We assessed the virologic efficacy of switching to co-formulated elvitegravir, cobicistat, emtricitabine, tenofovir disoproxil fumarate (E/C/F/TDF) in patients with controlled HIV infection.We conducted a retrospective multicenter observational cohort study including adult patients with controlled HIV-1 infection on any stable antiretroviral (ART) regimen, who switched to E/C/F/TDF. Success was measured by the proportion of patients with plasma viral load < 50 copies/ml at W48 using the FDA snapshot algorithm. We also assessed risk factors associated with virological failure (VF).3 and 24.6% of the patients had a history of previous virological failure. The reasons for switching were simplification (67.0%) and tolerance issues (22.0%). At week 48, 314 (82.0% [95% CI 78.4–86.0]) patients had HIV RNA < 50 copies/mL, 13 (3.5% [95% CI 3.64–8.41]) experienced virological failure. Genotype at failure was available in 6/13 patients with detection of resistance-associated mutations to integrase inhibitors and NRTIs in 5/6 (83.3%) patients. We found no predictive factor associated with virological failure except for a borderline significance with the duration of viral suppression before the switch. Tolerability of E/C/F/TDF was good with 23/382 (6.0%) patients experiencing mild adverse reactions.382 patients with HIV RNA < 50 copies/mL who switched to E/C/F/TDF were included in the study. Most patients (69.9%) were male, with median age 44 years (IQR 38–51), who had been on ART for a median of 7 years (IQR 4–13). Median CD4 count was 614/mmIn our cohort, switching well-suppressed patients to E/C/F/TDF resulted in few virologic failures and was well tolerated. However, resistance to integrase inhibitors emerged in patients with virological failure. The availability of single tablet regimens (STR) started with the release of Atripla® (efavirenz (EFV)/emtricitabine (FTC)/tenofovir disoproxil fumarate (TDF)) and has improved the effectiveness of antiretroviral therapy (ART), with more convenient regimens as a result of reduced pill burden . IntegraE/C/F/TDF was the second STR approved in France in February 2014 for the treatment of HIV infection in naïve patients. After that date, clinicians switched patients to E/C/F/TDF for various reasons, including convenience, tolerance, or patient’s request. In routine clinical care, the patients’ characteristics differ from those selected to participate in the STRATEGY studies, which could impact virologic response.We wished to assess the efficacy and safety of switching to E/C/F/TDF in a standard clinical setting. We hypothesized that non-selected, PWH, well suppressed on NNRTI, boosted PI or INSTI-based ART, should maintain virologic suppression at W48 after switching to E/C/F/TDF, without major tolerability issues.COREVIH IDF Est is a group of 27 clinical centers located in the Paris area, with approximately 11,000 HIV-infected patients on follow-up in 2014. All centers use the computerized Nadis® database as an electronic health record (EHR) for patient follow-up and care. Demographic data, clinical outcomes, ART history and laboratory tests (CD4 T cell count and HIV-1 RNA) are collected at each patient’s visit by the clinician, the rate of completion is monitored and is > 90%. In the EHR, the reason for any ART change has to be reported to be able to print the patient’s prescription, so the reason for the switch is accurately reported.We conducted a retrospective multicenter observational cohort study within the COREVIH IDF Est clinical centers enrolling ART-experienced patients. Eligible patients were adult patients (≥ 18 years old) with controlled HIV-1 infection on any stable ART regimen (no limit on the previous number of regimens) who switched to E/C/F/TDF between February 2014  and August 2015. Controlled HIV-1 infection was defined by plasma HIV-1 RNA < 50 copies/mL without ART modification in the previous 12 months.Before enrollment in the Nadis® database, it is required that patients sign an informed consent form which was approved by the Paris Saint-Louis ethics committee and Commission Nationale Informatique et Libertés (CNIL) allowing the use of patients’ data for non-interventional studies without the need for further consent in accordance with French regulations .Our primary objective was to assess the efficacy and tolerance of the switch to E/C/F/TDF measured by determination at W48 of the proportion of patients still on E/C/F/TDF and with plasma HIV-1 RNA < 50 copies/mL.At baseline (date of the switch), the following data were extracted: date of HIV infection, date of first ART, number of previous ART and type of regimen, nadir CD4 T cell count or CD4 T cell count at ART initiation, CD4 T cell count (within 6 months before the switch), the reason for switching to E/C/F/TDF, creatinine levels and estimated Glomerular filtration rate (eGFR) using MDRD, history of prior virologic failure and previous genotypes. If the genotypes were not available in the database for patients who failed , we went back to the paper chart or contacted the virology laboratory to collect the information. During the study period, genotypes were performed using Sanger sequencing. In France, it is usually recommended to perform genotyping in case of confirmed virologic failure with HIV RNA ≥ 200 copies/mL.During the 48 weeks of follow-up, any reason for ART change was collected, any plasma HIV-1 RNA measure between baseline and W48, clinical adverse events reported at each visit and creatinine levels at W48 were also collected.Our primary endpoint was the proportion of success defined as plasma HIV-1 RNA < 50 copies/mL using the FDA snapshot algorithm . Due to Virologic success was thus defined as plasma HIV-1 RNA below 50 copies/mL at week 48 with a window period of W36 to 72 weeks and no discontinuation of E/C/F/TDF.The secondary endpoints were: reasons for the switch as reported in the patient’s EHR ; the proportion of patients with virological failure defined as a confirmed viral load ≥ 50 copies/ml at two consecutive measurements within one year after the switch or one HIV RNA ≥ 50 copies and E/C/F/TDF discontinuation; resistant mutations in case of virologic failure; reasons for treatment discontinuation after the switch and tolerability of the treatment; risk factors for virologic failure.Of note, INSTI resistance testing in ART-naïve patients before ART initiation was not standard of care in France before 2014 but was performed in case of virological failure since 2008.The primary analysis was an intent-to-treat (ITT) analysis using the FDA snapshot algorithm at W48. Patients were classified in the following categories: (i) virological success defined as plasma viral load < 50 copies/ml at W48 (time window W36-W72) while on E/C/F/TDF; (ii) virologic failure: plasma viral load ≥ 50 copies/ml at any visit after the switch; (iii) no data: missing data or lost to follow-up and discontinuation of E/C/F/TDF for reasons other than virologic failure at a prior visit.Data are presented as median with IQR for continuous variables and frequencies with percentages for qualitative variables. Categorical variables were compared using Fisher’s exact tests while quantitative variables were compared using Wilcoxon signed-rank tests.Comparisons between patients with virological failure and virological success were performed to assess if the following baseline risks factors were associated with virological failure: age, gender, mode of HIV infection acquisition, use of INSTI or PI/r before switch, time since HIV infection diagnosis, duration of ART, duration of viral suppression before the switch, nadir and baseline CD4 T cell counts, creatinine plasma level, previous resistance-associated mutations (RAM) to at least one drug of the regimen.All tests were two-sided at the 0.05 significance level. Analyses were performed using R statistical package .Among the 10,128 patients on ART during the study period, 661 were receiving E/C/F/TDF and 382 were included in the present study. The two main reasons for non-inclusion were patients receiving E/C/F/TDF as initial ART regimen (n = 137) and HIV RNA ≥ 50 copies before the switch (n = 114). The study flow chart is reported in Fig. 1. Baseline characteristics of the patients are reported in Table Patients were mostly male (69.9%), with median age of 44 years, 42.0% were born in Africa and 89.0% had been infected via sexual transmission . At the time of the switch to E/C/F/TDF, the median duration of HIV infection was 11 years (IQR: 5–16) and the median time from ART initiation was 7 years (IQR 4–13). Before switching to E/C/F/TDF, a majority of patients received a combination of two NRTI and a third agent: ritonavir- boosted PI (PI/r) in 195/382 (51.0%), NNRTI in 84/382 (22.0%) and INSTI in 67/382 (17.5%) patients. Other unconventional regimens were used in a small subset of patients: PI/r-based combinations in 16/382 (4.2%) or other combinations in 20/382 (5.2%) patients. The reason for switching was simplification for 256/382 (67.0%) patients, tolerance issues for 85/382 (22.0%) and various other reasons for 41/382 (10.8%) of the patients.At W48, using the FDA snapshot analysis, 314 (82.0% [95%CI 78.4–86.0]) patients met the definition of success with HIV RNA < 50 copies/mL while still on E/C/F/TDF and 13 (3.5% [95%CI 3.64–8.41]) experienced virologic failure, 23 (6.0% [95%CI 3.6–8.4]) discontinued E/C/F/TDF due to an adverse event, 31 (8.2% [95%CI 5.6–11.4]) discontinued treatment for other reasons or were lost to follow-up and 1 patient died .Results of genotypic resistance at the time of virologic failure were available for six patients and not performed or not available for the seven remaining patients. Among the six patients with available genotype, five had NRTI and INSTI RAMs. Out of these five patients, comparison with genotype prior to the switch was possible in four: all had NRTI RAMs and one had INSTI RAMs.A genotypic test for resistance was available at baseline for nine of the 13 patients with virologic failure (69.0%) and 143 of the 314 patients with virologic success (46.0%).There was no significant difference between the two groups in terms of baseline characteristics or presence of resistance-associated mutations to NRTIs except that patients who experienced failure had undetectable viremia for a shorter period . Among the patients who failed, M184V and other NRTI RAM conferring resistance to TDF were more frequent, but the difference was not statistically significant.There was a significant change in creatinine levels between the switch and W48 but not clinically meaningful: the median creatinine level was 79 µmol/L (IQR 70–89) at baseline and 85 (IQR 75–96) at W48 (p < 0.001); data not shown; among the 382 patients, 38 and 57 creatinine values were missing at baseline and W48 respectively.All patients who discontinued E/C/F/TDF between the switch and W48 were analyzed to describe reasons for treatment discontinuation and identify clinically significant adverse events leading to treatment discontinuation. Among the 43 treatment discontinuations, 23/43 (54.0%) were related to mild adverse events: 10 gastro-intestinal, three renal adverse events and two mild transaminase elevation; other various adverse events were seen in eight patients . The three renal adverse events were laboratory abnormalities and patients were asymptomatic: one hypophosphatemia and two creatinine level elevation of less than 20%.In our retrospective cohort study of PWH fully suppressed on ART, the proportion of patients maintaining a plasma HIV RNA level < 50 copies/mL one year after switching to E/C/F/TDF was 82.0%. This proportion remains however lower than that reported in randomized clinical trials where success rates above 93% have been reported with a switch to E/C/F/TDF or E/C/F/TAF –20. ThesThese differences can also explain the higher rate of virologic failure in our study 3.5%) as compared to prior studies (1.0%) Table  8, 9, 1, 20. An .5% as coWhen we assessed baseline risk factors associated with virologic failure, we could not identify prior resistance associated mutations as a significant risk factor, possibly because of the low number of patients with virologic failure. However, previous cohort studies have also shown, that pre-existing NRTI resistance associated mutations were not associated with the risk of emerging resistance –25. AmonThe only factor we found associated with virologic failure was the duration of viral suppression before the switch which was 21.9 months in those with virologic failure as compared to 33.6 months in those without virologic failure (p = 0.05). This association between the duration of viral suppression and a lower risk of virologic failure is consistent with prior studies , 27.Of interest, and contrary to randomized trials and cohort studies, we report a high rate of integrase inhibitor-associated mutations in patients with virologic failure with 5/6 83.3%) patients showing at the time of failure the N155H (n = 4) or Q148H (n = 1) mutations  although higher than in prior randomized studies and was due to mild adverse events or laboratory abnormalities, such as gastro-intestinal-related adverse events.Our study has however several of limitations. Due to its retrospective design, a number of data are missing, especially regarding prior genotypic resistance tests. The low number of patients with virologic failure also precluded a more detailed analysis of risk factors associated with this outcome. Follow-up was short and the rate of study discontinuation was higher than in prospective studies.The strength of our study is to have enrolled patients with different treatment histories, and to provide an opportunity to better assess the antiviral activity and genetic barrier to resistance of E/C/F/TDF in these difficult-to-treat patients in a real-world setting. Indeed, our results underline the importance of analyzing in detailed treatment history when considering a switch to elvitegravir in well-suppressed patients. Caution is required with close monitoring of plasma HIV-1 RNA levels, if patients have experienced previous treatment failure, have prior NRTI or integrase resistance mutations or no resistance genotype available or in case of a short duration of viral suppression. In these cases, switching to a drug with a higher genetic barrier to resistance is advisable.


Studies have shown high early mortality after initiation of highly active antiretroviral therapy (HAART). We examined change in three-year survival and predictors of mortality of patients initiating HAART in Ethiopia since 2007 to 2019.  A retrospective cohort study was conducted in 47 health facilities (HFs) using records of 11,013 adult patients initiating HAART from 2007 to 2019. Study subjects were stratified as four different cohorts based on their calendar year of HAART initiation: 2007-2010, 2011-2013, 2014-2016, and 2017-2019. HFs were selected using probability proportional to size of patients. Survival rate and predictors of mortality were estimated by the calendar year using the Kaplan-Meier and Cox proportional hazard, respectively. We generated a pooled estimate of survival rate and predicators of mortality. 3, unsuppressed viral load, poor adherence, and drug resistance in all cohorts, respectively, have overall 2.0 (95%CI = 1.35 − 2.69), 4.66 (95%CI = 2.53 − 6.72), 6.78 (95%CI = 3.4 − 10.3), and 10.02 (95%CI = 6.91 − 13.82) times of mortality risk than those without. Patients with bedridden for cohort initiating HAART during 2007 and 2011 were 2.0 (95%CI = 1.35 − 2.69) times of mortality risk than those without.  Data from 1881, 3868, 3004, and 2260 patients were retrieved from each of the cohorts. Overall mortality for all cohorts at all times was 10.3%. A gradual decline of mortality was observed in the first three years of follow-up since 2007-2016 which were 21.37%, 10.03%, and 4.34% among patients who initiated HAART in 2007, 2011, and 2014 respectively. A mortality jump of 9.25% was observed among patents initiating HAART in 2017, which coincided with political instability happened in the country. Of the 21,638 person-years of follow-up among 11,013 adults, mortality was 5.23/100 person-years, while disaggregated by the cohorts, it was 14.77, 5.06, 2.12, and 4.17 per 100 person-years, respectively. Among all the cohorts, patients with CD4 count of ≤200 cells/mm Patients initiating HAART from 2007 to 2016 have continuously improved their survival during three-year cohort follow-up in Ethiopia. The significant decline of survival among those who initiate HAART as of 2017 calls for program intervention. Low CD4 counts, unsuppressed viral load, poor adherence, and drug resistance could be used as predictors for increased mortality to monitor the quality of HAART and improve clinical management of HIV/AIDS patients. Human immunodeficiency virus (HIV) is a global public health challenge and main cause for morbidity and mortality in sub-Saharan African countries since the first case was reported in the 1980s . The aimHIV/AIDS-related mortality of patients may depend on multiple general features including host factors, the patterns of diseases present, access to health care, diagnostic routines, and therapeutic interventions at the local level –7. SpeciIn Ethiopia with an estimated national prevalence of 0.96% and a total of 622,326 people living with HIV (PLHIV) in 2020 , free ARRobust evidence on survival rate and predictors of mortality at early stage of HAART initiation is, therefore, the crucial information needed for evidence-based decision-making in order to improve the patients' clinical management. In this regard, previous studies in Ethiopia were inconclusive. Therefore, this study was undertaken with objectives to estimate survival rate and identify predictors of mortality among PLHIV during the first three years of HAART between the years 2007 and 2019.A retrospective cohort study was conducted from December 2019 to March 2020. During this time of data collection, we retrieved data from 11,013 study participants attending 47 health facilities (HFs) who were initiated for HAART as of 2007. There were 9 regional and 2 city administrations and 1,047 HFs providing ART service for 578,739 PLHIV by 2019 in Ethiopia .All HIV-infected adults (age ≥ 15 years old) who were enrolled for ART care and support from December 2007 to November 2019 in the 47 selected HFs were considered as a study population.N = 311). For feasibility reason, we selected 47 (15%) HFs using probability proportional to population size (PPPS) of HAART patients in the HFs. In the second stage, we stratified the study participants in the selected HFs in a different cohort groups 2007-2009, 2010-2013, 2014-2016, and 2017-2019 based on the calendar year of HAART initiation. The list of ART patients with their unique ART number was retrieved from the ART clinic of the HFs, and a sample of ART patients was selected from each of the selected HFs using systematic random sampling according to the existing list of ART patients.We used a two-stage, stratified cluster sampling for this study. First, we include HFs which was providing ART service on or before 2007  were 1730, 3558, 2114, and 2114, respectively. Hence, the minimum sample size required for this study was calculated to be 10,131. Assuming exclusion of records of lost to follow-up (LTFU), transfer-in, and transfer-out, patients initiated for HAART before 2007 and children under the age of 15 to be 23% the final sample size required were 12,462.3), hemoglobin (mg/dl), ART regimens, adherence, and baseline functional status (ambulatory or bedridden)).The independent variables are baseline demographic characteristics  and clinical characteristics  clinical stage, CD4 count  were considered as outcome variable.3 and >200 cells/mm3 as defined by WHO consolidated guideline [n = 30 days) [Baseline functional status was categorized into two groups: normal activity and bedridden (>50% of the day during the past month)  as recoruideline . Medicat30 days) . Hence, 30 days) .Date of death was recorded either electronically or from the medical register of HIV-infected patients who died during the follow-up period from all causes. Patients missing their follow-up visits according to their appointment schedule for more than 3 months were recorded as loss to follow-up for whom the date of the last registered follow-up visit was recorded to define as loss to follow-up.Plasma viral load (PVL) test was performed at the regional testing laboratories in Ethiopia, using two different approaches: (1) COBAS® AmpliPrep/COBAS TaqMan® HIV-1 version 2.0 (v2.0), based on in vitro amplification of HIV-1 RNA from plasma with detection thresholds ranging from 20 (lower) to 10,000,000 (upper) RNA copies/ml designed specifically for HIV-1 groups M and O, and (2) Abbott Real-Time HIV-1 test Ref 2G3190, based on in vitro amplification by RT-PCR for the quantification of HIV-1 in plasma. Both rounds of VL tests were performed as per manufacturers' instructions. Second viral load tests were done at six-month follow-up for patients with initial viral load ≥ 1,000 copies/ml using similar techniques.CD4 cells were enumerated using whole blood samples prior to extraction of the plasma samples using FACScount® automated cell counter  at the health facilities.2+ and deoxyribonucleotide triphosphates (dNTPs) . RT-PCR condition was an initial cycle RT step at 50°C for 45 min and 94°C for 2 minutes and followed by 40 cycles of PCR at 94°C for 15 sec, 50°C for 20 sec, and 72°C for 2 minutes and an extension at 72°C for 10 min. For nested PCR, 2 ml of RT-PCR product was added to a 50 ml reaction containing 0.12 mM of the inner primers PRT-F2 and RTR2, 1x GeneAmp Gold Buffer II, 2 mM MgCl2, 400 mM each dNTP with 2.5 U of AmpliTaq Gold LD DNA polymerase . After initial denaturation at 94°C for 4 min, 40 cycles of PCR were performed in GeneAmp 9700 thermocycler with the PCR conditions as 94°C for 15 sec, 55°C for twenty seconds, and 72 for 2 min and following an extension at 72°C for 10 min. A 1% agarose gel electrophoresis with a product size of 1,084 base pairs was used to confirm nested PCR product. The confirmed PCR products were purified using Qiagen PCR purification kits and used for cycle sequencing reaction with BigDye terminator cycle sequencing kit 3.1 .In-house assay protocols developed and validated by the Chinese Center for Disease Prevention and Control (CCDC) were used for PCR amplification and sequencing . BrieflyData were collected from standard medical record registers and electronic records at ART sites adopted by the Ministry of Health of Ethiopia. There were three available registers: the first register was the Pre-ART register where all confirmed HIV-positive patients who visit ART site were registered. Then, all the patients who started ART regimen were transferred to ART register at the date of treatment initiation. The third register was patient's follow-up form. For each patient, the initial follow-up visit was scheduled for every two weeks after treatment initiation, and then on a monthly basis and as required based on adherence of the patient, medical records were updated for every patient during each follow-up visit. There was electronic medical record which comprises all history of HIV-positive clients since identified positive.The data elements retrieved include clinical characteristics and laboratory results and WHO clinical stage, CD4 counts, hemoglobin, ART regimens, medications, and functional status . Moreover, data of demographic characteristics  and individual factors (medication adherence) were also retrieved. Data of LTFU was separately retrieved and analyzed from the recorded report.Data management training was given for data collectors and supervisors who were health professionals working at the selected health facilities. The procedure was controlled by the investigator of the study. Completed data collection tools examined their completeness and consistency. Data from the records were entered in to a preestablished data entry template  using tablet computers.t tests or rank sum tests after testing the normality of the distribution using the Shapiro-Wilk test. HAART initiation date and the date of outcome  were used as the start as well as end point of follow-up time, respectively. Patients who were alive and in care were censored as of the date of their last clinic visit.The patients' characteristics were described in terms of frequency, mean/median value for continuous data, and percentages for categorical data. Continuous variables were also compared using P < 0.2 were considered to the multivariable Cox regression model. Independent variables with values of <0.05 within the multivariable Cox regression model were considered statistically significant predictors of mortality. The proportional hazard assumption was checked by both graphical and statistical tests of the goodness-of-fit test (Schoenfeld's method). All data analysis was done using STATA version 16.0 for each of the cohorts.Data analysis was done for each of the cohorts according to their calendar year. Follow-up time (in year) was calculated from the date of ART initiation to the date of death or censoring. The Kaplan-Meier analysis was done to estimate the survival rate of the study participants. The Cox proportional hazard regression was calculated to determine significant factors related to survival rate. We used both crude and adjusted hazard ratios (HRs) at 95% confidence intervals, and candidate variables with We finally conducted a meta-analysis for the survival rate of the different cohorts to get a pooled point estimate. Moreover, we conducted a meta-analysis for the predictors of mortality also to generate the pooled estimate of hazard ratio for the duration of 2007-2019.A total of 11,013 HIV patients attending 47 selected HFs were included in this study. Briefly, a data of 1881, 3868, 3004, and 2260 patients were retrieved from the cohorts.Of the total patients, 7152 (64.94%) were female and 10,089 (91.61%) were from the urban setting. The mean age of the cohorts was 40 years, ranging from 15 to 90 years old. More than half of the study participants were from Amhara, Oromia, Tigray, and SNNPR areas, which accounted 1555 (14.1%), 1542 (14%), 1504 (13.6%), and 1392 (12.6%), respectively. More than two-thirds of study participants were either with primary school education (42.9%) or no formal education (25%). About half of the study participants 5381 (48.9%) were married while 2261 (20.5%) of them were divorced, and equal number of them were widowed 2087 (19%). Predominant population of the study was government employees, house wives, and merchant which accounted 2087 (19%), 1840 (16.7), and 1767 (16%), respectively .Of the 21,638 person-years of follow-up among 11,013 study participants, mortality was 5.23/100 person-years, while disaggregated by the cohorts, it was 14.77, 5.06, 2.12, and 4.17 per 100 person-years, respectively. Mortality among people initiating HAART in Ethiopia during the year 2007 to 2019 at the first three years of follow-up was 10.3%. For all the cohorts, overall mortality was 21.37%, 10.03%, 4.34%, and 9.25%, respectively . PatientWhile mortality was disaggregated by the different demographic and clinical characteristics, the highest mortality for the cohort were among patients initiating HAART by 2007 were from Gambella and Amhara regions which was 25% and 24.47%, respectively. For the cohort initiating HAART in 2010, the high mortality was from Dire Dawa and Addis Ababa which accounted 12.73% and 11.98%. Considering cohort initiating HAART by 2010, there were no difference in mortality among the different regions in the country while the high mortality of cohort initiating HAART by 2017 was from Harari and Dire Dawa which accounted 14.69% and 14.63%, respectively. There were no differences among the cohorts with regard to the different age bands, gender, residency, and educational status. However, the high mortality was among divorced and widowed during the cohorts initiating HAART by 2007 which accounted 23.10% and 21.48%, respectively. Drivers were at higher mortality compared to other occupations across all the cohorts since 2007 to 2019 which accounted 29.87% during cohorts initiating HAART by 2007 to 11.86% by cohorts initiating HAART by 2017 .3 across all the different segments of the cohorts which accounted 25.73%, 12.55%, 5.65%, and 18.65% during all the cohorts, respectively  . Surviva3 was at 2.71 , 2.57 , 2.46 , and 2.70  times of mortality risk for all the cohorts, respectively, compared to those with CD4 count > 200 cells/mm3. Being bedridden were at 1.92  and 2.30  times risk of mortality among the cohorts of initiating HAART by 2007 and 2010, respectively , 12.29 , 8.54 , and 7.07  times of mortality risk for all cohorts, respectively, compared to those with good adherence. CD4 count of ≤200 cells/mmectively .3 were at 2.6 (95%CI = 2.2 − 3.0) times risk of death compared to those with CD4 count greater than 200 cells/mm3. Bedridden patients were at 2.0 (95%CI = 1.35 − 2.69) times risk of death compared to ambulatory patients. Being drug resistant for HIV was found to be a 10-fold risk of mortality compared to those who were susceptible 10.02 . Moreover, patients who were not virally suppressed at baseline were at 4.66 times risk of death   times risk of death compared to those who had good adherence. Patients with CD4 count of ≤200 cells/mm3, 6.72) .Mortality among people initiating HAART in Ethiopia during the year 2007 to 2019 in the first 3 years since ART initiation was 10.3%. Mortality significantly varied by the follow-up year 2007-2009, 2010-2013, 2014-2016, and 2017-2019 which was 21.37%, 10.03%, 4.34%, and 9.25%, respectively. The cohort initiating HAART by 2017, who was the first group to initiate HAART during 2007-2009, accounted for the highest rate of mortality of 21.37%. This was not consistent with other study conducted in Ethiopia during the year 2006-2010 that reported 7% mortality at 36 months of follow-up  which isDespite previous studies , 36–38 rBetween 2007 and 2016, survival of people living with HIV in the first 3 years since ART initiation improved substantially. However, there was a decline in survival as of 2017 to 2019. Overall survival among PLHIV initiating HAART in Ethiopia from 2007 to 2019 within three years of follow-up was 78.8% (95%CI = 61.39 − 95.17). This study was consistent with a study conducted in Debre Berhan Hospital, Ethiopia, which reported 81.7% survival during 2017 . SurvivaThe high mortality among bedridden patients (22.01%) during the year 2007-2010 may be explained by the late diagnosis of PLHIV as a result of the limited access to HIV testing, high rate stigma, and the limited access to HAART by the time , 46. BedMortality among patients with poor adherence was as high as 90.91%, 84.21%, and 50.00% for cohorts initiating HAART by 2007, 2010, and 2014, respectively, but not as high as 9.2% for cohort initiating HAART by 2017. Moreover, patients with poor adherence in all cohorts were at 6.78 (95%CI = 3.4 − 10.3) times risk of death compared to those who had good adherence. Patients with poor adherence were at 4.65 , 12.29 , 8.54 , and 7.07  times risk of mortality for all the cohorts, respectively, compared to those with good adherence. Former studies are also consistent with our report which was conducted in Gamo Gofa Zone, Ethiopia, that reported a 2.17 times risk of death compared to those with good adherence . The cur3 across all the different segments of the cohorts which accounted 25.73%, 12.55%, 5.65%, and 18.65% during the 2007-2010, 2011-2013, 2014-2016, and 2017-2019, respectively. Patients with CD4 count of ≤200 cells/mm3 were at 2.6 (95%CI = 2.2 − 3.0) times risk of death compared to those with CD4 count greater than 200 cells/mm3. While disaggregated by the different cohorts, patients with CD4 count of ≤200 cells/mm3 were at 2.71 , 2.57 , 2.46 , and 2.70  during 2007-2010, 2011-2013, 2014-2016, and 2017-2019, respectively, compared to those with CD4 count > 200 cells/mm3. Studies showed that CD4 count is one of the predictors of mortality in the sense that higher CD4 counts are related to longer survival time [3 were 1.3 times more likely to die in comparison to those whose CD4 was ≥200 cells/mm3. The reduction of CD4 count decreases the immunity of patients, exposing them to opportunistic infections and at high risk of developing serious illnesses leading to death [There was high mortality among patients with CD4 count ≤ 200 cells/mmval time , 49, 50.to death , 51.In our analysis, patients who were not virally suppressed at baseline were at 4.66 times risk of death and hence underscore the importance of viral load measurement as the primary marker of treatment efficacy and suggest the importance of switching ART regimens when there is evidence of virologic failure. Previous study conducted in China also demonstrated an association between HIVDR and mortality, consistent with previous studies. In addition, patients who developed HIVDR during treatment were nearly twofold more likely to die than those who developed HIVDR later . Our stuThe highest LTFU during 2007-2010 in our study (25.26%) was consistent with previous study conducted in 2010 which was 23.21% . MoreoveThere might be death among those groups of LTFU population which may underestimate the rate of mortality in this study.Even in the late HAART era, survival during the first 3 years of HAART continues to improve until 2016. However, it was significantly declining as of 2017. This calls for close follow-up and monitoring of PLHIV taking HAART. Poor adherence, low baseline CD4 count, and bedridden were predictors of mortality which calls for attention during clinical management of this group of population. Moreover, clinicians should consider viral load suppression at baseline since it is impacting survival. The high rate of loss to follow-up in recent years requires program attention.


Control and prevention of HIV infection require sustained adherence to antiretroviral therapy (ART) for patients with HIV (PWH) or those on pre-exposure prophylaxis (PrEP). ART is increasingly designated by payers as a specialty medication and often mandates specialty mail-order pharmacy for refills. Little is known about patient perspectives of pharmacy choice preferences for ART.A 20-question survey was distributed to patients (PWH and PrEP) of the Specialty Care Center in Omaha, NE. Participants >19 years, retained in care for >6 months, and experience with ART/PrEP refills at both local and mail-order pharmacies were considered for study participation. The survey was designed in 3 parts: perspectives on both pharmacy settings, ranking of pharmacy attributes, and pharmacy preference. Descriptive analyses were performed for all survey questions.Surveys were completed by 61 participants . Median age was 52 years, 85% White, 13% Black, 5% Latinx, and 80% commercially insured. Forty-eight participants (79%) reported insurance mandates to use a specialty mail-order pharmacy with 28 (58%) believing the mandate impacted their medical care. Forty-one participants (67%) preferred refilling prescriptions through a local pharmacy. Participants ranked “ease of refilling” as the most important attribute  and favored local pharmacies vs mail-order pharmacies for all pharmacy attributes .Scoring scale, 1=strongly disagree to 5=strongly agree.Midwest PWH and PrEP patients generally preferred local pharmacies to refill their antiretroviral therapies versus mail-order pharmacies for nearly all pharmacy attributes. Further, many participants felt specialty pharmacy mandates negatively impacted their medical care. Insurance payers should consider removing restrictive specialty pharmacy mandates for ART/PrEP prescriptions.All Authors: No reported disclosures.


Identifying subphenotypes within heterogeneous diseases may have an impact in terms of therapeutic options. In this study, we aim to assess different subphenotypes in children living with human immunodeficiency virus (HIV-1), according to the clinical, virological, and immunological characteristics.We collected clinical and sociodemographic data, baseline viral load (VL), CD4 and CD8 count and percentage, age at initiation of ART, HIV DNA reservoir size in peripheral blood mononuclear cells (PBMCs), cell-associated RNA (CA-RNA), ultrasensitive VL, CD4 subsets , humoral-specific HIV response (T-bet B cells), innate response  cells, NKp46+, perforin), exhaustion markers , CD8 senescence, and biomarkers for T-lymphocyte thymic output (TREC) and endothelial activation (VCAM). The most informative variables were selected using an unsupervised lasso-type penalty selection for sparse clustering. Hierarchical clustering was performed using Pearson correlation as the distance metric and WARD.D2 as the clustering method. Internal validation was applied to select the best number of clusters. To compare the characteristics among clusters, boxplot and Kruskal Wallis test were assessed.Three subphenotypes were discovered . Patients in cluster1 were treated earlier, had higher baseline %CD4, low HIV reservoir size, low western blot score, higher TREC values, and lower VCAM values than the patients in the other clusters. In contrast, cluster3 was the less favorable. Patients were treated later and presented poorer outcomes with lower %CD4, and higher reservoir size, along with a higher percentage of CD8 immunosenescent cells, lower TREC, higher VCAM cytokine, and a higher %CD4 PD-1. Cluster2 was intermediate. Patients were like those of cluster1, but had lower levels of t-bet expression and higher HIV DNA reservoir size.Three HIV pediatric subphenotypes with different virological and immunological features were identified. The most favorable cluster was characterized by a higher rate of immune reconstitution and a slower disease progression, and the less favorable with more senescence and high reservoir size. In the near future therapeutic interventions for a path of a cure might be guided or supported by the different subphenotypes. The cure of human immunodeficiency virus HIV-1) represents an unprecedented scientific challenge  represen, togetheSoon after the primary infection, a reservoir of long-lived, resting memory CD4 cells containing integrated HIV-1 DNA is established. Since infants have a limited number of memory cells, compared to adults, early treated perinatally infected infants may pose the best chance of clearing the HIV-1 DNA and several strategies have been proposed to clear the virus on these patients. However, the success of vaccines or therapeutic approaches have been limited and very heterogeneous among patients , host imin vitro and in vivo platform to inform treatment strategies leading to HIV remission. Usually, in pediatric HIV, these consortia studies provide high-dimensional information from small sample sizes. Numerous databases are created and populated as a result. The benefits and challenges of accumulating large amounts of biological information and modeling complex variable interactions are more tangible than ever. Integrating multi-level information could reduce the prediction model’s complexity and provide a unique opportunity to identify clinically relevant HIV-1 subphenotypes.Multidisciplinary consortia have been created in the last years to study the reservoir and the complex immunological response to HIV. One of these consortia is the EPIICAL Project , which aims to establish a predictive As in other disease areas –16, in tIn this study, we aim to identify and characterize pediatric subphenotypes according to clinical, virologic, and immunologic features of patients in a cohort of children and adolescents with early-treated perinatally-acquired HIV-1.Child and Adolescent Reservoir Measurements on early suppressive ART (CARMA) Study  was a mu6 peripheral blood mononuclear cells (PBMC) by quantitative polymerase chain reaction (qPCR)  . Human in (qPCR) , 19. HIVn (qPCR) .The natural killer (NK) phenotype and function were analyzed by flow cytometry and transcriptional profile of PBMCs by RNA-Seq . The sinThe B-cell phenotype and intracellular T-bet expression profile (MFI) was measured by flow Cytometry. After washing with PBS 10% FBS, cells underwent surface staining with the following monoclonal antibodies : CD3, CD10, CD16 (BV510), CD19 (APC-R700), CD21 (APC), CD27 (FITC), IgD (BV421), IgM (PE-CF594), IgG (BV605), CD11C (PC-7). Finally, stained cells were acquired on Cytoflex  and analyzed with FlowJo v10.0.8 (Tree Star) software. Following surface staining fixing and permeabilization of cells (BD permeabilization solution II 1x), cells were stained with an anti T-bet BV650 . For T-cell phenotype, LIVE/DEAD Fixable Blue Dead Cell Stain Kit from Thermo Fisher Scientific  was used to detect and exclude dead cells. After washing with PBS 10% FBS, cells underwent surface staining with the following monoclonal antibodies as previously described . Gating Study population characteristics were described using medians and interquartile ranges (IQR) and absolute numbers with frequencies for categorical variables.p=60), by using an unsupervised lasso-type penalty selection method for sparse clustering implemented in the sparcl R package , median CD4 percentage of 31.0% (IQR:18.0-38.0), and a median log10 VL of 5.28 copies/mL (IQR: 4.07-5.70). Immunological and virological analyses of the samples were done at a median of 12 years (IQR: 8.0-15.6) after ART initiation. The total HIV-1 DNA had a median value of 48.3 (IQR: 6.65-113) copies/106 PBMC and 255 (IQR: 75.0-434) on CD4 cells. The variables included as potential determining factors in the subphenotypes characterization are summarized according to the percentage of missing information in  in cluster 1 (50%) than in cluster 2 (9.1%) and cluster 3 (9.1%) (p=0.016).There were more patients with undetectable DNA reservoir  or cluster 1 . In addition, cluster 3 had higher viral loads, higher baseline CD8 percentages, and lower CD4 percentages. Interestingly, the viral load measured at the end of follow-up was significantly higher in cluster 2 than in cluster 1  or cluster 3 . No differences in total HIV DNA reservoir (PBMC) were found between patients in clusters 2 and 3. Likewise, patients in cluster 1 had significantly lower HIV DNA reservoir in CD4 cells (vs. 1.5 [0.5-1.75] vs. 2.5 [1.75-3.5]). The patients in cluster 1 presented significantly lower viral load measured with ultrasensitive techniques than those in cluster 2  than patients in cluster 2  vs. cluster 3: 866.7 , p=0.835].According to virological and immunological follow-up, there were not statistically significant differences between the clusters according to the presence of blips (cluster 1: 3/18 (16.7%) vs. cluster 2: 5/11 (45.5%) vs. cluster 3: 3/11 (27.3%), p=0.269). Similarly, the patients in the different clusters presented similar median CD4 cell counts at the end of follow up [cluster 1: 788.7  In a pediatric cohort with early-treated patients with long-term HIV viral control, three clusters were identified, revealing three distinct subphenotypes with specific clinical, virological, and immunological features. These three clusters were found in a pediatric cohort with a long-term viral control.The most informative features selected to build the clusters were mainly virological. The baseline viral load was the feature with the highest percentage of importance according to this model, meaning that this feature is the one than better differentiate between patients. This results are in concordance of research previously published suggesting that HIV-1 RNA plasma levels are a better progression marker than immunological markers such as CD4 cell count .The subphenotype composed by patients in cluster 1 is characterized by early (<3 months) treated patients, lower values of HIV-1 reservoir size at a median of 12 years (IQR: 7.3-15.4) after ART initiation, either in total PBMC DNA or on isolated CD4 cells, and low values of WB score which is an indicator of HIV-1-specific antibody concentration, as a proxy of low viral persistence. This subphenotype, with an apparent better immune and viral profile, was also characterized by higher values of TREC and lower values of VCAM, biomarkers for thymic output  and endoThese biomarkers may be useful for screening of people living with HIV for therapeutical interventions directed to erase the reservoir.In contrast, the subphenotype composed by patients in cluster 3 is characterized by later (>12 months) ART initiation, a lower baseline percentage of CD4 cells, a higher percentage of CD8 cells, and higher WB scores. We can observe that, although not statistically significant, this subphenotype has higher values of cell associated HIV-1 RNA. This ‘poor outcome’ subphenotype was also characterized by a higher percentage of immunosenescent CD8 cells, lower TREC values, a higher percentage of CD4 PD-1, and a higher percentage of NK cells. Thus, this subphenotype is associated with a poorer profile than cluster 1, higher cytotoxic response, and senescence. As in cancer, CD8+ T and the upregulation of PD-1 on CD8+ T cells may play a critical role in future immunotherapies . ConcernInterestingly, another subphenotype, patients in cluster 2, was identified. This phenotype was not only an unspecific subphenotype composed by patients unclassified in cluster 1 or cluster 3 but presented specific features that may indicate a signature. This subphenotype was characterized by early treated patients with a lower percentage of CD8 cells, lower TNF-alpha, higher PD-1, higher CD45RO+CD27+ TTM ICOS+, higher percentage of CD4 effector CD25+, and lower T-bet expression. In summary, this subphenotype was characterized by a weak innate and humoral immune response despite early treatment and a good baseline CD4 profile. There were statistically significant differences in the HIV-1 RNA viral load at the end of follow-up between cluster 1 and cluster 2, and more patients with blips during the follow up in cluster 2. This might be explained by a weak adherence in this subphenotype, but the difference is unlikely to be significant as all the patients were long-term suppressed. However, as a limitation of the study, we do not have specific ART adherence information.These findings suggest that although these patients are early treated and have higher CD4% at baseline, their weak innate and adaptive responses drive them to high reservoir size and probably poorer outcomes than those in cluster 1. This finding supports the idea that treating early, and prolonged suppression is not the only factor involved in long-term reservoir size. Likely, genetic factors involving host response to the virus may play a role. Again, identifying these patients early may be useful for personalized medicine. They might benefit for therapies that enhance the immune response, as broadly neutralizing antibodies.As the main limitation of this study, the sample size prevented us from externally validating the subphenotypes. However, a previous study showed that samples sizes of at least 40 subjects resulted in good (80% or higher) accuracy to detect the true number of clusters for a maximum of four separations . We beliIn conclusion, within a cohort of early treated children with perinatally acquired HIV who were suppressed for years and might be considered clinically similar, we have found three distinct subphenotypes. The most favorable cluster was characterized by with a higher rate of immune reconstitution and a slower disease progression, and the less favorable by a higher CD8+ response, more senescence and high reservoir size. An intermediate group of patients in cluster 2 with apparently good baseline features performed poorly and could be helped with immune-enhancing therapies such as anti-PD1 immunotherapy. On the other hand, patients with the most favorable phenotype may be susceptible to be treated with block-and-lock strategies by silencing HIV-1 expression for a prolonged drug-free remission.New therapeutic strategies could be tailored for these subphenotypes following the rapidly growing approach of precision medicine.caroline.foster5@nhs.net.The data analyzed in this study is subject to the following licenses/restrictions: The informed consent of the patients did not include a statement to make public their pseudonymized data. Requests to access these datasets should be directed to The CARMA study was approved by ethics committees within each country and informed assent/consent obtained from adolescents and/or parent(s)/legal guardian in accordance with country-specific law. Each participant received a unique study number, under which data was pseudo-anonymised. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.SD-R conceived the study and performed the statistical analysis. PRoj and AT designed and supervised the work. conceived, PP, NC, SZ, AR, ADR, AD, SP, SR, EN, A-GM, KD, DS, and KG planned and performed the laboratory experiments. PRoj and CG provided resources and supervised the study. All the authors provided critical feedback and helped shape the research, analysis, and manuscript. All authors contributed to the article and approved the submitted version.http://www.epiical.org/), supported by PENTA-ID foundation (http://penta-id.org/).This work has been supported within EPIICAL project by through an independent ViiV Healthcare grant to the PENTA (Paediatric European Network for Treatment of AIDS) Foundation. The funders had no role in study design, data collection, analysis, and interpretation, or manuscript preparation. CARMA was supported by EPIICAL  project, funded through an independent grant by ViiV Healthcare United Kingdom. This work is part of the EPIICAL project (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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The nitazoxanide plus atazanavir/ritonavir for COVID-19 (NACOVID) trial investigated the efficacy and safety of repurposed nitazoxanide combined with atazanavir/ritonavir for COVID-19.ClinicalTrials.gov ID: NCT04459286).This is a pilot, randomized, open-label multicenter trial conducted in Nigeria. Mild to moderate COVID-19 patients were randomly assigned to receive standard of care (SoC) or SoC plus a 14-day course of nitazoxanide  and atazanavir/ritonavir (300/100 mg od) and followed through day 28. Study endpoints included time to clinical improvement, SARS-CoV-2 viral load change, and time to complete symptom resolution. Safety and pharmacokinetics were also evaluated (n = 26) and SoC plus intervention arms . No difference was observed in the pattern of saliva SARS-CoV-2 viral load changes from days 2–28 in the 35% of patients with detectable virus at baseline (20/57) . There was no significant difference in time to complete symptom resolution . Atazanavir/ritonavir increased tizoxanide plasma exposure by 68% and median trough plasma concentration was 1,546 ng/ml , above its putative EC90 in 54% of patients. Tizoxanide was undetectable in saliva.There was no difference in time to clinical improvement between the SoC (Nitazoxanide co-administered with atazanavir/ritonavir was safe but not better than standard of care in treating COVID-19. These findings should be interpreted in the context of incomplete enrollment (64%) and the limited number of patients with detectable SARS-CoV-2 in saliva at baseline in this trial.https://clinicaltrials.gov/ct2/show/NCT04459286], identifier [NCT04459286].[ With over 574 million cases and more than 6.3 million deaths at the end of July 2022 , just ovin vitro studies on the anti-coronavirus activity of 727 compounds in the National Institutes of Health Clinical Collection small molecule library on mouse astrocytoma DBT cells infected with SARS-CoV for 1 h , has been shown to inhibit the major protease enzyme required for viral polyprotein processing during coronavirus replication , 16. It The nitazoxanide plus atazanavir/ritonavir for COVID-19 (NACOVID) trial is a pilot open-label randomized phase 2, multicenter, two-arm controlled trial conducted in Nigeria. Patients who recently tested positive for SARS-CoV-2 by means of reverse transcription-polymerase chain reaction (RT-PCR) assay and were symptomatic were eligible. Patients were considered to have a mild disease if they were ambulatory, need little or no assistance. Those with moderate disease were non-ambulatory but had no need for oxygen therapy, or required oxygen by mask or nasal prongs. Severely ill patients that required mechanical ventilation at screening, or had sepsis with end-organ involvement were not eligible. The national guideline for COVID-19 at the time required that all symptomatic cases be managed in isolation and treatment centers established within tertiary hospitals or purpose-built facilities. Hence, the NACOVID trial was conducted in an inpatient setting with participants enrolled after diagnosis and within 48 h of admission.ClinicalTrials.gov (NCT04459286) and Pan African Clinical Trials Registry (PACTR202008855701534).The National Health Research Ethics Committee, Nigeria  and the Central University Research Ethics Committee, University of Liverpool (reference number: 8074) approved the protocol. All patients provided written informed consent as per the ethics committee’s approved process. Further details about the trial design, inclusion and exclusion criteria are provided in the published protocol . The triin vitro anti-SARS-CoV-2 activity at doses shown or predicted to be tolerated by humans, (2) the likelihood of achieving effective concentration in relevant compartments, and (3) established human safety record. Randomization was implemented using a Research Electronic Data Capture (REDCap)  dem(REDCap)  module tOn study day 0 (baseline), patients provided informed consent and were assessed for eligibility. Those who met the eligibility criteria were enrolled and randomized to either continue the standard of care alone  or trial intervention in addition. The intervention consisted of 1,000 mg nitazoxanide twice daily and 300/100 mg atazanavir/ritonavir administered orally once daily in the night, both administered orally after a meal and directly observed by study staff on days 1–14.2, symptom monitoring using the Flu-PRO questionnaire and clinical improvement as well as adverse event monitoring was conducted by designated staff at each study site for all patients on days 1–14, and on days 21 and 28. Saliva for SARS-CoV-2 viral load was collected on days 0, 2, 4, 6, 7, 14, and 28. Saliva and dried blood spots for quantification of tizoxanide, the active metabolite of nitazoxanide, were collected on days 2, 4, 6, 7, and 14 about the same time as viral load samples. All samples were stored on-site at −20°C, or lower, and shipped to the testing laboratories: SARS-CoV-2 viral load at the African Centre of Excellence in Genomics of Infectious Diseases (ACEGID), Redeemers University, Ede and pharmacokinetic analysis at the Bioanalytical Laboratory, Obafemi Awolowo University, Ile-Ife, Nigeria. Study data were collected and managed with a 26-form electronic case report form using REDCap  and saliva samples were collected to determine the trough concentration of tizoxanide, the active metabolite of nitazoxanide (around 12 h after dose). These were collected on days 2, 4, 6, 7, and 14 at the same time as saliva samples for SARS-CoV-2 viral load. The drug-drug interaction potential of nitazoxanide and atazanavir/ritonavir was investigated in a separate healthy volunteer, two-period cross-over study approved by the Health Research Ethics Committee, Institute of Public Health, Obafemi Awolowo University (IPH/OAU/12/1574). In brief, drug-free healthy volunteers  were recruited. Each volunteer received 1,000 mg nitazoxanide 12 hourly after a standard meal for 5 days in the first period, followed by a 21-day washout period. In the second stage, they received 1,000 mg nitazoxanide 12 hourly combined with 300/100 mg atazanavir/ritonavir once daily for 5 days. Plasma samples were collected at 0.25, 0.5, 1, 2, 4, 6, and 12 h after dose on days 1 and 5 during both stages. Tizoxanide quantification was by validated LC-MS/MS methods on TSQ Vantage  with 50 ng/ml lowest limit of quantification. Data from the first seven participants who completed day 1 of both periods are included in this paper to show the outcome of single-dose interaction. The full study, including an embedded clinical cross validation of the plasma and dried blood spot bioanalytical methods, will be published separately.t-test and Chi-square test of association for continuous and categorical variables, respectively. Analysis of clinical improvement based on the 10-category ordinal scale was performed using the analysis of time-to-event data. Multivariable Cox proportional hazard regression analysis was conducted to assess the differentials in time to improvement. Analysis of cumulative  improvement rate was carried out using Kaplan-Meier survival curves. Primary and secondary outcomes analyses were adjusted for the baseline value of the outcome and randomization stratification factors. SARS-CoV-2 viral load was calculated from the RT-PCR cycle-threshold value. Daily symptom data were aggregated per category  and complete resolution was defined as the disappearance of all abnormalities. Covariates with p-value < 0.25 in the univariable Cox regression analysis were included in the multivariable model. These analyses were conducted using Stata Version 17.A sample size of 98 was estimated to provide more than 80% power to show or exclude 60% improvement in time to SARS-CoV-2 RT-PCR negativity in the intervention group compared with the control group at a two-sided type 1 error rate of 5%. Between-group (SOC vs. Intervention) comparisons of demographic, anthropometric, clinical and laboratory data of the participants were conducted using independent sample n = 45) and Olabisi Onabanjo University Teaching Hospital, Sagamu (n = 12). A total of 26 patients were randomized to the standard of care alone arm and 31 were randomized to the standard of care plus intervention arm  were withdrawn on February 1, 2021 and a new site  was added. However, no patient was enrolled from the new site as the second wave entered the decline phase before ethics and regulatory approvals of the amendments were secured. Hence, only 57 patients were successfully enrolled and randomized from the Infectious Diseases Hospital, Olodo, Ibadan  and 37 years  in the sp = 0.924 and no difference was observed after adjusting for potential co-founders in Cox proportional hazards regression analysis, including randomization stratification variables  and 6 had moderate disease (grades 4–5). Of the 31 patients randomized to the standard of care plus intervention, disease severity was mild in 25 and moderate in 4 patients. Three patients who required high flow oxygen (grade 6 severe disease) were enrolled . The time to achieve protocol-defined clinical improvement  in the entire cohort was 7 days and no difference was observed between the two arms . The hazard ratio (HR) was 1.027 (95% CI: 0.592–1.783), 10 copies/ml in SoC alone arm, and 5.17 log10 copies/ml in SoC plus intervention arm. In a very limited analysis of this outcome using days 2, 4, 6, 7, 14, and 28 follow up saliva viral load data from these patients, there was no trend toward a difference in the pattern of viral load changes between the two arms, Welch’s t-test p-value = 0.758 for comparison of means over the follow-up period  of patients with a mean of 5.05 logp period . The aHRp = 0.167) toward a shorter time in the standard of care alone arm (6 days) compared with standard of care plus intervention arm (10 days) (p = 0.105), except for disease severity where moderately ill patients were 67% more likely to achieve complete symptom resolution if they received standard of care alone compared with standard of care plus intervention . Further exploration of median time to complete symptom resolution in various subgroups using logrank tests showed no trend toward any benefit in combining the intervention with the standard of care (The median (range) time from enrollment to complete symptom resolution was 8 (6–14) days in the entire cohort, with a non-significant trend  . Multiva of care .The DSMB at their meeting of 14 November 2021 recommended terminating the trial as no further opportunities existed to recruit additional patients and accrued data did not indicate any trend of benefit in adding the intervention to the standard of care.Nitazoxanide  combined with the usual dose of atazanavir/ritonavir (300/100 mg od) was well tolerated in this cohort. Laboratory values of hematology and blood chemistry parameters on days 0, 7, and 14 were within normal ranges  with no 0–12 by 68.3% from 37.6 μg.h/ml (19.9–45.9) to 63.3 μg.h/ml (54.3–84.6). Also, the median (range) Cmax by 14.4% from 7,630 ng/ml  to 8,730 ng/ml   with 56.6 kg 7.5) body weight. Co-administration of nitazoxanide (NTZ) with atazanavir/ritonavir (ATZ/r) increased plasma tizoxanide median (range) AUC–14,271) . A totalpatients   and atazanavir/ritonavir 300/100 mg od) in addition to standard of care initiated within a few days of COVID-19 diagnosis did not experience a better outcome  compared with those who received standard of care alone. Crucially, tizoxanide plasma exposure was significantly enhanced when combined with atazanavir/ritonavir as expected, possibly nidation . Though 0 mg od ipolation . Our preclinicaltrials.gov identifier: NCT04463264; n = 45) showed no difference in the achievement of PCR negativity by day 7  (n = 379) that enrolled outpatients with mild or moderate COVID-19 within 72 h of symptom onset, 600 mg b.i.d. extended release nitazoxanide was reported to reduce progression to severe COVID-19 by 85%  compared with placebo . There was no overall difference in time to sustained clinical recovery (n = 113) reported a cumulative day-15 SARS-CoV-2 clearance rate of 88.7% in patients with mild COVID-19 who were treated with a combination of nitazoxanide (500 mg q.i.d.), ribavirin, and ivermectin plus zinc supplement compared with 13.7% in those who received supportive symptomatic therapy  (n = 392), PCR negativity was achieved in 29.9% of patients who received nitazoxanide (500 mg t.i.d. for 5 days) compared with 18.2% in the placebo arm (p = 0.009) and 55% reduction in viral load compared with 45% (p = 0.013). However, there was no difference in symptom resolution between the nitazoxanide and the placebo arms  . In the recovery . Elalfy ebo arms . Taken tSimilar to the Vanguard and SARITA-2 studies, data from the NACOVID study showed no difference in clinical improvement or symptom resolution between patients treated with standard of care alone vs. standard of care plus nitazoxanide  and atazanavir/ritonavir. However, we only achieved 64% of the target sample size of 89 required to show or exclude 60% improvement in time to SARS-CoV-2 PCR negativity . Additioin vivo efficacy. Inhalation delivery with targeted activation within the lungs , the Central University Research Ethics Committee, University of Liverpool (reference number: 8074), and the Health Research Ethics Committee, Institute of Public Health, Obafemi Awolowo University . The patients/participants provided written informed consent to participate in this study.AdOn, AnO, and SR conceived the initial study. AdOn designed the study and developed the protocol with input from all authors. AF, FB, BE, and BOA were responsible for study enrollment and data acquisition. CH was responsible for SARS-CoV-2 viral load determination using RT-PCR. AdOn, AbA, BA, and OOB were responsible for database management and pharmacokinetic analyses. AdOn, AbA, AF, and BE verified the underlying data. AFF and AdOn were responsible for analysis and interpretation of data. AdOn drafted the manuscript. AnO and OOB critically revised the manuscript. All authors contributed to conducting the trial, revised the report and read and approved the final version before submission, had full access to all the data in the study, and had final responsibility for the decision to submit for publication.


Patient retention in care and sustained viral load suppression are a cornerstone to improved health and quality of life, among people living with HIV. However, challenges of retention on ART remain among female sex workers (FSWs). We report lost to follow up (LTFU), viral load suppression, and the associated factors among FSWs that access HIV treatment at primary health care facilities in Kampala.We retrospectively abstracted and analysed patient management data of HIV positive FSWs who enrolled in care between January 2018 to December 2020. LTFU was defined as failure of a FSW to return for treatment at least 90 days from the date of their last clinic appointment. We defined viral suppression as having a last viral load of ≤ 1000 copies/ml preceding data abstraction. Data were analysed using Stata 15.1 software.A total of 275 FSWs were included in our study sample. We found low retention of 85.1% (n = 234) at six months, corresponding to LTFU of 14.9 (n = 41) within the same period. Retention decreased with duration of being in care up to 73.5% (n = 202) at 24 months, and this translates to LTFU of 26.5% (n = 73). Viral load testing coverage was 62% (n = 132) and of these, 90.9% (n = 120) were virally suppressed. Factors associated with LTFU in univariable logistic regression; and viral load suppression in multivariable logistic regression models were; having a telephone contact , having enrolled in HIV care aged ≥ 35 years , ; and having good ART adherence ,  respectively. Having good ART adherence remained statistically significant  in multivariable logistic regression for LTFU.This study found low retention among HIV diagnosed FSWs in care. Viral load suppression was acceptable and comparable to that of the general population, however viral load coverage was low. Strategies that increase retention in care and access to viral load testing such as individual client centred care models are vital to improve retention and viral load coverage among FSWs. At the end of 2019, key populations including female sex workers (FSWs) and their sexual partners accounted for 65% of new HIV infections globally [The HIV epidemic in Uganda is generalised with an estimated HIV prevalence of 5.4% in 2020 among the population aged 15–49 . AccordiIt is crucial to retain FSWs in HIV care and treatment programs to optimise viral suppression and improve health outcomes –11. HoweTwo studies have reported a combination of retention on ART and viral suppression among FSWs. The first study was conducted in Malawi and reported that, 69% of HIV-infected FSWs with a history of HIV care, only 52% reported current ART use, and of those, 45% were virally suppressed . The secIn Uganda, multiple targeted HIV prevention and strategies for treatment continuity have been scaled up, however, challenges of retention and low viral suppression remain among FSWs . ChallenThis was a retrospective review of medical records of FSWs diagnosed with HIV infection. These were individuals enrolled into the HIV care program from January 2018 to December 2020 at the six-government primary health care facilities in Kampala, Uganda.The study was conducted at six-government primary health care centres located in Kampala Uganda. These were Kawaala, Kisugu, Kiswa, Kitebi, Komamboga and Kisenyi, distributed across all the five administrative divisions of Kampala City, including Kampala Central Division, Nakawa Division, Makindye Division, Lubaga Division and Kawempe Division. The health centres serve as the main HIV outpatient clinics for the residential areas in Kampala and provide both curative and preventive health services that include HIV care for the general population and FSWs. The HIV services at the health centres are fully funded and implemented with support from the US Centres for Disease Control and Prevention.The study population was FSWs living with HIV who started ART between January 2018 and December 2020. There are over 8800 FSWs workers in Kampala  with HIVThe primary outcome of the study was ‘lost to follow up (LTFU)’ from HIV care, and a secondary outcome was virological non-suppression. LTFU from HIV care was defined ‘as failure of a FSW to return to the HIV clinic for ARV drug refill for at least 90 days preceding their last clinic appointment and not classified as transferred out to another clinic for treatment’. The definition of LTFU in this study was adopted from the Uganda Ministry of Health definition . We asseVirological non-suppression was defined as having a last viral load higher than 1,000 copies/ml, chosen based on WHO guidelines . Viral lFollowing WHO strategic information guidelines , viral lA data extraction form was developed to gather data of HIV FSWs routinely collected during case management. These are often reported to be associated with FSWs LTFU from HIV care. The following procedure were followed in the data collection process i) clinical data were extracted from HIV care/ART cards, a Ministry of Health medical chart for all ART patients used in all health facilities that provide ART services; ii) if CD4 counts and viral load results were not recorded in the HIV care/ART card, the laboratory records were reviewed; iii) data related to sex work were abstracted from key population specific registers that are routinely completed for all sex workers at enrolment or at any time a client identifies herself as a sex worker; iv) finally data were retrieved from the electronic medical record. The patient files were retrieved by a team of patient experts whose role at the facility is to retrieve charts for patients that routinely visit the clinics for drug refills. Assisted by one research assistant, data were collected by a member of the research team, who had taken lead in developing the protocol, study procedures, data collection and study ethics forms. The research assistant was a health worker familiar with HIV service tools and was oriented on the protocol, study procedures and how to extract data using a structured abstraction tool. Data collection took place between January and February 2021. To ensure quality of the data, all data abstraction forms were reviewed and 10% of the randomly selected FSW files were re-done by the research team. Data were entered into the Research Electronic Data Capture (REDCap) database.Data quality checks were done daily by crosschecking discrepancies, and completeness of data on all variables. The research team conducted real time form review and corrected missing or erroneous entries on site, where we could refer to the medical records. We checked for all forms of identifiable errors, and data completeness was conducted and exported into Stata version 15.0 for analysis.Data were analysed using Stata 15.1 software. The normally distributed continuous variables were described using mean and standard deviation, or else median and range where appropriate. The Shapiro Wilk test was used to assess for normality of continuous variables, and categorical variables were described as proportions and frequencies. A table was constructed to present data that describes the distribution of retention  at given time points . Virological outcomes  were also presented in a table. Both univariate and multivariable logistic regression models were performed on both outcomes, lost to follow up and virological non-suppression. We used 0.2 level of significance to select variables to include in the multivariate analysis model. Stepwise logistic regression modelling was undertaken so that predictive variables for lost to follow up and non-virological suppression is carried out by an automatic process, while controlling for confounding effect of other covariates. All factors with p ≤ 0.05 were then considered statistically significant.The study was approved by the Uganda Virus Research Institute ethics committee and the Uganda national Council of science and technology (reference number HS-2665). We also obtained approval from Kampala Capital City Authority health office to allow us have access to patients’ data. To ensure confidentiality, no personal identifiers were abstracted, and participant unique identification numbers were used on data collection tools. The data collectors also signed a non-disclosure agreement.(Table 1In this study we extracted data for 285 FSWs enrolled in care between January 2018 to December 2020 and 275 FSWs were eligible for inclusion in the study As illustrated in Table (Table ).Among the 275 participants assessed for virological status, 48% (n = 132) had tested and viral load test results recorded in their charts, 29.8% (n = 82) were due for testing but had not tested for viral load while 22.2% (n = 61) were not eligible for viral load testing as they had been in care for less than 6 months prior to the study. Viral load testing coverage among those eligible for viral load testing was 62% (n = 132). Of 132 participants with viral load results, 90.9% (n = 120) were virally suppressed with ≤ 1000 copies/mL In univariate logistic regression analysis, the following factors were significantly associated with LTFU; age, marital status, having a telephone contact, and ART adherence at last visit. In the multivariable logistic regression ART adherence at last visit was independently associated with LTFU, Table In Table This cross-sectional study assessed factors associated with retention and non-viral load suppression among HIV positive FSWs who were enrolled in care between January 2018 and December 2020 in primary health care facilities in Kampala, Uganda. The study found a high percentage of lost to follow up of 26% at 24 months of being in care. Retention in care was 85.5% at six months and it decreased to 73.5% at 24 months. Viral load testing coverage among those eligible for viral load testing was 62% (n = 132). The high LTFU and low viral load testing coverage may have been exacerbated by the COVID-19 lockdowns that led to disruptions of routine health care service delivery. Nonetheless, among the 132 participants with recent viral load testing results, 90.9% (n = 120) had viral load of ≤ 1000 copies/ml. This viral suppression rate is comparable to that of the general population of PLWHIV in Uganda [The retention on ART of 85% at 6 months and 74% at 24 months, indicates early interruption in treatment among newly diagnosed FSWs. Retention on ART in Uganda is 98% in the general population (5) while retention in our study averages 80%, this is an 18% difference in retention observed among FSWs compared to the general population. This is a cause for concern as this is a high-risk group which has the propensity to facilitate transmission of HIV in the population. Previous studies have shown a similar pattern of high LTFU among FSWs , 17. A rOur study found 90.9% viral suppression among FSWs. This is comparable to the viral suppression of 90% among PLHIV in the general population in Uganda . Althoug. Nevertheless, robust strategies must be instituted to improve access to viral load testing among FSWs. For example, community viral load sample collection has been recommended as a viable alternative that should be integrated into other community-based HIV services for FSWs and it has been successful in Zambia [The viral load coverage of 62% is extremely low, when compared to the 95% expected viral load testing coverage . The chan Zambia . HoweverOur study also found that younger FSWs aged below 25 years were likely to experience LTFU and be non-virally suppressed compared to the older FSWs. Our findings support the existing studies, although not conducted among FSWs, data shows that adolescent girls and young women living with HIV have lower uptake, delayed treatment initiation, and lower retention in care –40. FurtAs seen in a study conducted in a rural district of Uganda  and in KIn this study, FSWs whose ART adherence was categorised as ‘good’ at their last clinic visit had extremely high odds of a viral load suppression (2300%) compared to those whose adherence levels in their clinic records was documented as either ‘fair or poor’. Similarly, FSWs with good ART adherence had decreased odds to dropping out of care. Adherence to ART has widely been documented to be associated with viral load suppression , 21, 38.This study had strengths and limitations; recruitment was done from all government primary health centres in Kampala city. This led to an increased representativeness of the sample for the study. The limitations in this study that should be considered while interpreting study findings include: (i) Utilization of secondary data, routinely collected for patient management. Such data sometimes have gaps and may not warrant rigor for scientific research. (ii) Data on key variable such as disclosure, education, mobility status and income status known to affect LTFU were missed; (iii) Uganda HIV programs do not have national patient unique identifiers, making it impossible to track patients who shift unannounced to get HIV care services from other facilities, this may have resulted in overestimation of FSWs counted as LTFU. However, there is a dedicated team of FSWs peers who follow up and document clients who don’t return for their drug refill and this might have possibly minimised wrong categorisation.This study has shown that the risk of lost to follow up among HIV diagnosed FSWs on HIV treatment is high and the occurrence mostly happen in the first six months after initiating ART. Interventions to improve retention such as intensive adherence support, immediate attachment to FSW peer supporters and provision of individual need-based care should target newly enrolled FSWs at ART initiation. Although viral load suppression was acceptable and comparable to that of the general population, viral load coverage was grossly low. To address challenges of low viral load coverage, strategies that increase access to viral load testing such as disseminating information on benefits of routine viral load testing, extending testing services nearer to the FSWs by conducting viral load sample collection from the communities will go a long way to improve viral load coverage among FSWs. Lastly, the observation of having telephone contacts and their association to reduce LTFU, calls for expansion of technological media advancements in HIV programming and leveraging on mHealth for patient follow ups for timely viral load testing and sustained retention into care for improved health outcomes among FSWs.


The objective of this study was to determine the rates of virological failure (VF) and HIV drug resistance (HIVDR) amongst adolescents on antiretroviral Therapy (ART). A retrospectively designed study was conducted in 10 healthcare centers for adolescents living with HIV (ALHIV) in the two main cities of Cameroon , from November 2018 to May 2019. Sociodemographic, clinical, therapeutic and laboratory parameters were collected from medical records. All enrolled ALHIV had viral load (VL) measurements following the national guidelines. All patients with a VL ≥ 1000 copies/ml were called to perform genotyping tests. The chi-square test was used to determine the factors associated with VF. Out of the 1316 medical records of ALHIV, we included 1083 ALHIV having a VL result. Among them, 276 (25.5%) were experiencing VF, and VF was significantly higher in ALHIV with suboptimal adherence (p<0.001), older adolescents (p<0.05), those who lived outside the city where they were receiving ART (p<0.006), severely immunocompromised (p<0.01) and started ART at infancy (p<0.02). Among the 45/276 (16.3%) participants with an available genotyping resistance testing (GRT) result, the overall rate of HIVDR was 93.3% (42/45). The most common mutations were K103N  resulting in high-level resistance to Efavirenz and Nevirapine, followed by M184V  and thymidine analog mutations  associated with high-level resistance to Lamivudine and Zidovudine respectively. The high rate of VF and HIVDR among ALHIV regularly followed in health facilities in Cameroon highlights the need to develop interventions adapted to an adolescent-centered approach to preserve future ART options. Infection by the human immunodeficiency virus (HIV) remains a major public health problem with 36.9 million people living with HIV (PLHIV) worldwide, of which about 1.8 million were adolescents aged 10 to 19 years old and nearly 90% of them resided in sub-Saharan Africa (SSA) in 2020 , and 591 (54.6%) were female. More than half of adolescents  were orphans of one or both parents. More than 8 in 10 adolescents  partially  or completely  knew their HIV status. Of the 1083 participants, 1008 (93.1%) were infected by vertical transmission. The majority  of the participants were receiving a first-line regimen and 89.5% had been on ART for more than 24 months; with a median time on ART of 7 years [IQR:2–11]. In our study population, 49.9% of adolescents had changed ART , including 27.5% more than once. Unavailability of ART (62.5%) at the health center was the most common reason for switching, followed by discontinuity of follow-up (34.5%). At initiation, Nevirapine- or Efavirenz-based regimens were given to 998 (92.2%) participants. Up to 1044 adolescents (96.4%) respected their appointment and withdrawn their ARV drugs from the pharmacy on time. Of the 1083 ALHIV, 807 (74.5%) had a suppressed viral load according to the WHO threshold (VL <1000 copies/mL), and 731/1083 (67.5%) had an undetectable viral load (VL <50 copies/mL). A total of 276 participants experienced VF, therefore representing a failure rate of 25.5% in our study population. The rate of VF varied according to the healthcare facility, ranging from 16% to more than 63% as shown in Factors associated with VF included, being severely immuno-compromised at ART initiation with a CD4 count below 200 cells/mm3 (p = 0.01), having started ART between 4 and 9 years of age (p = 0.02), late adolescence (p = 0.05), followed up in a health facility located in Yaoundé (p < 0.001), followed up in a first category health facility according to the Cameroonian healthcare pyramid (p = 0.02), living out of the town in which they were receiving ART (p = 0.006), and late or absence drug withdrawal from the pharmacy (p < 0.001). However, no association was observed between VF and non-disclosure of HIV status, exposure to PMTCT, history of opportunistic infections, treatment regimens or duration on ART .A total of 45/276 (18.1%) plasma samples successfully underwent genotyping resistance testing (GRT). Of the 45 sequences, 42 (93.3%) harbored resistance to at least one ARV drug, with nearly 90% (40/45) having intermediate or high-level HIV drug resistance. About 71.1% of adolescents who underwent GRT had multiclass ARV resistance mutations. Moreover, 60% (27/45) carried a resistant virus to both NRTIs and NNRTIs and 11% (5/45) carried at least one drug resistance mutation (DRM) to three classes, namely NRTI, NNRTI and PI. Two participants (4.4%) had resistance only to NRTIs, seven (15.6%) harbored resistance only to NNRTIs and one (2.2%) was resistant only to PIs. Resistance to all drugs in the same class for NNRTIs and NRTIs was observed in 8/45 (17.8%) and 2 (4.4%) HIV-infected adolescents, respectively .Drug-resistance mutations (DRMs) were found in the three classes of drugs assessed. The DRMs frequently found were K103N leading to high-level resistance to Efavirenz (EFV) and Nevirapine (NVP) in 22 of 42 adolescents (52.3%), and M184V, triggering high resistance to Lamivudine (3TC) and Emtricitabine (FTC) in 20 of 42 (47.6%) ALHIV. Other NNRTI DRMs were V106I , K101E , and Y181C, Y188L, E138A, V179E, L100I, P225H, V108I , having low to high resistance against EFV and NVP alone or in combination. Additionally, thymidine analog mutations (TAM) resistance, including T215D, K219R, and M41L , and non-TAMs such as L74I  and K70N  were other DRMs associated with additional reductions in susceptibility to NRTIs, particularly Abacavir (ABC), Zidovudine (AZT) and Stavudine (D4T). The two main DRMs for PI were M46I and V82A found in 4 of 42 adolescents (9.5%), and associated with reduced susceptibility to both Atazanavir (ATV) and Lopinavir (LPV). The proportion of each DRM is shown in Of the 42 HIV-infected adolescents carrying DRMs to main ARVs used, we observed that 92.3% (n = 24/26) of the participants in our study who had received therapeutic regimens based on EFV or NVP were very resistant to these ARVs. Similarly, 73.3% (n = 11/15) of adolescents who received ABC had high-level resistance to Abacavir while 64.3% (27/42) were resistant to 3TC, 13.3% (2/15) at LPV/r and 11.1 (n = 3/27) at TDF .A total of 8 viral clades were found, among which 4 recombinant forms and pure subtypes. Of note, CRF02_AG was the most prevalent clade (55.6% ), followTo our knowledge, this is one of the few studies evaluating VF and HIVDR in a large cohort involving more than a thousand HIV-infected adolescents in Central Africa and precisely in Cameroon. Our results showed a high rate of VF (25.5%), representing a quarter of ALHIV in our study population. This strong trend has been reported in previous studies conducted in similar settings. Makadzange et al., in Zimbabwe in 2012 in a study involving 418 adolescents reported a 33% rate of virologic failure among ALHIV on ART . Similar3) at ART initiation and had started ART early in childhood (between 4–9 years old). A similar trend was observed in a previous study in Zimbabwe where a decreased risk of VF failure was associated with progressive increases in age at ART initiation [VF was higher among ALHIV who were poorly adherent to ART, were living outside the city where they received ART, were severely immunocompromised  and the NRTI M184V/I mutation (46.7%), followed by thymidine analog resistance mutations TAM, 35.7%). This mutation profile is correlated with the known mutations induced by the drugs used in our context. Indeed, these results were consistent with previous reports showing high levels of ART resistance and an accumulation of resistance mutations in HIV-infected children and adolescents receiving Lamivudine, Nevirapine, or Efavirenz as the backbone of first-line ART regimens –16, 35. .7%. ThisThe interest of this study lies in the inclusion of a large number of HIV-infected adolescents followed up in the two main cities in Cameroon. The results allow us to have a trend of routine monitoring of ALHIV on ART in the two largest cities of Cameroon and can be used by the program to improve the quality of care. Nevertheless, the main limitation of this study is related to the fact that our study was carried out in urban areas where access to health services and biological monitoring is greater than in the rest of the country. A national study would be necessary to better estimate the effectiveness of ART and the evaluation of resistance to HIV. On the other hand, we may have underestimated the VF because of the retrospective nature of this study by excluding the records of patients without VL. Finally, the low rate of successful genotyping has limited our understanding of mutation patterns in this age group.The rate of VF and HIVDR was high among ALHIV routinely followed in health centers in Cameroon. Strategies based on an approach centered on ALHIV and better therapeutic education could reduce the emergence of resistance within this vulnerable population.


Death competing risk survival regression models were used. Among 27,313 participants, with a median age of 36.8 years and median follow-up of 2.3 years, 245 patients (0.9%) were diagnosed with CKD . Compared with patients receiving AZT + 3TC + NVP, the risk of CKD measured by adjusted sub-distribution hazard ratio (aSHR) was 6.5 (95% CI 3.9–11.1) in patients on TDF + 3TC + LPV/r, 3.8 (95% CI 2.3–6.0) in TDF + 3TC + NVP, and 1.6 (95% CI 1.2–2.3) in TDF + 3TC/FTC + EFV. Among patients receiving TDF, compared with those receiving TDF + 3TC/FTC + EFV, the aSHR was 4.0 (95% CI 2.3–6.8) in TDF + 3TC + LPV/r and 2.3 (95% CI 1.4–3.6) in TDF + 3TC + NVP. TDF was associated with an increased risk of CKD, especially when combined with LPV/r or NVP.Tenofovir disoproxil fumarate (TDF) is associated with a risk of chronic kidney disease (CKD), especially in Asian populations. Data from the Thai national health insurance system was used to assess CKD incidence in patients receiving antiretroviral therapy in real-world practice. We analyzed data from patients who initiated one of the following first-line regimens: zidovudine + lamivudine + nevirapine (AZT + 3TC + NVP); zidovudine + lamivudine + efavirenz (AZT + 3TC + EFV); tenofovir + lamivudine + nevirapine (TDF + 3TC + NVP); tenofovir + lamivudine/emtricitabine + efavirenz (TDF + 3TC/FTC + EFV); and tenofovir +lamivudine +lopinavir/ritonavir (TDF + 3TC + LPV/r). CKD was defined as glomerular filtration rate <60 mL/min/1.73 m A larmellitus . High lemellitus ,7,8,9. SSince 2004, the Thailand National Health Security Office (NHSO) in charge of the National AIDS Program has provided free-of-charge health services and ART for HIV-infected individuals. Using data from adults registered with this program under the Universal Coverage Scheme (UCS) , we inveWe performed a retrospective cohort study using data from the National AIDS Program, covering HIV-infected individuals who received ART. This program is under the Universal Coverage Scheme (UCS), which covers about three-quarters of the Thai population (~47 millions). Participants eligible for inclusion were as follows: (i) aged 18 years or older having registered for ART between October 2006 and September 2013  2007 to 2013); (ii) received a first-line ART regimen recommended by the 2019 World Health Organization guideline ; and (iiThe exposure of interest was one of the first-line ART regimens: (i) zidovudine, lamivudine, and nevirapine (AZT + 3TC + NVP); (ii) zidovudine, lamivudine, and efavirenz (AZT + 3TC + EFV); (iii) tenofovir, lamivudine, and nevirapine (TDF + 3TC + NVP); (iv) tenofovir, lamivudine or emtricitabine, and efavirenz (TDF + 3TC/FTC + EFV); and (v) tenofovir, lamivudine, and lopinavir/ritonavir (TDF + 3TC + LPV/r) .2 for >3 months [The outcome of interest was the diagnosis (confirmed within 3 months) of conditions defined by the 2010 WHO ICD-10  as codes3 months .We used patients’ data from the date of ART initiation to last visit, switching of ART regimen, loss to follow up, end of study (30 September 2014), death, or confirmed diagnosis of CKD, whichever occurred first.We extracted the following variables at time of ART initiation: sex, age, weight, height, serum creatinine levels, fasting plasma glucose, serum triglycerides, serum total cholesterol, absolute CD4 cell count, HIV-1 ribonucleic acid (RNA) load, and history of comorbidities, including type 2 diabetes, hypertension, ischemic heart disease, tubulo-interstitial nephritis, gout, urolithiasis, hepatitis B virus (HBV) infection, and hepatitis C virus (HCV) infection.We considered that a patient was diagnosed with type 2 diabetes if either of the following records were available: confirmed fasting plasma glucose ≥126 mg/dL according to the 2013 American Diabetes Association criteria , or WHO The characteristics of participants in the study are presented as medians and interquartile ranges (IQR) for continuous variables, and as counts and percentages for categorical variables. The number of person-years of follow-up (PYFU) was calculated from the date of ART initiation to censoring date. For descriptive purposes, the overall CKD incidence rate was estimated by the number of newly diagnosed individuals divided by the total number of PYFU, and the 95% confidence interval (CI) was calculated using the quadratic approximation to the Poisson log-likelihood.Regarding missing data, all models were adjusted for the availability of serum creatinine measurement records at baseline and during follow-up. We imputed missing data by multiple imputation with chained equations (MICE) based on logistic regression for variables with ≤20% missing data, and for time-updated absolute CD4 cell count values if data were missing for more than 9 months after the previous known value . BaselinA propensity score for each first-line ART regimen was developed to minimize the possible bias of the choice of ART by the physician in charge, and all models were stratified by propensity score. This score was generated using multinomial logistic regression based on a fiscal year of ART initiation, sex, age group, and history of comorbidities  see .We estimated the cumulative incidence rate of CKD and corresponding 95% CI using a cumulative incidence function accounting for deaths without a prior CKD diagnosis as competing events . 2), and history of comorbidities at treatment initiation, time updated absolute CD4 cell count (<200 or ≥200 cells/mm3), and HIV-1 RNA load (<1000 or ≥1000 copies/mL). The following variables potentially associated with risk of CKD were considered for analysis: fiscal year of ART initiation, sex, age categories , body mass index .Of 152,664 HIV-infected adults, 100,081 were excluded from the study because their first-line ART regimens were not recommended by WHO guidelines, in addition to 25,270 patients because of insufficient data. Thus, a total of 27,313 patients were included in this analysis, and 15,389 (56.3%) were males.Over the 8-year study period, of these 27,313 patients, 817 (3.0%) were lost to follow-up, 5840 (21.4%) switched to a second-line ART regimen, and 1844 (6.8%) died . The med2 , and absolute CD4 cell count 146 cells/mm3 . The most common comorbidities were hypertension (3.9%), HBV infection (3.8%), tubulo-interstitial nephritis (1.9%), and DM (1.9%). At baseline, the median age was 36.8 years , body mass index 20.4 kg/mDuring the total 76,168 PYFU, of 27,313 adults, 245 (0.9%) were diagnosed with CKD, leading to a cumulative incidence of 3.2 per 1000 PYFU (95% CI 2.8–3.6). The incidence rate of CKD was lower during the first 2 years of follow-up compared to the incidence thereafter see .The incidence rate of CKD was higher in adults who received a TDF containing ART regimen  compared to those receiving a non-TDF containing ART regimen  .The estimated cumulative incidence of CKD at 8 years of follow-up was 1.9% (95% CI 1.4–2.3). It was 1.5% (95% CI 0.1–2.2) in patients on AZT + 3TC + NVP, 2.8% (95% CI 1.5–4.9) on TDF + 3TC/FTC + EFV, 4.0% (95% CI 2.6–5.9) on TDF + 3TC + NVP, 1.3% (95% CI 0.9–2.0) on AZT + 3TC + EFV, and 5.1% (95% CI 3.0–8.1) on TDF + 3TC + LPV/r.3 , TDF + 3TC + NVP , and TDF + 3TC/FTC + EFV   . Among p3, both being factors related to HIV infection.Using data from 27,313 HIV-infected adults on ART over a median follow up of 2.3 years , the estimated incidence rate of CKD was 3.2 per 1000 PYFU. Factors independently associated with CKD diagnosis were older age, type 2 diabetes, gout and urolithiasis, which are known risk factors in the general population ,23,24,25The Data Collection on Adverse Events of Anti-HIV Drugs (D:A:D) study in Europe, the USA, and Australia reported a CKD incidence rate of 1.8 per 1000 PYFU (95% CI 1.6–2.0) in HIV-positive adults , lower tIn our population, older age, T2DM, and hypertension were associated with the risk of CKD, as in the general population ,29,30,31Two studies in Africa reported that the risk of CKD preferably occurred during the first 3 years following HIV diagnosis and in the case of low CD4 cell counts ,35. In tWe found that TDF exposure increased the risk of CKD, as in the EuroSIDA Study Group , the U.SAs for the use of protease inhibitor, the Canadian HIV Observational Cohort study  and the In our study, attending physicians switched the regimens of 5840 (21.4%) patients due to virologic failure or side effects. The choice of the new regimen was guided by HIV-1 genotypic resistance test results, adherence, potential drug–drug interactions, relevant comorbidities, drug availability in the national program, and national guidelines. The cost of laboratory exams and drugs were not supported by the patients but by The National AIDS Program.There were several limitations in our study. The NAP database was primarily designed to facilitate the reimbursement of costs incurred by hospitals for the delivery of HIV-related medical services, and risk factors for CKD were not systematically recorded. This study was a retrospective analysis of data collected in a real-world setting and the choice of an ART regimen was not randomized, but made by attending physicians based on baseline characteristics and guidelines. The use of a propensity score may partly correct this bias, but cannot totally eliminate it. Another limitation is that some variables, such as laboratory results at ART initiation, were not recorded in the database  and could not be fully assessed in our analysis. Nevertheless, this national database provides a unique source of information reflecting the actual CKD burden in people living with HIV.Based on the analysis of a large national dataset from HIV-infected patients treated in the real world, the risk of CKD was relatively low overall and mostly concentrated in patients receiving TDF with a higher incidence in those also on NVP or LPV/r. The results of our study support the current recommendation of dose adjustment in patients with kidney function impairment.