 is a first-in-class inhibitor of HIV-1 capsid function (CA) with a long-acting activity that can be administered monthly or less frequently in extended-release parenteral formulations thanks to its low aqueous solubility. It binds with high affinity to CA hexamers between adjacent CA monomers and retains sensibility against HIV-1 mutants resistant to other ARV classes including mutants with a Gag alteration that conferred resistance to other maturation agents .In an in-vitro study, it displayed potent activity in MT-4 cells  and exhibited a mean EC50 of 0.05 nM in human PBMCs against 23 HIV-1 clinical isolates including all subtypes. In the same study, GS-6207 human serum protein-adjusted EC95 was found to be >10-fold lower than that of efavirenz (EFV), RPV, DTG, and atazanavir (ATV) while in primary human CD4+ T-cells and macrophages was >10-fold more potent and >22-fold more selective than them. GS-6207 also suppressed HIV-2 replication. GS-6207 antiviral activity decreased with increasing multiplicity of infection (MOI), but remains 5- to >100-fold more potent than four commonly used ARVs and exhibits low cytotoxicity in four human cell lines and primary hepatocytes (CC50 > 44 μM). It also showed synergistic antiviral activity when combined with other ARV classes .GS-6207 disrupts HIV capsid, a multimeric shell that is essential to viral replication, at multiple stages throughout the viral life cycle.Results from a phase 1b proof-of-concept study of a subcutaneous formulation showed antiviral activity with GS-6207 with significantly greater reductions in HIV-1 RNA versus the placebo across all treatment groups.1/2 between 30 to 38 days and concentrations measurable for at least 16 weeks. Tmax values ranged from 21 to 35 days and the increase in exposure (Cmax and AUC) between 30 and 100 mg was proportionate to dose [Preliminary PK data were consistent with sustained delivery with a dose interval of at least three months with a median apparent terminal t to dose .The above-mentioned data highlight the potential of GS-6207 for treatment in PLWH, regardless of ARV history.Albuvirtide (ABT) is a new injectable fusion inhibitor with once-a-week administration currently approved in China .ABT is a 3-maleimidopropionic acid (MPA)-modified peptide HIV fusion inhibitor derived from the N-terminal sequence of HIV-1 gp41 which can irreversibly conjugate to serum albumin that extends its half-life. Unlike enfuvirtide, it manages to form a stable α-helical conformation with the target sequence of gp41 and it blocks the fusion-active six-helix bundle (6-HB) formation in a dominant-negative manner preventing viral fusion and entry . This me3. They received either an intravenous weekly infusion of 160 or 320 mg of ABT and lopinavir/ritonavir (LPV/r) 400/100 mg twice daily. At week 7, decline of 1.9 (1.3–2.3) log10 and 2.2 (1.6–2.7) log10 copies/mL of HIV-1 RNA was observed from the baseline. Viral load suppression (HIV-RNA < 50 copies/mL) was achieved in 11.1% (1/9) and 55.6% (5/9) patients, while the CD4+ cell count change was −5 cells/mm3 and 52 for the 160 and 320 mg dose group, respectively [This molecule was evaluated in vivo by Zhang et al. in an open-label and randomized trial on 20 ART naïve patients with a HIV-RNA > 5000 copies/mL and a CD4+ cell count >350 cells/mmectively .Results from the phase 3 multicenter, open-label, randomized, controlled, non-inferiority TALENT (Test ALbuvirtide in experiENced patienTs) in HIV-1 infected patients who failed ART were presented. Adults infected with HIV-1 were eligible for inclusion if they had a plasma viral RNA load of at least 1000 copies/mL or higher. Patients were allocated (1:1) to the ABT plus lopinavir boosted with the ritonavir (LPV/r) group or the LPV/r plus two optimized NRTIs groups were enrolled with 347 PLWH for 48 weeks. A HIV-RNA load <50 copies/mL was obtained in 66% of the 2 NRTI group and 80% of the ABT group reaching the non-inferiority endpoint. Only in five patients in the ABT arm was a HIV-RNA load >500 copies/mL detected without evidence of resistance. No death occurred in the two groups and the more common adverse events were gastrointestinal abnormalities, rash, headache, dizziness, hematuria, cholesterol, and triglyceride elevation with no significant differences between the two groups .Currently, its role in therapy is still to be defined, potentially in heavily treatment experienced patients with limited treatment options left.HIV-1-specific broadly neutralizing antibodies (bNAbs) may be a key player as an “add-on” agent for HIV prevention, treatment, and perhaps, eradication .bNAbs have been shown to reduce VL and to potentially maintain viral suppression; however, rebound viremia with emergence of resistant acid strains has been observed in clinical trials as well as a not fully understood effect of the viral reservoir .Although efficient neutralization of free HIV virus has been described, bNAbs need further investigations to find their proper place in therapy.In the last few years, much progress has been made in terms of antiretroviral therapy regimens with new drugs and new formulations, but HIV-resistant strains, ART interactions, and long-term ART adherence remain important issues ,41,42,43The availability of routes of administration other than oral such as subcutaneous or intravenous may be an advantage and may allow the physicians to closely monitor assumption with direct observed therapy, especially in populations at high risk for interruptions  or in PLWH who report drug fatigue. Long-acting drugs with administration every 1–2 or more months may effectively reduce poor adherence to treatment.Pharmacokinetics and pharmacodynamics of injectable drugs allow more regular drug level through adequate therapeutic drug monitoring (TDM), decreasing the likelihood of erratic kinetics due to oral administration , and a more stable antiretroviral effect in an optic of treat as prevention (TaSP) and PrEP.Not the least, the access to molecules with a new mechanism of action opens awaited therapeutic chances to those heavily-experienced patients with few or no available treatment options .In conclusion, injectable agents might represent a turning point in the care of people living with HIV, allowing less frequent administration of ART, and hopefully more widespread use of PrEP, more stable drug levels in the blood, thus increasing the odds to get closer to ending the HIV epidemic.


P < 0.001), and for those on EFV-based treatment  and for those on DTG-based treatment . Results are similar in multivariable models adjusted for clinical characteristics and adherence. NNRTI resistance prior to treatment is associated with long-term failure of integrase inhibitor-containing first-line regimens, and portends high rates of first-line failure in sub Saharan Africa.Little is known about the impact of pretreatment drug resistance (PDR) on the efficacy of second generation integrase inhibitors. We sequenced pretreatment plasma specimens from the ADVANCE trial (NCT03122262). Our primary outcome was 96-week virologic success, defined as a sustained viral load <1000 copies/mL from 12 weeks onwards, <200 copies/mL from 24 weeks onwards, and <50 copies/mL after 48 weeks. Here we report how this outcome was impacted by PDR, defined by the World Health Organization (WHO) mutation list. Of 1053 trial participants, 874 (83%) have successful sequencing, including 289 (33%) randomized to EFV-based therapy and 585 (67%) randomized to DTG-based therapy. Fourteen percent (122/874) have ≥1 WHO-defined mutation, of which 98% (120/122) are NNRTI mutations. Rates of virologic suppression are lower in the total cohort among those with PDR 65% (73/112) compared to those without PDR  to non-nucleoside reverse transcriptase inhibitors (NNRTIs) on the efficacy of second-generation integrase inhibitors and find an association between NNRTI resistance prior to treatment and long-term treatment. However, recent concerns about DTG have emerged. For example, early data suggested a slight increased risk of neural tube defects following DTG exposure in pregnancy, although more recent data have been reassuring4. Secondly, greater weight gain was observed in patients treated with DTG compared to efavirenz (EFV) in two clinical trials in sub-Saharan Africa, as well as in cohort studies from the North America and Europe, leading to concerns about long-term effects of obesity with lifelong ART9.The increasing prevalence of non-nucleoside reverse transcriptase inhibitor (NNRTI) resistance in those initiating or re-initiating antiretroviral therapy (ART)10, the WHO and others are revisiting targeted use of efavirenz (EFV). Concerns remain about the use of EFV with widespread NNRTI resistance, which exceeds 10−15% in much of sub-Saharan Africa11. Pretreatment NNRTI resistance has been associated with a 2−3-fold greater risk of virologic failure (VF) for people initiating NNRTI-based regimens, both with older combinations such as nevirapine (NVP) and with EFV14. By contrast, the ANRS 12249 Treatment as Prevention Trial15 reported that the most common NNRTI mutation, K103N, when detected alone, was not associated with increased risk of VF on an NNRTI-based single tablet regimen containing tenofovir, emtricitabine and efavirenz16. A study in Kenya similarly suggested isolated K103N might have limited impact on EFV-based ART17.Whilst cost-effectiveness analyses continue to support the use of DTG as first-line therapy despite these issues20, there is relatively little data available on the efficacy of DTG in the context of high circulating NNRTI resistance. In the DAWNING trial, in which individuals failing NNRTIs were randomized to DTG or lopinavir/ritonavir, and over 90% had some evidence of NNRTI resistance, approximately 84% of individuals in the DTG arm achieved virologic suppression at 48 weeks. Notably the proportion of people suppressed at 48 weeks on DTG arm was lower than in most prior clinical trials, albeit of first-line therapy21. As such, additional studies are needed to better elucidate the impact of pretreatment NNRTI drug resistance on virologic outcomes with both EFV-based and DTG-based used first-line regimens in the region.These conflicting data have generated controversy in the field on optimal first-line regimens to balance safety, tolerability, cost, and the impact of circulating NNRTI drug resistance on virologic outcomes. Although clinical trial data in the United States suggest that DTG performs exceptionally well in ART-naive individuals and as a switch regimen in the absence of significant background resistanceHere we report results of next-generation sequencing of stored plasma specimens from participants in the ADVANCE clinical trial to determine the contributions of NNRTI pretreatment drug resistance (PDR) on 96-week virologic outcomes for individuals initiating EFV- and DTG-based ART. We hypothesize that NNRTI PDR significantly affects efficacy of EFV-containing regimens but has a negligible effect on outcomes for those initiating DTG-based therapy.P < 0.001).A total of 1053 individuals were enrolled in the ADVANCE trial. Of these, 991 (94%) consented for specimen storage and had pretreatment plasma available for testing, and 874 (83%) had successful sequencing of a pretreatment plasma specimen  of individuals had at least one WHO-defined PDR mutation at variant frequencies of 20% or greater . This pattern was true for participants initiating EFV-based ART  and DTG-based ART . Rates of virologic success were higher for both regimens for those with and without PDR in our secondary outcome, which assessed for persistent virologic failure with two consecutive viral loads >200 copies/mL, although the effect of PDR persisted , two were in the EFV arm (both failures) and of the six in the DTG arm, 2/6 (33%) achieved 96-week virologic suppression as defined by the primary outcome measure. Participants with K65R all had NNRTI mutations and 6/8 (75%) had M184V.In multivariable regression models, PDR remained a strong predictor of virologic success  after adjustment for demographic and clinical factors, and both self-reported and pill count-based adherence, as well as additive effects of PDR and adherence in both the EFV and DTG arms Table . The eff10 viral load from enrollment to week 12 was greater for those without PDR in the EFV arm , but not in the DTG arms , whereas those with and without PDR had similar time to initial suppression in the DTG arms . In adjusted Cox proportional hazards models, the effect of PDR remained significant only for those on EFV-based ART , but not for those DTG-based ART .In contrast to the effect seen with long-term virologic outcomes, PDR only had an effect on initial virologic response for individuals on EFV-based ART, but not those on DTG-based ART. The change in logn = 8). Isolated K103N was associated with lower virologic success for individuals on DTG-based ART, with the exception of our secondary outcome, for which the effect size was similar but the effect was not statistically significant.We considered the impact of isolated K103N  on virologic response to EFV and DTG (Supplementary information). Rates of virologic suppression were similar in participants taking EFV-based ART with and without the K103N mutation, although the number of individuals with K103N was small in this arm . We found similar effects of PDR on virologic success in analyses stratified by EFV vs DTG-based treatment (Supplementary information). In a subset of 38 individuals who had sequencing data available both prior to enrollment and at the time of failure, we found that new NRTI and NNRTI mutations developed among those in the EFV-based ART arm in 31% (5/16) and 40% (4/10) of individuals respectively, but that new resistance in the reverse transcriptase gene was rare among those in the DTG-based ART arms (6% [1/17] new NRTI mutations and 0% (0/11) new NNRTI mutations, Supplementary information). Finally, we found no difference in the effect of PDR on any outcomes in sub-analyses restricted to sequences with at least 1000× average depth coverage (Supplementary information).We report a strong association between drug resistance before treatment initiation, primarily to the NNRTI class, and virologic failure for people initiating first-line ART in the ADVANCE clinical trial. The effect was seen among individuals in the EFV arm and DTG arms, and persisted after adjusting for self-reported and pill count-based adherence and baseline viral load. When we considered a secondary outcome, which focused on persistent virologic failure , the effect of PDR on DTG persisted, but to a lower degree. In contrast to the effects seen for long-term outcomes, we did not find that PDR had an impact on time to initial suppression or change in quantified viral load from enrollment to 12 weeks, suggesting that NNRTI PDR affects longer-term maintenance of suppression for DTG-based ART or via a non-virally mediated behavioral mechanism. Nonetheless, the finding that NNRTI resistance appears to ultimately predict treatment failure among individuals initiating DTG-based ART in LMIC was unexpected, and to our knowledge not previously reported in the literature.23, although additional studies would be needed to corroborate this hypothesis. Whereas we found relatively little minority resistance and no effect of minority resistance on outcomes, existence of NNRTI resistance could be a surrogate marker of archived NRTI resistance24. Integrase resistance mutations were not assessed in this study, but are generally believed to be rare (<1%) in this region26. Importantly, PDR did not hamper time to initial virologic suppression or change in viral load from enrollment to week 12 among people on DTG-based ART. A similar phenomenon of early maintenance of suppression followed by longer-term treatment failure was also seen with DTG monotherapy studies28.A virologic mechanism to explain our findings has not been established. NNRTI mutations are not known to affect susceptibility of DTG. The observed effect we identified may be consistent with preliminary data suggesting higher replication of NNRTI mutant viruses in the context of drug pressure from integrase inhibitors31. Moreover, previous studies have demonstrated that prior ART exposure is associated with treatment failure and predicts virologic failure, even after controlling for PDR and treatment adherence, and thus could be a source of residual confounding if significant numbers of individuals in this study declined to disclose prior ART use33. Notably, a number of studies have reported denial of ART use among individuals determined to be taking therapy based on drug level testing36. The South African public HIV program has used EFV in first-line therapy since its inception in 2004 and has over 5 million on treatment. The number of individuals who have defaulted and are re-initiating therapy are likely to be significant, and it is impossible to identify such individuals within clinical trials using existing South African data systems. Thus, while our effect size for PDR is large, and adjusted for confounding, the possibility that prior treatment exposure is a confounder of this effect remains substantial.Alternatively, the lack of long-term suppression we identified in the DTG-based ART arms may be due to a behavioral component—pre-existing EFV mutations may be a surrogate of prior default among participants not disclosing previous ART exposure. Our multivariable logistic regression models included a measure of self-reported adherence and pill count-based adherence, both of which were highly predictive of virologic outcomes. Addition of these measures to our model did not meaningfully alter the effect size of PDR on virologic success. However, both self-reported and pill count-based adherence are imperfect measures, and can have a relatively low sensitivity to detect poor adherence, so residual confounding might be present21. By contrast, in this study the presence of drug resistance mutations at presentation for first-line treatment (or re-initiation after a default) appeared to signal the opposite—increased risk of virologic failure, perhaps mediated by poor adherence, or a virologic fitness deficit. Making this distinction about the clinical implications of drug resistance for clinical and public health purposes could be crucial. Fifth, our findings might signal a warning for national programs in the midst of large-scale switching from EFV-based to DTG-based ART, and support increased vigilance for the presence of treatment failure at the time of switch. Finally, these results signal the importance of future work to determine optimal treatment recommendations for individuals failing DTG-based ART, for which minimal data are currently available. Without such data, treatment programs should be advised to maintain virologic monitoring programs, adherence monitoring and support programs for those with failure, and regimen change guidance for individuals with intolerance or persistent virologic failure, even when documented drug resistance is absent. More novel strategies, such as real-time adherence and resistance monitoring, and long-acting injectable formulations of ART for those with adherence challenges should also be explored as these options become more widely available39.Whether the mechanism of effect is due to poor adherence or virologic mechanisms, our finding that NNRTI resistance, which is present in 10−20% of individuals initiating DTG in the region and is associated with a reduction in efficacy of DTG-based ART, has multiple public health implications. First, ensuring adequate virologic monitoring occurs with DTG-based regimens will remain a priority. Second, treatment programs will require ongoing attention to second- and third-line options, particularly if DTG failure or intolerance becomes more common than previously expected, and NNRTI-based regimens become more commonly used again. Third, integrase resistance testing, which is rarely done outside of research studies in resource-limited settings should become a consideration for referral laboratories in countries where DTG becomes the treatment of choice. Fourth, our data, in combination with the DAWNING study and others, highlight that the presence of drug resistance mutations might portend very different outcomes depending on the timing of when it occurs. In DAWNING, drug resistance mutations detected at the time of first-line failure were a surrogate measure of past adherence and predict success to second-line therapy6. DTG was non-inferior to EFV in that study, but baseline VL > 100,00 copies/mL predicted failure in both arms. NAMSAL reported a much lower prevalence of NNRTI resistance (6%) than we did (14%), which is consistent with other data in the region40. In NAMSAL, investigators reported no impact of baseline NNRTI resistance on outcomes, although 6/16 failures in the EFV arm had pre-existing NNRTI resistance. In that study, none of the three failures in the DTG arm at 48 weeks had baseline resistance to NNRTIs, the 6% of those that did appear to suppress during the study. By contrast, in our study, isolated K103N in the DTG arm was associated with lower virologic success in the primary analysis, albeit at 96 weeks. As in prior studies, we identified a very small number of individuals with resistance to both the NRTI and NNRTI drug classes, including K65R, M184V who we believe were unlikely to be treatment naive and who responded poorly to first-line ART. While the proportion is low, this finding is concerning from the point of view of the large-scale EFV to DTG-transition in sub-Saharan Africa, during which multi-class drug resistance is likely to be more prevalent44.NAMSAL is the only other randomized controlled trial that has compared DTG vs EFV-based first-line ART in sub-Saharan Africa. That study, conducted in Cameroon, compared low-dose 400 mg EFV to DTG as third agent at 48 weeks47. However, many studies, and particularly those considering newer ART regimens, have failed to demonstrate a role for these low-level mutant viruses in determining clinical outcomes48. We also found no association between PDR and outcome when considering individuals with mutations in between 2 and 20% of viral quasispecies, which supports current practice to use major resistance mutation frequencies for determination of clinically significant drug resistance.Next-generation sequencing is becoming more widely used in research studies to measure the prevalence and impact of drug resistance in LMIC, and has the added advantage of being able to detect resistant viruses at low frequencies22. Yet, prior studies have shown such an effect size for prior ART exposure49. Notably, known predictors of treatment success, such as adherence and pretreatment viral load, each predicted virologic success, which enhances the internal validity of our estimates. We also were unable to sequence approximately 15% of the study cohort due to unavailable specimens or failed sequencing. Despite that, our sample size remained large enough to detect relatively small changes in outcomes, and we detected no differences in characteristics between those who were and were not included in this sub-study, which reduces the risk of selection bias. Finally, our sequencing did not include the integrase region of the pol gene. Although resistance mutations that confer resistance to dolutegravir remain rare in South Africa, we cannot exclude the possibility of low-level resistance as a possible contributor to our findings26.Our study should be generalized in light of its conduct in South Africa, and the presence of NNRTI resistance-conferring mutations as the large majority of the PDR detected. As this is the first study to show an impact of PDR on the efficacy of first-line DTG, it requires corroboration from future studies of similar cohorts. The presence of a higher prevalence of PDR in the DTG arm suggests that there might have been imbalance between groups, which is most likely due to chance, because the study arm was determined by computer randomization. Nonetheless, we have low suspicion for selective dropout in the study because interest in DTG among patients and within society at the time of randomization was minimal. Our estimates could be susceptible to unmeasured or residual confounding, particularly due to the effects of prior ART exposure and/or imperfect adherence not captured by self-report or pharmacy pill counts. Notably, our estimates of the effect of PDR on virologic outcomes remained large and significant after adjustment for confounders, including adherence, meaning an unmeasured confounder would have to have a strong association (OR of 2.7 or greater) with both PDR and virologic success to reduce the effect of pretreatment drug resistance to nullIn summary, our study suggests that the presence of PDR to NNRTIs is negatively associated with long-term virologic outcome of both EFV- and DTG-based first-line ART in South Africa. In the context of highly prevalent PDR NNRTI resistance, our findings, if corroborated, have implications for first-line ART selection and treatment monitoring guidelines in the region. Future work should validate our findings, assess the contribution of pretreatment integrase mutations to outcomes, elucidate the impact of prior exposure to ART on treatment outcomes, and whether treatment failure observed on DTG-based ART is associated with emergence of integrase inhibitor mutations.50. The study enrolled non-pregnant individuals over 12 years old without chronic kidney disease. Individuals were excluded if they had more than 30 days of prior ART use, any ART use in the past 6 months, were pregnant, or were actively undergoing therapy for tuberculosis.The ADVANCE trial is an open-label, non-inferiority, phase three clinical trial comparing three regimens for the initial treatment of HIV (NCT03122262). Individuals were recruited from 11 public HIV clinics in Johannesburg, South Africa. All study visits and data collection procedures were performed at one of two research clinics in Johannesburg operated by the study staff. Consenting participants were randomized in a 1:1:1 ratio to (i) tenofovir disoproxil fumarate (TDF), emtricitabine (FTC), EFV; (ii) TDF, FTC, DTG, or (iii) tenofovir alafenamide (TAF), FTC, and DTG51. We limited our analyses to sequences with ≥100× depth of coverage and spanning PR codons 1–99 and RT codons 1–254  for extraction , HIV-1 pol gene amplification , and next-generation sequencing  as previously describedWe first described and graphically depicted the analytic sample to determine which study participants were included and excluded from this analysis. To assess for selection bias in this sub-analysis, we compared characteristics between individuals who had sequencing results available for this analysis with those who did not due to lack of available plasma specimens or failed sequencing. We then summarized clinical and demographic features of the analytic sample in total, and divided into those initiating EFV and DTG-based regimens. We then described the frequency and proportion of WHO-assigned PDR mutations overall, by drug class, and by treatment regimen.52. Our primary outcome of interest was 96-week virologic success, which we defined as sustained a viral load <1000 copies/mL from 12 weeks through 96 weeks, <200 copies/mL from 24 weeks through 96 weeks, and <50 copies/mL from 48 weeks through 96 weeks. Individuals censored with virologic suppression at 48 weeks or after are considered to have achieved virologic success. Individuals who did not complete 12 weeks of observation are not included in this analysis . We derived this definition to reflect treatment response in individuals who attain and maintain virologic suppression over the course of study observation. We estimated the proportion of participants who achieved virologic suppression by the presence or absence of PDR for the total cohort, and by EFV vs DTG treatment regimens.Our primary exposure of interest was PDR, which we defined as the presence of at least one of the WHO list of surveillance drug mutations detected in at least 20% of the viral population54: sex, age, partnership status (defined as married or with a primary partner vs not), educational attainment (dichotomized as tertiary education or less), active employment status, pretreatment CD4 T-cell count , pretreatment viral load , pill count-based adherence , and self-reported adherence (dichotomized as perfect adherence in the past 4 days vs any treatment interruptions in the past 4 days). We assessed for collinearity in our model by estimating variation initiation factors for each covariate within our fully adjusted model  restricted the definition of PDR to individuals with only the K103N mutation, (2) restricted the definition of PDR to individuals who had WHO-defined PDR mutations at variant frequencies of 2−20%, and (3) assessed finding stratified by those in the EFV- or DTG-based arms. In a subset of individuals who had sequencing data available both prior to treatment initiation and after failure, we compared changes in patterns of NRTI and NNRTI-class resistance over time. We also conducted restricted analysis to individuals with sequences with ≥100× depth of coverage. Finally, we estimate an E value to determine the magnitude of the effect size of an unmeasured confounder who need to have to reduce the association between PDR and virologic success to null22. Data analysis was conducted in Stata , coded by two separate investigators (M.J.S. and B.S.) and compared for reproducibility. A fully de-identified dataset and code for all analyses are available upon request to the corresponding author.In sensitivity analyses, we varied our definition of virologic success. To assess for the impact of NNRTI PDR on persistent virologic failure, for a secondary outcome we defined success in individuals without two consecutive visits up to 96 weeks with a viral load >200 copies/mL. In this definition, individuals censored or changed to a second-line regimen after a single viral load >200 copies/mL are considered failures, whereas those who discontinue with virologic suppression are considered as achieving virologic success. This outcome is meant to detect persist virologic failure by allowing for virologic blips or episodic failure followed by re-suppression. To assess the contribution of PDR on virologic response to therapy, we also considered a virologic potency outcome defined by the change in logThe study was approved by the institutional review board at the University of the Witwatersrand. All study participants gave written informed consent to participate.Further information on research design is available in the Supplementary InformationPeer Review FileReporting Summary


Patients infected with HIV may experience a succession of clinical stages before the disease diagnosis and their health status may be followed-up by tracking disease biomarkers. In this study, we present a joint multistate model for predicting the clinical progression of HIV infection which takes into account the viral load and CD4 count biomarkers.The data is from an ongoing prospective cohort study conducted among antiretroviral treatment (ART) naïve HIV-infected women in the province of KwaZulu-Natal, South Africa. We presented a joint model that consists of two related submodels: a Markov multistate model for CD4 cell count transitions and a linear mixed effect model for longitudinal viral load dynamics.Viral load dynamics significantly affect the transition intensities of HIV/AIDS disease progression. The analysis also showed that patients with relatively high educational levels , high RBC indices scores  and high physical health scores  were significantly were associated with a lower rate of viral load increase over time. Patients with TB co-infection , having many sex partners , being younger age  and high liver abnormality scores  were associated with a higher rate of viral load increase over time. Moreover, patients with many sex partners  and with a high liver abnormality score  showed significantly reduced intensities of immunological recovery transitions. Furthermore, a high weight, high education levels, high QoL scores, high RBC parameters and being of middle age significantly increased the intensities of immunological recovery transitions.Overall, from a clinical perspective, QoL measurement items, being of a younger age, clinical attributes, marital status, and educational status are associated with the current state of the patient, and are an important contributing factor to extend survival of the patients and guide clinical interventions. From a methodological perspective, it can be concluded that a joint multistate model approach provides wide-ranging information about the progression and assists to provide specific dynamic predictions and increasingly precise knowledge of diseases. This Markov process has an initial probability, denoted by P(S(0) = m), m ∈ E, which evolves over time and with a history (HE), which contains the state previously visited, durations and times of transitions [m and j relative to the given process history, as:Let a Markov process {nsitions , 31. Them,j thus denotes the transition probability of the patient being in state j at time t, given that the patient was in state m at time z.PIn the current study, we consider a joint model for the long-term trends of viral load biomarker and transition times into the different adverse effect states based on CD4 cell counts. This model consists of two related submodels: a Markov multistate model for the transition times data and a linear mixed effect model for the longitudinal data  process, both linked by a function of the shared random effects. HIV-infected ART-naive patients may experience many CD4 cell count fluctuations mostly before ART initiations. This suggests that transition times should be modelled by a multistate process. Figure yit  be the viral load count of HIV infected patient i at follow-up visit time t. Under Gaussian assumptions, the longitudinal viral load dynamics yit is modelled using the following model which is proposed by [xi(t) and zi(t) represents a vector of potentially time-varying covariates corresponding to the vector of fixed effects β and random effects bi, respectively. The model assumes that random effects are distributed as multivariate normal with mean 0 and covariance matrix D. We also assume that the errors are independent and follow a normal distribution, εi(t)~N, and that bi and εi(t) are independent [To model the long-term trend of viral load dynamics, we used a linear mixed effect model. Let posed by .\documeependent . The norependent . The rani, the instantaneous hazard rate of moving to state j conditioned on state m is defined as followshmj is the transition intensity for m = 1, …, 4 and j = m ± 1 sequential states defined by CD4 counts. hmj, 0(t) is the baseline intensity from state m to state j and can either be left unspecified or modelled parametrically, Xmj representing a matrix of covariates. αmj is the effect of the covariates on the hazard intensity hmj. For this model, if m < j, then a transition from m to j is defined as an immunological deterioration transition and a transition where m > j is defined as immunological recovery. In the extension of joint modelling, we used a Markov multistate model that takes into account the viral load biomarker through the shared subject-specific random effects bi. Thus, the instantaneous hazard, for a patient moving from state m ∈ E to state j ∈ E, at time t will be modeled as:In this sub-section, we model the transition intensities defined by CD4 cell count which takes into account the viral load biomarker. The standard approach of modelling the event history data , in whicWmj defines a multivariate function that represents the dependence structure between the longitudinal viral load trajectory and multistate CD4 count transitions. We can choose Wmj as the true baseline and slope of the viral load of HIV-infected patients. γmj represents the impact of the longitudinal viral load biomarker on the CD4 cell count progressive form state m to state j.Wmj. This dependence function was the same for all the CD4 cell count transitions and resulted in combining the true baseline and rate of change of the viral load fitted to capture the association between viral load dynamics and the instantaneous hazard rate to transitions between sequential events.As one of our objectives is to examine the relationship between transient states defined by CD4 cell count progression and the longitudinal viral load dynamics, we followed the approach adopted by Ferrer et al. , where tyi) and multistate CD4 count transitions (Si) is given byTo estimate the parameters in the shared parameter model, we used maximum likelihood estimation. A joint model can be estimated using the independence between the multi-state and longitudinal processes conditionally on the random effects. So, the likelihood for all the observed longitudinal viral load trajectory ,representing all the parameters contained in Eqn. (1) and (4); and the corresponding density functions, is then given byfVL representing the conditional function for the longitudinal viral load trajectory, ||x|| represents the Euclidean norm of a vector, fCD4 is the conditional function for the multistate CD4 count transitions, k denotes the number of transitions, S(Tr) between times Tr and Tr + 1,S(Tr + 1),δ denotes transition indicator and fb(bi| θ) the joint distribution of the random effects.i is often high and the density functions of the multi-state Markov process can be highly complicated, evaluation of the above integral (Eqn. 5) can be a major challenge and very intensive. Therefore, for the computations of the above function (eq. 5), a multi-step pseudo-adaptive Gaussian-hermit quadrature rule [Since the dimension of the random effects bure rule , 36 can The estimation approach was implemented under R (mstate and JM). With JM package initializing the parameters for the longitudinal and multistate sub-models, then, an extended JM function, called JMstateModel, which was mainly implemented by Ferrer et al. , can carThe completes disease progression situation is visualized and explained by Fig. β = 0.15; 95%CI: 0.045, 0.249) were significantly associated with a higher baseline viral load, as compared to those who were not co-infected with TB. Similarly, higher educational levels , higher weight , higher RBC indices , higher physical health score , higher social relationship score  and patients with stable sex partners , were significantly associated with lower baseline viral load. When we consider the effects of covariates on the long-term viral load trajectories (the slope), patients with higher educational levels and higher physical health scores were significantly associated with a lower rate of viral load increase over time. Similarly, patients with many sex partners, of younger age (< 20 years) and with higher liver abnormality scores were significantly associated with a bigger increase in viral load in ART-naïve patients.The results of the joint multistate model are presented in Table β = 0.59; 95%CI: 0.15, 1.03) and severe to advanced  disease stages, but had reduced the intensities of transitions from normal to mild  disease stages. Patients with many sex partners had significantly decreased the intensities of transitions from severe to advanced  disease stages. Middle-aged patients were significantly associated with a higher intensity of transitions from advanced to mild  and from mild to normal  disease stages, compared to those patients in the older age group. The psychological wellbeing score had significant effects on severe to advanced  and mild to normal  transitions. Patients with high scores of latent variable related RBC indices had significantly increased the intensity of transition from mild to normal  disease stage, but decreased the intensity of transition from mild to advance  disease stage. Moreover, having high weight, high physical health score and high level of independent score significantly reduced the intensities of transitions from normal to mild, mild to advanced and advanced to severe disease stages. Furthermore, having a high liver abnormality score significantly reduced the intensities of transitions from advanced to mild disease stage.For the multi-state sub-model results, patients with higher educational levels had statistically significantly increased intensities of transitions from mild to normal  and disease progressions of HIV/AIDS, viral load dynamics had a significant effect on the intensities of transitions of HIV/AIDS disease progression. As the baseline viral load of women in the study increased, the likelihood that women transited from advanced to mild (aHR = 0.72 = exp.(− 0.33)) stages of the disease decreased. Similarly, a higher baseline viral load significantly increased the intensities of immunological deterioration transitions. Moreover, as the long-term viral load trajectories of women in the study increased, the likelihood that women transited from normal to mild, mild to advanced and advanced to severe stages of the disease increased.The estimates of the joint longitudinal viral load biomarker and multistate CD4 cell count transition model were validated by using the graphical methods presented in Figs. In this study, we have presented a joint model for multi-state and longitudinal biomarker data. Such data are common for many medical and clinical studies in monitoring chronic diseases. Simultaneous modelling of this multistate and longitudinal biomarker outcome in joint models offers advantages over a separate model of each outcome, including more clinically meaningful adjusted association parameters, improved predictive accuracy, and more efficient parameter estimates. Also, using this joint multistate model not only an improved inference but also the opportunity for dynamic prediction. Król et al.  developeOur results showed that older age has been associated with a higher baseline viral load, which is in agreement with the previous studies , 43. We Patients with opportunistic infections and tuberculosis infection, in particular, are associated with increases in HIV viral load , 47. TheLatent variable related to aminotransferase were significantly associated with the change in viral load. Faster rises in the rate of change of viral load over time were observed in patients with higher liver enzymes abnormality. This finding concurs with the prior report , which nThe rate of change of immune recovery of a patient with higher education levels increased with greater rates, compared to those with low levels of education. This is supported by the findings of Maurya et al. , who fouThe results showed there was a significant positive relationship between QoL domain scores and intensities of recovery of HIV-infected patients. Studies conducted in South Africa  and Chintotal lymphocytes and basophils are positively and independently associated with CD4 cell count responses. Many studies also suggested that total lymphocytes can adequately serve as a surrogate biomarker for predicting CD4 count progression in resource-limited settings [Among the different hematological parameters for HIV infected patients, as expected, high scores of latent variable related to total lymphocytes and basophils counts in the blood had significantly reduced intensities of immunological deterioration transitions, a finding that is in accordance with the literature , where isettings –57. Simisettings , where aViral load biomarker significantly affects the transition intensities of HIV/AIDS disease progression. Having a high baseline viral load significantly decreased the intensities of immunological recovery transitions, but increased the intensities of immunological deterioration transitions. This was supported by previous studies, Farahani et al.  and MartThis study has some limitations, including the missing data, which are expected for a study conducted on data collected from patients’ files and when dealing with a long term follow-up period. We did not evaluate model performance with an alternative multistate sub-model, such as a full parametric multistate sub-model (including accelerated failure time models). However, model diagnostics have been performed and the residual and influence diagnostics affirmed no violation of implicit and explicit assumptions in our model. The other limitation is that the study was limited to adult females. Moreover, this joint model did not take into account the simultaneous modeling of many biomarkers and multistate outcomes before and after cART initiation. Bayesian multivariate joint models for analyzing many biomarkers  and multistate outcomes before and after cART initiation, will be our future research work.Overall, from a methodological perspective, it can be concluded that the joint multistate model approach provides wide-ranging information about the progression and assists to provide specific dynamic predictions and increasingly precise knowledge of diseases. Joint multistate modelling is necessary to explore the impact of the longitudinal biomarker outcome on the transitions between clinical states. Joint models are also an improvement over separate multisite models because they consider all the longitudinal observations that are predictive of the transition event of interest. Though this research presented the usefulness of the joint multistate model for analyzing the HIV/AIDS cohort data, the approach is applicable to a wide variety of chronic diseases. There is a need for increased research in terms of methods, so hopefully, this article will be helpful applied researchers  to familiarize with the method and interpretation of the results therefrom. From a clinical perspective, the findings of this study contribute to extend the survival of the patients and guide clinical interventions.