Maraviroc, a CCR5-antagonist, has resulted in larger increases in CD4+ counts both in naïve and experienced subjects compared to traditional antiretroviral therapy.Inflammation is a key feature of HIV infection and is correlated with long-term negative cardiovascular outcomes. Therapy-induced increases in CD4To examine if a member of the protein C anticoagulant and anti-inflammatory pathway, and marker of coagulation and inflammation, the soluble endothelial protein C receptor, is modified by infection and therapy-related variables in patients treated with Maraviroc. Endothelial protein C receptor, together with other established markers of inflammation and coagulation  was studied in 43 patients on traditional antiretroviral therapy and in 45 on Maraviroc during 48 weeks of follow-up.+ cell counts (more than 500 cells/µL by week 48).Soluble endothelial protein C receptor was the only marker that could discriminate at least partially between patients with a good response to Maraviroc and patients who did not respond with an adequate increase in CD4+ cells.Elevated levels of soluble endothelial protein C receptor, a sensitive marker of endothelial damage, indicated a low level of inflammation and coagulation activation in Maraviroc treated patients not picked up by other widely used markers. Persistent elevated levels of this marker at 48 weeks from beginning of treatment with Maraviroc were related to a poor increase in CD4 Since inflammation and coagulation work together, it is reasonable to suppose that novel markers of regulatory coagulation pathways could be useful in this setting.The understanding of the regulation of the inflammatory response in stable HIVThe protein C system is one of the main regulatory pathways of blood clotting: activated protein C inhibits two cofactors of the coagulation cascade (activated factors V and VIII) thereby limiting thrombin formation + cells Treatment with CCR5-antagonist Maraviroc (MVC) has resulted in larger increases in CD4+ counts both in naïve ®. Median time from diagnosis at baseline was 16 years (range 5–23).Eighty-eight HIV-infected patients were enrolled in the study after providing written informed consent approved by San Raffaele ethics committee. There were 70 men and 18 women, median age was 49 years (range). Forty-three were on antiretroviral therapy (ART) while 45 were on ART and were placed on MVC at the beginning of the study (defined as baseline), according to screening genotype, previous resistance tests and viral tropism determined by the phenotypic test TrofileBlood sampling as well as a medical visit were performed at baseline and at 4, 12, 24, 36 and 48 weeks after starting therapy. Blood for coagulation and inflammation markers was collected in trisodium EDTA, centrifuged at 1400 g for 15 min and platelet poor plasma was separated and stored at −80°C. Plasma samples were rapidly melted in a 37°C water bath before testing. No refrozen samples were used.+ absolute count and percentage, CD4+/CD8+ ratio, HIV-RNA). Coagulation and inflammation markers  were measured up to week 24, except for sEPCR which was measured also at weeks 36 and 48.The following variables were measured at each time point: blood glucose and insulin, lipid profile, and variables related to viral infection . Each assay contained a low level and a high level control. Inter-assay coefficient of variation (CV) for the high level was 8% and for the low level 16%. Normal reference range is: 0.2–10 µg/mL.th percentile of the normal distribution).D-dimer was measured by IMUCLONE D-Dimer ELISA . Each assay contained a low level and a high level control. Inter-assay coefficient of variation (CV) for the high level was 5% and for the low level 21%. Normal values are <400 ng/mL .sTM was measured by ELISA Eli-pair, Cell Sciences, Canton, MA, USA. Normal plasma was used as an internal control (low level) and the inter-assay CV was 38%. Normal values are <44 ng/mL  Tween 20, pH 7.5 (washing buffer), and were blocked with TBS-Casein  for 4 hours at 37°C. The wells were then washed, 50 µL samples were added in duplicate wells, and the plates were incubated for 1 h. The wells were aspirated, washed five times with washing buffer, and 50 µL of 2,2 µg/mL biotinilated JRK 1495 anti-human EPCR mouse monoclonal antibody were added. The plates were incubated for 1 h, washed five times, and 50 µL streptavidin–conjugated HRP diluted 1∶3000 (Sigma) were added and incubated for one additional hour. The wells were washed five times, and the substrate SIGMA FAST OPD  was added. The color development was stopped with 3 M H2SO4, and the endpoint absorbance at 490 nm was read. Each plate contained standards in duplicate wells from 62.5 to 1000 ng/mL purified human soluble EPCR in washing buffer. The inter-assay CV was 7%.sEPCR was measured by a previously employed, home-made ELISA assay th percentile of the normal distribution).Normal values are <297 ng/mL .All other tests were part of good clinical practice protocols and were carried out at the central laboratory of the San Raffaele Scientific Institute.Demographic, clinical and laboratory data were stored in an electronic database. Results for continuous variables are reported as median and range, for dichotomic variables as frequencies in percent or absolute counts. Differences between groups for dichotomic variables were evaluated by Fisher’s exact chi-square test. Differences by time and by treatment group in continuous variables were analysed first by analysis of variance for repeated measures, and then by direct comparison. P values <0.05 were considered significant.At baseline, 43 patients with not CCR5-tropic virus started salvage antiretroviral therapy based on genotypic test: 4 (9%) with enfuvirtide, 10 (24%) with protease inhibitors and 29 (67%) with non nucleoside reverse transcriptase inhibitors; all patients received raltegravir. Forty-five with CCR5-tropic virus started therapy containing MVC: 8 (18%) at standard dosage (300 mg twice daily); 9 (20%) in association with protease inhibitors (150 mg twice daily); 28 (62%) in association with non nucleoside reverse transcriptase inhibitors (600 mg twice daily).2 = 4.941, p<0.05).Patients on ART and on ART with MVC (i.e. at start of MVC therapy) differed for triglycerides and direct bilirubin levels only, while age and all other laboratory variables were similar . Moreove+ cell counts over time in patients on ART and in patients who were administered MVC as well. Lipid profile was better in the ART with MVC group, and improved or remained stable over time. Especially HDL cholesterol increased sooner in the ART with MVC group than in the ART only patients. As also shown in the figure, CD4+ cell counts increased in both groups (p<0.001 at 48 weeks compared to baseline in both groups), but increments were higher and occurred sooner in patients on MVC compared to patients on traditional ART. Other CD4+ related variables  varied similarly to CD4+ cell counts, but did not show significant differences between the two treatment groups at any time (not shown). HIV-RNA decreased in both groups to undetectable levels in the majority of patients by week 4 and remained low through week 48 in both groups . In general, median levels were within the normal range for CRP, IL-6 and sTM in both groups, while median D-dimer levels were increased above normal in both groups at all times. In contrast, since sEPCR levels showed a trend to change by time and treatment group, levels were measured beyond week 24 and are reported in th percentile of the normal range were considered and CD4+ cell numbers were plotted separately for ART patients or ART with MVC, two different graphs were obtained . Also in ART treated patients levels of sEPCR are higher in patients who respond less, though both curves are persistently below the arbitrary threshold of 500 cells/µL . There were no differences between the two groups at any time, however more patients had levels above the reference range over the study time in the ART only (n = 26) compared to the ART with MVC treatment group (n = 18). If levels of soluble EPCR at week 48 above or below the 95obtained . In bothcells/µL . Finally+ cell counts over time compared to patients on ART alone, while the decrease in viral load was comparable (by week 4 more than 50% and by week 48 more than 90% of patients had undetectable levels of HIV mRNA in both groups). In naïve patients, MVC improved lipid profiles + cell counts increases are similar to those reported in previous larger studies + cell counts in the ART with MVC group were 500 cells/µL by week 36 and then leveled off.In this study we observed that treatment experienced patients with a CCR5-tropic HIV1 virus treated with MVC in addition to ART showed a better lipid profile regardless of associated treatment and a greater and more precocious increase in CD4th percentile of the normal distribution) partially discriminated between patients who achieved and patients who did not achieve 500 CD4+ cells/µL by week 48. In general, the slope of increase in CD4+ by high or low levels of sEPCR at week 48 was significantly different. In patients who responded to MVC an exponential increase in CD4+ cells was associated with low levels of sEPCR at week 48 and low levels of D-dimer, and the converse was true in patients who did not respond adequately to MVC. The same trend were observed also in patients on traditional ART, though less marked.Inflammation and coagulation markers were studied as well, since both antiretroviral therapy and HIV infection are known to induce an inflammatory response and coagulation activation as a consequence of endothelial perturbation sEPCR is generated at the endothelial surface by cleavage of the extracellular portion of the receptor. Cleavage occurs through a metalloprotease + cells. MVC increases faster and sooner the CD4+ cell count, but the same relationship between CD4+ cell counts, sEPCR and D-dimer can be observed also in ART treated patients, though it’s less clear-cut. Second, a low-grade inflammatory and hypercoagulable state is observed also in patients with stable long-lasting disease and low levels of other, more traditional inflammatory and coagulation markers. Third, some patients who do not respond to therapy, either ART or MVC, by an increase in CD4+ cell counts, independently of reduction in viral load, have a persistent or increasing inflammation and coagulation activation. Fundenburg and coworkers also reported that decreases in inflammatory and immune markers in HIV+ patients were associated with an increase in CD4+ cell counts.13 The authors also suggested that the early, modest differential effect of MVC on several markers compared to the comparator of the trial suggested an additional direct effect of the drug on immune activation and inflammation. Moreover, MVC was reported to decrease T cell activation and to modulate the immune activation present in HIV patients, though through which mechanism is not clear Three important suggestions can be derived from this study. First, anti-HIV therapy seems to control inflammation and coagulation, and is associated with an increase in CD4+ patients, but sEPCR levels were shown to be associated with a hypercoagulable state and cardiovascular disease in diabetic patients + cells and increase their numbers, have a potential to control coagulation activation and inflammation in responsive patients at least in the short term. In the setting of antiretroviral naïve patients, Maraviroc was not associated with elevations in lipids and showed beneficial effects on lipid profiles of dyslipidemic patients Elevated D-dimer was found to be strongly associated with mortality and also to predict cardiovascular disease in HIV+ patients All patients signed informed consent for participation of Maraviroc Expanded Access Program.


We investigated the prevalence of wild-type virus (no major drug resistance) and drug resistance mutations at second-line antiretroviral treatment (ART) failure in a large HIV treatment program in South Africa.HIV-infected patients ≥15 years of age who had failed protease inhibitor (PI)-based second-line ART  were identified retrospectively. Patients with virologic failure were continued on second-line ART. Genotypic testing for drug resistance was performed on frozen plasma samples obtained closest to and after the date of laboratory confirmed second-line ART failure. Of 322 HIV-infected patients on second-line ART, 43 were adults with confirmed virologic failure, and 33 had available plasma for viral sequencing. HIV-1 RNA subtype C predominated . Mean duration on ART (SD) prior to initiation of second-line ART was 23 (17) months, and time from second-line ART initiation to failure was 10 (9) months. Plasma samples were obtained 7(9) months from confirmed failure. At second-line failure, 22 patients (67%) had wild-type virus. There was no major resistance to PIs found. Eleven of 33 patients had a second plasma sample taken 8 (5.5) months after the first. Median HIV-1 RNA and the genotypic resistance profile were unchanged.Most patients who failed second-line ART had wild-type virus. We did not observe evolution of resistance despite continuation of PI-based ART after failure. Interventions that successfully improve adherence could allow patients to continue to benefit from second-line ART therapy even after initial failure. South Africa has the largest government-sponsored antiretroviral treatment (ART) program in the world International guidelines endorse boosted protease inhibitor (PI)-based combination ART as an efficacious strategy after failure of NNTRI-based first line ART In resource-limited settings such as South Africa, many unanswered questions remain about the contribution of drug resistance to second-line ART failure. They include uncertainties about the susceptibility of HIV-1 subtype C, which accounts for nearly half of global infections and the majority in South Africa Here, we investigated the extent to which drug resistance mutations contribute to second-line ART failure in a large community-based ART program in South Africa.All study participants provided written informed consent. For participants age ≤18 years, an accompanying parent or guardian also provided written consent. Study procedures were approved by the University of Cape Town  and the Partners HealthCare Human Research Committee .The Gugulethu Clinic is an HIV referral center for a peri-urban township of Cape Town, South Africa. The clinic provides HIV-related care for more than 6,000 patients and serves an impoverished population of more than 300,000 individuals where the ante-natal HIV seroprevalence was 29% in 2006 Data from HIV-infected patients ≥15 years of age who had failed second-line therapy (2 consecutive HIV-1 RNA tests >1000 copies/ml) by October 1, 2009, were analyzed retrospectively using a cross sectional design. A single local laboratory performed HIV-1 RNA assays by branch DNA hybridization techniques  and CD4-count by flow cytometry . Genotypic testing for drug resistance was performed on frozen plasma samples obtained closest to, and on or after the date of laboratory confirmed second-line ART failure. We used International AIDS Society-USA criteria to define drug resistance mutations Viral RNA was extracted  from 140 µl of each plasma sample and HIV-1 protease  and reverse transcriptase  were amplified by a 1-step reverse transcription–polymerase chain reaction (PCR), followed by a nested-PCR using gene-specific primers, as described Population (“bulk”) sequencing was performed on resulting amplicons with the Taq Dye Deoxy Terminator Kit  and resolved on an ABI 3730 automated DNA sequencer. Sequence processing was done using the Sequencher program (Genecodes). Sequences were aligned to the HIV-1 subtype B reference strain HXB2 (GenBank accession no. K03455).Each sample was amplified in duplicate. A phylogenetic tree, using the PhyML program and including all the sequences generated as well as HXB2 and NL4-3 corresponding sequences, was used to confirm specimen identity and the absence of cross-contamination as an adjunct to the PCR negative control.Mean values were reported with standard deviations (SD). Demographic and laboratory characteristics were examined for association with drug-resistant virus at second-line ART failure. We used Fisher's exact test to compare the association of categorical variables, age dichotomized at the mean (≤35 or >35 years), and HIV-1 RNA  with the outcome. Statistical tests were two-sided with a significance level of 0.05. All statistical analyses were performed using SAS 9.1 software .Of 322 HIV-infected patients receiving second-line ART, 43 were adults (≥15 years) with confirmed virologic failure . Of thes10 copies/ml [IQR 3.5–4.7 log10 copies/ml], which increased to a median HIV-1 RNA of 4.6 log10 copies/ml [IQR 4.1–5.1 log10 copies/ml] at second-line failure.At second-line ART initiation, median CD4 count was 210/µl [IQR 108–310/µl] and median HIV-1 RNA was 4.1 logAt the first sample collection at second-line failure, virus from 22 patients (67%) was wild-type or lacked major drug resistance mutations . Among sMutations classified as “minor” PI resistance mutations by the IAS-USA were detected in 30 of 33 (91%) individuals; no major PI resistance mutations were found. The most frequent minor PI resistance mutations included K20R ; M36I , L63P , H69K , and I93L . Less commonly found mutations included L10FV  D60E , and I62V .Ten individuals had HIV-1 genotypes from the time of first-line ART failure available. The same minor PI resistance mutations present at second-line ART failure were also present at first-line ART failure, prior to PI exposure. Virus from 8 individuals had M184V at first-line ART failure; in 7 individuals this mutation was undetectable at second-line failure. All samples in which the M184V mutation was detected at first-line failure also carried major NNRTI resistance mutations. Of the 9 individuals with virus containing major NNRTI resistance mutations at first-line failure, 6 retained virus with detectable major NNRTI resistance mutations at second-line failure. Samples from 2 individuals had thymidine analog mutations (TAMs) at first-line ART failure, which were not detected at second-line ART failure.10 copies/ml [IQR 3.5–5.0 log10 copies/ml]. The genotypic resistance profile was also unchanged. Mean genotypic susceptibility score was 2.9 (±0.4) at second-line failure; this was unchanged for those with a repeat sample.Eleven of 33 patients had a second sample for resistance testing taken 8 (5.5) months after the first sample at second-line failure. Median HIV-1 RNA was unchanged from the first sample at 4.5 logIn patients aged 15–35 years, 29% had drug-resistant virus, compared with 42% of those aged >35 years, although this difference did not reach statistical significance. Thirty-one percent of individuals failing treatment with HIV RNA>10,000 copies/ml had drug-resistant virus, compared with 43% of individuals with HIV RNA≤10,000 copies/ml (p = 0.66).In this large ART roll-out program in South Africa we identified patients with confirmed virologic failure on second-line ART. Despite the absence of major PI resistance at first-line ART failure, most individuals failed second-line ART quickly (e.g. within a mean of 10 months) and two-thirds failed with wild-type virus. Furthermore, while patients remained on second-line ART with continued virologic failure, drug resistance did not develop over the follow-up period.Given the known potency of second-line ART regimens and the low frequency of drug resistant virus found, it appears that medication non-adherence is an important cause of second-line ART failure. While access to pharmacy refill, pill count, and patient-level pharmacokinetic data were not available, there are plausible patient-level, regimen-specific, and structural explanations for adherence problems on second-line ART. Drug toxicities related to lopinavir and didanosine and the buffered formulation of didanosine (the enteric-coated formulation was unavailable at the study site) likely hindered adherence Most patients had substitutions in PR at sites that are known to be polymorphic in HIV-1 subtype C. These minor resistance mutations were also present at first-line ART failure in samples from the 10 patients who had samples available for sequencing from that time point. This observation confirms a prior genotype study from this clinic of HIV-infected individuals who were ART-naïve and who had failed first-line where the same polymorphisms in PR were present Despite the absence of NNRTI exposure on second-line ART, virus from almost 30% of patients had at least one major NNRTI resistance mutation and virus from 15% had a mutation at the K103N codon, which suggests ongoing resistance to nevirapine and efavirenz. The persistence of NNRTI resistance is consistent with genotypic analysis of two other public sector South African cohorts of patients that failed PI-based ART There are several therapeutic implications for the absence of NRTI resistance at second-line failure in this study. While other studies have suggested a higher rate of emergence of K65R at the time of stavudine-based ART failure in HIV-1 subtype C infection, we found that K65R did not appear after exposure to first-line stavudine or second-line didanosine; this may hold promise for the increasing use of tenofovir in resource-limited settings with predominance of nonsubtype-B HIV clades Females represented 85% of the patients whose viruses were sequenced, which is slightly higher than the distribution of females commencing second-line ART (75%)In vivo resistance data suggest that the accumulation of accessory mutations in PR occurs rapidly only after major protease resistance mutations are established The low frequency of drug resistance to boosted-lopinavir at the time of virologic failure in this large ART-roll out program in Cape Town confirms other studies in Johannesburg and Soweto, South Africa, as well as in North America and Europe In those who experience virologic failure on second-line ART in South Africa, ART failure occurs quickly and most often with wild-type virus. However, rapid development of resistance does not occur. Interventions that successfully improve adherence could allow patients to continue to benefit from second-line ART therapy even after initial failure.


The most recent World Health Organization (WHO) antiretroviral treatment guidelines recommend the inclusion of zidovudine (ZDV) or tenofovir (TDF) in first-line therapy. We conducted a cost-effectiveness analysis with emphasis on emerging patterns of drug resistance upon treatment failure and their impact on second-line therapy.We used a stochastic simulation of a generalized HIV-1 epidemic in sub-Saharan Africa to compare two strategies for first-line combination antiretroviral treatment including lamivudine, nevirapine and either ZDV or TDF. Model input parameters were derived from literature and, for the simulation of resistance pathways, estimated from drug resistance data obtained after first-line treatment failure in settings without virological monitoring. Treatment failure and cost effectiveness were determined based on WHO definitions. Two scenarios with optimistic  and pessimistic (extensive emergence) assumptions regarding occurrence of multidrug resistance patterns were tested.In the base scenario, cumulative proportions of treatment failure according to WHO criteria were higher among first-line ZDV users  compared with first-line TDF users . Consequently, a higher proportion initiated second-line therapy  in the first-line ZDV user group 34%  relative to first-line TDF users . At the time of second-line initiation, a higher proportion (16%) of first-line ZDV users harboured TDF-resistant HIV compared with ZDV-resistant viruses among first-line TDF users . In the base scenario, the incremental cost effectiveness ratio with respect to quality adjusted life years (QALY) was US$83 when TDF instead of ZDV was used in first-line therapy (pessimistic scenario: US$ 315), which was below the WHO threshold for high cost effectiveness (US$ 2154).Using TDF instead of ZDV in first-line treatment in resource-limited settings is very cost-effective and likely to better preserve future treatment options in absence of virological monitoring. The public health approach for combination antiretroviral therapy (cART) in resource-limited settings includes the use of one standard first-line and one standard second-line regimen One particular concern regarding the widespread use of TDF in settings without virological monitoring is the potential for development of extensive nucleoside and nucleotide analogue cross-resistance via the emergence of the reverse transcriptase mutation K65R, and possibly also multidrug resistance patterns such as Q151M, although the latter has not been detected in well-controlled clinical trials in resource-rich settings Previous cost effectiveness analyses have already pointed towards better clinical outcomes of TDF use compared with other NRTIs in industrialized http://links.lww.com/QAD/A113), with deviations in how drug resistance mutations emerge (see below). In brief, the stochastic model, programmed in SAS 9.1, simulates a generalized heterosexual HIV epidemic in a resource-limited country by keeping track of individuals and their health status with regard to HIV and other co-morbidities. Individual characteristics are updated in three month time steps.The model presented here corresponds to the version described extensively in A typical simulation run, which is influenced by many random elements, shows the following characteristics: starting in 1989, the population of approximately 25 000 uninfected persons initially contains about 5 HIV infected individuals. The epidemic starts to spread via individuals who acquire HIV through heterosexual contacts with HIV-1 infected short or long term partners. The probability of transmission of HIV depends on whether the partner is undergoing primary infection, on the partner’s HIV-RNA viral load , on the subject’s gender and on the presence of other sexually transmitted infections. Each HIV-infected individual experiences HIV RNA levels, CD4 declines and mortality rates that correspond to their specific age and gender, health status with respect to co-morbidities, and to antiretroviral treatment exposure. We assumed that cART became available in 2007  or triggered by AIDS defining conditions. CD4 count determinations are performed every 6 months in diagnosed individuals, and if measured CD4 levels drop<200 cells/mmThe definition for treatment failure is based on clinical (new or recurrent WHO stage 4 condition), specific WHO clinical stage 3 conditions (e.g. pulmonary tuberculosis) and immunological criteria  and CD4 cell measurements occur on a 6-monthly basis. It is also assumed that virological testing is not available and that switching to second-line ART occurs almost immediately after detection of treatment failure at a rate of 80% per 3 months, unless an individual is lost to follow-up.Second-line ART consists of LPV/r, 3TC, and either ZDV or TDF, whichever has not been used in first-line treatment already. In this hypothetical setting with only two lines of treatment available, individuals who fail second-line therapy remain on the failing regimen.th–97.5th percentiles] from the distribution of point estimates from all simulation runs per analysis (n = 100). Unless stated otherwise, treatment outcomes were estimated on an intent-to-continue treatment basis by the Kaplan-Meier method, meaning that study outcomes were still attributed to the respective first-line strategy in spite of possible switches to second-line therapy.Clinical  and treatment outcomes  of the simulation are presented as medians . ThThe estimated 3-month incidence rates for NNRTI and 3TC mutations, which were also derived from genotypic data, are displayed in The effect of considering LPV/r worth only 1 drug, of immediate or delayed switching after detection of first-line treatment failure or of the assumed adherence benefit of TDF use on outcomes (and treatment costs in particular), and combinations of these parameters, were subjected to sensitivity analyses by re-running the simulation using predefined parameter values . In the Moreover, simulations were repeated in alternative settings, which included the availability of viral load monitoring, the effect of substituting drug components due to toxic side effects, and by introducing ART into a setting where transmitted drug resistance from D4T/3TC/nevirapine was present , 3TC+TDF+NNRTI (n = 24) or 3TC+D4T+NNRTI (n = 472) were analyzed. Given the small number of individuals who have received TDF in first-line treatment, rates of K65R and Q151M mutation emergence were also estimated from the D4T data and applied to a separate simulation representing an alternate, “pessimistic” scenario. The distribution of viral subtypes was as follows: C 53% (n = 320); G 16% (n = 97); CRF02_AG 14% (n = 83); and a variety of other non-B subtypes occurring at <4%.Probabilities for the emergence of resistance upon clinical or immunological treatment failure were calculated as the percentage of genotypic resistance tests showing a specific mutation pattern and are displayed in Out of a population of 4346  simulated HIV infected individuals, 2012  and 2045  individuals ever initiated ART with ZDV or TDF between the years 2007 and 2022 (end of simulation), respectively. The median age at time of cART initiation was 43 years, and 52% were women, irrespective of treatment strategy group. The median follow-up time after initiation of first-line therapy was 6 years. At time of therapy initiation, median values [interquartile range] of HIV RNA measurements were 5.09  log10 copies/mL, and median [interquartile] CD4 count measurements reached 140  cells/microliter, irrespective of treatment group. Around 7% Differences in first-line therapy outcomes were predicted with respect to CD4 cell count recovery, with a gain of 102 cells/microliter  within 1 year in the ZDV group and gains of 114 cells/microliter  (base scenario) and 107 cells/microliter  (pessimistic scenario) in the TDF group, respectively. Intent to treat viral suppression rates below 50 copies\mL after 1 year were estimated at 64%  among ZDV starters and at 68%  (base scenario) and 66%  (pessimistic scenario), respectively, in the TDF group.As shown in A higher proportion of ZDV starters was predicted to have initiated LPV/r-based second-line therapy within 6 years after antiretroviral treatment initiation  when compared with the group of TDF starters . Among individuals from the ZDV group who initiated second-line therapy, TAMs were predicted to be present in 28.4% , and none in the two TDF groups. Among individuals who started TDF as first-line therapy, the predicted proportion of K65R was almost 9-fold higher in the base scenario  compared with the pessimistic scenario . In contrast, while there were no Q151M mutations emerging in the base scenario, the prevalence of Q151M was estimated at 5.9%  in the pessimistic scenario. With respect to NNRTI mutations (56–57%) and M184V (62–63%), the simulation yielded almost identical estimates across the three groups (not shown).Next, we analyzed the potential activity of second-line regimens against a background of different resistance mutations patterns. Previous studies have demonstrated that ritonavir-boosted PIs such as LPV/r have a very high potency to inhibit viral replication and are very robust to the emergence of drug resistance For the cost effectiveness analysis, the cumulative treatment costs accrued after therapy start until death or the year 2022 (whichever came first) were compared . The medRegarding morbidity and life-years lived as outcomes, the three strategies seemed to be comparable: the six year Kaplan-Meier estimates for mortality were 25.9%  for the ZDV group and 23.3%  (base scenario) and 23.6%  (pessimistic scenario) for the TDF groups. The mean number of discounted life years lived since therapy start until death or 2022 per individual looked similar across the three groups  on resistance emergence and its consequences in terms of response to available second-line regimens and associated costs. Owing to uncertainty with respect to the influence of prolonged exposure to failing regimens and the effect of non-B subtype infection on NRTI-cross resistance we tested two pathways for resistance emergence while receiving TDF therapy. The base scenario assumed a rapid and frequent emergence of the TDF signature mutation K65R but only a very limited degree of NRTI cross-resistance. The second, pessimistic scenario was derived from analyses of genotypic resistance tests performed after failure of first-line combination treatment with D4T and was characterized by a more limited emergence of K65R, but a considerable risk for NRTI-cross resistance by the emergence of Q151M.Our analyses suggest that first-line TDF use is a cost-effective treatment strategy compared with first-line ZDV use when considering quality adjusted life years as outcome, although dominance of the TDF strategy was only observed in 11% to 46% of comparisons . The useDepending on the actual rate of NRTI multidrug resistance emergence, first-line TDF use may increase emergence of extensively NRTI class-resistant HIV by 8.5-fold (17/1000 first-line TDF users in the pessimistic scenario compared with 2/1000 first-line ZDV users). Observational studies have reported associations of K65R mutations with Q151M, possibly pointing towards a co-selection of these mutations Some limitations should be noted about this study. Like any model, our simulation involves simplifications of reality and is based on assumptions regarding input parameters. In particular, given the lack of real data we had to make assumptions regarding rates and extent of drug resistance following immunological failures in resource-limited settings, as shown in In summary, taking into account the possibility of more extensive drug resistance or possible long term renal toxicity by TDF use we conclude that first-line TDF use is likely to be a very cost-effective treatment strategy in resource-limited settings even in the absence of virological monitoring, because of the better tolerability and the small cost difference.Table S1Cost effectiveness results from sensitivity analyses. Numbers in brackets represent 95% simulation intervals, i.e. the range including 95% of all model predictions.(DOC)Click here for additional data file.Materials S1Description of settings for main simulations and details on modelling of resistance-adherence relationships.(DOC)Click here for additional data file.


TDF/FTC is the most commonly used recommended backbone in this setting. Our objectives were to compare times 1) to discontinuation of the third drug, 2) to virologic suppression (VL< 50 copies/ml), with discontinuation of the third drug considered as failure, 3) to an increase of at least 100 CD4 cells/mmART-naive patients in the FHDH ANRS CO4 cohort who started cART containing TDF/FTC plus either ATV/r or another recommended third drug  after 31/12/2003 and at least 12 month before the closing date of the database were analyzed. Multivariable Cox's proportional hazards models were used to control for the following potential confounders: Age, sex, geographical origin, transmission group, baseline CD4 cell counts and viral load, AIDS stage, HCV co-infection and year of starting.2910 patients (ATV/r=517 and Other=2393) were analyzed, with a median follow-up of 19.1 months (IQR: 9.8-30.4). The third drug was EFV in 1129 (47.2%), LPV/r in 1045 (43.7%) and f-APV/r in 219 (9.2%). Baseline median CD4 was 246 for ATV/r and 228 for other drugs (p=0.0064) and viral load 4.87 for ATV/r and 4.89 for other drugs (p=0.0688). At 24 months, the rates of the different outcomes were for ATV/r versus other drugs:• Discontinuation of the 3rd drug: 24% and 27% (aHR: 0.76 (0.61-0.94))• Virologic suppression (VL< 50 copies/ml): 83% and 84% (aHR: 0.93 (0.84-1.04))3: 83% and 80% (aHR: 1.09 (0.98-1.21))• Increase of at least 100 CD4 cells/mm• AIDS or death: 7% and 10% (aHR: 0.88 (0.61-1.28))• Hospitalization, AIDS or death: 17% and 21% (aHR: 0.93 (0.73-1.18))3 depending of the level of viral load (< or >=100 000 copies/ml) will also be presented.Sensitivity analyses using propensity scores and subgroup analyses in patients with CD4<200/mmIn this observational settings in ART-naive patients, use of ATV/r as third drug was associated with a lower rate of discontinuation and with no difference in terms of virologic suppression, immunological and clinical outcomes as compared to other recommended third drugs.


Gender differences in antiretroviral therapy (ART) outcomes are critical in sub-Saharan Africa. We assessed the association between gender and virologic failure among adult patients treated in a public routine clinic (one of the largest in West Africa) in Burkina Faso.We performed a case-control study between July and October 2012 among patients who had received ART at the Bobo Dioulasso Day Care Unit. Patients were eligible if they were 15 years or older, positive for HIV-1 or HIV-1+2, and on first-line ART for at least six months. Cases were all patients with two consecutive HIV loads >1000 copies/mL , or one HIV load >1000 copies/mL associated with immunologic or clinical failure criteria. Controls were all patients who only had HIV loads <300 copies/mL. The association between gender and virologic failure was assessed using a multivariate logistic regression, adjusted on age, level of education, baseline CD4+ T cell count, first and current antiretroviral regimens and time on ART.p<0.001). Compared to controls, cases were also younger, more immunodeficient at ART initiation, less likely to receive a protease inhibitor-based antiretroviral regimen and had spent a longer period of time on ART. After adjustment, male gender remained strongly associated with virologic failure .Of 2303 patients , 172 had virologic failure and 2131 had virologic success. Among the former, 130 (75.6%) had confirmed virologic failure, 38 (22.1%) had viro-immunologic failure, and four (2.3%) had viro-clinical failure. The proportion of men was significantly higher among the cases than among the controls (37.2% vs. 24.9%; Men on ART appeared more vulnerable to virologic failure than women. Additional studies are needed to confirm the poorer prognosis of men in this setting and to determine the causes for their vulnerability in order to optimize HIV care. From now on, efforts should be made to support the adherence of men to ART in the African setting. Gender differences in antiretroviral therapy (ART) are increasingly recognized as a critical issue in sub-Saharan Africa, where 7.5 million HIV-positive patients are now being treated ,2. In thMoreover, there is a growing body of evidence to suggest that men who access ART in sub-Saharan Africa are more at risk of therapeutic failure than women, independently of their later initiation of treatment. They are more likely to interrupt ART, to be lost to follow-up, to have poorer immunologic responses and are more likely to die than women –21. HoweEvidences of gender differences in virologic outcomes on ART in sub-Saharan Africa are limited and conflicting, with studies showing no gender difference and others showing poorer virologic outcomes among men than among women ,13,22–29A case-control study was performed between July and October 2012 among patients who had received ART at the Day Care Unit of the Sanou Souro University Hospital in Bobo Dioulasso (the second largest city in Burkina Faso). Routine prescription of ART started in 2002 (few patients were treated between 1999 and 2002), and this clinic now has one of the largest West African cohorts of patients and serves as a reference HIV clinic. HIV load measurements started in July 2008 in the context of an active screening of patients with suspected therapeutic failure. From September 2010, HIV load measurements were progressively scheduled once a year for all the patients on ART (starting with those who did not have measurements in the previous period) but this recommendation was applied at the physician's discretion and subject to the availability of tests. Patients were eligible for the study if they were 15 years or older, positive for HIV-1 or HIV-1+2, in care between July 2008 and June 2012, and on first-line ART for at least six months.confirmed virologic failure), one HIV load >1000 copies/mL associated with a WHO-defined immunologic failure criterion, three months apart (viro-immunologic failure), or one HIV load >1000 copies/mL associated with a clinical failure criterion , three months apart , at any time point after six months on treatment [Cases were all the patients who had either two consecutive HIV loads >1000 copies/mL, one to six months apart  or the Abbott RealTime HIV-1 quantitative assay . CD4+ T cell count were measured using a FACSCount device  or a CYFLOW counter  at ART initiation and every six months thereafter. The first-line antiretroviral regimens mostly included two nucleoside reverse transcriptase inhibitors (NRTIs) and one non-NRTI (NNRTI), but the latter drug was sometimes replaced by a protease inhibitor (PI) or a third NRTI. Adherence support was provided at ART initiation, two and four weeks later, and then on average every two months. Patients who did not attend scheduled appointments for drug supply were telephoned or visited at home. ART, biologic exams and other care were provided free of charge. Demographic and medical data were recorded in both individual paper and electronic  medical charts.Eligible patients were identified using the ESOPE database. Their data were then extracted and checked using paper medical charts and laboratory, pharmacy and psycho-social databases, as well as by interviewing the clinic staff members .Between-group comparisons of patient characteristics were performed using the Chi-squared or Fisher exact test for the categorical variables and the Mann–Whitney test for the continuous variables. A multivariate logistic regression model was then used to compare virologic failure between men and women, adjusted on the following variables: age (<35 vs. ≥35 years), level of education (lower than secondary school vs. secondary school or higher), baseline CD4+ T cell count (≤200 vs. >200 cells/µL), first and current antiretroviral regimens  and time on ART. A backward elimination procedure was used to determine the final model containing only gender, together with significant covariates and potential confounders.© 12.2  software.The time on ART was calculated as the number of months between ART initiation and the following events as appropriate: first of two consecutive HIV loads >1000 copies/mL or single HIV load >1000 copies/mL associated with an immunologic or a clinical failure criterion (for the patients with virologic failure); first HIV load <300 copies/mL (for the patients with virologic success); switch to a second-line regimen, transfer to another clinic, last clinical visit for the patients lost to follow-up, death or database cut-off date for this study  (for the patients eligible but not included). All analyses were performed with STATAp=0.003), slightly older , more likely to have reached at least the secondary school level  and on ART for a longer duration  than their counterparts who were not included.Of 4633 patients who had received ART in the Bobo Dioulasso Day Care Unit, 3448 (74.4%) were eligible for the study . Of themThere were 172 cases (patients with virologic failure) and 2131 controls (patients with virologic success). Among the cases, 130 (75.6%) had a confirmed virologic failure, 38 (22.1%) had a viro-immunologic failure and 4 (2.3%) had a viro-clinical failure. Only one case and 49 controls were dually positive for HIV-1 and HIV-2, while all the other patients were positive for HIV-1 alone.p<0.001; p=0.002), more immunodeficient at ART initiation , more likely to have received a first NNRTI-based regimen  and to receive a NNRTI-based regimen at the time of the study  and had spent a longer time on ART . By contrast, the level of education did not differ significantly between cases and controls (p=0.111).The proportion of men was significantly higher among the cases than among the controls , more likely to have reached at least the secondary school level  and more immunodeficient at ART initiation . Conversely, no gender differences were observed in terms of first and current antiretroviral regimens  and time on ART .Compared to women , men werp<0.001). Age, CD4+ T cell count at ART initiation, first and current antiretroviral regimens and time spent on ART were also associated with virologic failure in crude analysis while level of education was not  after adjustment for age, level of education, CD4+ T cell count at ART initiation, first and current antiretroviral regimens and time spent on ART (p<0.001) including age, level of education, first antiretroviral regimen and time spent on ART.Male gender remained strongly associated with virologic failure  and in another study in Uganda  [p=0.012) in the Democratic Republic of Congo and in 55% of men vs. 31% of women (p=0.003) in Tanzania [Our finding was consistent with other but not all African studies. In particular, very comparable strengths of association between gender and virologic response were reported in the DART  study in Uganda and Zimbabwe  ,23. AlsoTanzania ,25. ConvTanzania ,26,28,29Two key elements might explain the vulnerability of men to virologic failure. The first element relates to gender differences in pharmacokinetic and pharmacodynamic profiles of antiretroviral drugs ,32. HighOur study, based on a chart review in a routine-care setting, has several limitations. First, our results might not be fully generalizable. A quarter of eligible patients were excluded because they did not have HIV load measurements. Baseline characteristics of these patients were slightly different than those of included patients and, more importantly, their duration of ART was shorter (18 vs. 34 months). On the other hand, there might be different groups of patients because HIV load measurements were performed selectively, depending on the time periods. How this selection bias affected the association between gender and virologic failure is unclear. Second, biological or clinical events might have been under-reported. This information bias was minimized by analyzing all available paper and electronic files and by interviewing the clinic staff members. Third, because of the progressive strategy for HIV load measurements, we performed a case-control study that is less reliable than a prospective cohort study. However, we included all patients who fulfilled our definitions of virologic failure (cases) and virologic success (controls); took into account all available data for HIV load, CD4+ T cell count and clinical events; and adjusted the analyses for age, level of education, CD4+ T cell count at ART initiation, first and current antiretroviral regimens and time spent on ART. Finally, as already stated above, antiretroviral drug concentrations and adherence were not available; this prevented us from investigating the causes for the higher virologic failure in men than in women.Men on ART appeared more vulnerable to virologic failure than women, regardless of their HIV disease stage at ART initiation. Additional studies are needed to confirm the poorer prognosis of men in this setting and to determine the causes for their vulnerability in order to optimize HIV care. Efforts should be made to support the adherence of men to ART in the African setting.


Background. We have previously shown that 75% of individuals on antiretroviral therapy (ART) in a resource-limited setting who experienced virological breakthrough to >1000 copies/mL were resuppressed after an intensive adherence intervention. This study examines the long-term outcomes of this group in order to understand the impact of the adherence intervention over time. Methods. ART-naïve adults commencing ART between September 2002 and December 2009 were reviewed. Those who achieved suppression (<50 copies/mL) were categorised by subsequent viral load: any >1000 copies/mL  or not. Those with breakthrough were sub-categorised by following viral load into failed (VL > 1000 copies/mL) or resuppressed (VL < 1000 copies/mL). Their outcome  was determined as of the 13th April 2010. Findings. 4047 ART-naïve adults commenced ART. 3086 had >2 viral loads and were included in the analysis. 2959 achieved virological suppression (96%). Thereafter 2109 (71%) remained suppressed and 850 (29%) experienced breakthrough (n = 283 (33%) failed and n = 567 (67%) resuppressed). Individuals with breakthrough were younger (P < .001), had lower CD4 counts (P < .001), and higher viral loads (P < .001) than those who remained suppressed. By 7 years the risk of breakthrough was 42% and of failure 15%. Fewer adults with breakthrough remain in care over time (P < .001). Loss to care is similar whether the individuals failed or resuppressed. Interpretation. While 67% of those who experience initial virological breakthrough resuppress after an adherence intervention, these individuals are significantly less likely be retained in care than those who remain virologically suppressed throughout. Adherence to antiretroviral therapy is the key to successful treatment outcomes at both individual and programmatic levels. It has been shown that individuals taking 95% or more of their medication will maintain virological suppression and that this is readily achieved in resource-limited settings –3. More Poor ART adherence can be assessed by the use of a selection of objective or subjective adherence measures. These include 3-day recall, a visual analogue scale , and a cIf poor adherence is persistent or is not detected, virological breakthrough may occur. At this point, intensive adherence support is required to initiate a change in tablet-taking behaviour which can result in resuppression of the HIV before resistance develops. In 2007, this group showed that 75% of individuals with virological breakthrough to >1000 copies/mL resuppressed to <50 copies/mL at the subsequent viral load after an intensive adherence intervention [n = 929) and outcomes could only be determined to 32 months.In the previously published study, numbers of naive adults on treatment were limited  has been described previously . The HCTUntil the 2010 edition of the South African National Antiretroviral guidelines, first-line ART included stavudine (d4T), lamivudine (3TC), and either efavirenz or nevirapine. Zidovudine (AZT) or tenofovir could be substituted for d4T-related toxicity. ART for second-line therapy included AZT, Didanosine (ddI), and lopinavir/ritonavir , 13.The HCTC employed HIV-positive lay counselors to educate each individual prior to initiating ART and to provide on-treatment adherence support. Treatment preparedness included three small group education sessions and a home visit by a counselor assigned to the area where the individual lived. Further home visits occurred monthly after starting treatment and continued until viral suppression was achieved. Thereafter, home visits were only carried out if the individual was flagged as nonadherent, experienced virological breakthrough, or was identified as a defaulter through missed clinic visits.Patients on ART with a viral load >1000 copies/mL  at any followup visit received a targeted adherence intervention. These individuals were required to attend extracounselling sessions, which focussed on adherence issues, and weekly home visits were recommenced. The individual was issued with a pill box and a dosing diary. The viral load was repeated six to eight weeks after this intervention. Based on the second test, patients were either regarded as having resuppressed or having failed treatment. Patients with a second viral load >1000 copies/mL were prepared for second-line therapy while resuppression to a viral load <1000 copies/mL allowed for continuation on first-line therapy, with high-frequency home visits continuing. If the viral load had fallen to <50 copies/mL routine clinic care was recommenced.Data were accessed from clinical  and laboratory records  that were maintained on all patients included in the HCTC ART programme. These records were transferred on a weekly basis to an off-site database. Outcomes which included death, loss to followup, or transfer out were noted in the database and the date of the outcome was captured.“Virological breakthrough” refers to any individual whose viral load reached >1000 copies/mL after previous suppression to <50 copies/mL. “Resuppressed” refers to those individuals whose viral load subsequent to the one at virological breakthrough was <1000 copies/mL. “Virological failure” refers to individuals with two consecutive viral loads >1000 copes/mL. “Retention in care” refers to individuals still receiving care either on-site or at another site (transfer out). “Losses to care” included deaths and individuals lost to followup.Patients commencing ART at the clinic between 2 September 2002 and 31 December 2009 were reviewed retrospectively. Those <15 years of age and those who were nonnaïve at entry to the programme were excluded. Also excluded were those patients who had 1 or no viral load after commencement of treatment as well as those who never achieved virological suppression on ART. All individuals who achieved suppression after ART commencement and later experienced virological breakthrough were analysed and divided into those who went on to virological failure and those who resuppressed and continued on first line. Long-term outcomes including death, transfer out to care in another service, or loss to followup were determined for all individuals in the cohort.Demographic and baseline data were described using medians and proportions as appropriate. Baseline characteristics were compared using non-parametric statistics for data not normally distributed.Patients were right censored on 13 April 2010 if they remained in care. Patients who were more than 12 weeks late for a scheduled visit were considered lost to followup, and their last visit to the clinic was used as last date in care. Patients who were transferred out were considered to still be in care at the time of censoring. Kaplan-Meier survival analysis was used to assess risks of failure and loss to care.The University of Cape Town Research Ethics Committee approved data capture from the ART site at the HCTC. All individuals who enrolled onto the programme provided written informed consent.n = 256, 27%), were lost to followup , transferred to care elsewhere , or were within the first eight months of treatment . A small proportion of the cohort never suppressed on treatment and experienced early failure . These individuals were also excluded . Of those that initially suppressed on treatment, the majority did not have a subsequent viral load >1000 copies/mL . The remaining 850 individuals (29%) experienced virological breakthrough in that they had at least one viral load >1000 copies/mL while on treatment (P = .0003), and a higher viral load (P = .002) than those who remained suppressed throughout . At seven years into treatment, up to 42% of the population on ART have a risk of experiencing at least one viral load >1000 copies after prior suppression. Only 15% have a risk of going on to fail suggesting that 67% of those who experienced breakthrough might be expected to resuppress at the next viral load. The median time to breakthrough was 1.39 years (IQR 0.75–2.46 years), and to failure, 1.51 years (IQR 0.99–2.64 years). n = 186, 8.9%) and to death . Eleven percent (n = 235) were lost to followup. The outcomes for those who had a single viral load >1000 copies/mL and who then resuppressed differ significantly, with fewer remaining in care , largely as a function of increased loss to followup . There was no significant difference in proportion transferred to care elsewhere  or in deaths .While all individuals who never experienced virological breakthrough remain on first-line therapy, 46 individuals (8%) of those who resuppressed after breakthrough went on to fail at a time subsequent to their next consecutive viral load and switched to second-line therapy.The objective of this study was to determine whether those individuals on ART who experienced a single episode of virological breakthrough after prior successful suppression had similar long-term virological outcomes to individuals who remain suppressed on ART throughout. Of note, the majority of this treatment cohort achieved virological suppression (96%), a much higher proportion than noted in a recent systematic review of sub-Saharan African ART programmes where only 78% of treated patients achieved virological suppression at six months . SeventyPreliminary data from 2005 showed that the risk of failure remained relatively low in individuals who had virological breakthrough . This stA systematic review of patient retention in ART programmes estimated rates across 33 cohorts to range from 24 to 77% at only two years into the programme. Death and loss to followup accounted for the majority of these losses, as in our programme . Although the overall outcomes of our programme may seem reasonable compared to those of other current programmes, as the expansion of antiretroviral services continue, so must the effort to improve adherence to care. While our adherence intervention appears successful in that two-thirds of those who experience virological breakthrough did resuppress it is important to note that this intervention does not impact on loss to followup.Previous studies have identified subgroups of patients who are at risk of LTFU. These include pregnant women and younger people on ART . This stIntensive adherence programmes may result in retained first-line therapy for those individuals who have an initial viral breakthrough but they do not of themselves retain people in care. Remaining on first-line therapy is an important goal not only in terms of cost saving but also in terms of preserving treatment options in resource-constrained settings. However, increasing attention is being drawn to retention to care in these settings in order to secure public health impact. Adherence interventions should be targeted to those who have an increased risk of loss to followup and need to be broadened to address issues related to loss to care as well as tablet-taking behavior.


Immune activation is decreased by combination antiretroviral therapy (cART) in patients infected with human immunodeficiency virus (HIV), but residual activation remains and has been proposed as a cause of premature aging and death, but data are lacking. We analyzed the relationship between T-cell subsets after 18 months of cART and overall survival during 12 years of follow up.A cohort of 101 HIV infected patients who had undetectable plasma HIV after starting cART was included in 1997–1998. T cell subsets were analyzed by flowcytometry after 18 months of cART. Relation to survival was calculated using Kaplan-Meier curves and multiple Cox regression.Seventeen patients died during the observation period. The leading causes of death were non-AIDS cancer and cardiovascular disease. Higher levels of CD8 memory T cells  showed a significant beneficiary effect on survival, HR of 0.95  when adjusted for age, nadir CD4 count, CD4 count, and AIDS and hepatitis C status. T cell activation was not associated with increased risk of death.Larger and longitudinal studies are needed to accurately establish prognostic factors, but overall results seem to suggest that prognostic information exists within the CD8 compartment. Since the discovery and implementation of combination antiretroviral therapy (cART) the prognosis of human immunodeficiency virus (HIV) infected patients has improved enormously. As the HIV-infected patients’ life-expectancy increases and the risk of developing AIDS decreases the focus of attention is moving toward a documented excess non-AIDS morbidity and mortality due to cardiovascular disease and certain types of cancer. Several, probably coexistent, factors have been suggested as contributors to this, including excess of risk factors such as smoking, cART toxicity and foremost the theory that ongoing immune activation/dysfunction leads to chronic inflammation that causes comorbidity and mimics natural aging at the cellular level (“inflamm-aging” or “immunosenescence”) Studies in patients nor receiving cART have convincingly shown that increased levels of cellular and soluble markers of immune activation are linked to higher risk of progression to AIDS, lower CD4 counts and poorer prognosis We aimed to address the relationship between T cell subsets measured in 1997-98 18 months after start of successful cART and the overall survival during 12 years of follow-up in a cohort of HIV infected patients.The study was conducted at the Department of Infectious Diseases and the Department of Clinical Immunology at Rigshospitalet . The study population consisted of HIV infected patients included in the period September 1997–August 1998 on the basis of having reproducible plasma HIV RNA levels <200 copies/mL after starting cART. One-hundred-and-one patients with an immunological investigation done 18 months after cART initiation were included in this study. All patients gave written informed consent and the study was approved by the Ethics Committee.As treatment interruptions have never been part of the Danish treatment guidelines, the patients in this cohort have been offered cART continuously since the inclusion in 1997, although the drug combinations may have changed over the years due to drug development, side effects etc.This group of well treated patients underwent repetitive extensive immunological examinations at regular intervals for the first 24 months of treatment The patients’ baseline data have been collected from medical records and the Danish HIV Cohort and are presented in The immunological parameters used in survival analysis  are derived from blood samples collected 18 months after initiation of cART (+/−6 months).6 peripheral blood mononuclear cells were quantified by a prototype assay , in accordance with the manufacturer’s recommendations.T cell subsets were analyzed in fresh whole blood using 4-color flowcytometry and were defined as naïve CD4/8, memory CD4/8  and activated CD4 (HLA-DR+), and activated CD8 . Proviral HIV DNA copies per 10All immunological and virological methods have been described in greater detail elsewhere Statistical analyses were conducted using SPSS 11.5.The 101 subjects were divided into two groups, a survivor group that consisted of patients who were alive by 1/1-2010 (n = 84) and a deceased group of patients who had died before this time (n = 17) .For comparison of means in In order to identify risk factors for overall mortality in the population Kaplan-Meier analysis was used to construct survival curves and Cox regression analyses to estimate hazard ratios (HRs). Person years at risk were computed in an observation period from the day of the patient’s blood sample 18 months after initiation of cART (+/−6 months) till 1/1-2010 or death, whichever came first.th percentile of the given variables. Analysis of survival linked to T cell subsets are made with proportions of CD4+ and CD8+ cells respectively.Kaplan-Meier plots  were madUni- and multivariate Cox regression analysis was preformed only for patients with complete data for multivariate analysis (n = 90). In the multivariate analysis the T cell subsets – given as proportions of CD4 or CD8 T cells respectively - were adjusted for age, CD4 count at the time of T cell subset measurement, nadir CD4 count, as well as AIDS and hepatitis C status . Hazard Nadir CD4 count was defined as the lowest CD4 cell count measured before or during the first 18 months of cART.P-values <0.05 were considered significant.One-hundred-and-one patients entered the study in 1997-98. On the 1/1-2010 seventeen of those had died.The baseline data of the two groups  differedAll patients had HIV RNA measured approximately 4 times a year as part of standard care and in the survivor group measurements were below detectable limits in a mean of 81% of measurements vs. 72% in the deceased group.The causes of the seventeen deaths were: non-AIDS cancer (n = 5), cardiovascular disease (n = 5), hepatitis C (n = 3), one case of suicide, one case of pneumonia, one case most likely linked to alcoholism, and only one AIDS related case which was non-Hodgkin lymphoma. Three of the deceased patients had hepatitis C and they all died from liver failure due to this disease.In the survivor group there were two patients with a history of malignant non-AIDS cancer and two patients with a history of acute myocardial infarction.th percentile of memory CD8 cell  proportions (P = 0.004). Nadir CD4 count, proviral DNA, and total CD4 and CD8 counts did not influence on mortality.Kaplan-Meier survival analysis  revealedMultivariate Cox regression  confirmeWhen removing the three deceased patients who died of suicide, alcoholism and AIDS/lymphoma respectively these results remained largely unchanged .Age was a significant factor in several of the multivariate models with HR = 1.07−1.08, but none of the chosen adjusting factors were univariately significant.The present study exclusively included patients who had immunological studies done during fully suppressive cART and followed them for more than 10 years. The main findings were i) a high level of memory CD8+ T cells, defined as CD45RA-CD45RO+, was an independent predictor of increased overall survival and ii) immune activation defined as proportions of CD4+HLA-DR+ and CD8+HLA-DR+CD38+ showed no prognostic value.The causes of death among the subjects in the present study are largely consistent with those found in a Danish nationwide study of patients who were virally suppressed for more than 3 years, in which the primary causes of death were cancer, sudden death of unspecified cause, and liver disease, and very few deaths were due to AIDS related illness It is generally accepted that CD8 T cells play a role in controlling untreated HIV infection, but the exact role of CD8 cells displaying memory phenotype (CD45RA-CD45RO+) is only incompletely understood during cART.As the CD8+CD45RA-CD45RO+ subset in this study is not sub-characterized further, the specific subtype and function cannot be determined, and the subset most likely represents a mixture of early, antigen experienced CD8 cells, including central memory, effector memory and HIV specific CD8 cells (CD45RA+/−CD28-CD27+CCR7-) with specific cytokine releasing properties In accordance with the present results we have previously reported a protective effect of high CD8+CD45RA-CD45RO+ levels among untreated patients Our results failed to demonstrate the expected positive association between early immune activation and all-cause mortality. High levels of CD4 and CD8 cells expressing the activation markers CD38 and HLA-DR did not show any prognostic value.Most previous studies that have shown prognostic value of cellular immune activation markers differ from this study in that they primarily included treatment naïve patients as well as treated patients, were cross sectional or with shorter follow up periods.A study from Uganda recently showed that higher proportions of CD8+CD38+HLA-DR+ T cells six months after initiation of successful treatment was an independent predictor of increased mortality, but the same subset pre-cART had no significant impact It has been suggested that even in the well controlled cART treated HIV infection the immune system has similarities to that of old people and it has further been suggested that these changes formed the basis for the morbidity and mortality observed The strengths of this study are the un-interrupted, long-term treatment of the patients, a very long observation period combined with the accessibility of data on T cell subsets during cART. The weaknesses are the relatively small number of patients and the broad definitions of T cell subsets, primarily due to the limited amount of colors available for flowcytometry at the time, and the absence of data on the functional properties of the cells. Due to these factors the presented data should be interpreted with caution.In summary, the study demonstrated a significant survival benefit of high levels of CD8+CD45RO+CD45RA- T cells. T cell activation as defined as CD4+HLA-DR+ and activated CD8+ CD38+HLA-DR+ did not show prognostic value in this group of long term viraemically suppressed HIV patients.Larger and longitudinal studies including more specific T-cell subset analyses such as CD28 and CD57 are needed to accurately establish prognostic factors, but overall the results suggest that prognostic information exists within the CD8 compartment.


In sub-Saharan Africa, a shortage of trained health professionals and limited geographical access to health facilities present major barriers to the expansion of antiretroviral therapy (ART). We tested the utility of a health centre (HC)/community-based approach in the provision of ART to persons living with HIV in a rural area in western Uganda.The HIV treatment outcomes of the HC/community-based ART program were evaluated and compared with those of an ART program at a best-practice regional hospital. The HC/community-based cohort comprised 185 treatment-naïve patients enrolled in 2006. The hospital cohort comprised of 200 patients enrolled in the same time period. The HC/community-based program involved weekly home visits to patients by community volunteers who were trained to deliver antiretroviral drugs to monitor and support adherence to treatment, and to identify and report adverse reactions and other clinical symptoms. Treatment supporters in the homes also had the responsibility to remind patients to take their drugs regularly. ART treatment outcomes were measured by HIV-1 RNA viral load (VL) after two years of treatment. Adherence was determined through weekly pill counts.p = 0.12), and in intention-to-treat analysis . In multivariate analysis patients in the HC/community-based cohort were more likely to have virologic suppression compared to hospital-based patients .Successful ART treatment outcomes in the HC/community-based cohort were equivalent to those in the hospital-based cohort after two years of treatment in on-treatment analysis (VL≤400 copies/mL, 93.0% vs. 87.3%, Acceptable rates of virologic suppression were achieved using existing rural clinic and community resources in a HC/community-based ART program run by clinical officers and supported by lay volunteers and treatment supporters. The results were equivalent to those of a hospital-based ART program run primarily by doctors. In sub-Saharan Africa, HIV patients receive antiretroviral treatment (ART) with combination antiretroviral drugs (ARVs) mainly through urban-based programs. Economic and geographic constraints severely limit access to hospitals for poor patients living in rural areas. Since much of the population of sub-Saharan Africa is rural, these factors lead to large inequities in the provision of ART services and makes universal access to ART difficult to achieve. Attempts to expand ART services to rural areas, including those in Uganda, have been constrained by the shortage of trained health professionals in these regions. Alternative approaches are required, including those that can engage and make use of rural community resources Information on successful community-based ART programs in sub-Saharan Africa is limited. In Uganda, published results from other studies which used home-based or community-based care models show that a high number of HIV patients achieved suppressed HIV-1 RNA viral loads (VL) in these types of programs We tested the utility and effectiveness of a HC/community-based model for delivering ART in a sustainable manner using local health centre and community support and resources by providing ART to a rural population in Rwimi subcounty, Kabarole District. We compared virologic outcomes with results of a well-established hospital-based ART program offered at the best practice regional hospital in Fort Portal, the district capital. The follow-up time for patients in both care models was two years.We previously published the preliminary six-month treatment results from this project The specific objectives of the study were as follows:Objective #1: To assess the effectiveness of a rural HC/community-based ART program in Rwimi subcounty, Kabarole district; andObjective #2: To compare the treatment outcome (VL) in the rural HC/community-based ART program with a well-established hospital-based ART program offered at a best practice regional hospital in the district capital.We tested the hypothesis that a HC/community-based ART program in a rural subcounty can provide a high standard of care and can produce outcomes equivalent to a physician-centered ART model delivered in an urban hospital setting.This was a comparative cohort study where participants were followed-up according to where they chose to receive health care services. The study group consisted of an inception cohort of treatment-naïve HIV patients initiating HC/community-based ART in the study area. The comparison group consisted of an inception cohort of treatment-naïve HIV patients starting ART in a regional hospital. The first line treatment provided by the Ugandan national HIV/AIDS program consisted of stavudine, lamivudine, and nevirapine (or efavirenz for patients on rifampicin) to be taken twice daily. All patients were also prescribed daily co-trimoxazole. Each patient was followed up for two years from the start of treatment.An estimated 22,400 persons living with HIV (PLWHIV) reside in Kabarole district in western Uganda Consecutive treatment-naïve PLWHIV with a CD4 cell count of 200/µL or less and/or clinical symptoms were enrolled in both cohorts as they presented themselves at the two study sites. There were no refusals or exclusions among those who fulfilled the inclusion criteria. The intended sample size was approximately 200 patients in each cohort. Patients attending the health centre at Rwimi were eligible for enrolment if they fulfilled the following criteria: resident in Rwimi subcounty, age of 18 years and older, treatment-naïve, eligible for ART according to the Uganda national HIV guidelines, willingness to accept daily treatment support by family/friends and willingness to be visited by a trained community volunteer once a week. Participants were identified through the clinic when they presented with symptomatic HIV infection, through antenatal care, or through voluntary counselling and testing (VCT) which was expanded during the study period. A Ugandan physician trained and experienced in ART oversaw the enrollment of patients into the study to ensure that the clinical officers and community volunteers delivered ART care according to the national guidelines standard. The schedule for a regular follow-up visit at the health centre for community-based patients was set at every six months, at which time they were seen by a clinical officer, and necessary laboratory investigations were performed.For the hospital-based cohort recruitment criteria were: being a resident of Kabarole district, age of 18 years or older, treatment-naïve, and eligible for ART according to the Ugandan national HIV guidelines. Patients in the hospital-based cohort received the same care delivered to all other HIV patients in the hospital program except for viral load measurements at 6 and 24 months. Regular follow-up visits for hospital-based patients were scheduled every month, when they were seen by a physician or by a clinical officer when a physician was not available. Laboratory tests were conducted every six months. The hospital program’s own physicians enrolled patients into the study. The loss of follow-up in both groups was defined as death or the inability to contact a patient after missing an appointment.Enrollment in the HC/community-based cohort started in March 2006 while enrollment for the hospital-based cohort started in April 2006. By November 2006 the hospital-based cohort was fully recruited (n = 200) and by May 2007 185 patients had been recruited in the HC/community-based cohort. Because of slower than anticipated recruitment, we decided to cap recruitment at 185 in the HC/community-based cohort due to time and budget constraints.Sample size calculations were made using the main variable of interest, namely treatment success/failure based on suppressed VL. In the HC/community-based cohort we expected the treatment success to be 80% as per literature review. Our intended sample size of 200 patients in each cohort allowed us, with 0.80 power and a significance level of 0.05, to detect a difference of ±5% in successfully treated patients between the HC/community-based cohort and the hospital-based cohort which we believed would be a meaningful and practical difference The intervention was designed to provide ART to rural, impoverished PLWHIV most of whom would otherwise have had no access to treatment due to high transport costs imposed by hospital-based treatment. Duff et al. have shown in a previous study from the same area that transport costs to the hospitals providing ART and other treatment associated costs were the main barrier to accessing ART The motivation of the volunteers was based on the recognition and support they received from the health care program and the community. Basic supplies required for their work were provided, e.g. a bicycle, raincoats and gumboots. An annual volunteer appreciation day was organized with participation of the entire community and its leaders. The volunteers did not receive any cash payments. Monthly meetings of all volunteers were held with a volunteer administrator, where problems were discussed, solutions sought and where the report forms were delivered and checked by the administrator. The boots, raincoats and bicycles along with volunteer coordination, enrollment by a physician and support activities described above were the only external material inputs by the study, over and above the resources routinely available to this publicly funded clinic. The study also provided an emergency supply of ARVs and co-trimoxazole for stock outs.The hospital clinic was a busy outpatient HIV clinic with an average of 80–100 patients per day, where two physicians handled the initiation and the monthly follow-up of ART patients. In case a physician was not available, a clinical officer dealt with the routine follow-up.The primary outcome measure at 24 months after starting ART in each patient was virologic suppression . A secondary outcome measure was the increase in CD4 cell count/µL between baseline and follow-up tests. CD4 cell count tests  and HIV-1 RNA viral load tests  for both cohorts were carried out in the laboratory of the Joint Clinical Research Centre (JCRC) in Fort Portal, which is part of a network of laboratories with international quality control (tests for HIV-1 RNA levels≤50 copies/mL were not available in this laboratory at the time). Demographic data were derived from the standardized Ministry of Health clinical data sheets completed during the initial patient examination. Adverse outcomes were extracted from clinical records kept in the clinic and in the hospital. Data were entered into Microsoft Excel spreadsheets and Microsoft Access database and checked for inconsistencies or exceptional values. Adherence to the medication schedule was measured based upon weekly pill counts, where the actual number of pills remaining were compared with the calculated expected pill count; both data were recorded in the volunteer adherence logs.p = 0.2 in the univariate analysis or that were clinically important. The main interest in the multiple logistic regression analysis was to determine the association between virologic suppression and the dichotomous indicator of cohorts . To test if both treatments were equivalent, the limits of equivalence were assumed to be ±15%. Based on this assumption, the two treatments could be claimed to be equivalent if the difference between the proportion of success (θ) of the treatment 1 and treatment 2 lies in the interval −15% (θL) to +15% (θU). We tested the two one-sided hypotheses H0: θ = θL against the alternative H0: θ>θL and H0: θ = θU against the alternative H0: θ<θU, respectively. Equivalence between the two treatments was asserted if both hypotheses were rejected. Statistical analysis was performed using Stata (version 9.0) statistical software Statistical procedures included descriptive, univariate, and multivariate analyses. The statistical significance of the differences in the demographic, clinical, and immunological characteristics were tested using chi-squared tests for categorical variables, two sided-independent samples t-tests or Mann-Whitney U tests for continuous variables and survival analysis with the Kaplan-Meier curve and the estimation of the Hazard Ratio (HR). The association between virologic suppression and independent variables was determined using multiple logistic regression. The predictor variables considered for the analysis were those that were significant at Ethics approval was provided in Canada by the Health Research Ethics Board, University of Alberta, Edmonton, and in Uganda by the Uganda National Council of Science and Technology, Kampala, the School of Public Health, Makerere University, Kampala and the District Health Officer for Kabarole District. Each participant was informed about the study and provided written consent or a thumbprint. The volunteers and treatment supporters also provided written consent or thumbprint.Of the 185 patients who were recruited in the HC/community-based group, 24 (13%) were lost to contact and 32 (17%) died during the two-year follow-up . In the p = 0.049), education (p = 0.042), marital status (p<0.001) and occupation (p<0.001) between HC/community-based and hospital-based patients. As shown in Among the patients who remained in the study at two years, significant differences were observed in mean age . The median time to death for hospital patients was 57 days (25th–75th percentile = 6–102 days), and for community patients it was 63 days (25th–75th percentile = 14–140 days). This difference was not statistically significant (p = 0.633). The unadjusted Hazard Ratio (HR) for death in the HC/community-based groups was 1.20 . This comparison of mortality has its limitation, as the lost to follow-up group in both cohorts includes an unknown number of deaths. Crude mortality was higher in the HC/community-based cohort compared to the hospital-based cohort, though this difference was not statistically significant .The median VL at baseline was 172,500 copies/ml in the HC/community-based cohort. Baseline VL tests were not available in the hospital-based cohort. The median baseline CD4 cell count of those who died was significantly lower compared to survivors in both cohorts combined .None of the patients experienced severe adverse reactions , that required a change to second-line treatment according to the prevailing standards of practice in Uganda and limited treatment alternatives. Seventeen patients in the HC/community-based cohort developed a skin rash  and 23 patients in the HC/community-based cohort presented with peripheral neuropathy . The diagnosis of neuropathy is subjective, so misdiagnosis or over-diagnosis is possible. In the on-treatment analysis at the two year endpoint, 93.0% (120 out of 129 patients) in the HC/community-based cohort and 87.3% (124 out of 142 patients) in the hospital-based cohort respectively achieved virologic suppression (p = 0.673). The median increase in CD4 cell counts were 217 cells/µL after the two-year endpoint in HC/community-based patients and 193 cells/µL in hospital-based patients (p = 0.199). In the on-treatment analysis a multiple logistic regression analysis was carried out adjusted for age, sex, marital status, and baseline CD4 cell count levels (p = 0.046). Based on a 15% limit of equivalency, the treatments in the HC/community-based and hospital-based group were equivalent.When an intention-to-treat analysis was applied, which assumed that those who were lost to follow-up were not virologically suppressed, the corresponding numbers for virologic suppression at two years were 64.9% (120 out of 185 patients) in the HC/community-based cohort and 62.0% (124 out of 200 patients) in the hospital-based cohort . Monthly management meetings between the volunteers and the volunteer administrator took place regularly as planned with an attendance rate no lower than 85% at each meeting. Unscheduled visits of patients in the HC/community-based cohort were as follows: sixteen patients  were referred to the regional hospital, while 38 patients were referred to the health centre by the community volunteers or decided to attend the health centre on their own without referral. The number of unscheduled visits of hospital patients to the HIV clinic in the hospital was not systematically recorded.Our study results show that in rural western Uganda, ART can be delivered through a HC/community-based program using existing resources with treatment outcomes equivalent or marginally better than to those of the best-practice hospital in the district. This comparison hospital was part of a nationwide program through the Joint Clinical Research Centre (JCRC) and therefore represents high national standards of ART provision in Uganda. Our study findings demonstrate that a HC/community-based HIV treatment program can be a feasible, safe and effective option for increasing access to ART in rural areas. The positive results in our HC/community-based cohort are best explained as resulting from the support provided to the patients by volunteers, treatment supporters and the community at large. These support mechanisms were not available in the hospital ART program, as support for adherence in the hospital program was limited to the contacts during the monthly hospital visits. The advantage of the HC/community-based model is that it not only delivered equally successful treatment outcomes but also delivered treatment to rural patients who may have otherwise not been able to access the hospital-based treatment program because of distance and travel associated costs The proportion of virologic suppression in our HC/community-based cohort of 93% on active on-treatment patients and 68% in intention-to-treat patients, compare favorably with results from several other studies conducted in Uganda. Our results are superior to Chang et al. who reported 86% virologic suppression in active clients and 59% virologic suppression in intention-to-treat analysis after two years from a home-based ART program in a city program in Kampala, the nation’s capital Important to our study is the fact that it was not conducted in a controlled research setting as were most other studies, but rather based in a typical rural Ugandan area which was supported by a publicly funded clinic where all HIV patients who presented themselves consecutively were treated according to the Uganda’s national HIV guidelines without any pre-selection. Rosen et al., in their assessment of ART program outcomes, distinctly differentiate between research ART programs and non-research ART programs and state that treatment outcomes in the former are generally better as a result of patient selection, enhanced resources and optimal project conditions and that the results of such programs therefore cannot be readily extrapolated to general health services We could not definitively determine the mortality after two years in both cohorts as we were unable to follow-up all patients who were lost to contact to determine if they died. Therefore, we could not conduct a definitive analysis of mortality. If we use the result of 17% of mortality in the HC/community-based cohort at the two years endpoint, it compares well with the study by Chang et al. where mortality was 18% The difference between our study and the Jaffar et al. study In their comprehensive review of community-based ART programs, Wringe et al. identified several factors which they found to be important predictors for successful community-based ART provision: program retention of volunteers, adequate support for volunteers, a functioning referral service, community acceptance and appropriate program costs First, we did not have a randomized study design because randomization of patients was not possible. Rural patients would have been unable to access care at the distant regional hospital and patients who were close to the hospital would not have been willing to access rural services. Second, loss of follow-up may have affected the interpretation of the study. When we examined the baseline demographic and immunological characteristics of the patients lost to follow-up in both cohorts, we found they were not significantly different from those of the remaining participants. This may indicate that a possible selection bias was probably similar in both cohorts and therefore did not likely compromise the comparability of results for those remaining on treatment in both cohorts. Finally, information on adherence to ART and adverse reactions to antiretroviral drugs was not available in the hospital-based cohort. Therefore, adherence could not be compared with the hospital-based cohort.Our study shows that a non-physician-centered, non-hospital-based care model can deliver ART with the required quality of service, acceptable safety of patients, and with the treatment outcomes equivalent to those found in the facility-based ART program in the study area hospital. In the HC/community-based program the physician saw patients only once, unless referral was required for a clinical complication. With experience we didn’t think that the physician was necessary and in the post-study operation of Rwimi health centre, patients were started on ART by the clinical officer alone.Our care model made ART more easily accessible to patients for whom distance and transportation costs would otherwise have been major barriers to hospital-based care


Current consensus about treatment of HIV infection is that HAART must include two nucleoside reverse transcriptase inhibitors plus a third drug . There is a lot of interest about changing the basic structure of the antiretroviral regimen so we can be able to use nucleoside-sparing regimens. The main reason to support the investigation of NRTI-sparing strategies is the concern about the long-term toxicity of tenofovir and abacavir.In antiretroviral naïve patients candidates for nucleoside sparing regimens have included a boosted or unboosted protease inhibitor as the backbone drug to which a non-nucleoside reverse transcriptase inhibitor, an integrase inhibitor, a single nucleoside or a CCR5 inhibitor has been added. In patients who have already achieved suppression it is possible that a boosted protease inhibitor used as monotherapy might be all what is needed to maintain suppression. It is reasonable to predict that, compared to triple-drug HAART, the long term toxicity of these single and dual-drug regimens would be lower. Finding the right number of antiretrovirals that offers the optimal balance of long-term efficacy and toxicity is therefore a very important scientific question.This presentation would review the clinical trials that have explored NRTI sparing strategies for the treatment of antiretroviral naïve patients and also for maintenance of viral suppression. The presentation would highlight the possible benefits associated to NRTI-sparing strategies and the most promising candidates.