Even though use of antiretroviral therapy (HAART) decreases the incidence of opportunistic infections (OIs) they are continuing to be a major cause of morbidity and mortality. Studies concerning this problem are scarce in Eastern Africa. The aim of this study was to determine the incidence and predictors of OIs after initiation of HAART in Ethiopia.A health facility based single centered cohort study using structured data extraction sheet was conducted. The study population was all HIV positive ART naive adolescents and adults who started HAART between January 2009 and May 2012. Simple random sampling technique was used to select 317 patients from the record. Multivariate binary logistic regression model was used to determine factors for the occurrence of OIs after initiation of HAART.The incidence of OIs after HAART was 7.5 cases/100person years. Tuberculosis, oral candidiasis, pneumonia and toxoplasmosis were the leading OIs after HAART. A bed ridden functional status at initiation of HAART, presence of OIs before HAART, non-adherence and low hemoglobin level were predictors for the occurrence of OIs after HAART.The incidence of OIs after HAART was higher than in previous studies. Patients with the identified risk factors need strict follow up to reduce the morbidity and mortality attributed to OIs. Earlier initiation of HAART before advanced immune suppression, better management of TB and extended baseline assessment could help to reduce opportunistic infections and mortality after the initiation of HAART in Ethiopian patients. Determining whether it is IRIS or incomplete immunity with the occurrence of new OIs is difficult. The third group includes OIs that occur in patients with virology and immunologic failure on HAART [Before the widespread use of High Active Antiretroviral Therapy (HAART), opportunistic infections (OIs), which have been defined as infections that are more frequent or more severe due to immune suppression were the principal cause of morbidity and mortality in HIV patients . OIs thaon HAART , 2, 3, 4on HAART . In Ethion HAART . SeveralThe study was conducted in Ayder Referral Hospital, teaching hospital for the College of Health Sciences, Mekelle University, which is located in the city of Mekelle, Tigray Region (North Ethiopia). The Hospital commenced rendering its referral and specialized medical services in 2008 to the 8-million populations in its catchment areas of the Tigray, Afar and South-eastern parts of the Amhara Regional States. It provides a broad range of medical services to both in and out patients. As such, the hospital can be designated as the most advanced medical facility, by all accounts, in the northern part of the country and that it stands as the second largest hospital in the nation .th to July 30th 2012. All HIV positive ART naïve adolescents and adults ever started HAART in Ayder Referral Hospital were included. Initiation of ART in the HIV-positive patients followed WHO recommendations: all patients with WHO stage IV disease, WHO stage III disease with a CD4 cell count <350 cells/μl or with a CD4 cell count <200 cells/μl were eligible for ART. An ethical clearance letter was obtained from Mekelle University College of Health Science (CHS) ethical review committee and permission was obtained from CHS dean office before data collection. Any identifier information was excluded and confidentiality was kept during data collection. Sample size was determined using a formula for comparison of proportions. Internal comparison was done using a low baseline CD4 count as a predictor for occurrence of OIs after initiation of HAART. A total of 317 HIV positive adolescents and adults were selected using simple random sampling from 649 patients who started HAART during the period of January 2009 to May 2012. The samples were taken randomly using Excel Rand function. Data was collected from ART registry log-book and patients chart. Data extraction sheet was prepared and used to collect the data. The data was collected by health professionals who have training on HAART. After being coded it was entered to a data sheet of SPSS version 16.0. Multivariate binary logistic regression model was used to determine factors for the occurrence of OI after initiation of HAART. Kaplan-Meier was used to estimate OI free survival time after HAART initiation. Odds ratio, and P- value were determined to check association between variable and p-value <0.05 considered significant.Health facility based retrospective single-center cohort study was conducted among HIV positive patients to assess the incidence and risk factors for HIV related OIs after initiation of HAART. The study period was from January, 2009 to May 2012. Data collection was carried out from July 15Ethical clearance was obtained from the Institutional Review Committee(IRC) of College of Medicine and Health Sciences mekelle university. Permission letter was received from those administrative bodies of Ayder comprehensive specialized hospital, then proceeded with data collection.A total of 317 charts of patients ever having started HAART were included in the retrospective analysis. 184 (58%) patients were female; male to female ratio was 1:1.38. The mean age was 34.8±8.9 years. The minimum and maximum age was 16 and 78 years respectively. The majority of patients (74.1%) were in the age group 35–40 years .Half of the patients were married, 15.5% divorced, 4.3% widowed and 24.2% single. The majority of the patients (60.9%) were unemployed and 39.1% were working at initiation of HAART.As to the functional status of patients recording was traced for 314 patients, the majority was fit for work 60.8%), ambulatory was 27.7% and bed ridden 11.5%. The mean body weight at initiation of HAART was 48.9±9.5 kg, which is less than the average weight of an Ethiopian (63.5–72.5 kg) [%, ambula+ count of <200 cells/mm3. At the time of HIV diagnosis 80.1% of patients had a CD4+ cell count of <200 cells/mm3. At initiation of HAART 22.1% of the patients had a CD4+ count of <50 cells/mm3, 61.8% of the patients had CD4+ count of 50–199 cells/mm3. A total of 83.9% had a CD4+ count of <200cells/mm3, 14.2% of 200–349 cells/mm3 and 1.9% of >350 cells/mm3. The mean CD4+ cell count at initiation of HAART was 121±81 cells/mm3 (5 to 442 cells/mm3). The proportion of patients who had CD4+ cell count <200 cells/mm3 decreased from 83.9% at initiation of HAART to 23% at 6 months, 7.9% at 12 months, and 1.6% at 18 months after HAART initiation.The majority of patients (86.5%) who had OIs before HAART had a CD4Almost all (99.7%) patients started with Co-trimoxazole preventive therapy. INH (Isoniazid preventive therapy) was started for 21.1% of patients. INH preventive therapy was not prescribed for 26.5% of the patients due to past or current tuberculosis, but for 51.4% of the patients the reason for not prescribing INH was not documented. Initial HAART regimens used were AZT+3TC+NVP (29.7%), TDF+3TC+EFV (29%), D4T+3TC+NVP (20.2%), TDF+3TC+NVP (8.8%), D4T+3TC+EFV (7.6%) and AZT+3TC+EFV (4.7%). Adverse drug reactions were reported or documented in only 7.2% of the patients. The side effects reported were rash (21.7%), anemia (21.7%), nausea (13%), numbness (4.3%) and jaundice (4.3%). During treatment 91.8% had good adherence, 5.6% had fair adherence, 2.6% had poor adherence using patient´s self-report as method of adherence assessment and definition of adherence .The incidence of OIs after two weeks of initiation of HAART was 64 (20.2%) in 855 person years of follow-up or incidence density of 7.5 cases/100 person years. The duration of follow up time after HAART ranged from two weeks to 36 months. The number of OIs per patient ranged from none to three. At 3 months after HAART initiation the incidence of HIV related OIs was 48.2 per 100 person years, at 6 months 31.2 per 100 person years, at 12 months 19.3 per 100 person years, at 24 months 10.6 per 100 person years and at 36 months 7.5 per 100 person years. The majority of patients (57.1%) developed OIs within the first 3 months after HAART .The common OIs seen after initiation of HAART were tuberculosis (32.3%), oropharyngeal candidiasis (15.3%), pneumonia including pneumocystis jiroveci pneumonia  and CNS toxoplasmosis  .The diagnosis of OIs were made clinically in 45.3% of the patients, both clinical and laboratory in 43.8% and laboratory methods alone were used in 10.9% of the patients with OIs. Methods utilized were x-ray (52.9%), fine needle aspiration (20.3%), body fluid analysis (14.7%), x-ray and ultrasound (5.9%), sputum examination (2.9%) and endoscopy (2.9%).+ cell count was 250±111/μl for 46.5% of the patients which is a statistically significant elevation from the value at initiation of HAART (P = 0.007). After occurrence of OIs 60.3% of the patients improved and are still on treatment, 28.6% died, 6.3% were transferred to other health facilities for follow up and the status of 4.8% of the patients was unknown.At six months following HAART initiation the mean CD4In Kaplan-Meier, the median OI free survival time after initiation of HAART was two months with 95% confidence interval of 1.2–2.9 months. When the analysis was stratified with gender, the median OI free survival time after initiation of HAART for males and females was 3.3 and 1.8 months respectively, but the difference was not statistically significant.In bivariate analysis a bed ridden functional status at initiation of HAART , and WHO clinical stage IV disease  were predictors for occurrence of OIs after HAART.+ cell count of less than 200 cell/mm3 at initiation of HAART was associated with occurrence of OIs after HAART but the association was not statistically significant  , non-adherence  for HAART during their follow up period  and hemoglobin level of less than 7gm/dl at initiation of HAART  were independent predictors for occurrence of OIs after HAART. A CD4P: 0.34) .This study aimed to determine incidence and risk factors for OIs following the initiation of HAART in Ethiopia. Patients´ socio-demographic characteristics showed the typical distribution of an African setting similar as described by the Antiretroviral Therapy in Lower Income Countries (ART-LINC) collaboration . The majThe incidence of OIs after initiation of HAART was 7.5 cases/100 person years and half of it occurred within the first 3 months. This finding is higher than the incidence of HIV related OIs after initiation of HAART seen in different studies conducted in Zewditu Memorial Hospital Ethiopia 14.6%), the United States (16.6%), France 11.3%), and India (8.3%) .3%, and , 13. The.6%, the There are a number of predictive variables for the occurrence of OIs in our setting. Study patients who were bed ridden at the start of HAART were at increased risk of HIV related OIs after initiation of HAART  in bivariate analysis.Our study also revealed that presence of OIs at initiation of HAART was associated with an increased risk of OIs after HAART  which is in agreement with the studies conducted in Europe, Senegal and Nigeria , 16, 17.Non adherence for HAART was the predictor for occurrence of OIs after HAART  which is consistent with other studies in Europe and North America , 20, 21.Patients with low hemoglobin level had a higher risk of developing HIV related OIs after HAART  which is consistent with other studies .Most patients presenting in Ayder hospital were medically eligible for HAART according to WHO, at the time of HIV diagnosis, however for some patients WHO criteria did not allow earlier start of treatment at the time of the study. Earlier treatment is now also recommended by the WHO . In our + count of <200 cells/mm3 at initiation of HAART, which shows that patients had advanced immune suppression. The majority of patients (86.5%) who had OIs before HAART had a CD4+ count of <200 cells/mm 3 which is slightly higher than in the Indian study by Srirangaraj et al. (79.5%) [+ cell count at the initiation of HAART was not an independent predictor for OIs in our setting. In this study low baseline CD4+ cell count did not have a statistically significant association with the occurrence of OIs after HAART  but studies conducted in US by Buchacz et al. and the Swiss HIV Cohort Study revealed that low baseline CD4+ cell count was a predictor for occurrence of OIs after HAART [In our study 83.9% of the patients had a CD4 (79.5%) . Surpriser HAART , 23. ThiThe leading HIV related OIs occurring after HAART in our study were tuberculosis followed by oral candidiasis which is in agreement with the study conducted in Zewditu Memorial Hospital which revealed tuberculosis as the leading OI (66.5%). The main HIV related OIs in the Senegalese study were recurrent pneumonia (37.3%), tuberculosis (26.2%), recurrent herpetic ulceration (21.7%), visceral candidiasis (15%), which still showed tuberculosis as one of the most common HIV related OIs after HAART. The incidence of OIs after HAART in the Indian study was 8.3% and the spectrum of OIs ranged from herpes zoster, non-typhoidal salmonella, cerebral toxoplasmosis, oral candidiasis to cryptosporidiosis, which is different from our study and from European settings , 23. TheThe rate of reduction in incidence of OIs in our study was 35% within 6 months, and 39% within 12 months. Compared to the Swiss cohort the rate of reduction in incidence was low in the first 6 months and higher after 12 months (66% at 6 months and 16% at 12 months) .In our study 28% of the patients who started HAART died. 76% of the deaths occurred in the first 6 months after HAART initiation and tuberculosis is the leading cause of death, accounting for 64.6%. 84% of TB related deaths occurred in the first 6 months. In an Ethiopian study by Kassa et al. 57% of TB related deaths in HIV patients occurred within the first six months of HAART initiation . ManagemAccording to a study conducted in France, old age (>55years) was a predictor for occurrence of OIs after HAART but in our study age was not a predictor for occurrence of OIs after initiation of HAART . This co+ cell count did not have a statistically significant association with the occurrence of OIs, but high numbers of tuberculosis infections, lack of systematic initial OI screening and the fact that only WHO stage III and IV patients with less than 200/μl CD4+ cell could start HAART might have influenced these data. Earlier initiation of HAART before advanced immunosuppression, better management of TB and extended baseline assessment could help to reduce opportunistic infections and mortality after the initiation of HAART in Ethiopian patients.HIV-patients with the risk factors bed ridden at initiation of HAART, presence of OIs before HAART, non-adherence for HAART, and low baseline hemoglobin level need strict follow up to reduce the morbidity and mortality attributed to OIs. In this study low baseline CD4S1 File(DOCX)Click here for additional data file.S2 File(SAV)Click here for additional data file. 14 Feb 2020Incidence and predictors of HIV related opportunistic infections after initiation of highly active antiretroviral therapy at Ayder Referral Hospital, Mekelle, Ethiopia: a retrospective single centered cohort studyPONE-D-19-24196Dear Dr. ZekariasWe are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.Within one week, you will receive an e-mail containing information on the amendments required prior to publication. 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Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact With kind regards,Yatin N. Dholakia, MDAcademic EditorPLOS ONEAdditional Editor Comments:New guidelines for managing HIV infection recommend initiating ART as soon as one is diagnosed to have been infected.The findings presented in the study may therefore have no relevance in the recent times, however they are interesting and may be used as baseline to any future similar study from the institution. The fact that OIs were more common in the first few months of initiating ART may be missing diagnosis before initiating ART or related to IRIS as the cases had low CD4 counts at initiation. This has been appropriately mentioned.Journal Requirements:1. 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To assess the effect of HIV infection and combined antiretroviral therapy (c-ART) on various proatherogenic biomarkers and lipids and to investigate their relationship with subclinical atherosclerosis in a cohort of treatment-naive HIV-infected patients.We performed a prospective, comparative, multicenter study of 2 groups of treatment-naive HIV-infected patients  and a healthy control group. Laboratory analyses and carotid ultrasound were performed at baseline and at months 12 and 24. The parameters measured were low-density lipoprotein (LDL) particle phenotype, lipoprotein-associated phospholipase A2 (Lp-PLA2), interleukin-6 (IL-6), high-sensitivity C-reactive protein (hs-CRP), sCD14, sCD163, monocyte chemoattractant protein-1(MCP-1), and asymmetric dimethylarginine (ADMA). A linear mixed model based on patient clusters was used to assess differences in biomarkers between the study groups and over time.The study population comprised 62 HIV-infected patients  and 22 controls. Age was 37 (30–43) years, and 81% were men. At baseline, the HIV-infected patients had a worse LDL particle phenotype and higher plasma concentration of sCD14, sCD163, hs-CRP, and LDL-Lp-PLA2 than the controls. At month 12, there was an increase in total cholesterol (p = 0.002), HDL-c (p = 0.003), and Apo A-I (p = 0.049) and a decrease in sCD14 (p = <0.001) and sCD163 (p<0.001), although only in group B. LDL particle size increased in group B at month 24 (p = 0.038). No changes were observed in group A or in the healthy controls. Common carotid intima-media thickness increased in HIV-infected patients at month 24 . Plasma levels of sCD14, sCD163, and hs-CRP correlated with lipid values.In treatment-naive HIV-infected patients, initiation of c-ART was associated with an improvement in LDL particle phenotype and inflammatory/immune biomarkers, reaching values similar to those of the controls. HIV infection was associated with progression of carotid intima-media thickness. Persons with HIV (PWH) have a higher cardiovascular risk than non–HIV-infected individuals . In addiCompared with healthy individuals, PWH who are not receiving c-ART have higher plasma levels of the inflammatory, coagulation, and immune activation biomarkers that are related to cardiovascular disease in the general population. Viral suppression achieved with c-ART is associated with normalization of various biomarkers, although others remain persistently high even when c-ART is started at an early stage of infection –7. In PWLipid disorders, which are common in PWH, can be related to the infection itself or to specific antiretroviral drugs , 14. An The aims of this study were to investigate the effect of HIV infection and c-ART on LDL particle phenotype and atherogenesis-related biomarkers in a cohort of treatment-naïve HIV-infected patients and to assess the relationship between these variables and subclinical carotid atherosclerosis. The data we report can be added to findings published recently by our group on other atherogenesis-related pathways, mainly metabolism of HDL . To our 2, and pregnancy. The control group consisted of healthy, HIV-negative, healthcare workers. Group A patients whose CD4 count had decreased to <500 cells/μL were recommended to start c-ART and were not included in the follow-up analyses.We performed a prospective, observational, multicenter study of treatment-naive HIV-infected patients recruited in 2 metropolitan hospitals in Spain  and a hospital in Australia . HIV-infected patients were divided into 2 groups based on the need to begin c-ART in accordance with European guidelines at the time the study was designed : group AThe local ethics committees approved the protocol, and written informed consent was obtained from all participants prior to their inclusion in the study.We recorded and compared changes in LDL particle phenotype and inflammatory biomarker levels in the 3 groups over a 2-year follow-up period. We investigated the association between infection-related variables  and LDL particle phenotype and inflammatory biomarkers and examined correlations between these variables and subclinical atherosclerosis evaluated using carotid ultrasound.At baseline and months 12 and 24, patients underwent a clinical assessment, laboratory analyses, and carotid ultrasound. At each visit, smoking, c-ART use, and other medications  were recorded. The estimated overall cardiovascular risk was calculated using the Framingham score. Blood pressure and anthropometric data  were recorded.A venous blood sample was collected (after an overnight fast), centrifuged at 4°C, and stored at −80ºC until analysis. All laboratory measurements were performed at a central laboratory in Barcelona . Samples were shipped to the central laboratory at –80ºC, and aliquots were thawed only once before the analysis; the biomarkers analyzed have been shown to remain stable when preserved at this temperature . Total cLDL particle phenotype was determined using gel electrophoresis in 3% polyacrylamide tubes with a commercially available system . This method can separate 9 LDL subfractions: LDL1 to LDL3, which are large buoyant LDL particles (lb-LDL), and LDL4 to LDL9, which are sd-LDL particles. The results are expressed as LDL particle size (Å), percentage of sd-LDL particles, and cholesterol content in sd-LDL and lb-LDL particles.We followed the method of Sánchez-Quesada et al  to deterHigh-sensitivity C-reactive protein (hs-CRP) was quantified using an immunocolorimetry assay  in a Cobas c501/6000 autoanalyzer. The remaining biomarkers were measured using an enzyme-linked immunosorbent assay, as follows: interleukin-6 , monocyte chemoattractant protein-1 , soluble CD14 , sCD163 , and asymmetric dimethylarginine (ADMA) (BioVendor). Intra- and inter-assay variabilities were as stated by the manufacturers.th percentile of a reference population was considered indicative of increased cardiovascular risk  of TC in group B (as indicated by the model) at baseline and 12 and 24 months were 3.9 , 4.44 , and 4.36 , respectively. The adjusted means [95% CI] were 1.07 , 1.19 , and 1.22  for HDL and 1.24 , 1.33  and 1.36  for Apo A-I. No changes were observed in group B for LDL-c, Apo B, TC/HDL-c, the Apo A-I/Apo B ratio, or triglycerides. There were no changes in any of the lipid parameters in group A or in the control group Figs .LDL particle size and cholesterol content in lb-LDL particles improved in group B at month 24. According to the model, the adjusted means [95%CI] at baseline and 12 and 24 months in group B were 269.86 , 270.46 , and 271.53 , respectively, for LDL particle size and 1.66 , 1.87 , and 1.98  for cholesterol content in lb-LDL. There were no changes in group A or in the control group. At month 24, there were no significant differences in LDL phenotype between the 3 study groups  S2 Tabl.We carried out a correlation analysis with lipid variables including all participants. At baseline, LDL particle size correlated with several lipid variables and BMI  . No corrChanges were observed only in group B, with a significant decrease in sCD14 and in LOG(sCD163) at 12 months and a further decrease at 24 months. In line with the model, the adjusted means [95% CI] in group B at baseline and 12 and 24 months were 2.57 , 2.05 , and 2.03  for sCD14 plasma levels and 6.57 , 5.93 , and 5.98  for LOG(sCD163). During the study period, no changes were recorded for hs-CRP, which remained higher in group B at month 24 . No chanTotal Lp-PLA2 remained largely unchanged in all 3 groups during the study, although a significant decrease in LDL-Lp-PLA2 was observed at 24 months. Consistent with the model, the adjusted means [95% CI] for LDL-Lp-PLA2 in group B at baseline and 12 and 24 months were 62.79 , 62.82 , and 58.24   S2 Tabl.A correlation analysis based on CD4 cell count, HIV viral load, and the lipid variables was carried out at baseline. sCD14, sCD163, and hs-CRP levels correlated with those of several lipid variables . Various correlations were also found between plasma biomarkers .th percentile.At baseline, common c-IMT was thicker in the control group than in group B . There wAt baseline, common c-IMT correlated with age , Framingham score (Log) , TC , LDL-c , and BMI , but not with biomarkers, HIV viral load, or CD4.Cardiovascular risk measured by Framingham score (LOG) at baseline was similar in all 3 study groups and did not change significantly during the study period.A sensitivity analysis revealed a non statistically significant interaction between patients with a regimen containing a protease inhibitor or not  can lower expression of ATP-binding cassette transporters, thus reducing reverse cholesterol transport from the arterial wall to HDL particles. On the other hand, immune activation can also enhance the activity of reactive oxygen species and enzymes such as Lp-PLA2, thereby rendering LDL and HDL particles more pro-inflammatory , 33. DatIn our study, initiation of c-ART was associated with an increase in plasma lipid concentrations to levels similar to those of the controls, which can be considered a return to a “healthy” state . LDL parWe observed a beneficial effect of suppressive c-ART on biomarkers of inflammation (LDL-Lp-PLA2) and immune activation (sCD14 and sCD163), which reached concentrations similar to those of the controls. Nonetheless, some degree of inflammation persisted, as evidenced by the continuously elevated levels of hs-CRP. Previous studies have also shown improvements in biomarkers after suppressive c-ART, although continuously high plasma concentrations of some biomarkers of inflammation  and immune activation (sCD14) have been reported by several authors . Recoverth percentile, which was associated with increased cardiovascular risk, did not change during the study.Carotid-IMT and plaque are predictors of future cardiovascular events in the general population and have been used as surrogate markers of cardiovascular disease . At baseOur study has several major limitations. The small sample size at baseline and the withdrawal of some participants in group A  decrease the power of the study and may introduce bias in the results. Moreover, variability in the repeated measures of c-IMT could hamper interpretation of the results. Therefore, findings for c-IMT must be interpreted with caution, mainly in group A. Nonetheless, the fact that significant changes were recorded confers validity to the study. The prospective design and inclusion of treatment-naïve HIV-infected patients and healthy controls provided the opportunity to study the effect of HIV infection and c-ART on various biomarkers and on subclinical atherosclerosis. The use of different types of c-ART with specific effects on lipids, biomarkers, and even c-IMT , 24 may In conclusion, this study shows that c-ART normalizes the lipid profile and improves LDL particle phenotype and immune activation, although some degree of inflammation persists. However, c-ART was unable to prevent progression of common c-IMT. As c-ART alone did not fully normalize the values of biomarkers of inflammation, additional strategies are needed to reduce the non–AIDS-defining disorders associated with chronic inflammation.S1 Data(RTF)Click here for additional data file.


There is limited literature on the appropriateness of viral load (VL) monitoring and management of detectable VL in public health settings in rural South Africa.We analysed data captured in the electronic patient register from HIV‐positive patients ≥ 15 years old initiating antiretroviral therapy (ART) in 17 public sector clinics in rural KwaZulu‐Natal, during 2010–2016. We estimated the completion rate for VL monitoring at 6, 12, and 24 months. We described the cascade of care for those with any VL measurement ≥ 1000 HIV‐1 RNA copies/mL after ≥ 20 weeks on ART, including the following proportions: (1) repeat VL within 6 months; (2) re‐suppressed; (3) switched to second‐line regimen.There were 29 384 individuals who initiated ART during the period . Of those in care at 6, 12, and 24 months, 40.7% (9861/24 199), 34% (7765/22 807), and 25.5% (4334/16 965) had a VL test at each recommended time‐point, respectively. The VL results were documented at all recommended time‐points for 12% (2730/22 807) and 6.2% (1054/16 965) of ART‐treated patients for 12 and 24 months, respectively. Only 391 (18.3%) of 2135 individuals with VL ≥ 1000 copies/mL on first‐line ART had a repeat VL documenting re‐suppression or were appropriately changed to second‐line with persistent failure. Completion of the treatment failure cascade occurred a median of 338 days after failure was detected.We found suboptimal VL monitoring and poor responses to virologic failure in public‐sector ART clinics in rural South Arica. Implications include increased likelihood of morbidity and transmission of drug‐resistant HIV. UNAIDS estimates that to end HIV/AIDS as a public health threat by 2030, 95% of people living with HIV must be diagnosed, 95% of those diagnosed need to be taking antiretroviral therapy (ART), and 95% of those must achieve long‐term virologic suppression . To asceAccording to WHO guidelines, patients should receive VL monitoring at months 6 and 12 after ART initiation, and then annually thereafter. Those with a VL ≥ 1000 HIV‐1 RNA copies/mL should be retested after 3–6 months of adherence counselling support, and then either retained on first‐line therapy if re‐suppressed or switched to second‐line therapy if VL ≥ 1000 copies/mL , 5, therWe observed HIV‐positive individuals after ART initiation in a programmatic clinical cohort in KwaZulu‐Natal, to determine whether guidelines about management of virologic failure are being implemented. We hypothesized that poor adherence to VL monitoring guidelines has resulted in poor identification of treatment failure and prolonged duration on failing first‐line regimens.This study was conducted in the Hlabisa sub‐district as part of the Africa Health Research Institute (AHRI) demographic surveillance and clinical population cohort . All HIVm2000 RealTime System; Abbott Molecular, Abbott Park, Illinois, U.S.A). The results are delivered to the clinics during sample pick‐up and are manually entered by clinic clerks into TIER.Net. The paper results are subsequently filed in patients' clinical charts. Patients who have an HIV VL ≥ 1000 copies/mL after at least 6 months on ART are recommended to receive adherence counselling followed by a repeat VL 2–3 months after the initial detection of elevated VL. If the repeat HIV VL is ≥ 1000 copies/mL, individuals are meant to be switched to second‐line ART. Those with VL < 1000 copies/mL remain on first‐line therapy.Since 2010, South African HIV treatment guidelines have recommended VL monitoring in all HIV‐positive individuals at 6 and 12 months after initiating ART, and 12‐monthly thereafter if virally suppressed . HIV‐posData were extracted from Tier.Net, containing HIV records for patients on ART in the sub‐district and analysed using Stata version 14 . We first estimated the completion rate for VL monitoring at 6, 12, and 24 months, by using VL measurements which fall within the 6‐month (≥ 5 and ≤ 9 months), 12‐month (> 9 and ≤ 15 months) and 24‐month (> 21 and ≤ 27 months) windows after ART initiation, respectively. The denominators for each of these time‐points were people who had started ART and were in care at the evaluated time point, although there might have been interruptions outside of the time periods evaluated. As a sensitivity analysis, we examined VL monitoring restricted to individuals who remained continuously in care over each time period.We estimated optimal VL monitoring defined as completing both 6‐ and 12‐month VL for those on ART for a minimum of 15 months and at 6, 12, and 24 months for those on ART for a minimum of 27 months.We described the cascade of care for all individuals with a VL measurement ≥ 1000 copies/mL after at least 5 months on ART, including the proportion with a repeat VL within 6 months , the proportion who re‐suppressed, and the proportion who changed to a second‐line regimen if a repeat VL remained ≥ 1000 copies/mL. For the cascade of care analysis, we restricted our analysis to the first episode of virologic failure for each individual in the dataset. We examined factors associated with successful management of the first‐line cascade using logistic regression, among all individuals with virologic failure. Successful management was defined as having a repeat VL test within 6 months, and either VL < 1000 copies/mL on repeat testing or switch to an appropriate second‐line therapy.Ethical approval for the AHRI Population Intervention Platform Study and linkage to government ART records (TIER.net) was granted by the Biomedical Research Ethics Committee of the University of KwaZulu‐Natal, SA (BE290/16).Between January 2010 and December 2016, 29 384 HIV‐positive individuals initiated ART in the public sector in our study catchment area   and 6.2% (1054/16 965), respectively. The proportion of individuals with month‐24 VL monitoring recorded declined from 39.0% in 2010 to 12.5% in 2015. A similar decline was seen when optimal monitoring at 24 months was evaluated, going from 10.1% to 2.2%. Viral monitoring varied by clinic, with optimal monitoring at 12 months ranging from 2.7% to 33.9%, and that at 24 months ranging from 0.5% to 17.9%. Table . The res4) Table .In a representative population‐based longitudinal clinical cohort attending public sector primary care clinics in rural South Africa, we found significant deficits in VL monitoring and delayed or absent responses to virologic failure. Indeed, less than one in five individuals in this programmatic cohort were confirmed to have virologic re‐suppression or change to second‐line therapy after virologic failure, and those that did change therapy did so a median of 1 year after virologic failure. Such delays are likely to have significant deleterious individual and public health impacts through effects on patient morbidity, accumulation of drug resistance, and persistent risk of HIV transmission. Furthermore, suboptimal VL monitoring could lead to inaccurate decisions by policymakers on programme effectiveness and needs for second‐line ART.There are many potential reasons for the poor VL monitoring observed in this treatment programme: patients not being aware of or empowered to request recommended blood tests, facility staff not having training, sufficient time or resources to conduct blood tests when due, failure of results to reach clinics from the laboratory or failure to capture results on TIER.Net. It is a limitation of this study that we did not review clinical records as our ethics permission did not cover this, hence we are uncertain which of these factors might account for this poor VL monitoring. The decline in optimal VL monitoring over time was most apparent for the 24 month time‐point; by contrast, there appeared to be some improvement in more recent years in optimal monitoring at 12 months. Hence, we speculate that this could be due to prioritization of monitoring of patients with advanced disease as they start care over the first few months of treatment and a relaxation in monitoring frequency as patients become more established on ART, especially in the context of high patient burden and staff shortages. If VL data in the TIER.net database are not missing at random, such that they are more likely to be missing among those with a suppressed VL, it would falsely bias our findings to suggest worse VL suppression rates. However, TIER.net is the system most often used for regional and national HIV reporting, so our data would be similar to what would be expected for programmatic reporting by the Department of Health. A study in Khayelitsha, South Africa, comparing laboratory VL data with clinic level VL database over a 12‐month period reported a higher VL completion 84%) with laboratory records but with only 55% captured in clinic database 4% with l. AnotherBut perhaps more concerning than suboptimal VL monitoring is the incredibly low response to detectable VL we observed. Our findings are similar to a Mozambican study which also reported a poor cascade of care in response to virologic failure: an initial VL test occurred on time in only 40% (17 236) of individuals, 18% of whom had an elevated first VL, and 35% of whom had an appropriate repeat. Amongst these 1095 with a follow‐up VL, 62% had virological failure. Of those, only a third started second‐line ART . An asse.These data reinforce the urgent priority for ART care programmes across the region to identify strategies to ensure virologic failure is appropriately managed. Some proposed strategies include task‐shifting to allow nurses to change individuals to second‐line therapy with physician approval , immediaCI, DP, MJS and KB designed and implemented the study. KB did the statistical analysis. CI wrote the initial draft of the manuscript. All authors contributed to the review, interpretation and presentation of the findings. All authors approved the final version of the manuscript for submission.Table S1 Proportion of individuals aged ≥ 15 years with viral load monitoring, and with optimal monitoring, during first 12 and 24 months on ART, by clinic.1Table S2 Proportion of individuals aged ≥ 15 years with viral load monitoring, and with optimal monitoring, during first 12 and 24 months on ART, among those who have been continuously in care without interruption.Table S3 Proportion of individuals aged ≥ 15 years starting ART in each year, and still in care at 6, 12 and 24 months.Table S4 Individuals aged ≥ 15 years with viral load ≥ 1000, and proportion with repeat test in 6 or 12 months, among individuals starting ART in 2010–2016.Table S5 Factors associated with success in the first‐line cascade, among 2135 individuals aged ≥ 15 years with a viral load ≥ 1000 copies/mL.Click here for additional data file.


Nontuberculous mycobacteria can cause disseminated infections in immunocompromised patients and are challenging to treat because of antimicrobial resistance and adverse effects of prolonged multidrug treatment. We report successful treatment with bedaquiline, a novel antimycobacterial drug, as part of combination therapy for 2 patients with disseminated nontuberculous mycobacteria co-infected with HIV. Nontuberculous mycobacteria (NTM) cause a broad spectrum of disease, most commonly pulmonary infection, but also cause disseminated infection in immunocompromised patients, posing a major risk for illness and death . There was no information on Clinical and Laboratory Standards Institute/European Committee on Antimicrobial Susceptibility Testing for M. abscessus. The MIC breakpoint for this drug with M. tuberculosis was 0.25 mg/L . Compassionate access to bedaquiline was obtained from Janssen-Cilag https://www.janssen.com). Treatment was initiated , as per treatment for tuberculosis. Bedaquiline was well tolerated and treatment continued for a year; there was a brief interruption because of a delay in reapproval.At diagnosis of his disseminated NTM infection, HIV viral load was undetectable (CD4 count >900 cells/μL). Empirical treatment was begun and then refined after speciation as bscessus , panel Asistance . MIC estDuring his treatment for NTM, the patient showed adverse effects caused by intravenous amikacin (1 g/d) and mild renal impairment. Therefore, this drug was withheld until his renal function recovered. On its reinitiation at the same dose, tinnitus developed prompting permanent withdrawal of amikacin. Because of excellent progress, tigecycline was replaced with linezolid at that time.18Fluorodeoxyglucose-positron emission tomography/computed tomography imaging was used to monitor disease response  has been well tolerated, and the condition of the patient continues to be favorable.response . AlthougM. avium. Treatment with azithromycin, rifabutin, and ciprofloxacin was initiated. Ethambutol was excluded because of color blindness.Case-patient 2 was a 30-year-old man who had pyrexia, pancytopenia, and lymphadenopathy. Advanced HIV infection had been diagnosed 1 month earlier . He started antiretroviral therapy 10 days before he came to the hospital. Culture of lymph node, peripheral blood, and sputum all yielded M. avium. We performed sensitivity testing , along with tedizolid. Rifabutin was discontinued because of concerns over its effect on bedaquiline pharmacokinetics.Shortly after linezolid and azithromycin were discontinued his fevers and neutropenia returned. Mycobacterial blood cultures again showed After bedaquiline and tedizolid were initiated, his fevers resolved, and he made a steady recovery and had no side effects. Given his high risk for relapse, he received bedaquiline for 18 months on the advice of the British Thoracic Society panel, ensuring a year of effective therapy since his last positive blood culture. He has successfully immune reconstituted, continues to receive only antiretroviral therapy, and remains healthy.M. tuberculosis, bedaquiline has been shown to decrease the time to sputum culture negativity and improve outcomes (Treating disseminated NTM infections is challenging and often complicated by antimicrobial resistance and adverse effects of combination drug therapy. In multidrug-resistant M. novocastrense, M. shimodei, and M. xenopi, are intrinsically resistant (M. avium (In vitro sensitivity of NTM to bedaquiline has been demonstrated (These 2 case-patients were given bedaquiline on compassionate grounds, given the lack of alternative options because of drug resistance and toxicity. For both patients, bedaquiline enabled construction of an antimicrobial drug regimen that included >2 drugs to which the organism was susceptible in vitro and probably contributed to their positive outcomes. Both patients tolerated the drug and made good clinical progress after its initiation. Given the need for combination therapy, it is impossible to attribute the positive outcome of these cases to a single drug. Both patients received bedaquiline and clofazimine because there is evidence that this combination is synergistic against NTMs in vitro (>1 year, and neither showed evidence of the acquisition of drug resistance or disease relapse over that time or since. These case-patients provide support for use of bedaquiline for treatment of disseminated NTM infection, particularly when standard regimens cannot be used because of drug resistance or adverse drug effects.Use of bedaquiline as salvage therapy for pulmonary NTM infection is often complicated by the emergence of drug resistance and disease relapse (


Adherence to antiretroviral therapy (ART) and retention in treatment programs are required for successful virologic suppression and treatment outcomes. As the number of adolescents living with HIV continues to increase globally, more information about adherence and retention patterns during and through transition from child- to adult-centered care is needed to ensure provision of a high level of care and inform development of targeted interventions to improve patient outcomes in this vulnerable population. In this analysis, we sought to describe long-term trends in adherence, retention, and virologic suppression in adolescents receiving ART at a pediatric HIV clinic in Nigeria through transition to the adult clinic.The Jos University Teaching Hospital, United States President’s Emergency Plan for AIDS Relief (PEPFAR)-funded HIV clinic in Jos, Plateau State, Nigeria.We conducted a retrospective observational longitudinal evaluation of data that had been collected during the course of care in a large pediatric ART program in Nigeria. We used descriptive statistics to define our patient population and quantify retention from ART initiation through adolescence and transition to adult-centered care. Logistic regression was used to evaluate predictors of loss to follow-up. We used medication possession ratio (MPR) to quantify adherence for each year a patient was on ART. To evaluate adherence and virologic suppression, we measured the proportion of patients with ≥95% MPR and the proportion with virologic suppression  within each age cohort, and used bivariate analyses to examine any association between MPR and VL suppression for all person-years observed.A total of 476 patients received at least one dose of ART as an adolescent (ages 10–19 years). The proportions of patients lost to follow-up were: 11.9% (71/597) prior to adolescence, 19.1% (31/162) during adolescence, and 13.7% (10/73) during transition to adult-centered care. While over 80% of patients had ≥95% medication adherence in all age groups, their viral load suppression rates through adolescence and post-transition were only 55.6%–64.0%. For patients that successfully transitioned to adult-centered care, we observed 87.7% (50/57) retention at month 12 post-transition, but only 34.6% (9/26) viral load suppression.Our evaluation found considerable proportions of adolescents lost to follow-up throughout the ART program cascade. We also found discrepancies between the proportions of patients with ≥95% MPR and the proportions with VL suppression, suggesting that true medication adherence in this population may be poor. Significant attention and targeted interventions to improve retention and adherence focused on adolescents are needed in order for global programs to achieve 90-90-90 goals. With the great success of antiretroviral therapy (ART), larger numbers of children living with HIV are surviving into adolescence and adulthood. Adolescents, defined as persons aged 10–19 years, constitute a major driving force in the continued transmission of HIV globally, particularly in sub-Saharan Africa (SSA) . AdditioFrom the start of the HIV epidemic, attention on adolescents living with HIV has been limited in many settings , 5. PresWe conducted a retrospective evaluation of routinely collected data from pediatric patients enrolled in the Harvard/AIDS Prevention Initiative in Nigeria (APIN) President’s Emergency Plan for AIDS Relief (PEPFAR) program between 2006 and 2016. We evaluated patient-level data to examine adherence, virologic suppression, and retention patterns through the adolescent years, the proportion that transitioned from CCC to ACC, and adherence, virologic suppression, and retention patterns 12 months post-transition.We conducted a retrospective evaluation of HIV-infected pediatric patients enrolled on ART between 2006 and 2016 at the Jos University Teaching Hospital (JUTH), a Harvard/APIN PEPFAR Program-supported ART site in Nigeria. The patients entered the program either following diagnosis of HIV infection through the prevention of mother-to-child transmission (PMTCT) clinics or through the HIV testing services. Upon enrollment in the Harvard/APIN PEPFAR-supported HIV care program, written informed consent for care was obtained from parents and written assent from children 7–17 years of age, both of which included an option for permission to use collected data for secondary research. All patients were assessed for ART eligibility according to age-specific Nigerian National ART Guidelines in place at the time the patient was under treatment, which followed the relevant current World Health Organization (WHO) recommendations at the time of receiving care and treatment , 22. TheAll ART-eligible patients in the pediatric HIV program were placed on treatment by a pediatrician following a clinical examination and a set of baseline laboratory tests, which included hematology, clinical chemistries, CD4+ cell count, and plasma viral load (VL) measurements. The majority of patients were prescribed a 30-day supply of antiretroviral (ARV) medications. According to the clinical guidelines, following the first prescription pick-up, refills were obtained monthly and patients returned to the clinics every three months for the first year and every six months thereafter for routine clinical evaluation and laboratory monitoring, including hematology, clinical chemistries, CD4+ cell count, and VL, unless an earlier evaluation was medically indicated. In reality, some clinical and laboratory visits were late, missed, or not recorded; stock outs of test kits, i.e., VL assays, also resulted in missed laboratory tests. Patients with a failing VL result after 6 months of ART received enhanced adherence counseling, including assessment, education, and support, and were scheduled to return for a second VL test in three months. Those with a consecutive failing VL result were switched to second-line (2L) ART as determined by the pediatrician. All patient clinical, laboratory, and pharmacy data were entered and stored in electronic databases .Per program protocol, adolescents receiving care in the JUTH pediatric HIV clinic transferred to the site’s adult HIV clinic, where they received new patient ID numbers, by 18 years, but as early as 16 years. The age of transfer depended on the adolescent’s readiness, willingness, and comfort, and on parents’ request (for some parents it was convenient to move their children earlier so that they could follow the same clinic schedule). The decision was made after an adherence counselor met with the adolescent and sometimes also with the parents/caregiver to discuss and assess the adolescent’s willingness, maturity, and understanding of their disease. We reviewed the clinical records of the adult HIV clinic to identify those who transitioned and to assess their 12-month outcomes. Additionally, we reviewed the records of 14 of JUTH’s PEPFAR-supported satellite HIV care sites in Plateau State to identify additional transfer patients that were not recorded in JUTH’s clinical records based on their demographic information. Additional transfer patients that were found at the pediatric satellite clinics were classified as transfers and censored on their last ART pick-up date at JUTH; no new transfer patients were found at the adult satellite clinics that were not already recorded at JUTH.We evaluated patient variables at ART initiation . Baseline clinical assessments or laboratory evaluations for naïve patients were the closest measurements to, and up to six months before or 0.5 months after, their first ART pick-up date. Virologic suppression was defined as a single VL below the limit of detection (≤400 cp/mL).We classified patients as lost to follow-up (LTFU) if they had missed their last scheduled ART pick-up appointment by more than two months as of the date the study data were censored. Pediatric program data were censored on July 29, 2016; data for patients who transferred to the adult program were censored at 12 months after the date of transfer . Patients who missed a scheduled appointment by more than two months, but returned to the clinic before the data censor date, were classified as retained in care; their treatment lapse would be indicated in their adherence measurement. Patients for whom death, withdrawal, or transfer to non-Harvard/APIN sites was recorded during the period of evaluation were not considered LTFU. Data on deaths, withdrawals, or transfers were passively obtained when either patients or their parents/caregivers provided the information; active tracking of patients that were late to appointments was not feasible as part of the program.We used medication possession ratio (MPR), as a surrogate for adherence, to quantify adherence patterns –27. For Χ2 test and Fisher’s exact test, as relevant, and of continuous variables using Student’s t-test and the Wilcoxon rank sum test, as relevant. Statistical significance was defined at an α-level of 0.05.We summarized baseline demographics and clinical characteristics using standard descriptive statistical methods. Additionally, we plotted patient entry and exit points from the cohort to demonstrate numbers of patients included in the evaluation, highlighting those that entered prior to adolescence  and those that entered during adolescence . Bivariate comparisons of categorical variables were performed using the We measured retention in CCC as a proportion: the number of adolescents (≥10 years) in the cohort receiving care at the age of transition (≥16 years) or at the censor date over the number of adolescents who received at least one dose of ART. Similarly, we measured retention in ACC as the proportion of patients receiving care at 12 months in ACC over the number who transitioned to ACC and had 12 months of observation time (not censored). Patients who transferred outside of JUTH’s PEPFAR network were treated as censored on the date of transfer for the analyses.We built a logistic regression model to examine predictors of LTFU. We considered all variables that were significant at the α-level of 0.20 in bivariate evaluations for the multivariate model. Potential relevant interaction terms were also tested as part of the modeling process, but no significant interactions were found at the α-level of 0.05. We excluded potential predictors that were not significant in the multivariate model by stepwise backward selection, and presented only variables that remained significant at the α-level of 0.05 in the adjusted model.To examine adherence as measured by MPR and VL suppression patterns by age, we conducted small cross-sectional evaluations by creating cohorts by age, including children in a group if they received treatment for at least two months during that year. If a patient had more than one VL during a given year, we used first measurement for the analyses. For each age cohort, we computed the proportion of patients with ≥95% adherence as measured by MPR and the proportion of patients with suppressed VL. We computed proportions with ≥95% MPR for all patients in the age cohort as well as for only those with VL values. We also looked at all person-years with VL values and calculated an overall proportion with ≥95% MPR and an overall proportion with suppressed VL, and performed bivariate analysis to examine any association between MPR and VL suppression.As a sensitivity analysis for patients who dropped out part way through a year due to either death, withdrawal or LTFU, we also computed MPR values for age cohorts using an intent-to-treat (ITT) approach, where MPR for the drop out year was calculated as number of pills provided during that year until drop out divided by the full 365 days. There was no statistically significant difference between the proportions of patients with ≥95% adherence as measured by MPR using the per protocol (PP) and ITT adherence values; thus, we reported PP data. As a sensitivity analysis for missing VL data, multiple imputations of VL data for each age category were generated and we recomputed and compared the proportions with undetectable VL, and no difference was found; therefore, we have presented values based on those patients with data available. Further, we performed another sensitivity analysis for missing VL data in which we considered patients with missing VL as detectable and repeated the bivariate analysis to evaluate any association between MPR and VL suppression.We conducted all statistical analyses using Stata version 13.1 .A total of 869 children initiated ART at JUTH between February 2006 and July 2016 see .After creating cross-sectional age cohorts for each adolescent year from age 10 to 19, we found that the largest age cohort within the adolescent group was those aged 10 years . The majOf the adolescents that initiated ART prior to age 10 years, 304 (91.8%) were infected through MTCT, whereas of those that entered at age 10 years or above, 91 (62.7%) acquired HIV through MTCT; for the children initiating ART at age 10 years or above, 42 (29.0%) did not have a documented mode of transmission . The medOverall, 379 of 476 (79.6%) of the adolescents that received ART were retained in CCC or transitioned to ACC at the end of the study period. Of those, 283 (74.7%) had been enrolled prior to adolescence while the remaining patients were newly initiated on ART during adolescence. 97 (20.4%) adolescent ART patients were not retained prior to reaching age 18 years; 5 (1.1%) had died, 35 (7.4%) transferred or withdrew, and 57 (12.0%) were considered LTFU. Within the LTFU group, 24 (42.1%) had enrolled on ART prior to age 10 years and 32 (56.1%) enrolled during adolescence. In multivariate logistic modeling controlling for potential confounding variables , older age at ART initiation, later enrollment year, and longer duration on ART appeared to have slightly lower odds of LTFU .Of the total person-years , the proportion with ≥95% adherence as measured by MPR was 85.0%, and of those that had VL data (906 person-years), the proportion with ≥95% MPR was 83.6%. However, the proportion of total person-years with suppressed VL was 61.0%.Within each age cohort, the proportion of adolescents with follow-up VL values and average adherence ≥95%, as measured by MPR, ranged from 80.4% to 100% for all age cohorts . Of noteIn bivariate analyses, examining association between adherence as measured by MPR and VL for all person-years where patients had VL data, we found that patients with ≥95% MPR were more likely than those with <95% MPR to have undetectable VL. 64.5% of the person-years for patients with ≥95% MPR were associated with undetectable VL whereas 44.2% of person-years for patients with <95% MPR were associated with undetectable VL (p<0.001). While optimal MPR was positively correlated with VL suppression, the proportions with undetectable VL were low among both those with optimal and sub-optimal MPR.The number of missing VLs over all person-years was considerable; 49.7%  of total person-years were missing VLs. However, we did not see a significant difference in MPR between those with missing VLs versus those with VLs. As a sensitivity analysis for person-years that were missing VLs, we performed another bivariate analysis in which we considered all missing VLs detectable; we still found a significant correlation between MPR and VL suppression, with 31.8% of person-years for patients with ≥95% MPR were associated with undetectable VL compared to 24.6% of the person-years for patients with <95% MPR were associated with undetectable VL (p = 0.015).For the evaluation of transition from CCC to ACC, a total of 162 patients that received at least one dose of ART as adolescents had enough observation time from their ART initiation point to reach age ≥16 years. Of the patients that had sufficient time since entry to have transitioned to ACC, 116 (71.6%) reached age 16 years while still in the JUTH ART program. The remaining patients did not reach age of transition in the JUTH program, where 12 (7.4%) transferred or withdrew prior to or at the time of reaching transition age, 3 (1.9%) had died, and 31 (19.1%) were LTFU. Of the 116 patients who reached age 16 years in the JUTH program, 43 (26.5%) had yet to transition at the end of the cohort observation period. Of the remaining 73 patients not censored, 58 (79.5%) were transitioned to ACC and 10 (13.7%) were LTFU. The median age at ART initiation for the patients for whom we could evaluate transition was 11.2 years (IQR: 9.5–13.9 years) and of those patients, 17 (29.3%) had initiated ART prior to age 10 years.Of the 58 patients that transitioned, 57 (98.3%) had been enrolled with sufficient observation time to evaluate retention at 12 months in ACC; of those patients, 50 (87.7%) were retained for at least 12 months post-transition, and 5 (8.8%) were LTFU. Despite 87.7% retention at 12 months post-transition, VL data were only available for 26 of those retained; of those with VL data, only 9 (34.6%) had an undetectable VL at 12 months post-transition. A sensitivity analysis comparing the 26 patients who had VL results and the 24 without VL results at month 12 showed that patients with risk factors other than MTCT or unknown appeared more likely to have VL results (70.6%) than those who acquired HIV through MTCT ; no differences were seen between the two groups by sex, age at enrollment, previous ARV experience, enrollment year, duration on ART, regimen, or VL at time of transition to adult program.Our retrospective evaluation found that 19.1% (31/162) of adolescents who received ART in the pediatric program and had enough observation time to reach age ≥16 years were LTFU before reaching the age of transition. Furthermore, while we found that over 80% of adolescents had ≥95% MPR in all age groups, less than 64.0% had VL suppression, suggesting that true adherence to medication was poor. Achieving high levels of retention and adherence in adolescent populations is fraught with challenges, which include stigma and discrimination, concomitant substance abuse, forgetfulness, suspicion of therapy, complicated regimens, decreased quality of life, work and family responsibilities, non-disclosure of HIV status, pill burden, drug toxicity and cost of transportation to the health facility . The uniBeyond adolescence, another consideration regarding long-term retention is transition to ACC. In our program, we found that 13.7% (10/73) of patients who reached the age of transfer and had sufficient observation time to transition to ACC were LTFU. More research is needed to identify the reasons why some adolescents fail to transition in order to inform program-specific interventions that promote successful transition , 30, 38.In this longitudinal evaluation, the proportion of patients with VL suppression throughout the adolescent years was below 64.0% among those with VL data. VL suppression was especially poor among the patients that were retained on ART at least 12 months post-transition to ACC, at a mere 34.6% (9/26) among those with VL data. This poor VL suppression in adolescents was most concerning of our findings in this evaluation. In the era of 90-90-90, where the third goal envisions 90% of patients virally suppressed, adolescents will pose a particular challenge in achieving targets.Prior studies utilizing pharmacy refill and/or MPR as proxy measures of adherence in adults have shown strong correlation with clinical outcomes –27, 51. Our findings suggest that both adherence counseling and monitoring for adolescents may require different methods than what is typically used for adults. Adherence counseling for adolescents should be effective without feeling punitive such that some adolescents may feel a need to hide poor adherence. Furthermore, since monitoring MPR does not necessarily provide a clear picture of VL outcomes, more regular VL monitoring for adolescents might be warranted, and particularly during the first year after transition to ACC. This will enable more timely adherence interventions, drug resistance testing when criteria are met, and quicker switch to 2L. Considering the widening disparity in MPR and VL suppression for 17 and 18 year olds, we suggest routine drug susceptibility testing for all viremic adolescents at the time of transition to ACC where resources are available. More research is required to clarify the potential clinical, psychosocial, behavioral and logistical reasons behind the disparity between the measures and to develop better ways to monitor and support adolescents.To our knowledge, this is the first longitudinal evaluation of a pediatric ART cohort through transition to adult care in Nigeria. A strength of this study is that we have over ten years of observational data, including available VL measurements, through which we were able to track the patients through adolescence and transition from CCC to ACC. A notable limitation given our study design was a small sample size for assessing transition from CCC to ACC. It also must be noted that the number of missing VLs was considerable. However, we found no significant difference in MPR between those with missing VLs versus those with no missing VLs and were able to demonstrate no change in overall interpretation of results in our sensitivity analyses. The lack of association between MPR and VL missingness may suggest that the missing VLs were due to programmatic issues, i.e., test kit stock outs, rather than patient level of engagement in care. It is also possible that clinicians may be more likely to prioritize VL testing for patients who appear to be less adherent or are not doing well clinically. Overall, despite the limitations, our study design allowed us to track a single cohort and show that even with limited numbers, we could reinforce that retention in adolescence must be addressed, and that for those that successfully transitioned and were retained 12 months post-transition, virologic suppression is a critical issue and adherence must be effectively measured and reinforced.There remains a need for research to inform development of evidence-based adolescent adherence and retention interventions as well as transition models for ART programs in RLS. As determinants of retention might differ by population, understanding rates of transfer and influences on those rates in RLS are critical for building evidence-based HIV-specific health care transition models in these settings . Our goaS1 FigShaded boxes highlight patients that received ART as adolescents; green shading highlights patients that initiated ART prior to adolescence and yellow shading highlights patients that initiated ART as adolescents.(TIF)Click here for additional data file.


The plasma concentration of patients treated with efavirenz (EFV) 600 mg was found to exceed the upper limit of the proposed therapeutic window in most Chinese HIV-infected individuals; thus, dosage reduction of EFV to 400 mg daily warranted consideration. This study aimed to assess the pharmacodynamics of EFV 400 mg for HIV-1-infected patients in China.Twenty cART-naïve individuals were enrolled in this study. EFV 400 mg combined with tenofovir (TDF) and lamivudine (3TC) as an initial antiretroviral regimen was administered for 48 weeks. EFV concentration and T cell subsets as well as HIV RNA load were evaluated at baseline and at 4, 12, 24, and 48 weeks. Moreover, neuropsychiatric adverse effects were also assessed by the Hamilton depression (HAMD) scale and Pittsburgh sleep quality index (PSQI).10 copies/mL at baseline, and it decreased by 4.6 (IQR: 3.98–5.18) log10 copies/mL from baseline to week 48. Three of 20 (15%), 10 of 20 (50.0%), 17 of 20 (85%), and 18 of 19 (95%) participants had a plasma viral load less than 50 copies/mL at weeks 4, 12, 24, and 48, respectively. The median CD4 cell count was 330 (IQR: 237–410) cells/μL at baseline, and it increased to 473 (IQR: 344–574) cells/μL at 48 weeks. The HAMD score was 5 (IQR: 3–9.8) and 3 (IQR: 2.25–4) at baseline and 48 weeks, respectively. The PSQI score was 4 (IQR: 2–5.8) and 3 (IQR: 2–4) at baseline and 48 weeks, respectively. Dizziness was the most common event, occurring in 70% of patients within the first 2 weeks of treatment.Eighteen males and two females whose median age was 26 (interquartile range [IQR]: 23–32) years completed 48 weeks of follow-up. The median EFV concentrations were 1.88 (IQR: 1.54–2.42), 1.74 (IQR: 1.36–1.93), 1.93 (IQR: 1.66–2.22), and 1.85 (IQR: 1.54–2.14) mg/L at weeks 4, 12, 24, and 48, respectively. The viral load was 4.59 (IQR: 4.10–5.19) logPatients prescribed with EFV 400 mg-containing agents demonstrated favourable virological and immunological responses. And the plasma EFV concentration was within the recommended therapeutic range, with fewer adverse reactions than with EFV 600 mg. EFV 400 mg was effective and safe in Chinese HIV-infected patients.NCT04596488; Registered 21 October, 2020; Retrospectively registered. It was reported that 38 million people were living with HIV-1 and that 25.4 million patients were accessing combined antiretroviral therapy (cART) worldwide in 2019 [However, neuropsychiatric adverse events, such as dizziness and nightmares, occur frequently in patients prescribed EFV, which forced many patients to replace EFV with other agents –8. InterSome literature has revealed that EFV 400 mg is safe and effective in HIV-infected patients , 13. HowWe performed a prospective trial from June 2017 to December 2018 at the clinics of the Department of Infectious Disease in Peking Union Medical College Hospital (PUMCH). Eligibility criteria for adult participants included (1) HIV treatment-naïve, (2) age of 18 years or older, (3) willingness to complete the HAMD and PSQI scales and follow-up regularly, and (5) not participating in other studies. The exclusion criteria were as follows: (1) acute HIV-1-infected patients; (2) an AIDS-defining illness within 2 weeks of entry; (3) transaminase and alkaline phosphatase levels beyond three times the upper limit of the normal range, bilirubin level more than 2.5 times the upper limit of the normal range, and serum creatinine level in excess of 1.5 times the upper limit of the normal range; and (4) pregnancy or breast feeding.Participants were assessed at baseline and weeks 4, 12, 24 and 48 for clinical adverse events, physical examination findings and biochemical analyses. Moreover, they were asked to complete the HAMD and PSQI scales at each visit.CD4+ T lymphocytes and CD8+ T lymphocytes were determined by flow cytometry  using commercially available monoclonal antibodies, and plasma HIV-1 RNA load was measured using a COBAS Ampliprep/TaqMan 48 Real-time RT-PCR Test  according to the manufacturer’s instructions. The detection range was from 20 to 1,000,000 copies/mL. Viral suppression was defined as a plasma HIV-1 viral load below 50 copies/mL. Those who were not capable of achieving a plasma HIV-1 viral load < 200 copies/mL after 48 weeks of treatment were considered to experience virological failure.Blood samples were collected in ethylenediaminete-traacetic acid (EDTA) tubes at weeks 4, 12, 24 and 48 of EFV 400 mg treatment in the morning. After centrifugation, plasma samples were transferred to and stored at − 80 °C until analysis. EFV concentrations were assayed in plasma samples at the Department of Pharmacy and Pharmacology at PUMCH using a validated high-performance liquid chromatography method with ultraviolet (UV) detection, as described in a previous study [Trained clinicians evaluated depression by asking patients whether they had experienced the items that are included in the HAMD scale in the prior week. Patients with scores < 8 on the HAMD scale were considered to be normal, patients with scores of 8 to 20 tended to be depressed, patients with scores of 20 to 35 were thought to be depressed, and patients with scores > 35 were severely depressed. Participants also self-administered the PSQI to evaluate sleep disturbance during the prior month. A score > 5 on the PSQI was defined as sleep disturbance in this study.The Institutional Review Board of PUMCH approved this study, and each participant provided written informed consent.p-value < 0.05. Descriptive statistics are presented as the mean with standard deviation (SD) or median (M) with interquartile range (IQR). Student’s t-test was used for parametric data, and the Mann-Whitney U test was conducted for comparison of noncategorical variables. Categorical variables were analysed by the Chi-squared test or Fisher’s exact test. Associations between continuous variables were tested using a nonparametric Spearman rank correlation test.Analyses were performed using SPSS 23.0 , and statistical significance was defined as a From a total of 166 cART-naïve patients seeking HIV care in PUMCH, 20 were eligible for this study. Reasons for exclusion are detailed in Fig. p > 0.05). Moreover, the EFV concentrations of 93.67% (74/79) of the samples were within the proposed therapeutic window of 1.0–4.0 mg/L. Only 6.33% (5/79) of patients had plasma EFV concentrations < 1.0 mg/L, at 0.884, 0.814, 0.916, 0.885, and 0.79 mg/L. None of the patients had EFV concentrations > 4.0 mg/L , 1.74 (IQR: 1.36–1.93), 1.93 (IQR: 1.66–2.22), and 1.85 (IQR: 1.54–2.14) mg/L, respectively. No significant difference was found in EFV concentration at any time-point  log10 copies/mL. At 48 weeks, the median decrease from baseline was 4.6 (IQR: 3.98–5.18) log10 copies/mL  log.24 IQR: .98–5.18 .24 IQR: .98–5.18 Overall, the median HAMD scores were 5 (IQR: 3–9.8), 3 (IQR: 2–6), 3.5 (IQR: 1.0–4.8), 3 (IQR: 2–6.5), and 2 (IQR: 1–3.5) at baseline, week 4, week 12, week 24, and week 48, respectively. Six patients were likely to be depressed at baseline, and the condition did not progress during the follow-up. The median PSQI scores were 4 (IQR: 2–5.8), 3.5 (IQR: 2–5), 3 (IQR: 2.3–4.8), 3 (IQR: 1.5–6.5), and 4 (IQR: 3–6) at baseline, week 4, week 12, week 24, and week 48, respectively. None of them experienced poor sleep throughout the duration of follow-up  . The ENCThe common EFV-related CNS adverse events were dizziness, abnormal dreams, insomnia, and depression , 24. It The PSQI includes a 19-item questionnaire that evaluates sleep quality and efficiency during the prior month . The HAMOur study has several limitations that warrant mention. First, this is a pilot study with a limited sample size and thus limited power. Therefore, a randomized, multicentre study should be performed to further investigate the efficacy and safety of EFV 400 mg in HIV-infected individuals from China. Second, we were unable to measure the frequency of the G516T polymorphism , 31–34, Our study preliminarily demonstrated that EFV 400 mg-containing regimens were successful in suppressing HIV RNA replication and rebuilding immunological function in HIV-infected Chinese patients. Importantly, the plasma EFV concentration remained within the normal range, and CNS toxicity was reduced. These results suggested the efficacy and safety of EFV 400 mg in HIV-infected individuals from China, providing more appropriate treatment for these patients.


Early detection of viremia in HIV infected patients on anti-retroviral therapy (ART) is important to prevent disease progression as well as accumulation of drug resistance mutations. This makes HIV viral load (VL) monitoring indispensable in HIV infected patients on ART. However VL, being an expensive test, results in heavy financial burden on health services. Hence, cheaper surrogate markers of viremia are desired to reduce overall cost of management of HIV infected patients.We enrolled aviremic  and viremic  HIV infected patients at 1 year after ART initiation. Viremic individuals were identified as those having a plasma VL of more than 1000 copies/µl and aviremic individuals as less than 40 copies/µl. The study participants also included immuno-virologically discordant patients as they demonstrate differential degrees of immune-reconstitution and are likely to harbour concomitant infections influencing levels of immune-activation markers screened as the surrogate markers. Immune activation markers viz. plasma hs-CRP, soluble-CD14 and Galectin-9 levels were estimated by ELISA, IL-6 by luminex assay and percentages of CD38+ CD8+ cells were determined by flow cytometry. The levels were compared between viremic and aviremic patients and correlated with plasma viral load. Receiver operated curve (ROC) analysis was done for plasma Galectin-9 levels.Viremic patients had significantly higher levels of Galectin-9 and %CD38+ CD8+ cells  than aviremic patients. Levels of the other activation markers did not differ between viremic and aviremic individuals. Galectin-9 levels (r = 0.76) and %CD38+ CD8+ cells (r = 0.39) correlated positively with VL. Area under curve for Galectin-9 levels for distinguishing between viremic and aviremic individuals was 0.98. Youden index, sensitivity, specificity, positive predictive value and negative predictive value for Galectin-9 levels were 0.87, 0.97, 0.90, 0.87 and 0.98, respectively, at the cut-off value of 5.79 ng/ml.Plasma Galectin-9 levels could identify viremic individuals with sensitivity and specificity of more than 90%. Thus, they showed a potential to serve as a surrogate marker of viremia in HIV infected patients on ART and would have cost implications on HIV management especially in resource-limited settings. However, the findings need to be confirmed in the patients on ART for different durations of time. Antiretroviral therapy (ART) has significantly impacted Human Immunodeficiency Virus (HIV) epidemic worldwide. The primary goal of ART is to suppress HIV viral load. UNAIDS 90-90-90 target for elimination of HIV as a public health threat includes achievement of viral suppression in the treated individuals as its last ‘90’ . FailureWHO has recommended annual viral load testing for monitoring HIV infected patients on ART . HoweverThere have been several studies to identify surrogate biomarkers of viremia. CD4 count is being used as a marker of treatment success and is a part of patient management under our programme also. However, immune-virologically discordant responses are known to occur in 8–24% of the patients on ART  reducingWe evaluated immune activation markers like high sensitivity C-reactive protein (hs-CRP), soluble CD14 (sCD14), bacterial lipopolysaccharide (LPS), Interleukin-6 (IL-6), Galectin-9, CD38 expressing CD8+ cells to determine their role as a possible surrogate marker of viremia. Being immune activation markers, their elevated levels have been reported in different infections even in HIV uninfected individuals. However, these markers were also shown to correlate with HIV viral loads in different studies and hence were selected in the present study , 12–16. This was a cross-sectional study conducted at ICMR-National AIDS Research Institute (ICMR-NARI). HIV infected patients at 1 year after initiation of anti-retroviral therapy were enrolled from Yashwantrao Chavan Memorial Hospital (YCM) and B.J. Medical College (BJMC) ART centers. HIV infected patients visiting these centres were screened based on their CD4 counts at baseline and at 1 year as well as viral load values at 1 year to identify the eligible study participants. Patients with the rise of at least 100 CD4 cells/μl and viral load of less than 40 copies/ml were selected as treatment responders. Patients with the rise of less than 50 CD4 cells/μl and viral load of less than 40 copies/ml were selected as Immunologic non-responders (INR). Viremic patients with viral load of more than 1000 copies/ml were enrolled under two categories. Treatment failures had immunologic failure as defined under the national guidelines and Virologic non-responders (VNR) had an increase of at least 50 CD4 cells/μl. Blood samples collected after written informed consenting procedure. Plasma and PBMC were separated by density gradient centrifugation using Ficoll-Hypaque.Plasma concentrations of Galectin-9, hs-CRP, sCD14 were measured using commercially available ELISA Kits . The ELISAs were performed according to manufacturers’ manuals. Concentrations of the immune-activation markers in the samples were determined by plotting standard curve as per the manufacturer’s instructions.Plasma LPS levels were determined using Limulus Amebocyte assay . Plasma samples were heat-inactivated by incubating at 60 °C for 30 min before measuring the levels.Frequency of CD38+ CD8+ cells in the study participants was determined in by flow cytometry using frozen PBMCs. PBMCs were revived and rested for 2 h before staining them with anti-CD3 PE/Dazzle 594 , anti-CD8 APC/Cy7 and anti-CD38 FITC  as described previously . The celInterleukins 6 (IL-6) levels were estimated in plasma samples by a luminex assay along with other proinflammatory cytokines using Bio-Plex 200 system  as per the manufacturer’s instructions.Data analysis was done using GraphPad Prism software. Non-parametric tests were used for the statistical analysis. Mann–Whitney  test was used for comparison between viremic and aviremic groups. Multiple group comparisons were assessed through Kruskal–Wallis test with Dunn’s multiple comparison testing. Correlations with viral loads and CD4 counts were done using Spearman correlation test. easyROC: a web-tool (ver. 1.3.1) was used for receiver operating characteristic (ROC) curve analysis.Characteristics of patients enrolled in the study are mentioned in Table Systemic immune activation was assessed by estimating CD38 expressing CD8+ cells and soluble markers like hs-CRP, sCD14, LPS, IL-6 and Galectin-9. Levels of these markers were compared between viremic versus aviremic individuals  for the levels was slightly lower than the negative predictive value (98%). Very high sensitivity and negative predictive value indicated role of the levels as a screening test for identifying viremic patients. However considering its lower positive predictive value and specificity, the results would be required to be confirmed further by viral load test to avoid misidentifying aviremic individuals as those having virologic failure. The rate of virologic failure has been shown to vary from 2.9 to 26.0% in patients in Sub-Saharan Africa and Southeast Asia  indicatiOther markers like hs-CRP, sCD14, LPS and IL-6 did not vary significantly among viremic and aviremic individuals. Virally suppressive ART had been shown to have no effect on CRP levels in one of the studies  and coulThus systemic immune activation markers like hs-CRP, sCD14, IL-6, LPS did not vary significantly in viremic and aviremic individuals precluding their role as surrogate markers of viremia in HIV infected patients on ART. Among the two markers, plasma Galectin-9 levels and frequency of CD38CD8+ cells which differed significantly in these individuals, plasma Galectin-9 levels correlated strongly with viral load values. ROC curve analysis demonstrated very high sensitivity and slightly lower specificity of the levels in diagnosing the patients with viremia suggesting its role as a screening test for identifying viremic HIV infected patients on ART. This cheaper and simpler ELISA test could help to cut down cost of HIV management tremendously and also might help to increase coverage of virologic monitoring even in resource-limited settings and hard to reach population. However, the findings need to be confirmed on a larger sample size and in HIV infected patients with varying durations of ART since the patients included in the study were on ART for 1 year.