Introduction: In 2016, Rwanda implemented “Treat All,” requiring the national HIV programme to increase antiretroviral (ART) treatment coverage to all people living with HIV. Approximately half of the 164,262 patients on ART have been on treatment for more than five years, and long-term retention of patients in care is an increasing concern. To address these challenges, the Ministry of Health has introduced a differentiated service delivery approach to reduce the frequency of clinical visits and medication dispensing for eligible patients. This article draws on key policy documents and the views of technical experts involved in policy development to describe the process of implementation of differentiated service delivery in Rwanda.Discussion: Implementation of differentiated service delivery followed a phased approach to ensure that all steps are clearly defined and agreed by all partners. Key steps included: definition of scope, including defining which patients were eligible for transition to the new model; definition of the key model components; preparation for patient enrolment; considerations for special patient groups; engagement of implementing partners; securing political and financial support; forecasting drug supply; revision, dissemination and implementation of ART guidelines; and monitoring and evaluation.Conclusions: Based on the outcomes of the evaluation of the new service delivery model, the Ministry of Health will review and strategically reduce costs to the national HIV program and to the patient by exploring and implementing adjustments to the service delivery model. Sub-Saharan Africa carries the highest burden of HIV, with approximately 70% of all people living with HIV worldwide living in the region. Despite major progress by governments, donors, and international and national implementing partners, access to antiretroviral therapy (ART) in sub-Saharan Africa remains below the global average, with less than 50% of people living with HIV on ART, and coverage is considerably lower in some countries in the region .Rwanda is one of a few countries in sub-Saharan Africa that has achieved high rates of HIV diagnosis and ART coverage, along with high rates of retention and medication adherence with viral suppression ,3. As ofThe successes of Rwanda’s national HIV programme are closely tied to a series of health system improvements made over the past 15 years, including a strengthened infrastructure, introduction of community-based health insurance, improved workforce skills, and training of community health workers to deliver preventive, diagnostic and therapeutic services at the village level .Despite successes, Rwanda faces new challenges and opportunities for increasing and sustaining access to antiretroviral therapy. In July 2016 new guidelines were launched implementing “Treat All,” under which all identified people living with HIV (PLHIV) would immediately begin ART irrespective of immunological or clinical status –9, but cThe national ART coverage target to reach 81% (the second “90” of the UNAIDS 90–90-90 targets)  of PLHIVThese two challenges of increasing enrolment and ensuring long-term retention have pushed the Ministry of Health of Rwanda to implement new operational strategies. These include reorganizing the existing patient flow and the frequency of clinical visits and the collection of medication from the pharmacy.Patient flow has been simplified by removing two steps – registration and vital signs regular checks at HIV clinic reception, clinic consultation for file records; the pharmacist at each clinic has been trained to capture key information required before delivering ARVs at each pick up visit in a short time; and unnecessary visits have been removed such pre treatment and regular counselling sessions.Previous ART guidelines recommended clinic visits every three months for medical consultations, monthly medication pick up, monthly adherence counselling, and every three months visit for psychosocial support. The latest ART guidelines, issued in July 2016, recommend differentiating ART delivery, with spaced clinic visits and pharmacy pick up for patients who are stable on ART, with the anticipated outcomes of increasing efficiencies at the site level for the benefit of patients and clinical staff, leading to sustainable cost savings.This article summarizes the sequential policy actions taken towards phased implementation of spaced clinic visits for stable patients in Rwanda.Implementation of spaced clinic visits, as outlined in The first step was to convene a national technical consultation, which was held in August 2015. This immediately proceeded the meeting of the WHO guidelines development group in which the evidence supporting spaced clinic visits was presented . The natIt was recommended that for the first phase of the new service delivery model a stable patient would be defined as “a PLHIV >15 years old who has been on ART for 18 months with two viral load results of less than 20 copies/ml using Amplicor HIV-1 DNA test v1.5. and who is considered adherent (defined ≥90% adhering to taking their self-reported ART medication) under ART guidelines.” Under this initial definition, up to 85% of all PLHIV on ART would be defined as “stable.” The last viral load will be considered as recent if the results were reported at least after two months after blood collection for the test. All adult clients on second- and third-line treatments requesting to be part of the differentiated ART model, and fulfilling the eligibility criteria, are further evaluated and, if they show adequate adherence to treatment and viral suppression, are enrolled in the new ART model. Similarly, in accordance with other existing national guidelines, all members of key population groups can be included provided they meet the general eligibility criteria.The following patients are currently considered non-eligible for the new model: all PLHIV clients on ART less than 18 months; patients on second and third line ART and not meeting adherence and viral load criteria; patients co-infected with NCDs such as diabetes, cancer, and heart disease in the intensive period of treatment until clinical symptoms are stabilized, pharmacy visit and laboratory visits will be coordinated with visits for their chronic conditions until patients is stabilized for that condition, that is patients hospitalized or in acute phase management; malnourished PLHIV  in nutrition follow up services; all HIV positive clients who have TB and/or hepatitis (C and B) co-infections until after six months of ARVs treatment; and children under 15 years of age defined by the national HIV guidelines as paediatric patients.Patients in this category will follow the standard ART guidelines: three monthly medical consultations, monthly medication pick up, monthly adherence counselling, and three monthly psychosocial support.With the introduction of the “Treat All” recommendations and the expanding availability of ART , it is aThe model aims to delink clinical visits from ART refills visits for stable patients by decreasing patient clinical visits to once every six months and pharmacy pick-up for medication visits (both ARVs and OIs prophylaxis) to once every three months ,14. PharSelection of stable patients for the new ART model is anticipated to take a month. High volume sites will enrol patients in cohorts (i.e. groups of patients attending the clinics at the same time) and these facilities will take a maximum of three months to enrol all patients in cohorts. The clinics can organize a reasonable number of cohorts given total number of patients (20–30) per cohort.Health providers at health facility level will use patient registers and patient charts to classify patients receiving ART in different categories including: patients eligible for the new model; patients non-eligible for new model; and special considerations , patients with other co-infections, and other considerations to be addressed on a case-by-case basis).Health providers, supported by clinical mentors, will coordinate routine clinical consultations, planned medicine pickup with laboratory visits to reduce visit frequencies for patients. During the preparation phase, health providers will register stable patients (those eligible for the new spacing model) who have the same day visits and group them as a cohort. These patients/cohorts will be required to attend clinic on the same day to receive the same services.Patients eligible for new ART delivery model are required to participate in one to two education and counselling sessions. During these sessions, health providers assess willingness to participate in the model, explain the benefits and risks related to the model, and summarize how the model works . If eligible patients are pregnant women, adolescents, or patients with any chronic diseases that have a different consultation schedule, education sessions are adapted to a particular group, focusing on challenges for that specific group and how ART model will be aligned with the exiting conditions.In parallel, support has been provided to community HIV services platforms to improve linkage and retention in treatment and adherence for all PLHIV including children born to key populations. At the community level, community healthcare workers and volunteers refer children to health facilities for HIV services. Facilities also work with community structures, including support groups and peer educators, for adherence support promotion, and retention in care.Pregnant or breastfeeding mothers on ART will require different follow-up and health providers need to coordinate their clinical and pharmacy visits with ANC or PMTCT visits on a quarterly basis. A different frequency of clinic visits for pregnant women is used from the beginning of pregnancy until the end of the breastfeeding period. At the end of breastfeeding period, pregnant and breastfeeding mothers who meet all other eligibility criteria can then be enrolled in the new ART model. However, follow up of exposed and infected new born and younger children remains a special case requiring more regular contact with health services, both at the clinic and in the community.Due to school routines and other competing priorities, adolescents at schools are scheduled for pharmacy and clinical visits every three months, timed with school break periods. All adolescents in school continue in this model until the end of their secondary education and at least 19 years of age. After this time they are transitioned to the spacing model as adult patients provided all other eligibility criteria are met. Adolescent out of school are be considered on a case-by-case basis based on virological, adherence and socioeconomic criteria.Civil society and the private sector have been engaged to provide inputs through a civil society organization (CSO) consultation held in February 2016. This meeting engaged numerous community partners and their constituencies, including the NGO umbrella groups for health CSOs and PLHIV, as well as the CCM Secretariat, UNAIDS, and MOH/RBC. A second consultation was held during a mid-term review of the national ART programme in June 2016. During this process, civil society groups and implementing partners were encouraged to voice concerns on the new ART and service delivery model. Concerns were raised about implementation considerations: Increase of lost to follow up while contacts to clinics will be spaced- quality of household storage of drugs and associated losses or misuse.In mid-2016, the RBC conducted a series of consultative meetings and workshops with health care providers, clinical mentors, district pharmacy directors, local leaders and community health workers. The objective of this consultation process was to seek support and feedback for the implementation of the new service differentiated model. During these consultations, experience sharing from the providers helped RBC to refine implementation steps including for example, the need to increase the storage space at the District Pharmacies.The recommendations from the technical working group were presented to the Minister of Health, Minister of State for Public health and Primary Health Care, and the Permanent Secretary for Health, for agreement in December 2015. Following this, a costed plan was presented to US President’s Emergency Plan for AIDS Relief (PEPFAR) to request US$4 million one-time additional central funding to cover the transition to three-month drug pick-ups nationally for stable patients and the related supply chain monitoring in order to increase the national buffer stock to support the rollout of the three-month drug pick-ups. PEPFAR approved US$3.67 millions of this request in June 2016 during PEPFAR’s Country Operational Plan (COP) review meeting.Since 2005, the funding allocation for commodities in Rwanda is done by using a “common basket” mechanism; largely depending on external donor contributions. Under the Coordinated Procurement and Distribution System (CPDS) all actors in quantification, procurement and distribution from government, bilateral and multilateral partners meet regularly to estimate the needs and submit their report to Resource Management Committee (RMC) of the CPDS. The RMC requests financial contributions from each partner. In 2016, Of the total needs for ARVs, laboratory commodities and drugs for opportunistic infections prophylaxis and treatment; PEPFAR contributed 26 million USD , the Global Fund contributed 19 million USD while The government of Rwanda has been investing in supporting infrastructure, running costs and personnel for HIV supply chain systems.Quantimed, a quantification software tool developed by USAID’s Strengthening Pharmaceutical Systems Project [The national HIV Quantification Committee drafted a supply plan for all ARV drug needs in Rwanda in December 2015. The quantification exercise was supported with the use of Implementation of the three-month drug supply policy will occur as soon as the buffer stock was in place at facility level. In line with current practices within the national supply chain system, health facilities will calculate and order additional quantities necessary for subsequent orders. Additional shipments are needed for procurement to meet the demand on the national commodities supply due to the change in the service delivery model to three-month drug pick-ups. The cost of the entire ARV procurement needed to cover the transition was calculated at $US 3,677,180 USD. It was estimated that additional extra cost on other supply chain expenditures is minimal and could be managed within existing budget.Ongoing monitoring of the supply chain on at least a quarterly basis will be put in place to adjust future shipments, monitor stock status, and avoid situations of expiry or stock out of medications. A full review of the implementation of the new policy and its effect on the distribution and storage system by the new supply chain mechanism is planned within the first quarter of rollout. Outputs from this review will inform future decisions regarding inventory control and distribution and procurement, as well as the national quantification of commodities, in order to realize cost savings and ensure commodity security. Based on all of these factors, the implementation of the three-month drug pick ups is, planned to start in December 2016.The revision of comprehensive HIV guidelines in Rwanda is carried out every two years based on most recent evidence available and priorities for the country and is a broadly consultative process involving experts from national technical working groups, implementing partners, bilateral and multilateral funding partners involved in HIV response in Rwanda, and external experts.The revision and approval of the 2016 guidelines was concluded with the endorsement by the Ministry of Health. A nationwide training of health care providers was undertaken over a three-month period to ensure that at least two nurses in each of the 500 health centres in Rwanda were trained to implement the new guidelines. Trainings consisted of an overview on basics in HIV testing, treatment, and follow up, the benefits of the Treat All strategy, and evidence supporting differentiated service delivery and how best it can be implemented according to the country context. The trainings combined both expert presentations and groups discussions. At the end of each session, participants were encouraged to suggest improvements in the implementation plan. In addition, RBC has established clinical mentorship teams (one nurse and one doctor) who received advanced training in HIV management, located at each district hospital and supporting all health centres in the catchment area. These teams provide continuous education and skills transfer to the nurses responsible for managing ART. At the end of each training, participants received a written summary of the guidelines and the Ministry of Health issued an official letter to implement the new changes.Each health centre was tasked to assess the number of stable patients and clinical services implementing partners will contact sites regularly to ensure that all sites are implementing the new service delivery model according to the national guidelines. Health centres are supported by clinical mentors to identify stable patients ahead of implementation. Implementation will be phased to allow for adaptation as necessary. Starting in October 2016, stable patients having an appointment will be asked to come back after six months and will be told to keep coming monthly for their drug pick ups only until the three-month drug pick ups are aligned with the patient’s new clinical visit schedule pending additional drugs for three months pick ups are expected to arrive in December 2016. These two appointments are conducted in different offices and drug pick up at pharmacy takes approximately five minutes while clinical visit in a consultation room is estimated to 20 min per patient. With an estimated average of ten consultations a day per health care provider, the spacing of clinical visits is expected to result in the following benefits: reduced burden on the clinics; increased time and quality of care for cases that need more clinical investigation; reduced frequency of travel for patients; and reduced likelihood of inadvertent disclosure of status as clients will spend less time in clinic services.On 1 December 2016, patients with appointments for ARVs will receive 3 months supply if classified as stable and will be asked to come back one week before the end of their three-month stock. The transition to three-month drug pick-ups is expected to rollout over the course of three months so that at the end of the three-month period, beginning in December 2016, all stable patients will be receiving three months of drugs and will align one of every two three-month drug pick ups with one of the six-clinical visits . During Expected challenges include: stock outs ; loss to follow up ; sharing of pills between patients; and issues of home storage of ARVs and confidentiality:To mitigate these anticipated challenges, a quantification and distribution team has been established and tasked to meet every two weeks to monitor implementation and report regularly to the leadership of the RBC and MoH for real time changes and decisions making. The technical working group will continue to discuss the role of community workers in implementation of the new model in the framework of peer support to the network of people living with HIV.Implementation of the new model will be adaptive so that on a quarterly basis, changes may be incorporated according to information and data received during implementation. For example: three-month pick ups may be better implemented in rural settings than in urban areas given high patients mobility in urban areas; if this is found to be the case, a two-month pick up may be proposed for such areas.The National HIV program with support from PEPFAR through CDC and WHO has established a technical group in strategic information to design how the new model will be evaluated on technical performance and financial reporting. Rwanda has a good M&E infrastructure for HIV with the TRACNet database that has been operating since 2004 and has recently been successfully integrated into Health Management Information System (HMIS). Since 2010 The TRACNet/HMIS has an interoperability system with Electronic Medical Record (EMR) and captures most of HIV individual patient data from testing to enrolment and follow up, covering 305 health facilities out of 500 existing in Rwanda. These systems will provide key data to track progress in the implementation of Treat All and outcomes of the new service delivery .Enhanced indicators will be included such as number of patients that came for clinical visits and drug pick ups will be added in existing M&E systems. Financial indicators will be included based on visit and pick-up indicators, including case load of health workers and time spent to consult the patient.Based on the success of the new service delivery model, the Ministry of Health will review and seek to further strategically reduce costs to the national HIV program and to the patient by exploring and implementing adjustments to the service delivery model. For example, moving to 12-month clinical visits and 6-month prescription drug refills, and expanding the definition of “stable patient” to be more inclusive and reach more PLHIV. These and other modifications such as viral load results turn around time, adherence measurement to the service delivery model will seek to support the continued delivery of ART as part of the national HIV programme while maintaining quality.


Human immunodeficiency virus/Acquired immunodeficiency syndrome associated morbidity and mortality has reduced significantly since the introduction of highly active antiretroviral therapy. As a result of increasing access to highly active antiretroviral therapy, the survival and quality of life of the patients has significantly improved globally. Despite this promising result, regular monitoring of people on antiretroviral therapy is recommended to ensure whether there is an effective treatment response or not. This study was designed to assess virological and immunological failure of highly active antiretroviral therapy users among adults and adolescents in the Tigray region of Northern Ethiopia, where scanty data are available.A retrospective follow up study was conducted from September 1 to December 30, 2016 to assess the magnitude and factors associated with virological and immunological failure among 260 adults and adolescents highly active antiretroviral therapy users who started first line ART between January 1, 2008 to March 1, 2016. A standardized questionnaire was used to collect socio-demographic and clinical data. SPSS Version21 statistical software was used for analysis. Bivariate and multivariate logistic regression analyses were conducted to identify factors associated to virological and immunological failure. Statistical association was declared significant if p-value was ≤ 0.05.+ T-cells count < 250 cells/μL and male gender. Similarly, immunological failure was associated with non-adherence, tuberculosis co-infection and Human immunodeficiency virus RNA ≥1000 copies/mL.A total of 30 (11.5%) and 17 (6.5%) participants experienced virological and immunological failure respectively in a median time of 36 months of highly active antiretroviral therapy. Virological failure was associated with non-adherence to medications, aged < 40 years old, having CD4The current result shows that immunological and virological failure is a problem in a setting where highly active antiretroviral therapy has been largely scale up. The problem is more in patients with poor adherence. This will in turn affect the global targets of 90% viral suppression by 2020. This may indicate the need for more investment and commitment to improving patient adherence in the study area. Proper phocytes ,5Major challenges especially in low and middle income countries such as poor adherence to medications , defectsHIV infected individuals on HAART are usually recommended to monitor clinically, immunologically and virologically on a regular manner to ensure successful treatment, identify adherence problems and determine whether HAART regimens should be switched or not. Compared to clinical or immunological monitoring, virological monitoring provides an early and more accurate indication of treatment failure and the need to switch from first-line to second-line drugs, reduce the accumulation of drug resistance mutations and improving clinical outcomes. However, due to the high costs and technical demands of the test, clinical and immunological assessments are usually recommended to start and monitor the efficacy of therapy . As a reAs of 2016, 19.5 million people living with HIV were accessing ART with an approximate coverage of 53%. Of these, 11.7 million people accessing ART were from East and southern Africa with coverage of 60% . EthiopiThere are substantial numbers of ART users in the Tigray regional state , howeverThe study was conducted in Mekelle Hospital (MH) and Ayder Comprehensive Specialized Hospital (ACSH), both located in Mekelle city. Mekelle, the capital city of Tigray Regional state is located 783 Km north of Addis Ababa, the capital city of Ethiopia. There are five public hospitals in the city. These two hospitals were selected purposely due to their higher flow of patients. MH is administered by the Tigray Regional Health Bureau, whereas ACSH is a University hospital under the Federal Ministry of Education. According to the information obtained from the ART clinics, by May 2016 there were about 8,727 and 1,564 people living with HIV (PLHIV) ever enrolled; 6,789 and 1,387 ever started ART; 4,189 and 1,222 were actively on ART in MH and ACSH, respectively. The sample size (n = 260) was determined using the single mean proportion formula.+ count) were also collected from each study participants prospectively using questionnaire during data collection period, September 1 to December 30, 2016.A retrospective follow up study was used on HIV infected individuals on first line ART. Base line and follow up clinical and laboratory data were collected from each study participants’ medical records using checklists. In addition, socio demographic characteristics, clinical and laboratory data  and adults (≥20 years) who initiated HAART between January 1, 2008 and March 1, 2016. Patients who were less than 6 months on ART, who had been on second line regimen, lost to follow up, febrile, and transfer in were excluded from the study. Virological and immunological failures defined based on WHO consolidated guide line 2016 were the primary outcome variables of the study. Socio-demographic characteristics  and information related to HIV infection and ART  were the predictor variables.RNA extraction and Plasma Viral load Determination: During the collection time we collected blood samples for each patient and did a single viral load using the standard procedure. Briefly, HIV-1 RNA was extracted from 0.2 mL of plasma using Abbott m2000sp automated sample preparation system  in Tigray Health Research Institution (THRI). Extracted RNAs were measured using Abbott m2000rt quantitative Real Time HIV-1 assay  with HIV-1 RNA detection level of 40 to 10 million copies/mL based on the manufacturer’s procedures.CD4+count: Data on CD4+ T-cells count which was measured at baseline and every six months of interval then after during regular follow up visit was collected from medical charts. In addition, we have also collected blood samples from each participant during the data collection period and measured CD4+ count at ACSH ART laboratory using the BD FACSCount TM  following the manufacturer’s protocol (“.+ count) were included in each test to evaluate run validity. Furthermore, CD4+ and viral load reagents were checked for expiry date. Filled forms and questionnaires were checked for completeness and consistency daily during data collection period by principal investigator.Quality of laboratory data was kept by strictly following standard operational procedures during sample collection, handling and transportation. Negative, low positive and high-positive ; and low, medium and high controls  was used to compute continuous variables and counts with percentage for categorical variables. Binary and multiple logistic regressions were used to examine the relationships of independent variables with the primary outcomes. A p-value of ≤ 0.05 with 95% confidence interval was considered as statistically significant correspondingly.+ and viral load results were attached with the patients’ medical records to be used as follow up and base line data respectively. Study participants who had virological and immunological failures were linked with responsible health professionals for proper management.Institutional ethical clearance was obtained from the Mekelle University, College of Health Sciences Ethical Review Committee (ERC0816/2016). Written informed consent or assent was also obtained from study participants and/or families and/or guardians. Furthermore, permissions were also obtained from Tigray regional health bureau and medical directors of Mekelle hospital and Ayder Compressive Specialized hospital. Each data was kept confidentially using codes and initials instead of names. CD4.A total of 260 HIV infected individuals on first line ART regimen were included in the study, of which 151 (58.1%) of them were females. The minimum and maximum age of the participants was 10 and 63 years old, respectively with median age of 39 (IQR: 32–48) years old. One hundred seventeen (45.0%) were married, and 229 (88.1%) of the study participants were infected through sexual contact. The majority 197 (75.8%) of the study participants were attended primary school and above. One hundred four (40%) of them were self-employed with a median income of 1500 birr. Urban dwellers accounted 211 (81.2%) of the participants + count was162 cells/uL (IQR: 85–269) and increased by 116 cells/uL, and reached 278 (IQR: 172–413) cells/uL after 6 months of HAART. It further increased to 300, 336, 395 and 398 cells/uL after 12, 18, 24 and 30 months of HAART, respectively (“).Study participants were on first line HAART for 6 to 108 months with a median follow up time of 36 months. The baseline median CD4+ count below 100 cells/μL which is an indication of immunological failure. The median age among those who had poor immunological recovery was 39 (IQR: 33–43) years. 9/17 (52.9%) and 10/17 (58.8%) of them were males and were given TDF 3TC EFV at base line respectively. In addition, 11/17 (64.7%), 11/17 (64.7%) and 7/17(41.2%) of them have history of malnutrition, opportunistic infections and non-adherence at least once respectively. Furthermore, 11/17 (64.7%) and 14/17 (82.4%) of them had CD4+ count < 100 cells/μL and WHO clinical stage III/IV at base line respectively.In median time of 36 (IQR: 24–54) months of ART follow up, 17 (6.5%) of the study participants had persistent CD4.Non-adherent study participants were 5.68 times more likely to experience immunological failure (AOR (95% CI) = 5.68 (1.86–19.8), p = 0.021) compared with those who were good adherent by adjusting TB co infections and viral load. Furthermore, it was statistically significant that patients having HIV RNA level ≥ 1000 copies/mL had 12.33 times higher odds of immunological failure (AOR (95% CI) = 12.33(3.06–29.7), p<0.0001) than those who had < 1000 copies/mL by adjusting other factors. Likewise, immunological failure was 3.8 times more likely to occur in TB co-infected individuals (AOR (95% CI) = 3.80 (2.01–12.90), p = 0.003) compared to TB non infected individuals by adjusting adherence and high viral load  was 12,239  copies/mL and 202 (IQR: 87–350) cells/μL respectively.Of the 260 participants, 221 (85%) of them had suppressed viral load (Plasma HIV RNA level: <150copies/mL), 9 (3.5%) had 150–999 and 30 (11.5%) of them had high viral load (HIV RNA level ≥1000 copies/mL) after median time of 36 (IQR: 24–54) months on ART.Median viral load and CD4+ count. Study participants aged less than 40 years old had 4.43 times more likely to experience virological failure than these who were older than 40 years old (AOR (95%CI) = 4.43 (1.57–12.46), p = 0.005) by adjusting gender, adherence and CD4+ count. Likewise, being male was 4.6 times more likely to experience virological failure (AOD (95% CI) = 4.60 (1.72–12.33), p = 0.002) as compared to females by adjusting other factors. Furthermore, individuals having CD4+ count <250 cells/μL were 2.81 times more likely to develop virological failure (AOD (95% CI) = 2.81 (1.051–7.51), p = 0.04) as compare with those who have greater CD4+ count in a median time of 36 months of ART follow up by adjusting adherence, age and gender (Table 4).Virological failure was 16.37 times more likely to happen in non-adherent individuals (AOR (95% CI) = 16.37 (4.65–57.68), p <0.001) compared with those who had good treatment adherence by adjusting gender, age and CD4In Ethiopia HAART scale up began in 2005 and since then its coverage was 82.8% by 2015 . HAART gThis study described immunological and virological failure and associated risk factors among HIV infected individuals on first-line regimen from 6 months to 9 years duration on ART. Twenty nine (11.2%) of the study participants were under the category of clinical WHO stage IV at ART initiation. After 6 months of ART, WHO stage IV cases had decreased to 13 (5.0%) and fall to 1 (0. 4%) after median time of 36 months ART follow up. This was similar to a study conducted in Surat, India .Majority (93.1%) of the study participants had good adherence (≥ 95%) to treatment, similar value to one study conducted in Colombia 92% . However+ counts of the study participants’ was 162 cells/μL. This was comparable with the studies conducted in southern Ethiopia 156 cell/μL [+ count than our study. This variation may be explained with differences in time of initiation of ART in patients infected by HIV for long period of time. Since long duration of HIV infection without initiation of ART favors viral replication which in turn leads to lower CD4+ count.The median baseline CD4 cell/μL  and Keny cell/μL , but hig cell/μL . Studies cell/μL , Jimma 1 cell/μL , and Lib cell/μL  have repImmunological failure was found to be 6.5% in a median time of 36 month of ART follow up. Our finding was similar with a study conducted in Liberia 5.1% . However+ count below 250 cells/μL following clinical failure, or persistent CD4+ count below 100 cells/μL [+ count to baseline or below sever immune suppression (CD4+ count< 200 cells/μL) [+ count > 350 cells/μL despite virological suppression [+ count < 350 cells/μL [+ count below 100 cells/μL. Besides, higher immunological failure in other studies may be attributed to the higher non-adherence rate [This variation in immunological failure may be related with the WHO guideline which varies overtime. For example, in our study immunological failure was defined based on the 2016 WHO guide line, as fall of CD4cells/μL . Howevercells/μL ,30,31 deells/μL) ,24,22,31ells/μL) ,30, failpression , CD4+ cocells/μL ; in addince rate , 20, 22,+ cells and ultimately depletion of their number.Non-adherent individuals were 5.68 times more likely to experience immunological failures than those who had good adherence (p = 0.021). This is in tandem with the study conducted in Gonder , souther+ cells and results in immunological failure [Immunological failure was 3.8 times more likely to occur in TB co-infected individuals compared to TB non infected individuals (p = 0.003). This was similar with reports from southern Ethiopia , Gonder  failure .Study participants with HIV RNA level ≥ 1000 copies/mL showed 12.33 times more likely to experience immunological failure (p <0.001) in a median time of 36 months of ART follow up as compared with those who have HIV RNA level less than 1000 copies/mL. Similar results have been reported from India , Nepal , London The overall virological failure  in this study was seen in 30 (11.5%) study participants. This was similar with a study conducted in Gonder 11.8% , Addis AUnlike to our result, higher virological failure was reported from Kenya 23.7%  and 24.6Non-adherence was strongly associated with virological failure , this was comparable with a studies conducted in Gonder , Uganda Likewise, being male was 4.6 fold risk to develop virological failure (p = 0.002) than females and this was lined with a study conducted in Burkina Faso , SwazilaVirological failure was 4.43 times more likely to happen in individuals aged less than 40 years old (AOR(95% CI) = 4.43(1.57–12.46), p = 0.005). This was supported by several studies conducted in Kenya , 47, Sou+ count may reflect viral replication due to treatment interruption or resistance [+ count and odds of virological failure. Those who had CD4+ count <250 cells/μL were 2.81 times more likely to have virological failure (p = 0.040) in a median time of 36 months of ART as compared with those whose CD4+ count was ≥ 250 cells/μL. This association was similar with studies conducted in Tanzania [Low CD4sistance . This apTanzania , SwazilaTanzania  and PeruTanzania . Though Tanzania  and BostTanzania  have supOur study was not without limitation. One may argue that taking consecutive viral load measurements would be a better strategy to determine the virological failure than a single measurement. However, in Ethiopia and mainly in the study area, patients on HAART were followed using CD4+ count and WHO clinical stages. Hence we were unable to get data on viral load from the patient’s chart and that could be our limitation of the study. Due to the budget limitations, we only did a single viral load measurement during the collection time. Therefore, researches using consecutive viral load measurements are needed to have a representative data on the virological failures in the country.+ count < 250 cells/μL in a median time of 36 months on ART, and male gender were predictors for virological failure. Similarly, non-adherence, TB co-infection and HIV RNA level ≥1000 copies/mL were associated with immunological failure. Hence our result highlights the need for more commitment and effort from all stake holders on these predictors so as to sustain the long term efficacy of HAART there by achieving the ambitious target of 2020.After a median time of 36 months on ART, virological and immunological failure in the study area were (11.5%) and 17(6.5%), respectively. Non-adherence, aged < 40 years old, having CD4S1 Table(DOCX)Click here for additional data file.S2 Table(SAV)Click here for additional data file.


In a setting of high tuberculosis and human immunodeficiency virus type 1 infection coprevalence, low prevalence of isoniazid monoresistance, treatment with daily standardized antituberculosis regimens throughout and high uptake of antiretroviral therapy were associated with low frequency of acquired drug resistance. Prevention of transmitted resistance should be prioritized.In a setting of high tuberculosis and human immunodeficiency virus type 1 infection coprevalence, low prevalence of isoniazid monoresistance, daily treatment with standardized antituberculosis regimens throughout the study period, and high uptake of antiretroviral therapy were associated with low frequency of acquired drug resistance. Prevention of transmitted resistance should be prioritized. We estimated the incidence of acquired isoniazid and rifampicin resistance in rifampicin-susceptible tuberculosis in a setting of high human immunodeficiency virus type 1 (HIV-1) infection and tuberculosis coprevalence.GeneXpert MTB/RIF–confirmed patients with rifampicin-susceptible tuberculosis were recruited at antituberculosis treatment initiation in Khayelitsha, South Africa. Liquid culture and adherence assessment were performed at 2 and 5–6 months. MTBDRplus was performed on mycobacteria-positive cultures to ascertain acquired drug resistance (ADR). Spoligotyping and whole-genome sequencing were performed to ascertain homogeneity between baseline isolates and isolates with ADR. Baseline isolates were retrospectively tested for isoniazid monoresistance. An electronic database review was performed to ascertain tuberculosis recurrences.Mycobacterium tuberculosis strain during or subsequent to treatment. One strain was confirmed to have ADR, 2 were confirmed as causing exogenous reinfection, and 2 were unrecoverable for genotyping. Incident ADR was estimated to have ranged from 0.3%  to 1% . Seventeen of 279 baseline isolates  had isoniazid monoresistance (13 of 17 had an inhA promoter mutation), but 0 of 17 had amplified resistance.A total of 306 participants  were recruited. Ascertainment of outcomes was complete for 284 participants. Five acquired a resistant Treatment with standardized antituberculosis regimens dosed daily throughout, high uptake of antiretroviral therapy, and low prevalence of isoniazid monoresistance were associated with a low frequency of ADR. Mycobacterium tuberculosis. In 2015, in South Africa there were 19613 laboratory-diagnosed cases of rifampicin (RIF) resistance among an estimated 454000 incident tuberculosis cases 7) [Participant recruitment was at Site B Ubuntu Clinic, a primary care integrated HIV/tuberculosis clinic, during March 2013–July 2014. Patients with GeneXpert MTB/RIF-confirmed RIF-susceptible pulmonary tuberculosis were recruited at the commencement of tuberculosis therapy. Exclusion criteria included age of <18 years, receipt of treatment for tuberculosis within the previous 6 months, a positive result of a pregnancy test, decline of HIV testing, inability to expectorate sputum, or receipt of ≥3 doses of tuberculosis treatment before screening. Patients received routine programmatic management via the Ubuntu Clinic. Patients received directly observed treatment during the first 1–2 weeks, during which time they received adherence counseling and a home visit. Thereafter, the majority received a monthly supply of antituberculosis drugs, which were self-administered. The intensive phase of treatment consisted of daily RIF/INH/pyrazinamide (PZA)/ethambutol (EMB) therapy for 2 months, and the continuation phase involved daily RIF/INH therapy for 4 months  missing ≥5 doses in the previous month, based on pill counts and/or self-report on interview; and (2) use of the Arkansas test to evaluate an archived 2-month urine specimen [Data were collected on sociodemographic characteristics, contacts with MDR-TB, previous tuberculosis treatment, and comorbidities. Participants underwent sputum induction . Baseline bacterial load was estimated via smear grading and days to culture positivity in liquid mycobacterial growth indicator tubes (MGITs). The presence of cavitation with a >1-cm maximum diameter on a chest radiograph was noted. Extensive disease on a chest radiograph was noted as either involvement of >1 lung lobe or involvement of ≥1 of 3  zones per lung. Participants underwent HIV testing , determination of CD4At the 2-month and 5–6-month follow-up visits, participants underwent sputum induction with nebulized 3% saline. Sputum cultures yielding mycobacteria were screened for ADR to RIF and INH, using the GenoType MTBDRplus line probe assay, version 2.0 .Spoligotyping  was performed by the internationally standardized method  on sequeParticipants were reviewed at 5–6 months to ascertain treatment outcome as per the World Health Organization definition . Electro2 between isolates could be attributed to technical error, a significant change in MIC in paired baseline and 2-month cultures was predefined as a ≥4-fold increase or decrease. For participants with ADR, extended phenotypic DST was performed using Sensititre MycoTB plates (Trek Diagnostic Systems) as previously described (Supplementary Table 1) [We retrospectively tested for INH monoresistance in 279 stored baseline isolates through use of the MTBDRplus test and/or minimum inhibitory concentration (MIC) analysis. Clinical notes were reviewed to determine the duration of treatment and outcomes in cases of baseline INH monoresistance. MICs were determined for isolates from a randomly selected subcohort of 109 participants at baseline and from the first 20 consecutive participants with paired cultures at baseline and 2 months, using the Bactec MGIT 960 system with EpiCenter software and the TBeXist application (Supplementary Methods) [If a 1% incidence of ADR is assumed, 299 patients must be followed up during chemotherapy to have a 95% probability of observing at least 1 case of ADR. The proportion of participants with ADR was calculated, inclusive of the whole cohort and restricted to those in whom ascertainment was complete. All figures and analyses were performed in GraphPad  Prism.A total of 306 patients with microbiologically confirmed RIF-susceptible pulmonary tuberculosis were recruited. + T-lymphocyte count was 231 cells/mm3 , and 47 of 191 (25%) had a CD4+ T-cell count of <100 cells/mm3. Seventy-four of 191 (39%) were receiving ART at baseline, and 47 of 191 (25%) had achieved virologic suppression. Twenty of 59 patients (34%) who had received ART for >6 months at baseline had a viral load of >200 copies/mL. By 2 months, 135 of 191 HIV-1–coinfected patients (71%) were receiving ART. Demographic and clinical characteristics were comparable between the study cohort and the overall clinic . None ofBy 2 months after treatment initiation, 228 of 289 participants  had experienced culture conversion. Two hundred seventy of 306  had an outcome of cure or treatment completion. There were 22 patients in whom ascertainment of ADR was incomplete . There were 10 treatment failures and 9 recurrences over the study follow-up period. There were 6 deaths during treatment and 8 subsequent to treatment completion, of which 5 were attributable to tuberculosis . Supplem+ T-lymphocyte count, <100 cells/mm3) at the time of death. The spoligotype of sequential isolates was different (LAM3/Beijing) in 1 of these 3 cases. The drug-resistant strain could not be recovered for spoligotyping in the other 2 cases. If it is assumed that the 2 recurrences were not exogenous reinfection, the proportion of cases with ADR in the cohort was 3 of 306 . The proportion of cases with ADR, excluding 22 for whom follow-up was incomplete, was 3 of 284 . On the assumption that the 2 recurrences were exogenous reinfections, the proportion of cases with ADR in the cohort was 1 of 284 .Following treatment cure, 3 cases received a diagnosis of culture-confirmed drug-resistant tuberculosis (MDR in 2 cases and RIF monoresistance in 1 case) within 14 months of treatment cessation. All 3 cases died  and had As illustrated in inhA promoter mutations. Treatment outcomes are shown in The baseline prevalence of INH monoresistance, determined by either MIC analysis and/or MTBDRplus testing, was 17 of 279 . Of 47 cases in which INH DST was performed by both methods, discordant results were observed for 3 . Forty-one percent of patients were HIV-1 coinfected, 18% were undergoing retreatment, and 12% had been previously in prison. All cases determined to have INH monoresistance by MTBDRplus had 7 4(RIF/INH)7, there are limited data available on the frequency of and associated factors in the development of ADR in RIF-susceptible tuberculosis. Within this cohort, which had a baseline INH monoresistance of 6.1% (low-level resistance associated with inhA) and a significant proportion with advanced immunosuppression (25% with HIV-1 and tuberculosis and a CD4+ T-cell count of <100 cells/mm3), the estimated incidence of ADR was 0.3%–1%. Our data suggest transmitted drug resistance as the predominant perpetuator of the MDR-TB epidemic in Khayelitsha. This is supported by molecular epidemiology studies that have shown significant clustering of MDR M. tuberculosis strains in difference provinces of South Africa, implying ongoing transmission [In the current era of both timely ART and a daily tuberculosis treatment regimen consisting of 2(RIF/INH/PZA/EMB)smission .inhA promoter; MIC range, 0.2–1 mg/L [The generalizability of our findings of low rates of ADR to areas with elevated PZA/EMB resistance is unclear. Although PZA monoresistance is likely to have been a risk factor for acquired INH resistance in case 1 , we obse2–1 mg/L ). All reThere was evidence suggestive of incomplete adherence to both ART (34% did not have virologic suppression at baseline) and tuberculosis treatment (8%–13%). No patient with good adherence developed ADR during treatment. Several previous studies have shown that nonadherence is a risk factor for ADR . It is pAlthough pharmacokinetic variability may be a determinant of long-term outcomes, including ADR, we have previously shown in a subset of this cohort that the proportion with low concentrations of RIF, INH, and PZA was not significantly different between patients who experienced treatment failure or tuberculosis relapse and those with good long-term outcomes .M. tuberculosis strains from a population enriched for HIV- infected participants were similar to MIC distributions from different geographical populations and lineages [M. tuberculosis strains of lineage 2 and 4 [The MIC profiles of lineages , 25. Kha 2 and 4 . Retreat 2 and 4  to steri 2 and 4 . HoweverThere is significant variation in estimates of the incidence of ADR among cases of RIF-susceptible tuberculosis in the literature , which mIS6110 RFLP, spoligotyping, and MIRU-VNTR) lack discriminatory power [Confirmation that drug resistance was acquired/amplified during treatment requires ruling out infection at baseline due to 2 strains with discordant drug susceptibility  and subsequent exogenous reinfection. Spoligotyping was performed on sequential isolates to screen for the above. Conventional molecular typing, which uses mobile or repetitive elements , we cannot rule out potential selection bias. The predominant cause of missed enrollment was previous commencement of treatment in other clinics or inpatient settings and during periods when the research team was unable to recruit . However, baseline demographic characteristics, HIV-1 seropositivity, median CD4 matched . HoweverTo summarize, in this setting with a high coprevalence of HIV infection and tuberculosis and a low prevalence of INH-monoresistant tuberculosis, treatment of RIF-resistant tuberculosis with a standardized tuberculosis regimen administered daily in both the intensive and continuation phases and high ART coverage were associated with a low frequency of acquired resistance to INH and RIF. Public health efforts should therefore emphasize prevention of onward transmission of drug resistance.The Journal of Infectious Diseases online. Consisting of data provided by the authors to benefit the reader, the posted materials are not copyedited and are the sole responsibility of the authors, so questions or comments should be addressed to the corresponding author.Supplementary materials are available at Supplementary_Table_1Click here for additional data file.Supplementary_Table_2Click here for additional data file.Supplementary_Table_3Click here for additional data file.Supplementary_Figure_1Click here for additional data file.Supplementary_methodsClick here for additional data file.


Background: Biomarkers predicting the risk of VL treatment failure and relapse in VL/HIV coinfected patients are needed. Nested within a two-site clinical trial in Ethiopia (2011–2015), we conducted an exploratory study to assess whether (1) levels of Leishmania antigenuria measured at VL diagnosis were associated with initial treatment failure and (2) levels of Leishmania antigenuria at the end of treatment  were associated with subsequent relapse.Methods:Leishmania antigenuria at VL diagnosis and cure was determined using KAtex urine antigen test and graded as negative (0), weak/moderate (grade 1+/2+) or strongly-positive (3+). Logistic regression and Kaplan-Meier methods were used to assess the association between antigenuria and (1) initial treatment failure, and (2) relapse over the 12 months after cure, respectively.Results: The analysis to predict initial treatment failure included sixty-three coinfected adults [median age: 30 years interquartile range (IQR) 27–35], median CD4 count: 56 cells/μL (IQR 38–113). KAtex results at VL diagnosis were negative in 11 (17%), weak/moderate in 17 (27%) and strongly-positive in 35 (36%). Twenty (32%) patients had parasitologically-confirmed treatment failure, with a risk of failure of 9% (1/11) with KAtex-negative results, 0% (0/17) for KAtex 1+/2+ and 54% (19/35) for KAtex 3+ results. Compared to KAtex-negative patients, KAtex 3+ patients were at increased risk of treatment failure .P: 0.03].Forty-four patients were included in the analysis to predict relapse . When achieving VL cure, KAtex results were negative in 19 (43%), weak/moderate (1+/2+) in 10 (23%), and strongly positive (3+) in 15 patients (34%). Over the subsequent 12 months, eight out of 44 patients (18%) relapsed. The predicted 1-year relapse risk was 6% for KAtex-negative results, 14% for KAtex 1+/2+ and 42% for KAtex 3+ results [hazard ratio of 2.2 (95% CI 0.1–34.9) for KAtex 1+/2+ and 9.8 (95% CI 1.8–82.1) for KAtex 3+, compared to KAtex negative patients; Conclusion: A simple field-deployable Leishmania urine antigen test can be used for risk stratification of initial treatment failure and VL relapse in HIV-patients. A dipstick-format would facilitate field implementation. Leishmania donovani complex. The parasite predominantly infects reticuloendothelial cells  is a vector borne protozoan disease caused by species of the Leishmania infection, have hardly been explored in resource-constrained settings.HIV infection is one of the main risk factors for VL, and the HIV epidemic caused the re-emergence of VL in the endemic South-European countries  the level of Leishmania antigenuria measured with the KAtex assay at the time of parasitologically confirmed cure—end of treatment—was associated with subsequent relapse in VL/HIV co-infected patients.Nested within a clinical trial on secondary prophylaxis, we conducted an exploratory study to assess whether (1) the level of This laboratory study was nested within a clinical trial conducted between 2011 and 2015 in two VL treatment sites in North-West Ethiopia  for a minimal period of 1 year. The main analysis focused on patient outcomes at 12 months after VL cure, and has been reported before. Pentamidine was found to be safe, effective and feasible to implement in resource-constrained settings . The KAtex urine assay is semi-quantitative, with three levels of agglutination: 1+: weakly positive; 2+: moderately positive; 3+: strongly positive. Agglutination of any degree visible to the naked eye was considered positive, whilst no agglutination was taken as negative. Urine samples were aliquoted within 3 h after collection and kept at −20°C, as KAtex tests were performed in batch on stored samples. The diagnosis of VL relied on parasite detection in tissue aspirates , and grading was done as reported before WHO, . GradingAssociations between patient characteristics and the level of KAtex antigenuria was assessed using the Kruskal-Wallis test for continuous variables and the Fisher's exact test for binary/categorical variables. We calculated the proportion with initial parasitological treatment failure, stratified by KAtex result. We used logistic regression to quantify the association between the KAtex test result and the risk of initial treatment failure, with the strength of association expressed as odds ratio's (OR) and 95% confidence intervals (95% CI). KAtex 1+ and 2+ results were pooled together due to the low sample size in each of these categories. There were thus three categories: negative (0); weakly/moderately positive (1+/2+); strongly positive (3+). The 1 year risk of relapse was determined using Kaplan-Meier methods, stratified by KAtex result, with follow-up time starting at the time of achieving VL cure and censored at the time of death, relapse or lost to follow-up, or after 12 months if none of these events had occurred. We used hazard ratio's (HR) and 95% CIs to quantify the association between the KAtex test result and the risk of relapse. To assess whether the KAtex result could be a non-invasive measure of the tissue parasite load, we assessed the association between the KAtex level (non-invasive test) and the parasite grading on tissue aspiration (invasive test). The association between the tissue parasite grading and the risk of initial treatment failure and relapse was assessed as well. All analysis was done using Stata version 14.Leishmania antigenuria at VL diagnosis and initial treatment failure  were on ART at the time VL was diagnosed. The median CD4 count at VL cure was 116 cells/μL (IQR 95–181). When achieving VL cure, KAtex results were negative in 19 (43%), weakly/moderately positive in 10 (23%) and strongly positive (3+) in 15 (34%). KAtex 3+ patients were more likely to have a history of VL, to be on ART at the time of VL diagnosis, and had higher tissue parasite grades at VL diagnosis, although only the latter association with tissue parasite count reached statistical significance. Over the subsequent 12 months, four patients died, seven were lost to follow-up and eight patients relapsed. The predicted 1 year relapse risk was 6% for KAtex negative tests, 14% for KAtex 1+/2+ results, and 42% for KATEX 3+ results , see Figure For the analysis assessing the association between the KAtex result at the time of cure and the risk of subsequent relapse, 44 patients were included Figure . The medLeishmania antigenuria at the time of VL diagnosis to predict increased risk of initial treatment failure in HIV coinfected patients. Higher levels of Leishmania antigen allowed to identify those at highest risk of failure. In addition, higher levels of Leishmania antigen in the urine at the time of VL cure were associated with an increased risk of subsequent VL relapse in Ethiopian VL-HIV coinfected patients receiving pentamidine secondary prophylaxis. In Europe, where L infantum is prevalent, a positive KAtex test during the post-treatment follow-up of HIV patients has been found predictive of VL relapse .The level of L infantum endemic areas in France, continuous replication and circulation of the L infantum parasite was demonstrated over a period of up to 10 years, both during asymptomatic phases and symptomatic VL relapse episodes. This entity was defined as “active chronic VL”  parasites. In one European study, parasites could be cultured from the blood of asymptomatic HIV patients with positive urine antigen tests after VL treatment, indicating that viable parasites still remain detectable and in circulation in some patients after treatment  with written informed consent from all subjects. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the Ethiopian regulatory authority, the National Research Ethics Review Committee, the University of Gondar Institutional Review Board (IRB), the Ethics Review Board of Médecins sans Frontières, the IRB of the Institute of Tropical Medicine, Antwerp and the Ethics Committee of Antwerp University Hospital.JvG and ED conceived the study. BM, TM, HF, YT, EA, RM, KR, FV, and WA contributed in data acquisition. Analysis was done by JvG. Interpretation of data was done by JvG, ED, and KR. JvG drafted the first draft of the manuscript. ED, BM, TM, HF, YT, EA, RM, KR, FV, and WA commented on the first draft of the manuscript. All authors read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


ART) has led to expansion of HIV treatment and prevention across sub‐Saharan Africa. However, age and gender‐specific disparities persist leading to failures in fulfillment of Sustainability Development Goals, including SDG3  and SDG5 . We assessed ART initiation and adherence, loss to follow‐up, all‐cause death and early death, according to SDG3 and SDG5 indicators among a cohort of HIV‐infected children and adolescents enrolled in care in Dar‐es‐Salaam, TanzaniaGlobal scale up of anti‐retroviral therapy (SDG3 indicators included young (<5 years) and older paediatric children (5 to <10 years), early adolescent (10 to <15 years) and late adolescent (15 to <20 years) age group divisions and the SDG5 indicator was gender. Associations of age group and gender with ART initiation, loss to follow‐up and all‐cause death, were analysed using Cox proportional hazards regression and with adherence, using generalized estimating equations (GEE) with the Poisson distribution. Associations of age group and gender with early death were analysed, using log‐Poisson regression with empirical variance.ART ), while females in late adolescence were at greatest risk of late death . Late adolescents demonstrated greater non‐engagement in care ). Among both males and females, early paediatric and late adolescent groups experienced significantly greater loss to follow‐up.A total of 18,315 enrollees with at least one clinic visit were included in this cohort study. Of these 7238 (40%) were young paediatric , 4169 (23%) older paediatric, 2922 (16%) early adolescent and 3986 (22%) late adolescent patients at enrolment. Just over half of paediatric and early adolescents and around four fifths of the late adolescents were female. Young paediatric patients were at greater risk of early death, being almost twice as likely to die within 90 days. Males were at greater risk of early death once initiated on SDG3 and SDG5 within services for children and adolescents living with HIV in sub‐Saharan Africa. Young paediatric and late adolescent age groups were at increased risk of late diagnosis, early death, delayed treatment initiation and loss of continuity of care. Males were more likely to die earlier. Special attention to SDG3 and SDG5 disparities for children and adolescents living with HIV will be critical for fulfillment of the 2030 SDG agenda.These findings highlight equity concerns critical to the fulfillment of  Non‐engagement and loss to follow‐up are important indicators of failure in continuity of care 22.1The cohort included all HIV‐infected patients who were under 20 years of age at enrolment in services, between October 2004 and September 2014, within the urban HIV care and treatment clinics of Dar‐es‐Salaam, Tanzania  and the US President's Emergency Plan for AIDS relief (PEPFAR)). At the beginning of the study period the study catchment area included 28 clinics, which grew to 48 clinics by the end of the study period. Patients under the age of 15 years were considered paediatric for treatment purposes. The year of MDH enrolment was categorized, to reflect changes in Tanzanian National AIDS Control Program treatment guidelines, as 2004 to 2007, 2008 to 2011, and 2012 to 2014. Verbal consent for inclusion within research activities within the clinical programme was obtained from parents of children or from those patients over the age of 16 years, at enrolment, as appropriate. The Harvard TH Chan School of Public Health and Muhimbili University of Health and Allied Sciences Institutional Review Boards gave ethical clearance for this study (IRB 17‐1998).2.2All participants received free routine care and treatment for HIV according to Tanzanian National AIDS Control Program (NACP) Ministry of Health and Social Welfare guidelines, approved by the World Health Organization (WHO). Patients eligible for ART received free ART provision, subsidized by the Tanzanian government. Patients on ART were followed every 28 days for repeat physician assessment, refill of ART medication and counseling to discuss adherence, dosing and drug side effects. Late adolescent patients, who did not receive ART received supportive care and regular assessment of their eligibility for ART initiation every 6 months. Pediatric patients on care were reviewed monthly if under 5 years of age, or were reviewed every 3 months if above 5 years of age. ART initiation criteria differed by CD4 count percentage, age and period of enrolment. Before 2008, ART was initiated regardless of CD4 count percentage for children who were at WHO disease stage III/IV; for children with WHO stage I/II disease, ART was initiated if CD4 was below age‐adjusted thresholds ). For those <12 months of age, criteria changed in 2008. After 2008, ART was initiated if CD4+ % was <25 for those at WHO stage I/II and for all children who were <12 months of age, regardless of CD4+ % or WHO stage. Patients age 15 or older were treated by adult criteria. Weight and height were recorded at each visit. Data on ART and TB treatment, pregnancy and next appointment date were collected at each visit and laboratory measurements, and CD4 counts were performed and recorded every 6 months.2.3Person‐time was divided between time “pre‐ART” and time “on ART”. Patients whose time of follow‐up coincided with their time to ART initiation were considered pre‐ART, as they had no follow‐up on ART. For both types of person‐time we considered 3 outcomes: “early death” , ‘late death’ , “loss to follow‐up” . Patients on ART were considered lost to follow‐up, if time to death or the study cutoff date was more than 190 days after the scheduled appointment at their last recorded visit, or if there was no scheduled appointment recorded, more than 120 days later than their last visit. In addition, among patients on care, we considered the outcome of “ART initiation”. Among patients on ART, we considered the outcome of “non‐engagement in care”, defined as being 20% of the interval between visits later than the date of the scheduled appointment.2.4Standardized forms were completed at each visit to detail clinical information. Standardized procedures for the measurement of height and weight were in place to record these at each clinic visit. Blood samples were taken at registration and every 6 months thereafter for hematologic, biochemical and immunologic profiling. Data assurance processes were in place at the point of entry including review checks, double data entry and supervisory checks for inconsistencies identified on second entry. Furthermore, weekly quality assurance checks of data were in place.2.53 for children older than 5 years of age) in keeping with 2007 WHO guidelines Primary determinants in the analysis included SDG3 and SDG5 indicators, generated through categorizing patients into five‐year age groups  and according to gender, to compare intragroup differences in outcomes to assess equity. All analyses were undertaken separately among pre‐ART and on ART patients. Baseline characteristics were examined for the young and older paediatric, early and late adolescent age group, as well as gender groups. Means and standard deviations or medians with interquartile ranges were used to describe the centrality and distribution of continuous measurements and proportions to describe categorical measurements of baseline characteristics. Baseline covariates including WHO stage and immunodeficiency for age, HIV wasting syndrome (defined as at least 10% weight loss if the patient had diarrhoea and chronic weight loss and documented fever for at least 30 days not attributable to any concurrent condition), TB treatment, year of first clinic visit, district of clinic and marital and pregnancy status (for older adolescents). Immunodeficiency for age categories were constructed  and 95% confidence intervals (CI) for early death were determined using generalized estimating equations (GEE) with the log link and the Poisson distribution to approximate log‐binomial regression Hazard ratios (HR) for receiving a prescription for ART were determined using proportional hazards models, adjusted for death and loss to follow‐up, using inverse probability weighting. Relative risks (RR) and 95% confidence intervals (CI) for non‐engagement in care were determined using GEE models with the log link, the Poisson distribution, and the exchangeable working covariance structure a priori knowledge. Adjusted models included age group, gender, WHO HIV stage, BMI or weight‐for‐length z‐score , HIV wasting syndrome, immunodeficiency for age, TB treatment at enrolment, year of first clinic visit  and district of Dar es Salaam . In all situations where the analysis used a subset of the data , inverse probability weighting was used to adjust for censoring.Given that the central exposures of interest in this study were baseline values (to include gender and age group at enrolment), we did not adjust for time‐varying covariates. We controlled for baseline covariates measured at enrolment to adjust for differences between age and gender groups. Covariates used included immunodeficiency for age and WHO HIV clinical stage based on 2007 WHO guidelines Cumulative incidence curves were constructed, using the Breslow estimator for multivariate proportional hazards models and adjusted for the following variables at enrolment: WHO HIV stage, immunodeficiency for age, HIV wasting syndrome, BMI or weight‐for‐length z‐score, pregnancy status, year of enrolment and district. Results were standardized to WHO HIV stage 1, CD4 high (500+ or 25%+), no HIV wasting syndrome, BMI or weight‐for‐length z‐score at least −2, not treated for TB, not pregnant, year 2004 to 2008, Ilala district.p‐values for interaction were calculated, using the likelihood ratio test. For log‐Poisson models, p‐values for interaction were computed using the robust score test. All statistical tests were two‐sided, and p‐values of 0.05 or less were considered statistically significant. If the interactions were significant at the p = 0.05 level, we reported the results for age group within gender and for gender within age group. To test for non‐proportionality of hazards over time we divided the follow‐up time for each outcome at the mean and introduced two‐way interactions with age and gender. We selected backwards on these variables, retaining other model variables. No adjustment was made for multiple comparisons. Statistical analysis was undertaken using SAS 9.3 .For each outcome, univariate models of age group and gender SDG3 and SDG5 indicators, multivariate adjusted models, and models including interactions of age group with gender, were constructed. For proportional hazards models, 3A total of 18,315 patients who were under 20 at MDH enrolment were included in our data. Of these, 10,790 (59%) were female, and 7325 (41%) were male. Among the paediatric and early adolescent patients there were approximately equal numbers of girls and boys, but among the late adolescents around 80% were young women. Around a third of the females who enrolled in late adolescence were pregnant at enrolment (Table p < 0.01), with early adolescents being most likely to receive prescriptions among the girls, but older paediatric patients being most likely to receive prescriptions among the boys (Table Median follow‐up time (IQR) was 656 145, 1605) days. Among all patients, 12,299 (67%) received prescriptions for ART, including 658 (4% of those who received ART prescriptions) whose last follow‐up was the same as the date of the ART prescription .Figure Figure 4Current experience of enrollees in HIV care and treatment programmes across sub‐Saharan Africa is being increasingly well described It has been well recognized that young children living with HIV remain vulnerable to shortcomings in testing Recent evidence also suggests that adolescents remain vulnerable to poor adherence and loss of retention within HIV care programmes SDG 5 indicators were implicated significantly for early death in our findings. Additionally, crude death rates were the highest among males, being worst among the younger paediatric patients, reducing among the older paediatric patients, before worsening with increasing age category into late adolescence. Higher death rates among males may be explained by later presentation and greater non‐enegagement with care among Within the context of an integrating framework of SDGs, leveraging the educational sector could facilitate changes within primary and secondary education to improve adolescent male knowledge and attitudes towards health (SDG4.1‐4.7). Demonstrating links between the health of males of sexually active ages and consequent economic productivity, both through the education sector (SDG4.1‐4.7) and employment sector (SDG8.1‐8.6) could further highlight opportunities for intervention. Integrating SDG approaches may ultimately allow for greater alignment of intersectoral efforts in achieving the unifying objective of improved control of and response to the HIV epidemic for children and adolescents living with HIV.Overall SDG3 and SDG5 indicator findings point to a number of key stages of life during which more rigorous attention to age‐ and gender‐specific needs may render significant benefits. Adolescents living with HIV remain particularly vulnerable to health inequity within HIV services, experiencing greater non‐adherence, loss to follow‐up and higher cumulative risk of death, than across other age categories. Those who enroled in care in early adolescence within our cohort had the highest cumulative mortality overall, across the age groups, with males having higher cumulative risk of death across every age group. Paediatric and early adolescent patients within our cohort may have been the most likely to have been perinatally infected, representing particularly high‐risk groups . Higher cumulative risk of death among those enrolled during early adolescence, may point to longer duration of perinatally acquired HIV infection and shortcomings in management of earlier infection. More rigorous attention to testing and linkage to care for children affected by HIV in early life, or loss of retention within care, during earlier childhood may reduce the impacts on mortality in early life SDG5 was implicated in our findings with females in late adolescence being more likely to experience delayed ART initiation. Many of the adolescent girls in our cohort were pregnant at enrolment, representing an important time during which adolescent girls access services. Adolescent females may generally present at an earlier disease stage during a high‐risk period of sexual reproductive life. However, a lack of integration of sexual and reproductive health services within HIV services SDG 3.7) may lead to discrimination against women and girls in sub‐Saharan Africa  may leadSDG3 indicators utilized in this analysis may have formed proxy indication of most likely mode of transmission, given that paediatric and early adolescent infections were more likely to have been perinatally transmitted and late adolescent infections were more likely to have been sexually transmitted. These limitations are usual to data from clinical cohorts, as engagement with clinical services relies on prevailing social and cultural norms concerning health‐seeking behaviors. Further measures for appraising SDG3, SDG5 and related SDG targets may be incorporated into future studies. Gains in health from application of integrating SDG framework approach to programme management, monitoring and evaluation could also be demonstrated in future research work. While studies from enrollees within HIV treatment services in sub‐Saharan African countries are becoming increasingly available, population‐based sampling is ideally needed for a more accurate estimation of population health Despite the widespread expansion of ART treatment, further action is required to improve access to care and retention within health services Our data highlight important equity concerns for children and adolescents seeking HIV treatment and care services in sub‐Saharan Africa. Threats to the fulfillment of Sustainability Development Goals (SDGs) concerning health for all ages (SDG3), gender equality (SDG5), education (SDG4) and economic growth (SDG8) are highlighted by this study. Further downstream consequences of failed attempts to effectively treat and care for HIV‐infected children and adolescents within sub‐Saharan African health services would additionally undermine efforts to reduce inequalities within and among countries (SDG10). Efforts to improve national systems of data monitoring and accountability (SDG17) need to incorporate the measurement of the health of children and adolescents living with HIV, within integrating SDG frameworks in the future, to realize maximum benefits for population governance.5Strengthening health services for HIV‐infected children and adolescents in sub‐Saharan Africa will require special attention to age and gender inequities for fulfillment of the SDGs by 2030.The authors have no competing interests to declare.SC, EH, DS and WF designed the study. AM, DS, NU and LM contributed significantly to data collection. SC and EH performed the analysis. SC wrote the first draft.All authors have read and approved the final manuscript.Table S1. Disaggregation of hazard ratios by age‐gender interactions over time for outcomes according to non proportionality testsClick here for additional data file.


We studied the frequency and risk factors for loss of long-term non-progressor (LTNP) and HIV controller (HIC) status among patients identified as such in 2005 in the French Hospital Database on HIV (FHDH-ANRS CO4).3 were classified as LTNP and those with ≥10 years of known HIV infection and 90% of plasma viral load (VL) values ≤500 copies/ml in the absence of cART as HIC. cART initiation without loss of status and death from non AIDS-defining causes were considered as competing events.We selected patients who were treatment-naïve and asymptomatic in 2005 (baseline). Those with ≥8 years of known HIV infection and a CD4 cell nadir ≥500/mmvs ≤50 cp/mL, after adjustment for the baseline CD4 cell count.After 5 years of follow-up, 33%  of 171 LTNP patients and 17%  of 72 HIC patients had lost their status. In multivariable analyses, loss of LTNP status was associated with lower baseline CD4 cell counts and CD4/CD8 ratios. Only VL was significantly associated with loss of HIC status after adjustment for the baseline CD4 cell count, the CD4/CD8 ratio, and concomitant LTNP status. The hazard ratio for loss of HIC status was 5.5  for baseline VL 50–500 One-third of LTNP and one-fifth of HIC patients lost their status after 5 years of follow-up, raising questions as to the possible benefits and timing of ART initiation in these populations. Individuals who spontaneously control HIV infection provide a model of natural protection relevant to vaccine development and immune intervention. Although many definitions coexist , these pHere we examined the frequency and predictive factors for loss of LTNP and HIC status over time among patients identified in the French Hospital Database on HIV (FHDH_ANRS CO4) in 2005 .3. HIV controllers (HIC) were patients known to have been HIV1 seropositive for more than 10 years and in whom 90% of plasma HIV RNA values were below 500 copies/ml. Only patients who had at least one follow-up visit after 2005, with CD4 and plasma HIV RNA measurements, were eligible for this analysis.The French Hospital Database on HIV  is a nationwide hospital-based cohort created in 1989, in which clinical and biological data on HIV-infected patients throughout France are prospectively recorded . To date3 in the LTNP group and more than 10% of HIV RNA values >500 cp/mL in the HIC group. ART initiation without loss of status and death from non AIDS-defining causes, were considered as competing events.We used a competing-risk approach to estimate the cumulative incidence of loss of LTNP and HIC status , as defiFollow-up was measured from the date of status identification in 2005 (baseline) until loss of status, a competing event, or the last follow-up visit, whichever occurred first. The subdistribution hazard ratio (sdHR), hereinafter referred as”risk”, for status loss was estimated, along with its 95% confidence interval (95%CI). MultivaSAS software version 9.4  was used for all analyses. P values <0.05 were considered to denote statistical significance.In 2005, among the 202 LTNP patients included in our previous analysis , 184 patAmong the 101 previously studied HIC patients, an update showed that 18 patients started antiretroviral treatment before 2006, one patient developed AIDS, and two patients were also infected by HIV-2. Among the remaining 80 HIC patients, 72 had a follow-up visit after 2005 and were thus included in this analysis. Of them 50 had a last HIV RNA value below 50 cp/mL and were previously referred as “Elite HIC” . Thirty-Table 1. The mean follow-up after 2005 was 4.85 (+/- 2) years.The patients’ baseline characteristics are described in Fig 1A shows the cumulative incidence of loss of LTNP status during up to 7 years of follow-up. At 5 years, the risk of loss of LTNP status was 0.33 .55 of the 171 LTNP patients lost their status: one developed AIDS , 14 patients started cART without loss of status, and 2 patients died of non AIDS-defining causes . Two patients with both LTNP and HIC status lost their LTNP status. .In univariable analyses, baseline factors associated with LTNP status loss were a low CD4 cell count, a low CD4/CD8 ratio , high HIV RNA load, and no concomitant HIC status vs 0.59 (IQR 0.3–0.97) respectively.Being an elite LTNP was associated with a reduced risk of LTNP loss although not significantly . In the final multivariable model, the baseline CD4 cell count and CD4/CD8 ratio remained significantly associated with loss of LTNP status after adjustment for baseline HIV RNA load. A 2-fold increase in the baseline CD4 cell count was associated with a 69% lower risk of LTNP status loss . The CD4/CD8 ratio was inversely associated with status loss . Baseline HIV RNA was not significantly associated with LTNP status loss . Of note, CD4/CD8 ratio was slightly higher in elite LTNP than in non-elite LTNP; median 0.78 (IQR 0.67–1.19) 3 at baseline and 21% a CD4 nadir below 350/mm3. Fig 1B shows the cumulative incidence of loss of HIC status. At 5 years, the risk of HIC status loss was 0.17 . At the end of follow-up, 37/72 patients (51%) had HIV RNA values below 50 copies/mL.Among the 72 HIC, 12 patients lost HIC status by losing HIV RNA control, 5 patients initiated cART without status loss and 3 died from non AIDS cause . Among the patients who maintained their HIC status, 40% of patients had a CD4 nadir below 500/mmIn univariable analyses, baseline HIV RNA load was significantly associated with HIC status loss . Low CD4 cell counts and concomitant LTNP status both had borderline significance (p = 0.06), while the CD4/CD8 ratio was not significant (p = 0.29). When adjusted for baseline HIV RNA (not shown), neither the CD4 cell count  nor concomitant LTNP status  was significantly associated with loss of HIC status, while HIV RNA load remained significant, with an sdHR above 5.5 for VL 50–500 vs ≤50 cp/mL.In this study of a large hospital cohort, we found that 33% of long-term non-progressors and 17% of HIV controllers had lost their status 5 years after being identified as such. Interestingly, in addition to a lower baseline CD4 cell count, a lower CD4/CD8 ratio was associated with loss of LTNP status, whereas viral load >50 cp/ml was the strongest predictor of loss of HIC status.Few studies have examined the long-term outcome of LTNP and HIC patients –9. ContrOne third of our LTNP patients lost their LTNP status after 5 years. Loss of LTNP status was associated with a lower baseline CD4/CD8 ratio and a lower CD4 cell count, whereas HIV RNA load was the only factor associated with loss of HIC status. HIC patients with HIV RNA values between 50 and 500 cp/mL had a much (5.5-fold) higher risk of progression than patients with values below 50 cp/mL (ie elite HIC). The CD4/CD8 ratio, concomitant LTNP+HIC status and the CD4 cell count did not reach statistical significance. However, the sdHR for the CD4/CD8 ratio was close to 1, clearly indicating no association with loss of HIC status. By contrast, the sdHRs for the CD4 cell count and concomitant LTNP+HIC status were both close to 0.5, and the lack of statistical significance may have resulted from a lack of power.3.It is important to identify factors associated with loss of LTNP and HIC status, because the few relevant reports suggest that ART initiation before loss of status might be beneficial in these populations. Indeed, Hatano et al.  found thvs deferred ART in asymptomatic adults with CD4 cell counts above 500/mm3 [Given the relatively frequent loss of LTNP status observed here, our data suggest that all LTNP patients should begin cART without delay. This is in line with the results of the INSIGHT-START trial, which showed a clear clinical benefit of immediate  500/mm3 , especia 500/mm3 .3 should be offered cART, especially as 1 in 5 of such patients will lose their HIC status after 5 years. Regarding HIC patients with HIV RNA values below 50 cp/mL and CD4 cell counts above 500/mm3, the answer to whether or not cART should be started is less clear. However if cART were to be deferred, the stability of the CD4 cell count should be closely monitored. If cART were to be initiated, the timing of treatment initiation should be considered with care, and the reasons must be clearly explained, as these patients have learn to cope with their exceptional status [Treatment of HIC patients with stable immunovirologic status is controversial . Some arl status  and somel status .Our results indicate that one-third of LTNP patients and one-fifth of HIC patients will lose their status within 5 years, and highlight the question of ART initiation in these patients. However, whatever the status, LTNP or HIC, initiation of ART should be carefully discussed with the patients in order to find the adequate time to interrupt a long period of exceptionality.