Rates of first antiretroviral therapy (cART) modifications are high in most observational studies. The age-related differences in treatment duration and characteristics of first cART modifications remain underinvestigated. With increasing proportion of older patients in HIV population it is important to better understand age-related treatment effects.Patients were included into this analysis, if being cART naïve at the first visit at the clinic. Follow-up time was measured from the first visit date until first cART modification or 28 February 2013. First cART modification was defined as any change in the third drug component i.e. protease inhibitor (PI), non-nucleoside reverse transcriptase inhibitor (NNRTI), integrase inhibitor or fusion inhibitor. Cox proportional hazard models were used to identify factors related to first cART modification in three age groups: <30, 30–50 and >50.In total 2027 patients with 14,965 person-years of follow-up (PYFU) were included. The oldest group included 136 patients with 1901, middle group 1202 with 8416 PYFU and youngest group consisted of 689 patients with 4648 PYFU. Median follow-up time was 5.8 (IQR 3.4–9.4) years, median time on first cART was 4.4 (IQR 2.1–8.5) years. 72.4 % of patients started PI-based and 26.1 % NNRTI-based regimen. In total 1268 (62.5 %) patients had cART modification . Durability of first cART was the best in patients over 50 y.o. . Factors associated with discontinuation in this group were late presentation  and PI use .Rates of first cART modifications or discontinuation were comparable in all groups; however older patients were significantly longer on first cART regimen. Rates of first combination antiretroviral therapy (cART) modifications are high in most observational studies –5. RecenWith increasing cART utilization, either by earlier initiation or wider access to treatment, it is of highest priority to re-evaluate factors associated with antiretroviral drug toxicities occurrence in clinical settings, especially in relation to toxicities requiring treatment modifications –9.Older age has been linked to increased risk of treatment related toxicities –12. DataMost studies focus on comparing patients over and less than 50 years of age , 17. As Therefore we have investigated first cART durability and modification causes comparing three age groups.This is a retrospective, longitudinal analysis of cART naïve, HIV-infected adults enrolled in Polish Observational Cohort of HIV/AIDS Patients (POLCA) study. POLCA is an observational database cohort where data are collected in real-time from the clinic database. The cohort has been established in 1994 with the purpose of prospective, active observation of HIV-positive patients routinely followed in HIV Out-Patient Clinic, in the Hospital of Infectious Diseases in Warsaw. All data are recorded in the electronic database. On the day of dataset export the cohort included 3087 HIV-positive patients 18 years of age or older with 15,814 person-years of follow-up (PYFU) and 18,269 CD4 cell count and 12,090 HIV RNA measurements. In addition a history of clinical visits, antiretroviral treatment history, demographic characteristics and results of all tests performed in the clinic are available for each patient. Since 2005 a CoDe procedure has been adapted to collect data on death cases in the cohort  and PI use  remained statistically significant , injecting drug use as HIV infection mode , nadir CD4+ count , unknown anti-HBc total status , cART group as ITI  and FI  remained statistically significant , (Table In this study we present that patients over 50 years of age had much better treatment durability as compared to other age groups. Factors significantly increasing the risk of cART modification in this group of patients were PI use and late presentation. Although rates of first cART modifications were comparable in both groups, treatment discontinuation due to its toxicity or failure was more frequent among oldest patients, whereas due to non-adherence in younger patients. This is to our knowledge the first study to present such age-related differences in the frequency of the discontinuation causes.Co-infections and co-morbidities are more frequent in patients over 50, thus toxicities more likely to occur and more likely to be the cause of treatment modifications , 22. HowInterestingly PI based cART regimens were preferable in all groups and in older patients were associated with increased risk of treatment modification. Higher PI utilization may reflect the need to initiate treatment immediately due to low CD4+ lymphocyte count and when the genotyping test result is not yet available. Although the primary mutations are infrequent in Poland it is generally preferred to receive genotyping test result before starting treatment . This coWe found that older patients had better viral suppression, defined by the proportion of patients with latest HIV RNA level below 50 copies/ml. Studies investigating effects of age on treatment response are inconsistent and does not provide insight into failure related modifications across age groups , 18, 25.In our study late presentation was 20 % higher in older patients and only in this group of patients significantly associated with lower risk of treatment modification. Studies of large HIV-positive populations present lower lymphocyte CD4+ count and shorter time to AIDS for older patients, which is well in line with higher rate of late presenters among older patients in most observational cohorts . In a laThe presented lower rate of non-adherence related treatment modification in older patients is well in line with data published by other cohorts .There are some limitations, which need to be highlighted. We focused exclusively on the third drug in regimen. We estimate that differences presented in our work would be even more profound, should the NRTI group switching be included. Due to small numbers we were not able to investigate further the effects of specific antiretroviral drugs and the drug-related risk of ART discontinuation . We haveIt needs to be mentioned that our study’s background may vary from other countries and/or regions in terms of demographics, preferred first line treatment regimens and timing of treatment initiation.Although persons over 50 years old are contributing to approximately half of HIV-positive population treatment modifications in this group of patients are rarely investigated . StudiesAlthough rates of first cART modifications in our study were comparable between age groups, we have shown a substantial differences in reasons for treatment modification. Older patients were also significantly longer on first cART regimen. In multivariate Cox proportional hazard models factors significantly increasing the risk of cART modification in older patients included late presentation and PI use. Our findings present age-related differences in terms of treatment tolerability warranting the need for further studies in this area, as well as opening a discussion about age-adjusted approach in HIV treatment strategies.


The national guideline extends the recommendation for initiating antiretroviral therapy in HIV infected persons, regardless of baseline CD4 since 2013 but the choice of treatment regimens in our guide is determined by the CD4 levels. Objectives: analyzing ART regimens prescribed in newly HIV-infected patients, identifying the factors that influenced regimens choice and analyzing viro-immunological evolution under therapy.Retrospective study of adult patients with confirmed HIV infection who initiated antiretroviral treatment in a hospital for infectious diseases in Bucharest, between January 2012 and December 2013.Of the 499 patients confirmed with HIV infection, 243 (48.70%) have initiated antiretroviral therapy. Comparative analysis shows that treated patients have a higher median age , with a significantly higher proportion of women  and a percentage of IV drug users significantly lower .Schemes with 2 NRTIs+PIs were preferred  followed by those with 2 NRTIs+NNRTIs , 2 NRTIs+IIs  and other schemes . The choice of the ARV regimen was not influenced by age, gender, route of transmission and RNA-HIV1 at baseline.M. tuberculosis most frequently received regimens with NNRTIs , IIs  and other schemes  than with PIs.The proportion of patients with CD4<350 cells/cmm at baseline was significantly higher in those treated with 2NRTIs+PIs, compared to those treated with 2NRTIs+NNRTIs . Patients co-infected with HIV/HCV and HIV/HBV were most commonly treated with IIs  and PIs  than with NNRTIs. Patients co-infected with There were no statistically significant differences in the CD4 cell count increase at 6 and 12 months of therapy, or in the percentage of patients with undetectable RNA-HIV1 after 6 months of treatment. The percentage of patients with VL undetectable at 6 months was 51.06% for those treated with NNRTIs, 34.29% for those treated with PIs, 30.7% for those treated with IIs and 20% for those treated with other regimens. These values reflect the important issues of adherence to ARV therapy seen in our patients.In our patients a CD4 cell count below 350 cells/cmm and co-infections influence the choice of the ARV regimen. Inadequate adherence is responsible for the small percentage of patients with VL undetectable after 6 months of treatment.


Maraviroc is an HIV entry inhibitor that alters the conformation of CCR5 and is poorly efficient in patients infected by viruses that use CXCR4 as an entry coreceptor. The goal of this study was to assess the capacity of ultra-deep pyrosequencing (UDPS) and different data analysis approaches to characterize HIV tropism at baseline and predict the therapeutic outcome on maraviroc treatment.113 patients with detectable HIV-1 RNA on HAART were treated with maraviroc. The virological response was assessed at months 1, 3 and 6. The sequence of the HIV V3 loop was determined at baseline and prediction of maraviroc response by different software and interpretation algorithms was analyzed.UDPS followed by analysis with the Pyrotrop software or geno2pheno algorithm provided better prediction of the response to maraviroc than Sanger sequencing. We also found that the H34Y/S substitution in the V3 loop was the strongest individual predictor of maraviroc response, stronger than substitutions at positions 11 or 25 classically used in interpretation algorithms.UDPS is a powerful tool that can be used with confidence to predict maraviroc response in HIV-1-infected patients. Improvement of the predictive value of interpretation algorithms is possible and our results suggest that adding the H34S/Y substitution would substantially improve the performance of the 11/25/charge rule. Human immunodeficiency virus (HIV) entry starts with the attachment of the viral envelope glycoprotein gp120 to the CD4-positive T-cell receptor and to either of two chemokine coreceptors: CCR5 or CXCR4 . The assHIV has a quasispecies distribution, characterized by the coexistence of closely related but distinct viral populations, including major and minor viral populations, in any given infected individual. Thus, pre-existing minor CXCR4 viral populations can be selected by maraviroc, expand and become predominant, ultimately leading to treatment failure, in spite of the exclusive detection of CCR5 viruses at baseline with inadequately sensitive methods. Previous studies have established that the presence of more than 2% of CXCR4 viral variants at baseline was predictive of maraviroc failure . HoweverNext-generation sequencing methods, such as ultra-deep pyrosequencing (UDPS), have been developed to increase sequencing capacity while generating clonal sequences. They have been shown to be as sensitive as phenotypic methods ,10. An iIn this work, we used UDPS and different analytical approaches using statistical learning to assess HIV tropism and the capacity of baseline genotypic assessment to predict the therapeutic outcome on maraviroc treatment.One hundred and thirteen patients with detectable HIV-1 subtype B RNA receiving highly active antiretroviral therapy (HAART) were enrolled in this study and treated with maraviroc in combination with optimized background therapy . The chaPatient’s sera were collected at baseline (D0) and month 1, 3 and 6  of maraviroc therapy. The patients were considered as responders to maraviroc if HIV RNA level  had decreased by at least 1.0 log relative to D0.The sequence of the HIV V3 loop was determined at D0 by means of UDPS in the 113 patients, as previously described . BrieflyMethod 1: consensus sequences were generated from UDPS data at D0 and used as a surrogate of population sequencing; they were interpreted by means of the geno2pheno[coreceptor] algorithm (Max-Planck-Institute), based on recommendations from the European Consensus Group on Clinical Management of HIV-1 Tropism Testing  , an adaptation of the geno2pheno algorithm to multiple sequence files, such as those obtained with UDPS  analysis  and 461,044 for PyroTrop analysis . Most of the removed sequences were rejected because the coverage of the V3 loop was partial . In addition, PyroTrop rejected poor quality sequences or sequences which acceptable quality on only a portion of the V3 loop.Concordance between the four methods is shown in The performance of the four methods in predicting the virological response to maraviroc was compared. As shown in The ability of each observed amino acid at each position in the V3 loop to predict maraviroc response was assessed by means of machine learning. Position 34, particularly the H34Y/S substitution, was the only one found to be significantly associated with the response to maraviroc by means of a decision tree approach  . SubstitIn this study, we assessed the performance of methods based on consensus (mimicking population sequencing) and UDPS sequence analysis, followed by geno2pheno or Pyrotrop data analysis, to predict the response to maraviroc in HIV-1 subtype B-infected patients under HAART therapy. Our results show that using UDPS instead of population sequencing improved specificity and the positive and negative predictive values, while the use of our in-house software Pyrotrop for UDPS sequence analysis further improved specificity and the positive predictive value as compared to geno2pheno. Overall, the rates of correct prediction of maraviroc response were significantly improved when using UDPS and analyzing the data with Pyrotrop, versus consensus sequence and the geno2pheno algorithm.It is currently possible to assess the distribution of HIV entry coreceptors and predict the response to maraviroc by means of sequencing methods, most often based on Sanger sequencing, now based on UDPS, using various software/algorithms. Recent studies have suggested that UDPS improved the prediction of maraviroc response when used instead of Sanger sequencing ,24. NeveIn addition, our analysis suggests that predictions based on the 11/25 charge rule can be improved by including other parameters in the algorithm. Indeed, we found that the presence of an H34S/Y substitution was significantly associated with CCR5 genotropism. This association was even stronger than the individual associations of substitutions at positions 11 or 25 and was not fully reflected by charge changes. Thus, H34S/Y deserves to be included into a new algorithm. It must be emphasized, however, that all patients in the study were infected with HIV-1 subtype B and maraviroc failure occurred in only 16% of them at M1. Thus, this approach will require prospective confirmation in other, larger cohorts of patients infected with different HIV subtypes and followed for more than 6 months on treatment.www.hiv.lanl.gov/content/sequence/HIV/mainpage.html). As shown in It is interesting to note that the H34S/Y substitution has been recently reported to play an important role in V3 affinity for both CCR5 and CXCR4, in particular when combined with a Q32K substitution . In our In conclusion, UDPS is a powerful tool that can be used with confidence to predict maraviroc response in HIV-1-infected patients. Different data analysis tools can be used and we validated here the performance of our in-house Pyrotrop software that may represent a performing alternative to geno2pheno. Improvement of the predictive value of the algorithm used is possible and our results suggest that adding the H34S/Y substitution would substantially improve the performance of the 11/25 charge rule with these new approaches.S1 FigOnly one patient experienced a viral rebound at M6.(DOCX)Click here for additional data file.


Interventions during primary HIV infection (PHI) can modify the clinical course during the chronic phase. The long-term effect of structured treatment interruptions (STI) followed by low doses of interleukin-2 (IL-2) in treated PHI patients is unknown.Twelve PHI patients with viral load (VL) <20 copies/mL, CD4 cells >500 cells/mm3, and CD4/CD8 ratio >1, on antiretroviral therapy (ART) initiated within the first 90 days of infection and continued for at least 12 months were included. They underwent four STI and were then allocated (week 0 of the study) to ART alone or ART plus low doses of IL-2. ART was stopped once VL <20 copies/mL . Primary endpoints were VL<3000 copies/mL and CD4 cells >500 cells/mm3 at 48 weeks; secondary endpoints were immune activation, inflammatory markers until 48 weeks and the time before resuming ART (CD4 <350 cells/mm3 or AIDS) after ‘final stop’, compared between groups.Ten out of 12 patients were males, median age was 35 years and the main risk was men-who-have-sex-with-men. Only one out of 12 patients (in the STI group) maintained VL<3000 copies/mL and CD4 cells >500 cells/mm3 without ART at 48 weeks. All other virological and immunological parameters were comparable between groups at week 0, 'final stop' and week 48. However, the proportion of CD8-CD38+ cells, tumor necrosis factor and srIL-2 were higher in the IL-2 group at 'final stop' and week 24. All these differences vanished during follow-up. At 5 years after the final stop 3 out of 6 patients in the IL-2 group and 6 out of 6 patients in the STI group have resumed ART (P = 0.19).STI and IL-2 failed to achieve virological control after ART interruption. STI were not deleterious in long-term follow-up, an important issue for eradication and functional cure trials.NCT02300623ClinicalTrials.gov  Potent combination antiretroviral treatment (ART) during primary HIV infection (PHI) results in strong viral suppression rates, rapid recovery of CD4 T cells, 2, and Soon after the introduction of potent ART, observational case reports identified patients receiving ART during PHI that controlled HIV replication after ART discontinuation and reported that this control was associated with strong HIV-specific cell-mediated immune responses, 15. TheIn our trial, we used IL-2, one of the first cytokines discovered to promote T-cell growth, as an aThese considerations provided the rationale for this pilot clinical trial to evaluate the impact of STI during PHI with or without the addition of low-dose recombinant IL-2 to boost HIV-1 specific immune responses and achieve a control of HIV viremia. Although STI in chronic HIV infection has shown to increase the risk of opportunistic infection and death , it can Enrolment started in March 2000 and finished in November 2001. Long-term follow-up for the last included patient finished in April 2012. All patients with PHI on stable effective ART for at least 12 months were invited to participate. The flow diagram of the study is shown in -A detectable plasma viral load (PVL) or p24 antigen detection coupled with a negative or indeterminate LIA assay (according to CDC criteria), or-A negative HIV-1 EIA in the preceding 90 days, or-A positive EIA and LIA assay with acute retroviral syndrome in the 90 days preceding the start of ART plus documented negative HIV-1 EIA within the previous year.Diagnosis of PHI was defined by:Date of infection was assumed to have occurred two weeks before the onset of acute symptoms. In asymptomatic patients this date was calculated as the midpoint between the last negative and first positive test.All patients started stavudine, lamivudine and non-boosted-indinavir at usual doses, according to recommendations at that time, within 90 days of HIV exposure, and had to show good virological and immunological responses, defined as undetectable PVL (<20 copies/mL in the last two controls), CD4 T cells higher than 500 cells/mm3 and a CD4/CD8 ratio >1 in the 8 months prior to enrolment.off-ART), separated by at least 16 weeks of treatment–or the time necessary to return to PVL <20 copies/mL—(on-ART). At the end of 4thoff-ART cycle (week 0), an interim evaluation was performed and the second phase initiated. During the second phase, the first 6 patients received ART until they reached PVL<20 copies/mL, discontinuing thereafter . The last 6 patients received ART and low doses of IL-2. ART was stopped after reaching PVL<20 copies/mL  and IL-2 after 6 months of treatment. IL-2 was prescribed at a dose of 750,000 UI/m2 daily and was self-administrated in all patients after training with a specialized nurse; administration was checked and verified during follow-up visits.The study design included two phases . The firth off-ART, week 0) and 24 and 48 weeks after the end of 4th off-ART. A long-term follow-up analysis was also performed up to 9 years from the final stop. It included survival rate, clinical events, time to resume ART, CD4-CD8-CD4/CD8 ratio. This was performed, as standard of care, during follow-up visits.In both groups, ART was resumed in patients whose CD4 cell count dropped below 350 cells/mm3 in two consecutive determinations or in patients who developed opportunistic infections. Evaluations were performed at interim analysis  was not performed.HIV serology was determined with a microparticulate enzyme immunoassay (MEIA) AxSYM system  and confirmed with LIA . PVL was determined using the Amplicor HIV-1 Monitor Ultra Sensitive Specimen Preparation Protocol Ultra Direct Assay  with a limit of detection of 20 copies/mL. Those samples below the detection limit were retested with a lower limit of detection of 5 HIV-1 RNA copies/mL as described. HIV-1-RGenotypic mutations of both reverse transcriptase (RT) and protease (PR) genes from viral RNA were tested using the ViroSeq HIV Genotyping System v.2  and ABI3100 sequencer. Samples for genotype were drawn at baseline and when patients presented PVL higher than 1,000 copies/mL after the final ART discontinuation. Resistance mutations were re-interpreted according the HIV2007 IAS consensus. Viral subtype was inferred comparing the “fasta sequence” in REGA HIV-1 Subtyping Tool—Version 2.0. The HLA6/mL in a serum-free medium X-VIVO 10. Cultures were plated in triplicate at 2 × 105/well in 7-day assays, in 96 round-bottomed microplates . Cells were cultured in the absence or presence of Pokeweed mitogen 10 μg/mL (Sigma) and 5 μg/mL of HIV-1 recombinant proteins gp160 and p24 . Incorporation of tritium-labeled thymidine was assessed for the last 18 hours of culture . Results were expressed as mean counts per minute (cpm). The stimulation index (SI) was calculated for each sample using the formula: SI = mean cpm for cells with stimulus/mean cpm for cells without stimulus. Positive antigen-specific responses were defined as >3,000 cpm and SI >3. For analytical purposes, results were expressed as ‘positive’ or ‘negative’ CD4 proliferative responses to HIV-1 P24 protein.Freshly isolated PBMCs were washed twice and resuspended at 2 × 10An ELISPOT assay (enzyme-linked immuno spot assay) was used to measure HIV epitope-specific CD8+ T-cell interferon-release from cryopreserved PBMC samples. A mean The primary endpoint was the proportion of patients who maintained a PVL <3,000 copies/mL and CD4 cells >500/μL at 48 weeks from the end of the 4th STI . An interim analysis was performed at week 0 and at week 24.Virological and immunological parameters during follow-up and changes from baseline were summarized by median and interquartile range (IQR) values. For the purpose of analysis, undetectable PVLs (<5 and <20 copies/mL) were considered equivalent to 5 and 20 copies/mL, respectively. The PVL values underwent log10 transformation before analysis.2 test and the Fischer exact test were used, as appropriate, to compare categorical variables. Continuous variables were compared between subgroups using the Mann-Whitney test. For long-term analysis and time free of ARV after final stop, Kaplan-Meier curves and the log-rank test were used. All p were considered significant at p<0.05. For missing values related to endpoints, the most recent available determination for this variable was considered and specifically mentioned in the results section. All statistical analyses were performed with Stata and SPSS software.The χThe study was approved by the Hospital Clínic Ethics Committee Board, and by the Spanish Regulatory Agency (‘Agencia Española del Medicamento’). All participants gave their written informed consent before enrolment. Registration of the trial in clinicalTrails.gov (NCT02300623) was retrospectively performed (registration was not compulsory at the time of the study conception).Fourteen patients were enrolled . Two patOf the 12 patients, 10 were male, median age was 35 years (IQR 28.5–2.54) and the main risk category was homosexual/bisexual intercourse. PHI was symptomatic in 9 of 12 patients, and the median interval between the estimated date of infection and ART initiation was 11 weeks (IQR 5.5–12), median VL was 103,500 copies/mL , median CD4 cell count 536.5 cells/mm3 (IRQ 391–612.5) and CD4/CD8 ratio 0.735 (IQR 0.425–0.970), all variables being comparable between the two groups. All patients were infected with HIV-1 B subtype virus, none had evidence of transmitted antiretroviral drug resistance and all patients were in Fiebig 4 phase at the time of ART initiation. None of the patients showed genetic variation in the CCR5 co-receptor gene, HBV or HCV co-infection.3, (IQR 848–1328) with a median increase of 487 cells/mm3 since PHI. All but one patient had tonsillar RNA-HIV-1 below 40 copies/mg (patient #17 had 104 copies/mg). Baseline data at inclusion are shown in The median time of treatment was 22.5 months (range 12–45), RNA-VIH-1 was below 5 copies/mL in 11/12 patients (patient #14 had 12 copies/mL), and the median CD4 count was 1,067 cells/mmOnly one out of 12 patients (in the STI group) maintained VL<3000 copies/mL and CD4 cells >500 cells/mm3 without ART at 48 weeks.nd, 19,200  copies/mL in 3rd and 20,000  in 4th (st off-ART cycle and 24.45 days in the 4th p = 0.09). After resuming ART, all patients showed rapid declines in PVL in each treatment phase. The number of patients fulfilling Responder criteria was 2 out of 12, 4 out of 12, 5 out of 12 and 4 out of 12 patients during 1st to 4th off-ART cycle respectively. After 24 weeks of follow-up, 2/6 patients in the IL-2 arm and 2/6 patients in the non-IL-2 arm maintained PVL <3,000 c/mL and after 48 weeks only one  out of 12 patients did. Between weeks 40 and 60, all patients presented VL around log4. VL dynamics after 4th STI are shown in Viral load rebounded during STI and at follow-up in all patients except for patient #2, who maintained viral load <5 copies/mL until 48 week after the ART interruption. The peak of PVL rebound was highest in the first STI, PVR rose to 150,500 copies/mL  and decreased to stable levels during the following off-ART cycles: 23,250  copies/mL in 2) in 4th . There wth STI , the end of ART , week 24 and week 48 is shown in th STI, the end of ART , week 24 and week 48. However, the proportion of CD8-CD38+ cells was significantly higher at the end of ART  for the IL-2 group. TNF and srIL-2 were also higher in the IL-2 group and the end of ART  and at 24 weeks of follow-up. These differences vanished at 48 weeks of follow-up. CD4 cell dynamics after 4th STI and until week 48 are shown in CD4 cells dropped in every STI but never below 500 T CD4 cells/μl. Immunological, virological and cytokine evolution at the end of 4None of the 12 patients presented specific CD4 responses before STI. This response increased to 5/6 patients at 3rd STI cycle for the STI group and to 4/6 patients at 2nd STI for the IL-2 group. However, they decreased progressively for both groups (2/6 for the STI group and 1/6 for the IL-2 group at week 0-end of 4th STI-), and, at week 48, all but one patient in the IL-2 group had lost these HIV-specific CD4 responses.Regarding HIV-specific CD8 responses, 1/12 presented specific CD8 responses before STIs (in the IL-2 group), which also increased in both groups during STI. The number of patients presenting HIV-specific CD8 responses was comparable in both groups in 1st, 2nd and 3rd STI . However, at week 0-end of 4th STI- these responses decreased to zero patients for the IL-2 group compared to 4 in the STI group (p = 0.014), and at 48 weeks of follow-up, they were absent in all 12 patients .st, 2nd, 3rd, 4th STI respectively).Considering the 12 patients together, there were no statistically significant differences in the VL doubling time among those patients eliciting a strong CD8 response compared to those eliciting a weak CD8 response .3 for the STI group and 325/mm3 for the IL-2 group (p = 0.855); CD4 percentage and CD4/CD8 ratios were also comparable for both groups. Immunological parameters remained comparable during long-term follow-up. Nine years after final stop the number of CD4 and CD8 cells and CD4/CD8 ratio were not different between groups: CD4 cells = 769.5/mm3 for the STI group and 844.5/mm3 for the IL-2 group (p = 1), CD4 percentage = 38.88 for the STI group and 38.7 for the IL-2 group (p = 0.394) and CD4/CD8 ratio = 1.20 for the STI group and 0.95 for the IL-2 group (p = 0.522). Time to resume ART after the final stop is shown in One patient in the IL-2 group died at 7 years and 10 months following the final stop due to metastatic colon cancer, aged 60. Overall 11/12 patients were alive at 9 years after the final stop. No other patient presented an AIDS-related opportunistic infection or neoplasm or other non-AIDS defining cancer. All patients in the STI group resumed ART at the end of the long-term follow-up and 5 out of 6 in the IL-2 group . Most of the patients in both groups resumed ART with a NNRTI (efavirenz)-based regimen. At the time of resuming ART, CD4 cells were comparable: 291/mmResponder, only one patient in the STI group had less than 3,000 copies of HIV-1 RNA, thus failing to show control of viral replication in both groups. We have seen no differences in the CD4 levels and viral load between groups. Thus, our 12 patients rebounded during the follow-up, with a relative decrease in the PVL with the following interruptions, but none of them evolved as a post-treatment controller, which has been calculated to occur in around 10% of the patients treated during PHI[The most recently published reports suggest that a favorable immunological outcome is obtained when ART is initiated very early in the course of primary HIV infection , 35, 36.uring PHI. HoweverThe IL-2 group showed higher immune activation and higher levels of inflammatory markers during the initial 24 weeks of follow-up. It is not clear whether this higher immune activation and inflammation impact the clinical outcome negatively in the long-term follow-up, but the only death, due to a non-AIDS defining cancer, was noted in the IL-2 group. Chronic inflammation and immune activation, among other factors, have been associated with non-AIDS defining cancers among HIV-infected patients. HoweverIt seems that the window to obtain an immunological advantage when treating PHI is very narrow, as suggested by a recent cohort study in whichAs far as we know, this study is the first to evaluate the effect of daily low-dose IL-2 in association with STI during PHI. It is also one of the few studies reporting such a long period of follow-up, giving a reliable view of the intervention effect. It has, however, several limitations. First, the small size of patients in both arms probably prevented any statistically significant difference being found in the time to resume ART. Secondly, the indication to resume ART was outside of the originally selected period of follow-up of the study, and it was driven by the clinical decision of the attending physician; however, CD4 cells at resuming were not statistically different among both groups, allowing us to compare them. Third, at the time of the design of this study, a VL lower than 3000 copies/mL and a CD4 cell count higher than 500 cells/mm3 was not considered an indication for ART. Nowadays most clinicians would treat these patients, since indications for ART have evolved and most guidelines recommend ART as of diagnosis, regardless of CD4 cell count or VL. Finally, due to the lack of clinical benefit in large clinical trials, the interest on IL-2 administration in HIV infection has significantly decreased.In conclusion, in the short term, STI proved able to boost specific immune responses, but these responses were lost 48 weeks after stopping ART. IL-2 failed to boost the specific anti-HIV T-cell immune responses. There was an increased immune activation and inflammation in the IL-2 group that also vanished during follow-up. In the long-term follow-up, there was a trend to delayed need to resume ART in the IL-2 arm, not reaching statistically significant differences. Although considering that the potential delay of ART in a lifetime treatment might not be very relevant, this small study suggests that immunological interventions during PHI may impact the long-term outcome. Probably these results cannot be translated into clinical practice, but they may encourage further research in this topic. Larger studies are needed to prove whether IL-2 or other immune modulating strategies may be useful in the setting of PHI.S1 CONSORT Checklist(DOC)Click here for additional data file.S1 Protocol(DOC)Click here for additional data file.S2 Protocol(DOC)Click here for additional data file.


Pill burden during antiretroviral treatment (ART) is associated with worse adherence and impaired virological suppression. We compared the effectiveness, tolerance, and persistence on treatment of single tablet regimens (STRs) with non-STR once-daily regimens in patients receiving first-line ART.Retrospective analysis of naïve HIV-1 infected patients prospectively enrolled in the French Dat’AIDS cohort and initiating first-line ART with STRs or once-daily non-STRs from 2004 to 2013. The primary outcome was time to treatment discontinuation defined by any change in the treatment regimen. STR and non-STR groups were compared controlling for baseline risk factors by inverse probability weighted treatment Cox analysis (IPWT) and propensity-score matching (PSM).Overall, 3212 patients  were included. Median time to treatment discontinuation was shorter in non-STR patients than in STR patients, both in the IPWT  and the PSM cohort . This difference disappeared when censoring ART modification for simplification, both in the IPWT  and the PSM cohort . A lower rate of virological failure was observed with STRs than with non-STRs in both cohorts . A lower rate of treatment modification for adverse event was observed with non-STRs in the IPWT cohort , but not in the PSM cohort .First-line therapy with STRs was associated with a longer time to treatment discontinuation than with non-STRs. However, when ART modification for simplification was not considered as a failure, STRs and non-STRs were similar. During the past decades, HIV combined antiretroviral therapy (ART) has drastically evolved with as a consequence a better control of HIV infection and a reduction of HIV-related morbidity and mortality. Adherence to treatment has been reported as a key factor for ART success and international guidelines underscore the importance of simplifying regimens to improve adherence . TreatmeSince comparisons between STRs and non-STR once-daily regimens are sparse, we compared the effectiveness, tolerance, and persistence on treatment of STRs with non-STR regimens in patients receiving first-line ART in a French large cohort of HIV-infected patients.All adult naive HIV-1 infected patients prospectively enrolled in the French Dat’AIDS cohort and receiving either an STR or non-STR once-daily first-line ART from 2004 to 2013 with HIV-RNA data >6 months were retrospectively analyzed. The Dat’AIDS cohort represents a collaboration between about 30 major French HIV treatment centers throughout the country  and inclThe primary outcome was time to treatment discontinuation defined as the delay between starting and stopping the first line antiretroviral therapy. Reasons for stopping therapy which were prospectively collected included simplification, clinical or biological toxicity, virological failure and other reasons such as pregnancy, pharmacological interactions, or patient’s willingness.Virological failure definition was similar as that used in the ACTG 5202 study  time before the primary outcome was 1.18 years [0.44–2.26], corresponding to 1.15 years [0.41–2.26] in the non-STR group and 1.34 years [0.59–2.28] in the STR group. During follow-up, 58% of patients receiving STRs had no treatment modification compared with 32% of patients receiving non-STR regimens , and in the matched cohort . This difference was no longer statistically significant in the matched cohort  .A total of 499 patients receiving an STR with 2 NRTI + 1 NNRTI (100%) were compared with 872 non-STR patients receiving similar drug components (32.1%). Results are presented in Based on a cohort of 3212 naïve patients, our study compared the effectiveness and tolerance of STR and non-STR once-daily regimens in real life conditions. When considering treatment failure as a virological failure or any treatment modification over time, a benefit was observed for STRs, which induced less ART modifications than non-STR regimens. However, our results show that this effect is mainly due to treatment simplifications that occurred in almost 28% of patients in the non-STR group . AnotherWhen focusing on virological efficacy only, a benefit of STRs is observed whereas non-STR once-daily regimens seem to be associated with a better tolerance. It should be noticed that the rate of virological failure in both groups of patients is very low (<5% in the matched cohort). Therefore, the benefit of STRs on virological efficacy, if any, may only have a limited clinical impact. Since the difference in tolerance observed on the whole cohort disappears when focusing on the matched cohort , it is rThe Dat’AIDS cohort is a French large multicenter prospective cohort based on data from about 30 HIV centers scattered throughout the country  and inclNowadays, most international guidelines recommend decreasing pill burden to prevent non-adherence to treatment. Some authors have shown that besides a 20% rate of complete non-adherence, 3–13% of patients reported a selective non-adherence  hereby stressing the potential benefit of STRs . Lower pIn conclusion, the median time to treatment discontinuation was shorter in non-STR patients than in STR patients but this difference was driven by ART modification for simplification while a STR cannot yet be simplified further. Virological efficacy seems slightly better with STRs than with non-STR regimens. STRs were prescribed to patients with a higher chance of favorable outcomes than patients receiving non-STR as first-line ART. After accounting for baseline differences, the superiority of STRs over non-STR regimens was mainly driven by treatment simplification, suggesting a preference for STR rather than indicating failing therapy . STRs weS1 Table(PDF)Click here for additional data file.S2 Table“Overall effectiveness” indicates that failure is defined as treatment discontinuation, occurrence of adverse event, or any cause of treatment modification. “Overall effectiveness (simplification censored)” indicates that failure is defined as treatment discontinuation, occurrence of adverse event, or any cause of treatment modification except treatment simplification (censored). “Virological efficacy” indicates that virological failure is defined as viral load (VL) > 1000 copies/mL between W16 and W24 or VL > 200 copies/mL after W24. “Tolerance” indicates that failure is defined as the occurrence of an adverse event anytime during therapy. A Hazard Ratio (HR) <1 is in favor of STR.(PDF)Click here for additional data file.


Few studies have evaluated the impact of pre-treatment drug resistance (PDR) on response to combination antiretroviral treatment (cART) in children. The objective of this joint EuroCoord-CHAIN-EPPICC/PENTA project was to assess the prevalence of PDR mutations and their association with virological outcome in the first year of cART in children.HIV-infected children <18 years initiating cART between 1998 and 2008 were included if having at least one genotypic resistance test prior to cART initiation. We used the World Health Organization 2009 resistance mutation list and Stanford algorithm to infer resistance to prescribed drugs. Time to virological failure (VF) was defined as the first of two consecutive HIV-RNA > 500 copies/mL after 6 months cART and was assessed by Cox proportional hazards models. All models were adjusted for baseline demographic, clinical, immunology and virology characteristics and calendar period of cART start and initial cART regimen.3 (98–639), and HIV-RNA 5.2 log10copies/mL (4.7–5.7). Of 37 children , 5.5–10.6) harboring a virus with ≥1 PDR mutations, 30 children had a virus resistant to ≥1 of the prescribed drugs. Overall, the cumulative Kaplan-Meier estimate for virological failure was 19.8 % . Cumulative risk for VF tended to be higher among children harboring a virus with PDR and resistant to ≥1 drug prescribed than among those receiving fully active cART: 32.1 % (17.2–54.8) versus 19.4 % (15.9–23.6) (P = 0.095). In multivariable analysis, age was associated with a higher risk of VF with a 12 % reduced risk per additional year .Of 476 children, 88 % were vertically infected. At cART initiation, median (interquartile range) age was 6.6 years (2.1–10.1), CD4 cell count 297 cells/mmPDR was not significantly associated with a higher risk of VF in children in the first year of cART. The risk of VF decreased by 12 % per additional year at treatment initiation which may be due to fading of PDR mutations over time. Lack of appropriate formulations, in particular for the younger age group, may be an important determinant of virological failure.The online version of this article (doi:10.1186/s12879-016-1968-2) contains supplementary material, which is available to authorized users. Pre-treatment drug resistance (PDR) mutations have been demonstrated to be a major reason for virological failure (VF) after starting combination antiretroviral treatment (cART) in HIV-infected adults –6. It isIn vertically infected children, exposure to single-dose nevirapine given for prevention of mother to child transmission (PMTCT) is associated with reduced efficacy of this drug when used for early treatment , and theWe assessed the prevalence of PDR mutations and their association with virological outcome in the first year of cART in children within a large collaboration of HIV observational cohort studies (EuroCoord-CHAIN-PENTA-EPPICC) in Europe and Thailand.This study was conducted under the joint efforts of the Collaborative HIV and Anti-HIV Drug Resistance Network (CHAIN) and the EuroCoord network .Cohorts participating through the EuroCoord network submitted defined dataset  events and genotypic resistance test) to their network-specific Coordination Centre, using the HIV Cohort Data Exchange Protocol .Ethics approval was granted by the ethic committees of each of the participating cohorts according to local regulations. Written informed consent from participants’parents or legal guardians was obtained by the participating cohorts according to national legal and ethics requirements.3) as well as time to start antiretroviral prophylaxis. In Thailand national antiretroviral prophylaxis regimens have evolved from ZDV monotherapy for mothers and infants in 2000 to ZDV monotherapy plus single dose nevirapine (SD-NVP) in 2004 then to NVP-based cART for women with CD4 < 200 cells/mm3 or ZDV/SD-NVP for women with CD4 > 200 cells/mm3 with a 7-day post-partum tail regimen of ZDV/lamivudine to prevent NVP resistance in SD-NVP exposed women [Maternal and infant prophylaxis data were not available for this analysis. Over the period of the study, no specific PMTCT protocol was recommended in Europe however some countries had their own PMTCT guidelines –31. Praced women .HIV-infected children aged <18 years were included in this study if they started cART between January 1,1998, and December 31, 2008 and if they had ≥1 sample for a genotypic test taken before the initiation of cART, whereby cART was defined as receiving at least three antiretroviral drugs. Genotypic resistance tests could have been performed retrospectively at each virology lab, i.e. test results may not necessarily have been used to guide first-line treatment. HIV genotyping assays were based on population sequencing techniques. We obtained nucleotide sequences for 93 % and amino-acid sequences for 7 % of the children. Alignment of nucleotide sequences was done centrally at the Copenhagen regional coordinating centre. If more than one genotypic test result was available mutations were cumulated.PDR mutations and resistance were defined in two steps. First, the World Health Organization 2009 list of NRTI, NNRTI and PI mutations for the surveillance of transmitted drug resistant HIV strains  was usedSecond, for children harbouring a virus with ≥1 PDR mutations, the Stanford algorithm version 6.0.5  was usedVirological failure was defined as the first of two consecutive viral loads >500 copies/mL after 6 months of cART (window 6–16 months), considering the date of first viral load >500 copies/mL as failure date. Children were censored if they died, stopped cART or were lost-to-follow-up. The time to virological failure was described by Kaplan-Meier curves and analysed by Cox proportional Hazards models. Baseline is defined as date of cART initiation.10 transformed) and CD4 count, subtype , region of origin , year of treatment start , previous AIDS diagnosis  and HIV transmission risk group  and initial cART regimen . We conducted a stratified analysis according to initial cART regimen . Proportionality assumptions were checked graphically by depicting the  according to log and by testing an interaction term between the covariables and the survival time. Analyses were performed using SAS 9.2 and 9.3 . P < 0.05 was considered significant.All multivariable models were adjusted for the following potential confounders chosen a priori: sex, age, pre-treatment viral load  of 1.95 if risk groups were well balanced (i.e. 50 % of patients with high risk and 50 % with low risk). The HR limit would be 2.17, 3.05 and 4.64 if risk groups were not balanced whatever the direction  .3 , and median HIV RNA load 5.2 log10 copies/mL   were female and a large majority was infected through vertical transmission of HIV (Table Two hundred thirty two (48.7 %) children initiated cART with 2 nucleoside reverse transcriptase inhibitors (NRTIs) and 1 nonnucleoside reverse transcriptase inhibitor (NNRTI) and 41 (8.6 %) with 3 NRTIs and 1 NNRTI, 139 (29.2 %) with 2 or more NRTIs and 1 unboosted protease inhibitor (PI) (mostly nelfinavir), 43 (9 %) with 2 or more NRTIs and 1 boosted PI, and 21 (4.8 %) with other combinations of three or more drugs (Table P = 0.043).At least one PDR mutation was identified in 37 children  of whom 76 % harbored a virus with NRTI, 46 % with NNRTI and 8 % with PI resistance mutations and 30 % had PDR mutations to 2 ARV classes (Table P = 0.93). Furthermore, baseline characteristics were not different between children with and without PDR mutations   corresponding to 449 person years (PY) of follow-up; children with fully active treatment were followed-up over a median of 12  months (424 PY of follow-up), and children with PDR and receiving a treatment to which the virus was resistant were followed over a median of 11  months (26 PY of follow-up). Median number of viral load measurements after baseline was 4  and there was no difference in median viral load measurements between the group no PDR/PDR susceptible and the group PDR and resistant with 4  and 4  measurements, respectively. Virological failure occurred in 83 of 446 children who started with fully active cART (no PDR or having “PDR and fully-active cART”) and in 9 of 30 children of the “PDR and resistant” group. The overall estimated cumulative Kaplan-Meier risk of virological failure at 12 months of cART was 19.8 % . Children in the ‘PDR and resistant’ group tended to have higher cumulative risk of virological failure than those with no PDR or having ‘PDR and fully-active cART’, at 32.1 % (17.2–54.8) versus 19.4 % (15.9–23.6) (P = 0.101) and also after adjustment for covariables .In univariable analysis, younger age, year at cART initiation (1998–1999 vs 2007–2008), initial cART regimen (Unboosted PI plus ≥ 2NRTIs vs NNRTI plus ≥ 2NRTIs) and region of origin (African vs Europe) were significantly associated with VF Table . PDR andP < 0.001). The association between initial cART regimen and virological failure persisted in the multivariable model. In stratified analysis according to the initial treatment regimen, the association between PDR and resistance to ≥ 1 prescribed antiretroviral drugs was not significantly associated with a higher risk of virological failure neither in the > =2NRTI + 1NNRTI stratum nor in > =2NRTIs + an unboosted PIs stratum  and was similar to that reported in a large European multicohort study, 9.5 %  of 10,056 patients, mostly adults , 17–25.P = 0.095) but no direct association between PDR mutations and VF was found, in contrast to what was reported in the large European multicohort study [Cumulative incidence of virological failure tended to be higher among children starting cART with PDR and resistance ≥1 drug prescribed than among those starting with a fully active regimen  were more likely to receive boosted PI regimen.Our findings of higher risk of VF in younger children support the 2013 WHO recommendation to treat all children <3 years of age with boosted-PI . In addiOur study has some limitations. It was an observational study and some resistance results were obtained retrospectively. However, all children starting cART with a sample for HIV genotypic resistance testing were included in the analysis and testing was performed with no knowledge of the outcome. Association of outcome with age may be different at the era of WHO PMTCT option B+. Indeed, in that context more pregnant women receive NNRTI-based cART and children who may become infected with resistant virus selected during treatment failure may have NNRTI resistance mutations that can persist longer than those selected by single dose-nevirapine. Another limitation is that we were not able to assess the effect of the pretreatment CD4 percentage since this was measured in only 49 % of children and to address adherence and specific HIV subtypes effect. Lastly, despite the large study population it was not possible to specifically analyze more substrata as the power was already limited for the overall question of this analysis.Our study shows that the risk of VF decreased with age at treatment initiation. We hypothesize that this finding might be due to fading of PDR mutations over time although the direct association between those resistance mutations and VF did not reach statistical significance potentially due to lack of power. Furthermore, misclassification due to the relatively low sensitivity of population sequencing in detecting mutations in viral subpopulations long after initial infection or exposure to ARVs for the prevention of mother to child transmission shortly prior to infection could have occurred diluting the effect. Also, lack of appropriate formulations, in particular for the younger age group, which may possibly have resulted in poorer adherence, might be an important determinant of virological failure.


Kenya is one of the first African countries to scale up a national HIV viral load monitoring program. We sought to assess program scale up using the national database and identify areas for systems strengthening.Data from January 2012 to March 2016 were extracted from Kenya’s national viral load database. Characteristics of 1,108,356 tests were assessed over time, including reason for testing, turnaround times, test results, treatment regimens, and socio-demographic information.The number of facilities offering viral load testing increased to ~2,000 with >40,000 tests being conducted per month by 2016. By March 2016, most (84.2%) tests were conducted for routine monitoring purposes and the turnaround time from facility-level sample collection to result dispatch from the lab was 21(24) [median (IQR)] days. Although the proportions of repeat viral load tests increased over time, the volumes were lower than expected. Elevated viral load was much more common in pediatric and adolescent patients  than in adults .Coverage of viral load testing dramatically increased in Kenya to >50% of patients on antiretroviral therapy (ART) by early 2016 and represents a relatively efficient laboratory system. However, strengthening of patient tracking mechanisms and viral load result utilization may be necessary to further improve the system. Additional focus is needed on paediatric/adolescent patients to improve viral suppression in these groups. Kenya’s national viral load database has demonstrated its usefulness in assessing laboratory programs, tracking trends in patient characteristics, monitoring scale-up of new policies and programs, and identifying problem areas for further investigation. National HIV programs in resource-limited settings historically have used CD4 cell count, a marker of immune status, to monitor patient response to HIV antiretroviral therapy (ART). However, viral load (VL) measurement of plasma HIV concentration is a more direct measure of response to treatment. VL testing, which has been widely available in high-income countries for many years, is used to assess viral response to therapy and identify patients who may be failing treatment. The benefit of VL is that it is able to detect treatment failure earlier and more accurately than CD4 testing, enabling healthcare workers to give patients the care they require through more extensive adherence counselling or switching to second line drugs. Yet VL testing has traditionally been relatively expensive and required intensive infrastructure and human resources, creating barriers to scale-up.Despite these challenges and concerns about feasibility in resource-limited settings, a nationThe program was designed to include an electronic data management system for patient monitoring, including patient demographic details and regimen information. Facility-level data feed into a national laboratory information system (LIS) database managed by the National AIDS & STI Control Programme (NASCOP) and are available publically via a national dashboard, an interactive computer interface tool that graphically presents program indicators.  LaboratoThe aim of this analysis was to track the scale-up of Kenya’s VL program from 2012 to 2016 and identify areas for further investigation and systems strengthening using data captured in the national database.m2000 systems and Roche Cobas Ampliprep/Cobas TaqMan, as described previously 21 (24) days by 2016. The primary source of delays appeared to be the time between lab receipt of the VL sample and lab processing of the sample, followed by transport time to the lab. The proportion of routine tests increased over time, as did the proportion of tests that appeared to be subsequent tests from the same patients. The proportion of tests that reported elevated VL decreased by 2015–2016; in these years, among patients receiving routine VL after at least 6 months on treatment, elevated VL was 16.4%. Elevated VL was more common among children and adolescents, as well as males. Samples from Nairobi and Central Kenya were slightly more likely to be suppressed than samples from elsewhere. Missing data and inconsistencies in the database were observed, although some of these issues appeared to be decreasing over time. Follow-up tests appeared to be uncommon among patients with a first elevated test; virologic failure was very high in those who had a second test.Kenya’s program has demonstrated an impressive scale-up of testing volumes and the database has demonstrated its utility in tracking growth and monitoring problem areas. As the program grew through 2014, VL testing turnaround times increased greatly, as sample transportation systems were streamlined and laboratories adapted to respond to increased demand. Turnaround times from sample collection to laboratory result dispatch decreased to approximately 3 weeks (not including time to results delivery), most of which was laboratory processing time. Given the volume of samples and the size of the country, these processing times may be considered reasonable, but it may be possible to decrease turnaround times further still in subsequent years, such as through review of laboratory workflow and identification of inefficiencies. Introduction of point-of-care VL testing, which allows VL tests to be processed at the facility within hours, is likely to dramatically decrease turnaround times and may reduce the burden on centralized laboratories for VL testing, further improving systems efficiencies.In this national-level analysis, viral suppression among routine testers in 2015–2016 was similar to what has been described in other studies, 12 but In this database, elevated VL was much more common in children and adolescents than in adults, consistent with previous studies in Kenya and elsewhere in sub-Saharan Africa.–17 ChildThere were modest differences in the proportion of males and females with viral suppression. Not surprisingly, vastly more women received tests than men, likely explained by greater care-seeking behaviour in women as well There were also modest regional differences in suppression, with a higher proportion of suppressed patients in Nairobi and Central Kenya compared to Eastern and Western Kenya. This may be due to geographic differences in access to services and/or patient characteristics.As registry-based data, our findings are limited by several factors including incomplete or inaccurate entries. Ability to confirm tests as coming from the same patients and assess repeated testing was limited; therefore, analyses were primarily cross-sectional and included some repeat tests from the same individuals. Due to the limited ability to link patients in the database, the longitudinal analysis was of limited scope and must be interpreted cautiously. There was no information on adherence or indication for treatment  and the database was not directly linked to clinical or patient care data, so we could not distinguish the cause of failure (nonadherence vs. resistance) and did not assess treatment regimens in detail. It is not possible to discern from these data the extent to which the changes in viral suppression over time are due changes in the populations being tested (targeted vs. routine) vs. changes in ART formulations. Due to these limitations and the observational nature of these data, causal conclusions cannot be drawn and thus the analysis was primarily descriptive. Finally, the database does not capture private sector patients, although only a very small percentage of HIV patients are managed in this sector.While Kenya’s VL program has grown substantially, there is room for continued growth and improvement of the quality of patient care. As countries move towards treating all patients with HIV, regardless of CD4 count, further expansion of VL testing volumes and capacity will be needed. As programs scale up, it will be crucial to put strong patient tracking and failure management programs into place to ensure that VL tests are used effectively and patients are placed on the best possible treatment. Neighbouring countries such as Malawi and Uganda are also building national databases to track their programs, which are already demonstrating their utility. Building


Background: Myanmar has a high burden of Human Immunodeficiency Virus (HIV) and second-line antiretroviral treatment (ART) has been available since 2008 in the public health sector. However, there have been no published data about the outcomes of such patients until now.Objective: To assess the treatment and programmatic outcomes and factors associated with unfavorable outcomes  among people living with HIV (aged ≥ 10 years) receiving protease inhibitor-based second-line ART under the Integrated HIV Care Program in Myanmar between October 2008 and June 2015.Design: Retrospective cohort study using routinely collected program data.Results: Of 824 adults and adolescents on second-line ART, 52 patients received viral load testing and 19 patients were diagnosed with virological failure. However, their treatment was not modified. At the end of a total follow-up duration of 7 years, 88 (11%) patients died, 35 (4%) were lost to follow-up, 21 (2%) were transferred out to other health facilities and 680 (83%) were still under care. The incidence rate of unfavorable outcomes was 7.9 patients per 100 person years follow-up. Patients with a history of injecting drug use, with a history of lost to follow-up, with a higher baseline viral load and who had received didanosine and abacavir had a higher risk of unfavorable outcomes. Patients with higher baseline C4 counts, those having taken first-line ART at a private clinic, receiving ART at decentralized sites and taking zidovudine and lamivudine had a lower risk of unfavorable outcomes.Conclusions: Long-term outcomes of patients on second-line ART were relatively good in this cohort. Virological failure was relatively low, possibly because of lack of viral load testing. No patient who failed on second-line ART was switched to third-line treatment. The National HIV/AIDS Program should consider making routine viral load monitoring and third-line ART drugs available after a careful cost–benefit analysis. Globally, the number of HIV-positive patients accessing antiretroviral therapy (ART) has doubled since 2010 and 17 million people were on ART at the end of 2015  9 years) switched to second-line ART due to failure on first-line ART. Baseline and follow-up characteristics of this second-line cohort are shown in Baseline CD4 counts were available for 823 (99%) patients and baseline HIV viral load tests were available for 560 (68%) patients. At the start of second-line treatment, patients had a median CD4 count of 115 (IQR 62–213) cells/μl and HIV-1 RNA of 4.8 (IQR 4.2–5.3) log10 copies/ml. Most of the patients (77%) received tenofovir (TDF) as part of their second-line ART regimen. All second-line regimens were based on LPV/r. Two patients were prescribed ritonavir-boosted raltegravir (RAL/r) and etravirine (ETV) combined with LPV/r as part of their second-line regimen. Median follow-up duration on second-line ART was 24 (IQR 12–34) months. The maximum duration of second-line treatment of the patients who were still under care without virological failure was 7 years.Of 824 patients, 52 (6%) patients received viral load testing after initiation of second-line treatment during the study period and 19 (37% of those tested) were diagnosed with virological failure according to WHO criteria. None of these 19 patients switched to third-line ART during the study period. The incidence rate of virological failure after starting second-line ART was 1 patient per 100 person years follow-up (PYFU) (95% CI: 0.7–1.7). The cumulative probability of virological failure at year 7 was 6% (95% CI: 3–9%) .Figure 1Among 824 patients on second-line ART, 88 patients (11%) died, 35 (4%) patients were lost to follow-up, 21 (2%) were transferred out to other health facilities and 680 (83%) were retained under care at the end of the study period. Of 88 deaths, 48 (55%) patients died within 1 year of starting second-line ART. Of 35 patients lost to follow-up, 17 (48%) were also lost to follow-up within 1 year. Of 19 patients who experienced virological failure, 12 patients were still under care, 1 patient was transferred out, 5 patients died and 1 patient was lost to follow-up at the end of the study period. The incidence rate of death and lost to follow-up combined was 7 patients per 100 PYFU (95% CI: 6–8) and the cumulative probability of death and lost to follow-up at year 7 was 26% (95% CI: 20–33) .Figure 2Overall, 136 (17%) patients’ outcomes were unfavorable  at the end of the study period. The probability of an unfavorable outcome at year 1 was 8% (95% C.I: 7–11), at year 2 it was 15% (95% CI: 13–18) and at year 7 it was 30% (95% CI: 25–37%) ; the incFactors associated with unfavorable outcomes are shown in This study is the first to report on the outcomes of a second-line ART cohort of patients being managed in a public health setting in Myanmar. Treatment failure was suspected based on clinical and immunological criteria and only these patients received viral load testing. The WHO recommends systematic viral load testing for all patients  . HoweverThe failure rate and overall outcomes of this patient cohort are better than in other studies from similar resource-limited settings ,5,7,8,13Adolescents only accounted for 5% of this second-line ART cohort although the evidence suggests that the adolescent age group is more likely to fail on first-line ART due to complex psychosocial, behavioral and clinical reasons –17. MoreMyanmar has a concentrated HIV epidemic. The HIV burden was very high in key populations with HIV prevalence rates ranging from 6% to 23% while HIV prevalence in the general population was 0.5% in 2015 . In addiOne in five patients in this cohort experienced delayed switching to second-line treatment. This delay in treatment is not uncommon in many resource-limited countries ,24. TreaAlthough more than half of this cohort was on ART for more than 2 years, only 6% of patients were tested for HIV viral load after 6 months of second-line therapy. This can explain the lower rates of virological failure and may indicate the under-diagnosis of second-line treatment failure. In addition, the evidence suggests that most of the second-line treatment failure cases are not actually resistant to second-line therapy in the initial years of treatment and they have high viral loads due to problems with drug adherence .Among the 19 patients who met the virological failure criteria, none of them were switched to a third-line regimen. As there is no information on their patterns of HIV drug resistance, it is difficult to know whether their therapy was not modified because it was deemed clinically unnecessary to switch or because the third-line ART regimen was not available in the program. This underscores the need for HIV drug resistance testing in Myanmar for those patients diagnosed with second-line ART failure and the need for third-line ART for those with confirmed resistance to second-line ART to prevent further transmission of resistant HIV.Risk factors for unfavorable outcomes in our own study and in other studies have consistently included high viral load and low CD4 counts at baseline, having a history of being lost to follow-up and experiencing delayed switching to second-line ART after first-line failure ,8,13,25.In this cohort, about one third of patients receiving second-line ART were at a decentralized site and they had better outcomes than people in the ART Center. The probable reason is that these patients had good ART outcomes in general because only those who are clinically stable are referred to a decentralized site. This highlights the success of the decentralization strategy by the national program to bring the treatment including second-line treatment nearer to the patients’ residence for easy access.We also noted that patients who had a history of receiving treatment at private clinics before coming to IHC had a better outcome. There is no study comparing outcomes between the public and private sectors. However, we assume that the patients who seek care from the private sector are more likely to be well-off economically and hence might have maintained better adherence to the treatment.This study had a large sample size with a long duration of follow-up of patients on second-line ART in comparison with other studies. The study was based on routinely collected public health program data which can reflect the reality of second-line ART management in a resource-limited setting. We used standard virological failure and other programmatic outcomes definitions in accordance with WHO guidelines, enabling comparisons with the findings from other studies. We had robust and reliable data with dates of outcomes for each patient, thus enabling time-to-event analysis. We also reported this study according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines .There is risk of selection bias as we excluded patients who were on a LPV/r-based regimen with no documentation of the reason for switching from first-line ART to a LPV/r-based regimen and who were already on a LPV/r-based regimen when they registered at IHC. In addition, there is no information on clinical and immunological failure diagnosed by the clinician in patients on second-line ART who did not receive viral load testing. Hence, there may be an underestimation of the treatment failure rate in this study. A few patients had had HIV drug resistance testing done with out-of-pocket expenditure but the results were not documented in this database. We do not have data on cause of death and cannot therefore determine if the death was HIV-related or not.Long-term outcomes of patients on second-line ART were relatively good in this cohort. Most of the deaths and loss to follow-up occurred in the first year of treatment. A low percentage was found to have virological failure because only a very small percentage of patients was tested for viral load. Thus, routine viral load monitoring is recommended for the cohort of second-line ART patients. Finally, the National HIV/AIDS Program should consider making available third-line ART drugs for such patients after a careful cost–benefit analysis.


Despite the growing number of people on antiretroviral therapy (ART), there is limited information about virological non-suppression and its determinants among HIV-positive (HIV+) individuals enrolled in HIV care in many resource-limited settings. We estimated the proportion of virologically non-suppressed patients, and identified the factors associated with virological non-suppression.We conducted a descriptive cross-sectional study using routinely collected program data from viral load (VL) samples collected across the country for testing at the Central Public Health Laboratories (CPHL) in Uganda. Data were generated between August 2014 and July 2015. We extracted data on socio-demographic, clinical and VL testing results. We defined virological non-suppression as having ≥1000 copies of viral RNA/ml of blood for plasma or ≥5000 copies of viral RNA/ml of blood for dry blood spots. We used logistic regression to identify factors associated with virological non-suppression.adj = 6.3, 95%CI = 5.5–7.2) when compared with suspected treatment failures . The odds of virological non-suppression decreased with increasing age, with children aged 0–4 years  and young adolescents  registering the highest odds. Poor adherence  and having active TB  increased the odds of virological non-suppression. However, being on second/third line regimens  protected patients against virological non-suppression.The study was composed of 100,678 patients; of these, 94,766(94%) were for routine monitoring, 3492(4%) were suspected treatment failures while 1436(1%) were repeat testers after suspected failure. The overall proportion of non-suppression was 11%. Patients on routine monitoring registered the lowest (10%) proportion of non-suppressed patients. Virological non-suppression was higher among suspected treatment failures (29%) and repeat testers after suspected failure (50%). Repeat testers after suspected failure were six times more likely to have virological non-suppression (ORYoung age, poor adherence and having active TB increased the odds of virological non-suppression while second/third line ART regimens were protective against non-suppression. We recommend close follow up and intensified targeted adherence support for repeat testers after suspected failure, children and adolescents. The number of people accessing antiretroviral therapy (ART) has gradually increased in the recent years . With thThe Ugandan guidelines recommend that viral load testing should be done 6 months after initiating ART and thereafter annually for people who have achieved viral suppression. However, people with detectable viral loads undergo targeted intensified adherence support for 6 months followed by confirmatory viral load testing in order to differentiate poor adherence from treatment failure. Those with treatment failure as defined by two detectable viral load measurements above the threshold are switched to second-line ART .Previous studies have highlighted a number of factors that may be associated with virological suppression. Patients with WHO clinical staging 4 are more likely to be non-suppressed while those whose health status is evaluated by physicians on each clinic visit are less likely to experience virological failure . ChildreIn 2014 the Joint United Nations Programme on HIV/AIDS (UNAIDS) set new targets towards elimination of HIV, including diagnosis of 90% of HIV infected individuals, access to treatment for 90% of identified HIV infected persons, and 90% viral suppression among those initiated on treatment . These tDespite the increasing number of HIV+ patients accessing ART , there iThis was a descriptive cross-sectional study using a large national dataset of routinely collected program data  that were submitted to the Central Public Health Laboratories (CPHL) from all health facilities in Uganda between August 2014 and July 2015.The study was conducted at CPHL where the centralized VL testing is done in Uganda. Centralized monitoring of response to ART using viral load as a gold standard started in August 2014. The samples come from all over the country from both private and government health facilities offering HIV ART services. Uganda is located within the East African region with a population of 34.9 million  and a geWe used VL testing data for samples corresponding to HIV positive patients who had been on ART for at least 6 months. Data generated from the start of VL testing at CPHL in August 2014 to July 2015 were considered for the study.The primary outcome was virological non-suppression, defined as having ≥1000 copies of viral RNA/ml of blood for plasma or ≥5000 copies of viral RNA/ml of blood for dry blood spots . We abstWe analyzed the entire study data set to estimate the proportion of patients with virological non-suppression, and to identify factors associated with virological non-suppression. In-addition, we conducted sub-group analyses in line with the 3 major reasons for viral load testing in Uganda . We used univariate analysis to establish the socio-demographic and clinical characteristics of the study population, the overall and group specific proportions of patients with virological non-suppression. Virological non-suppression proportion was defined as the percentage of the number of total not suppressed among the total number tested. The proportion with viorological non-suppression were further evaluated by age group, gender, duration on treatment, reported adherence levels, pregnancy status, breast feeding status, having active TB, treatment line, reason for VL test  and health facility level.We created the outcome variable of suppression status by categorizing the viral load results into two groups. All results <1000 or 5000 copies/ml of blood for plasma and DBS respectively were categorized as suppressed while ≥1000 or 5000 copies/ml of blood for plasma and DBS respectively were categorized as not suppressed. At the exploratory analysis stage, we realized that the percentage of variables with missing values was <10% of all the variables in the data set. Missing values were dropped automatically from each variable and analysis was conducted based on the totals with complete records.p-value <0.05 (two-sided). Data were entered into Excel 2007 and analyzed using Epi-info version 7.We used bivariate analysis to determine strengths of association between the independent variables and the outcome variable . Crude odds ratios (OR) and 95% confidence intervals were calculated. We used multivariate logistic regression to identify factors independently associated with virological non- suppression. Adjusted odds ratios (OR) and 95% confidence intervals were calculated. We considered the reason for viral load testing  in Uganda as the main exposure variable of interest. We adjusted for age, sex, ARV adherence, treatment line , identification for treatment initiation at baseline , having active TB, duration on treatment, and health facility level. We dropped the option “other” under the option for indication for treatment initiation at baseline when conducting bivariate and multivariate analysis. This was due to the fact that it was not clear which categories of patients were categorized as “other”. In the sub-analyses, age group was considered to be the main exposure variable of interest. In addition, factors were entered into logistic regression models based on biological plausibility, previous literature, and statistical significance in bivariate analysis. We tested for interaction and did not find any statistically significant interaction terms to report on. Pregnant and breast feeding status were excluded from model building because they only apply to females. Statistical significance was considered at We used program data collected for routine patient care at all health facilities in Uganda and submitted to the Central Public Health Laboratories (CPHL) which is mandated to conduct centralized viral load testing in Uganda. All data did not carry personal identifiers. The data were not accessible by any other third parties other than the study team. Permission to use the data was sought from the Ugandan Ministry of Health under whose mandate CPHL falls.Table Table In general, the proportion of virologically non-suppressed patients decreased with increasing age, with the highest proportion being 29% for children aged 0–4 years, followed by 27% for adolescents aged 15–19 years and least 7% for adults aged 35+ years. The same trend is observed across the 3 patient sub-categories. Males (13%) had a slightly higher proportion of non-suppressed patients compared the females (10%). Breast feeding (6%) and pregnant (8%) mothers had the lowest proportion of virologically non-suppressed patients amongst all the different patient categories explored. In general, virological non-suppression was highest amongst patients with reported adherence levels of <85% (35%) followed by patients with 85–94% (17%) and least among those with adherence levels >95% (10%). Regional and National referral hospitals had the highest proportion of virologically non-suppressed patients (12%), followed by specialized HIV care services with 11%, and least health centre IV and general hospitals, and health centre II and III each with 9%  and repeat testers after suspected failure  were more likely to be virologically non-suppressed, compared with routine testers. In addition, young age was significantly associated with virological non-suppression: Children aged 0–4 years  and adolescents aged 15–19 years  were more likely to be virologically non-suppressed compared with patients aged 35+ years. Patients with reported adherence level < 85%  were also more likely to be virologically non-suppressed compared to patients with >95% adherence level. Similarly, patients on second/third line treatment , patients with active TB  were also more likely to be virologically non-suppressed. Pregnancy  and breast feeding  were protective against virological non-suppression , and repeat tester after suspected failure , being a child aged 0–4 years , being an adolescent aged 15–19 years , having reported adherence level < 85% , and having active  were significantly associated with increased odds of virological non-suppression. However, being on second/third line treatment  reduced the odds of virological non-suppression  and pregnancy  increased the odds of being virologically non-suppressed . On the other hand, among repeat testers after suspected failure, having active TB was associated with the highest odds of virological non-suppression .In a sub-group analysis of the factors associated with virological non-suppression among suspected treatment failures and repeat testers after suspected failure, we found that, among suspected treatment failures, breast feeding , stepped-up adherence counseling (3 sessions) and education on the value for VL testing among other interventions. However, despite the use of a standard tool in Swaziland, there was no difference in the non-suppression rate amongst the re-testers which the authors associated with weaknesses in the counseling training and supervision . AlthougAn elevated VL indicates poor adherence or resistance –25. The We found that children and young adolescents were significantly more likely to be non-suppressed compared to the rest of the age groups. Similarly, a recent study conducted in the US reported that older patients were more likely to achieve viral suppression . TreatmeOur findings reveal that virological non-suppression is a common phenomenon even among people with good adherence, which highlights the need to ensure wide coverage and access to viral load testing services. This requires huge investments in viral load laboratory testing infrastructure and services, including point of care diagnostics especially in hard to reach areas. Further, a sufficient pool of trained providers is key to ensuring proper tracking, timely viral loads and quick action (including adherence support) based on the results.HIV-associated TB is common among people on ART in Africa . A numbeThe major limitation with our study was use of program data which had missing records. To enhance data quality, the laboratory is attempting to reduce this gap by making immediate phone calls to facilities where the samples are derived from. The cross-sectional study design may have misclassified transient viraemia as ‘non-suppressor’ leading to higher proportions of patients with virological non-suppression. In-addition, the cross-sectional study design, could not allow causality to be established. Clustering due to repeated samples in the same individual may have influenced the results in either direction. However, because of inconsistencies in the numbering of samples, we were not able to identify any repeat testers; and for this reason, we were not able to account for clustering effect in the analysis. In addition, although many studies have identified patient’s CD4 count as one of the major factors associated with virological suppression, we did not assess it in our study. This was due to the fact that the data collection tool that was used to collect the data analyzed in this study did not have an option for patients’ current CD4 count. The other limitation is that there could have been selection bias arising from the fact that the samples with complete records could have been obtained from individuals who were more motivated to seek viral load testing; or that patients who were tested could have been more likely to be non-suppressors. However, given that we used secondary data, it is very difficult to tell the extent to which selection bias exists or affects the interpretation of results. Our overall non-suppression level of 11% (suppression of 89%) suggests that Uganda is close to achieving the 90% viral suppression which is the UNAIDS target among HIV infected individuals on treatment. However, our study sample was only 100, 678 HIV-positive individuals versus the 750,896 individuals who were on active ART by the end of 2014 . Thus, oThe strength of this study was its large sample size and data on samples derived at the national level and thus provides a national outlook on the critical challenge of non-suppression amongst different populations receiving ART. This study identifies populations that require enhanced and targeted interventions to optimize ART and raises questions for additional research in this field.Repeat testers after suspected failure registered the highest proportion of non-suppressed patients. Young age, poor adherence and having active TB increased the odds of virological non-suppression. Being on second/third line regimens was protective against non-suppression. We recommend close follow up and intensified targeted adherence support for suspected treatment failures, repeat testers after suspected failure, children and adolescents, and adherence to ART guidelines by ART clinics.


Human immunodeficiency virus (HIV) compromises the nutritional status of infected individuals and in turn, malnutrition worsens the effects of the infection itself by weakening the immune system consequently accelerating disease progression and death. However, few studies have examined the association between nutritional status at antiretroviral therapy (ART) initiation and early mortality. Therefore, this study assesses pre-ART nutritional status and other baseline characteristics and mortality among adult patients on ART at Fiche Hospital, Ethiopia.A retrospective cohort study was conducted among 489 ART enrolled adult patients between August 01, 2006 and September 30, 2013 in Fiche Hospital. Study participants were selected by using systematic random sampling method. Actuarial table was used to estimate survival of patients after ART initiation and log rank test was used to compare the survival curves. Cox proportional-hazard regression was used to determine independent predictors of time to death.2 (AHR = 5.4 95% CI 3.03–9.58), baseline ambulatory functional status , bedridden functional status , WHO clinical stage III , WHO clinical stage IV  and CD4 count less than 200 cells/μl , two and more opportunistic infections .Most of the study subjects were females 254 (51.9%). A total of 489 patients were included in the analysis, of whom 87 died during a median study follow-up of 22 months. The estimated mortality among malnourished was 21, 28, 33, and 38% at 5, 10, 15, and 25 months respectively with mortality incidence density of 5.63 deaths per 100 person years. The independent predictors of mortality were: BMI <18.5 kg/mUndernutrition at the time of ART initiation was associated with increased risk of death, particularly during the first 3 months after ART initiation. Interventions to promote earlier HIV diagnosis and treatment and integrating nutrition counseling at all stages of ART implementation may improve ART outcomes in this vulnerable population. Provision of antiretroviral therapy (ART) for HIV-infected individuals is rapidly expanding in sub-Saharan Africa . HIV its2 indicates that a person is underweight, 18.5–24.9 kg/m2 is normal weight, and 25.0–29.9 kg/m2 is overweight and 30.0 kg/m2 or above is obese. HIV compromises the nutritional status of infected individuals and in turn, malnutrition worsens the effects of the infection itself by weakening the immune system consequently accelerating disease progression and death . The median CD4 cell count at ART initiation was 145 cells/μl (IQR 80–222). Three hundred thirty five (68.5%) of the patients had CD4 counts <200 cells/μl. The median hemoglobin level was 12.90 g/dl (IQR 10.9–14.6). Most of the study subjects at ART initiation were 220 (45%) in WHO stage III and 197 (40.3%) in WHO stage II. With regard to functional status, 197 (40.3%) participants were ambulatory at baseline and 27 (5.5%) were bedridden. Out of those who participated, 304 (62.2%) had no previous opportunistic infection, 68 (13.9%) had one previous opportunistic infection and 117 (23.9%) had two and more previous opportunistic infections . With regard to educational status, 36 (26.1%) of the participants who had no education died after initiation of ART. The proportion of mortality is higher among males than females (19 vs. 17%)  of 22 (14–34) months; 17 (5–34) months among malnourished adults and 23 (17–34) months among non-malnourished adult patients. All the study subjects contributed 1545.4 person year of observation (PYO); 429.35 PYO for those who were malnourished HIV adult patients and 1116.05 PYO for non-malnourished patients. Out of the study subjects, 87 patients died during the study period giving a mortality rate of 5.63 per 100 person-year observations (87 deaths/1545.4 PYO). Of the 87 deaths, 27 (31%) occurred within the first 3 months of ART initiation and 41 (47.1%) died in the first year of follow-up. The overall estimated survival duration after ART initiation was 48 (95% CI 46.32–50.84) months.Actuarial life table analysis showed that probability of survival time among malnourished adult ART patients was 79, 91, 93, 94, and 98% at 5, 10, 15, 20, and 30 months respectively. The probability of survival time among non-malnourished adults was 97, 99, 99 and 98% at 5, 10, 15 and 35 months respectively .The overall estimated survival time after ART initiation using Kaplan–Meier survival analysis was 48 months (95% CI 45.32–50.68). The survival experience after initiation of ART estimated by the Kaplan–Meier survival analysis by educational status showed that there was significant difference in median survival time among the groups, no education 44 months (95% CI 40.18–48.82) and secondary education 53 months (95% CI 49.98–56.02), .There was significant difference in median survival time among working functional status 54 months (95% CI 52.49–57.51), ambulatory status 41 months (95% CI 36.88–44.22) and bedridden 34 months (95% CI 24.86–43.14) , WHO stage III and IV, CD4 cell count <200 cells/µl and opportunistic infections with two and more. Patients with a BMI <18 kg/m2 had a 5.4-fold increased risk of mortality (95% CI 3.03–9.58) as compared to those with ≥18.5 kg/m2. The hazard rate for dying is 3.84 times more with baseline functional status of ambulatory compared to patients with functional status of working . Similarly, Patients with baseline functional status of bedridden had 4.78 times increased risk of death as compared to patients with baseline functional status of working . HIV-infected patients with baseline WHO clinical stage III had twofold increased risk of death compared to patients with stage I and II , and the risk of death among WHO clinical stage IV patients was even higher- compared to stage I or II patients . Patients starting ART with CD4 count less than 200 cells/μl had threefold higher death hazard (95% CI 1.48–5.88) as compared to those starting ART with more than 200 cells/μl. Patients with two and above opportunistic infections had 2.3 times higher mortality as compared to those who had no starting opportunistic infection   at the start of ART was an independent predictor of early mortality . This is in line with studies conducted in several sub-Saharan Africa , 13–16. Patients with advanced clinical diseases (WHO stage III or IV) had higher mortality compared to patients with WHO stage I or II. This finding was supported by several other studies , 19–22. In this study, patients with two and above opportunistic infections had 2.3 times higher mortality as compared to those who had no starting opportunistic infection. This study established a similar finding with the studies in sub-Saharan Africa that showed OIs were found to be significant predictors of death among patients under ART , 24, 25.Adult HIV-infected patients who were bedridden at ART initiation had higher risk of mortality compared to the patients with working functional status at treatment initiation. This result is in line with the study done in Eastern Ethiopia and those described elsewhere , 23, 26.Patients starting ART treatment with CD4 cell count ≤200 cells/μl was an independent predictor of mortality in this study. This finding is consistent with studies , 27. StuOur study was subjected to several important limitations. Selection bias is possibly introduced due to the fact that patients with incomplete records of variables were excluded. In addition, because we could not ascertain outcomes of patients lost to follow-up, our mortality results might be an underestimation. Anthropometric measurements might not be measured or recorded correctly.Undernutrition at the time of ART initiation was associated with increased risk of death, particularly during the first 3 months after ART initiation. With regard to nutritional status, there was a significant difference in median survival time between malnourished adults 35 months and non-malnourished adults 52 months. Being malnourished, late WHO stage, having low CD4 cell count, ambulatory and bedridden functional status and two and more opportunistic infections were factors independently associated with death. Interventions to promote earlier HIV diagnosis and treatment and nutrition counseling should be integrated at all stages of ART implementation, such as during adherence counseling, regular follow-up sessions, and meetings of PLWHA support groups may improve ART outcomes in this vulnerable population.