In Henan, China, first-line antiretroviral treatment (ART) was implemented early in a large number of treatment-experienced patients who were more likely to have a drug resistance. Therefore, we investigated the human immunodeficiency virus (HIV)-1 drug resistance profiles among patients in Henan who experienced virological failure to ART.A cross-sectional survey was administered in 10 major epidemic cities from May 2010 to October 2011. Adult patients who experienced virological failure  with >1 year of first-line antiretroviral treatment consented to provide blood for genotype resistance testing. The clinical and demographic data were obtained from the patients’ medical records. Logistic regression analysis was performed to determine the factors associated with ≥1 significant drug resistance mutation.We included 3,235 patients with integral information and valid genotypic resistance data. The city, age, CD4 counts, virus load, treatment duration, and World Health Organization stage were associated with drug resistance, and 64.76% of patients acquired drug resistance. The nucleoside reverse transcriptase inhibitor (NRTI), non-(N)NRTI, and protease inhibitor resistance mutations were found in 50.26, 63.12, and 1.30% of subjects, respectively. Thymidine analogue mutations, NNRTI and even multidrug resistance complex were quite common in this patient cohort.Multiple and complex patterns of HIV-1 drug resistance mutations were identified among individuals who experienced virological failure to first-line ART in Henan, China during 2010–2011. Therefore, timely virological monitoring, therapy adjustments, and more varieties of drugs and individualized treatment should be immediately considered in this patient population. Continuous improved antiretroviral therapy (ART) has been one of the most significant breakthroughs in human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) prevention and control over the past 30 years because of its outstanding effect on reducing AIDS mortality and morbidity , 2, amelThe Chinese government initiated the China Comprehensive AIDS Response program to provide free HIV treatment in 2002, which rapidly scaled up the National Free Antiretroviral Therapy Program. Subsequently, drug resistance surveillance in different areas was attempted, and the popularization of drug resistance monitoring was performed in 2010. The Henan Province has always drawn concern because of the extensive spread of HIV among former plasma donors and the earlier initiation of the National Free ART Program with a large number of ART patients , 7. NumeThe administration of ART, delivery of antiviral drugs, adherence education, and collection of plasma specimens mainly depended on the local centers for disease control and prevention (CDC) and the community clinics in the Henan Province. The CD4 cell counts were measured twice and virus load were measured once 1 year by a local CDC and Henan CDC, and the results were provided to treating physicians and the national HIV/AIDS case reporting system. All the cases of HIV/AIDS in China are reported via the national HIV/AIDS case reporting system. Records in this system include identity and demographic information, HIV testing results, the self-reported transmission route, and health status information. Base data for this study was derived from this system. For the purpose of this study, virological failure patients  underwent genotypic drug resistance testing and the results were also provided to treating physicians and the national HIV/AIDS case reporting system.Written consent was obtained from patients to participate in the China’s routine HIV/AIDS surveillance program and the regular administration of the national ART program, and parental consent was also obtained on behalf of the participants aged less than 18 years. Since the data and the samples used in this study were collected as a function of surveillance program above, no additional informed consent was required. This study was reviewed and approved by the Institutional Review Board of the Henan CDC.According to the aforementioned conditions, first-line ART-virological failure patients (aged ≥15 years) were selected if the virus load was ≥1,000 copies/mL with >1 year of treatment from May 2010 to October 2011 in 10 cities that held the highest HIV-1 epidemic in the Henan Province. The patients could not followed or refused to give samples were not included. The first-line ART regimens consisted of two nucleoside reverse transcriptase inhibitors (NRTIs): (azidothymidine [AZT] or stavudine [D4T]) + (didanosine [DDI] or lamivudine [3TC]) and one non-(N)NRTIs: (nevirapine [NVP] or efavirenz [EFV]). AZT, D4T, DDI, and NVP are generically produced in China, whereas 3TC and EFV are branded drugs that became available in 2005.http://hivdb.stanford.edu).The CD4 cell counts were measured using flow cytometry by the local CDCs. The plasma HIV-1 virus load was tested by the local city and Henan CDCs using the Abbott Real-Time HIV-1 assay , NucliSENS EasyQ-EasyMag HIV-1 assay , or Cobas AmpliPrep-Cobas TaqMan HIV-1 assay . Samples with a virus load of ≥1,000 copies/mL underwent HIV-1 drug resistance genotyping using an in-house method developed by the national core laboratories as described in previous studies , 13. A fp value <0.05) and those clinically meaningful were included in the multivariable regression model. The tests were two-sided, and a p-value <0.05 indicated statistical significance. All the statistical analyses were performed using SPSS, version 19.0 .The demographic variables were analyzed using descriptive statistics, and the risk factors for developing HIV drug resistance were analyzed using logistic regression. Variables associated with resistance in the univariate analyses  patients, according to the Stanford HIV Drug Resistance Database. The frequency of NNRTI, NRTI, and PI resistance mutations were 63.12, 50.26, and 1.30%, respectively. In this study, 42.60% of patients had both NRTI and NNRTI resistance mutations, 7.67% had NRTI but not NNRTI, and 20.53% had NNRTI but not NRTI resistance mutations  emerged as the most common NRTI resistance mutation, followed by thymidine analogue mutations (TAMs): T215Y/F (27.17%), M41L (18.39%), D67 N (12.21%), K70R/E/G (10.20%), L210 W (10.17%), and K219E/Q (10.02%). The prevalence of >1 TAMs was 42.32%. Furthermore, the prevalence of M184 V/I + TAMs was 21.36%, TAMs-1  was 8.96%, and TAMs-2  was 4.61%. Fifty-one (1.58%) and thirteen (0.40%) patients had the K65R/N and Q151 M complex, respectively. Among the NNRTI resistance mutations, K103 N (34.84%) was the most common NNRTI, followed by Y181C/V/I (22.04%) and G190A/S/E (18.24%)  in whom the first-line therapy had virologically failed.In the early years, the magnitude of the focus was on former plasma donors, however, with the change of the HIV epidemic, sexual intercourse has been the focus of HIV/AIDS control and prevention, which has attracted substantial resources –17. ThisThe prevalence of HIV drug resistance is not constant across Henan. Zhumadian, Kaifeng, Shangqiu, Nanyang, and Xinyang have assembled a great deal of resources in the field of HIV/AIDS control and prevention because of their high HIV epidemic . CompareNNRTIs have a low genetic barrier to resistance. Therefore, a single mutation is often sufficient for causing resistance to the currently recommended first generation of NNRTIs, NVP, or EFV , 20, whiAs expected, M184 V/I was the most commonly detected NRTI resistance mutation, which was also found in previous studies , 22, andThe emergence of transmitted HIV drug resistance can be anticipated, because such a large quantity of individuals acquired HIV drug resistance in this population-based survey. Recently, a moderate level of prevalence for transmitted HIV drug resistance has been reported in Henan . More acDrug resistance mutations were undetected in 35.26% of patients among this treatment failure cohort, a significant proportion of individuals without mutations for treatment failure has also been reported in all similarity studies , and nonIn conclusion, long-term ART roll-out leads to a comparatively high prevalence of HIV drug resistance among individuals who have experienced virological failure to first-line ART in Henan during 2010–2011, indicating a magnitude of former plasma donors. Multiple mutations and complex patterns have been identified, which may cause a growing number of those being treated with second-line therapy with partial or no activity. Performing routine drug resistance surveillance programs and timely therapy adjustment, especially among former plasma donors, ensuring access to new kinds of drugs, and initiating individualized treatment must be a priority in order to preserve programmatic treatment success in long-life therapy.Data and materials availability Sequences generated for this study were deposited in the national AIDS treatment database of China.


Access to pediatric HIV treatment in resource-limited settings has risen significantly. However, little is known about the quality of care that pediatric or adolescent patients receive. The objective of this study is to explore quality of HIV care and treatment in Nigeria and to determine the association between quality of care, loss-to-follow-up and mortality. A retrospective cohort study was conducted including patients ≤18 years of age who initiated ART between November 2002 and December 2011 at 23 sites across 10 states. 1,516 patients were included. A quality score comprised of 6 process indicators was calculated for each patient. More than half of patients (55.5%) were found to have a high quality score, using the median score as the cut-off. Most patients were screened for tuberculosis at entry into care (81.3%), had adherence measurement and counseling at their last visit (88.7% and 89.7% respectively), and were prescribed co-trimoxazole at some point during enrollment in care (98.8%). Thirty-seven percent received a CD4 count in the six months prior to chart review. Mortality within 90 days of ART initiation was 1.9%. A total of 4.2% of patients died during the period of follow-up (mean: 27 months) with 19.0% lost to follow-up. In multivariate regression analyses, weight for age z-score (Adjusted Hazard Ratio (AHR): 0.90; 95% CI: 0.85, 0.95) and high quality indicator score  had a protective effect on mortality. Patients with a high quality score were less likely to be lost to follow-up (Adjusted Odds Ratio (AOR): 0.42; 95% CI: 0.32, 0.56), compared to those with low score. These findings indicate that providing high quality care to children and adolescents living with HIV is important to improve outcomes, including lowering loss to follow-up and decreasing mortality in this age group. Though numerous challenges have limited scale-up of pediatric antiretroviral therapy (ART), significant progress has been made. The Institute of Medicine defines health care quality as the extent to which health services provided to individuals and populations improve desired health outcomes and are consistent with current professional knowledge. Moreover, quality assessment of pediatric HIV care and treatment lags far behind that of adults internationally. Several national programs have identified process and outcomes indicators to guide improvement efforts. However, few reports of HIV care quality that focus on pediatric or adolescent services have been published. Nigeria is home to the second largest number of people living with HIV in the world after South Africa. In 2012, approximately 3,400,000 people in Nigeria were living with HIV, including 430,000 children. The study protocol and assessment tools were submitted to the National Health Research Ethics Committee of Nigeria (NHREC) and approved on April 9th, 2011. Individual signed, written informed consent from participants was waived by NHREC. Patient information was de-identified prior to analysis. Unique patient identifiers were assigned to each patient to protect patient confidentiality.A retrospective cohort study was conducted including patients enrolled in care between November 2002 and December 2011. This chart review was a component of a larger assessment of access to pediatric and adolescent treatment services funded by the United States Government/PEPFAR Nigeria Program.  PurposivCharts representing 10% of the total number of patients 0–18 years of age receiving antiretroviral therapy (ART) in the 10 states chosen were selected using random sampling. Each site was asked to provide a list of all enrolled patients 0–18 years of age meeting the inclusion criteria by medical record number. Chart design and contents were standardized in 2008 to include the same variables across all sites throughout the country, and sites maintained either paper or electronic records.Patients were eligible for inclusion in the study if they were 0–18 years of age and initiated ART during the study period. Follow-up was censored either at the time of the loss to follow-up (as defined below), death or the end of the study period.The two main outcomes were lost to follow-up and death. Loss to follow-up was defined as no evidence of a visit to the clinic or drug pick up for 90 days following the last scheduled appointment as documented in the chart. Death was only counted if verified by the patient's family or if death occurred within the hospital.The primary independent variable of interest was a quality score comprised of six process indicators: (1) screening for tuberculosis at entry into care, (2) adherence measurement at last visit, (3) adherence counseling at last visit, (4) prescription of co-trimoxazole at any time since enrollment, (5) at least one CD4 count in the last six months, and (6) documented weight at last visit. These indicators are recommended by the World Health Organization and should be standard components of clinical practice as outlined by the 2005 and 2010 National Guidelines on Paediatric HIV and AIDS Treatment and Care in Nigeria. Additional patient characteristics and clinical variables related to the outcomes of interest were also collected including: gender, age at ART initiation, CD4 count/percentage , baseline weight/height (to determine age-for-weight z-score), current ART regimen, and facility type . Viral load measurement was not standard of care during the study period, and therefore was not included as an outcome measure.3 or a percentage less than 15%, while “moderate immunosuppression” was defined as CD4 count between 750 and 1500 cells/mm3 or a percentage of between 15% and 25%. “No immunosuppression” was defined as an initial CD4 count of 1500 cells/mm3 or more or a percentage of 25% or more. For patients between two and five years of age, “severe immunosuppression” was defined as an initial CD4 count less than 500 cells/mm3 or percentage less than 15%, “moderate immunosuppression” as an initial CD4 count of between 500 and 1000 cells/mm3 or percentage of between 15% and 25%, and “no immunosuppression” as an initial CD4 count of 1000 cells/mm3 or more or percentage of 25% or more. For patients five years of age or older, “severe immunosuppression” was defined as an initial CD4 count less than 200 cells/mm3 or percentage less than 15%, “moderate immunosuppression” as an initial CD4 count of between 200 and 500 cells/mm3 or percentage of between 15% and 25%, and “no immunosuppression” as an initial CD4 count of 500 cells/mm3 or more or percentage of 25% or more. Baseline immunosuppression at entry into care was calculated using patient age and either initial CD4 count or initial CD4 percentage. For patients less than two years of age, “severe immunosuppression” was defined as an initial CD4 count less than 750 cells/mmMeans and standard deviations were computed for continuous variables and counts with percentages for categorical variables. Differences in mortality and loss to follow-up by age group and differences in quality indicators by year of initial visit were compared using chi-square statistics. Bivariate methods were used to examine the relationships of individual independent variables with the primary outcomes of survival and loss-to-follow up, including Kaplan-Meier estimation with log rank testing. One predictor Cox proportional hazards regression models were used for survival and one predictor logistic regression models for loss to follow-up.In survival analyses, associations were estimated using hazard ratios (HR) with 95 percent confidence intervals (CI). In the analysis of loss to follow-up, associations were estimated using odds ratios (OR) with 95 percent CIs. The multivariate logistic regression models included independent variables that were significant in the bivariate models defined as p<0.05 and/or were potential confounders of the relationship between the quality score and the outcomes  and age at ART initiation). The multivariate Cox regression model was limited to four predictors due to the number of deaths in the sample, using a guide of ten events or deaths required per predictor. The proportional hazards assumption was checked by graphical methods and by testing interaction terms that included the log of follow-up time. The discrimination ability of the logistic models was measured by c-statistics with calibration assessed using Hosmer-Lemeshow chi-square statistics and their associated p-values. Where data were sufficient, we tested for interactions among the independent variables in these models. Patient-level variability across sites was investigated using the intra-cluster correlation coefficient (ICC). The ICC was close to zero, indicating similarity between within-site variability and variability across sites. We employed an alpha of 0.05 in all statistical tests to determine statistical significance. All data management and statistical analyses were performed using SAS for Windows version 9.2.A total of 1,516 patients were sampled from 23 sites. Most patients (73.6%) received care at urban facilities . The aveThe mean duration of follow-up time was 27.7 months (±19.7). Most patients were on an ART regimen comprised of AZT/3TC/NVP (81.5%) at the time of chart review. For those on regimens containing d4T, the mean length of time on the regimen was 36.7 months (±18.5).Most patients were screened for tuberculosis at entry into care (81.3%) and had adherence counseling at their last visit (89.7%) . SimilarTwo quality indicators improved over time. The percentage of patients with a CD4 count in the last six months (p<0.0001) and weight for age documented at the last visit (p = 0.0034) was higher for those with an initial visit in more recent years (2008 to 2011) than for those who enrolled in care prior to 2008.Documented mortality within 90 days of ART initiation was 1.9% . A totalPatients with a high quality score were more likely to survive over time (p = 0.0011) and less likely to be loss to follow-up (p<0.0001) than patients with a low quality indicator score  and 2. GIn multivariate Cox regression analyses, adjusting for other factors, weight for age z-score  and high quality score  had a protective effect on mortality. Patients with severe baseline immunosuppression were more likely to die than those with no immunosuppression  . AdjustiTo our knowledge, this is the first report of a pediatric and adolescent HIV care and treatment quality assessment in Nigeria. Our findings suggest that providing high quality care to children and adolescents living with HIV is associated with lower loss to follow-up and mortality, providing compelling evidence that investing in quality has the potential to retain this age group in care and save lives.In this study, six process indicators were selected to measure quality. Overall, receipt of services was high. More than 80% of patients were screened for TB at entry into care. However, a higher percentage of adolescents were screened for TB compared to pediatric patients. Though the World Health Organization recommends screening for TB in pediatric patients as described, under-diagnosis and diagnostic delays are common. The quality score devised for this study was significantly correlated with both loss to follow-up and mortality, with a higher score associated with decreased loss to follow-up and increased survival. This finding correlates with limited data from studies in the US demonstrating the association between quality of HIV care and clinical outcomes. Very limited clinical outcomes data are currently available from the Nigerian pediatric and adolescent HIV treatment program. Though the focus of this study was not solely on clinical outcomes, this study provides a reasonable estimate of loss to follow-up and mortality within the Nigerian national program. Early mortality was 1.9% across all age groups, while mortality during the period of follow-up was noted to be 4.2%. Compared to data from similar pediatric and adolescent cohorts in sub-Saharan Africa, mortality was lower in the Nigerian program. This study has several limitations. Sites were not randomly selected because we wanted to include a geographically diverse sample. Furthermore, we were limited to certain states due to safety concerns. We did not measure all site characteristics that may have impacted the process indicators included in the quality score in this study. This was because our goal was to focus on process, not structure. Furthermore, we knew from a larger assessment that all the sites had similar resource availability.  Though wPediatric and adolescent access to antiretroviral therapy in Nigeria is expanding. Since 2013, the number of facilities across the country that provide ART to children and adolescents has increased significantly. In order to expedite access to treatment, decentralization or down-referral of pediatric care to primary health clinics has been initiated. Efforts are also underway to standardize services across facilities and to ensure that quality improvement is incorporated into regular in service training.  As pediatric and adolescent ART access continues to expand in Nigeria and in similar resource limited settings, ensuring the quality of care that patients receive will be essential to reducing mortality and loss to follow-up. The next logical step toward achieving this goal in the Nigerian treatment program would be to use these data to inform a quality improvement intervention. Quality improvement studies are infrequently published in the medical literature. However, a few studies have demonstrated the efficacy of quality improvement in HIV care and treatment in resource limited settings. File S1http://www.aidstar-one.com/focus_areas/treatment/resources/report/pediatric_tx_nigeria. Accessed 2013 Dec 14.Greeson D, Ojikutu B, Kolapo U, Higgins Biddle M, Cabral H, et al. (2012) Rapid assessment of pediatric HIV treatment in Nigeria. Arlington, VA: USAID's AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1. Available at: (PDF)Click here for additional data file.


In resource constrained settings, immunological assessment through CD4 count is used to assess response to first line Highly Active Antiretroviral Therapy (HAART). In this study, we aim to investigate factors associated with immunological treatment failure.A matched case-control study design was used. Cases were subjects who already experienced immunological treatment failure and controls were those without immunological failure after an exactly or approximately equivalent duration of first line treatment with cases. Data were analyzed using SPSS v16.0. Conditional logistic regression was carried out.6 to M12). The rate of increment was 8.8  and 1.8  cells/µl/month for controls and cases, respectively . In conditional logistic regressions grouped baseline CD4 count (P = 0.028), old age group and higher educational status (P<0.001) were significant predictors of immunological treatment failure.A total of 134 cases and 134 controls were included in the study. At baseline, the mean age ±1 SD of cases was 37.5±9.7 years whereas it was 36.9±9.2 years among controls. The median baseline CD4 counts of cases and controls were 121.0 cells/µl (IQR: 47–183 cells/µl) and 122.0 cells/µl (IQR: 80.0–189.8 cells/µl), respectively. The median rate of CD4 cells increase was comparable for the two groups in the first six months of commencing HAART (P = 0.442). However, the median rate of CD4 increase was significantly different for the two groups in the next 6 months period (MSubjects with immunological treatment failure have an optimal rate of immunological recovery in the first 6 months of treatment with first line HAART, but relative to the non-failing group the rate declines at a later period, notably between 6 and 12 months. Low baseline CD4 count, old age and higher educational status were associated with immunological treatment failure. Treatment with Highly Active Antiretroviral Therapy (HAART) has significantly improved the quality of life and life expectancy of People Living with HIV and AIDS. In 2011, more than 8 million people living with HIV and AIDS in low and middle income countries were receiving HAART The primary goals of initiating HAART among HIV patients are to suppress HIV viral replication and to restore immune function. The clinical decision to check whether such goals have been achieved is made through periodic viral load testing and/or CD4 cell counting CD4 cell count is a crucial element in monitoring treatment response and practically it remains the best predictor for immunological failure. However, different studies have consistently reported low sensitivity of CD4 counts in detecting virological failure among African adults Even though the definition of immunological failure of therapy is not straight forward, the WHO defined criteria have been widely used. Using these criteria, patients who have experienced immunological failure were found to have an increased risk of clinical progression to AIDS and mortality when compared with patients with complete immunological response Understanding of factors that are associated with immunological treatment failure could be a key step in offering stringent care for those at risk of treatment failure. Several clinical and other factors that contribute to poor immunological response to HAART treatment have been documented. However, most of such factors were from routine clinical documents and lack other socio-demographic variables as potential predictors of immunological failure. Therefore, in this study we aim to investigate clinical, and other socio-demographic variables associated with immunological failure in resource limited setting.A matched case-control study was conducted in two major hospitals which started delivering HIV clinical care services in 2004/5 in Ethiopia; namely Adama Hospital in Oromia Region and Yirgalem Hospital in Southern Nations, Nationalities and Peoples' Region (SNNPR). According to the 2010 report of Ethiopian Federal HIV/AIDS Prevention and Control Office, a total of 10,881 patients have ever started ART and 7,171 patients were actively on treatment in the two hospitals in 2010 Eligibility criteria for initiating HAART during the study period of interest was: stage I and II when CD4 count <200, stage 3 when CD4 count <350 cells/µl and stage 4 at any CD4 count th month of initiating treatment and then at every 12 month interval.Both case and control participants were initially identified from routine ART registers. This register contains basic clinical and a few demographic variables of all subjects who are starting treatment. Normally, the patient's information on this register is updated every time the client comes to the HIV care clinic. In addition to the baseline information, this register also contains the CD4 count, weight and functional status of the clients at the 6Data were collected from follow up forms, ART registers and through direct interview with patients using structured and pretested questionnaire. Information retrieved from follow up forms and ART registers include number of visits paid to the hospitals, date of treatment initiation and date of experiencing immunological treatment failure, weight, height and CD4 counts. Other variables like residential area, marital status, and educational status were obtained through direct interview with the study subjects.HIV care clinic health workers in both hospitals conducted the data collection with periodic supervision from the investigators. Ethics Committee of Hawassa University approved the study and written consent was received from the study participants.The primary end-point was immunological treatment failure defined using the WHO criteria. Quantitative rate of increment for CD4 counts was also investigated. Possible determinants for immunological treatment failure were age, place of residence, marital status, baseline CD4 count, regimen type, baseline WHO clinical stage, and average health facility visiting time in months, baseline body mass index (BMI), educational status, and sex.In this study, cases were subjects who experienced immunological treatment failure and controls were those who didn't experience immunological treatment failure after taking first line treatment for an exactly or approximately equivalent duration with cases. Once cases were identified, they were matched with controls who started treatment in the same month and year with the cases. This was achieved because the ART register was filled in such a way that all subjects who started treatment with in same month and year were entered on the same page and they were not mixed up with patients starting treatment in another month of the same year. In case of multiple possible controls, one control was selected using lottery method.Initially, the ART registers in both hospitals were carefully examined to pick up the required number of cases and controls. On the ART register, each row corresponds to a patient and the second page of the register contains the updated information at different visiting times; namely, at treatment initiation, after 6 month of starting treatment and then every year. Initially, we screened each patient's row to verify whether they had already experienced immunological failure or not. We reviewed the ART registers of patients who started treatment from November, 2004 to June, 2012. After checking a total of 4,000 patient rows, we had identified 170 subjects who experienced immunological treatment failure. However, 36 subjects weren't actively on treatment (were either transferred out or lost from care) and thus 134 subjects who experienced immunological treatment failure were selected as cases (n = 134) and each were paired with single controls, resulting in a total of 268 study subjects. The whole data collection took place from February 2013 to August 2013.Data were entered, cleaned and analyzed using SPSS V 16.0. Normality tests were performed before running any statistical computations. CD4 cell count response was calculated using median rate of increase from baseline to 6 months, from 6 months to 12 months and from 12 months to 24 months. Nonparametric test (Mann-Whitney U test) was used to compare CD4 counts in the two groups.Univariate conditional logistic regression was first used to detect possible predictors of immunological treatment failure. Multivariate analysis was performed by fitting a stratified Cox model on matched pairs to adjust for potential confounders. Variables showing significant effect during univariate analysis and other possible determinant variables from literature reviews were included in the stratified Cox model. Results were reported as the multivariate adjusted odds ratios (AORs) with 95% confidence intervals (CIs) for the association between predictor variables and the outcome . For all statistical tests, significance level was set at alpha (α) of 0.05.At baseline, the mean (±1SD) age of cases was 37.5±9.7 years, whereas it was 36.9±9.2 years among controls. The median baseline CD4 count was 121.0 cells/µl (IQR: 47–183 cells/µl) for cases and 122.0 cells/µl  for controls. The median baseline CD4 count wasn't significantly different in the two groups . At baseline 45.2% (n = 28), 51% (n = 78) of controls and 54.8% (n = 34), 48.7% (n = 74) of cases were in WHO clinical stage IV and III respectively. All study participants (both cases and controls) were started on first-line regimen composed of two nucleoside analogue-based drugs (zidovudine (AZT) or stavudine (d4T) or tenofovir (TDF) plus lamivudine (3TC)) plus one non-nucleoside analogue drug (either nevirapine (NVP) or efavirenz (EFV)). D4T/3TC/NVP was the commonly initiated regimen among both cases and controls. Other baseline characteristics of study participants are shown in Median follow up duration was 57.5 months (IQR: 35.5–75.2 months) for controls. Similarly, cases had median follow up duration of 59 months (IQR: 38.5–76.0 months). This comparable follow up duration  was achieved by selecting controls who were initiated on HAART in similar month and year with cases.The median switching time from first line to second line HAART was 25.0 months (IQR: 14.0–44.0 months). The common second line regimes were Abacavir/Didanosine/Kaletra  and TDF/3TC/Kaletra. CD4 counts were consistently recorded in the first 2 years. The third, fourth and fifth year CD4 counts were highly affected by missing values and were excluded from rate calculations.CD4 cell counts poorly fit normality assumptions for both cases and controls . Moreover, different transformations tried couldn't fulfill normality assumptions.The median rate of increase was calculated for subjects who had CD4 counts between the two given points namely month0 to month6, month6 to month12 and month12 to month 24. Accordingly, the number of participants who had documented CD4 counts between month0 to month6, month6 to month12 and month12 to month24 were 94, 77 and 87 for the immunologically non-failed group and they were 92, 82 and 84 among the immunologically failed group respectively. The median rate of CD4 cells increase was almost similar for the two groups in the first six months of commencing HAART . The median rate of CD4 increase was significantly different for the two groups for the next 6 months period. The rate of increment was 8.8  and 1.8  cells/µl/month for controls and cases, respectively . In the second year (12 month to 24 months) the rate of increase slowed down remarkably for the two groups (1.92 and −0.13 cells/µl/month for controls and cases) and wasn't significantly different among the two groups  .The prevalence of baseline CD4 count of <250 cells/µl among control subjects was 85.0%, and 89.0% among case subjects; this prevalence has declined to 53.0% for controls and 65.0% for cases after 6 months of treatment. The prevalence of CD4 counts of <50, 50–99, 100–149, 150–249 and ≥250 after 6 months of treatment was 8.2%, 6.1%, 24.5%, 26.5% and 34.5% among cases and was 2.0%, 5.1%, 10.2%, 35.7%, and 46.9% among controls respectively.Both conditional univariate and multivariate analysis were carried out to assess potential predictors of immunological treatment failure. In the conditional univariate analysis, baseline CD4 count significantly predicts immunological treatment failure. The odds ratio of immunological failure was 0.27  times less likely among the > = 250 cells/µl CD4 cell count when compared with subjects with baseline CD4 count of <50 cells/µl. The adjusted analysis also remained in the same direction. The average health facility contact time (in months) was also assessed as potential predictor and was found that clients who had infrequent visits to visit health facilities were found to have lesser odds of experiencing treatment failure but this was not statistically significant .In the conditional univariate analysis, baseline age was found to be a significant predictor of immunological treatment failure. The odds ratio of immunological failure was 1.78  times more likely among the older age group (≥40 years) than younger ones (<40 years). The adjusted analysis also remained in the same direction. Moreover, subjects with higher educational status were found to have higher odds of experiencing immunological treatment failure. For instance, patients who have attained tertiary level education were 3.51 times more likely to experience immunological treatment failure when compared with those who have never attended formal education .Retaining patients on first line ART treatment for as long as possible is one strategy to maximize the benefits gained from first line regimens which are cheap and easy to take for patients compared with second line regimen The median switching time observed in this study was 25.0 months (IQR: 14.0–44.0 months) and this is consistent with findings elsewhere st quartile1 = 14 months), long after warning sign. This finding may suggest rate of CD4 increment in this period might be used to predict future immunological failure. Among patients with CD4 count of <50 cells/µl, 66.7% of them experienced immunological treatment failure at later time. Timing of immunological treatment failure also depended on the baseline CD4 count. For instance, out of 36 cases of treatment failure in the first 14 weeks on treatment initiation, 77.8% (n = 28) had CD4 counts of <200 cells/µl. The effect of baseline CD4 count was also significant on conditional multiple logistic regression after controlling for possible measured confounders. The probability of developing new opportunistic infections like tuberculosis is high if the baseline CD4 count is low In the next phase, month 6 to month 12, the CD4 median rate of increase has shown remarkable difference in the two groups. The rate of increment was 4.9 times higher among controls when compared with cases. The seed of treatment failure might have already been sown at this stage even though the median switching time was 25 months (1Another major predictor of immunological failure which would have been considered was adherence to treatment as such observations were made in other studies Age was shown to have a significant influence on probability of immunological treatment failure in the univariate analysis and multivariate analysis. In fact, most literatures support that older age groups are more likely to have failure of therapy and switch to second line regimen than younger group The other significant observation found in this study was the negative association between educational status and immunological recovery. One logical step to explain this will be to go one step behind and look at how educated people do generally in terms of adherence to treatment when compared with less educated people. On the literature we have found no consistent finding addressing this issue. A systematic review conducted by Peltzer et al has found a negative association between educational status and adherence to treatment in 8.2% of the studies The limitation of this study could be that the classification of cases ad controls and most of the data were collected from formats and registers which could result in information biases. However, due to the vertical program and rigorous monitoring system of HIV services in both hospitals, such bias might not play an overriding role. In addition, lack of information about those cases who were lost from care may also adversely influence the findings. Using only immunologic criteria may not adequately define treatment failure as immunologic criteria isn't highly sensitive to detect treatment failure. There are documented evidences that there could be virologic response but immunologic response may not be detected.In the current study, it was found that patients with low baseline CD4 count, old age group and those with higher educational status are more likely to have immunological treatment failure. It was also noted that patients with immunological treatment failure have an optimal rate of immune recovery in the first 6 months of treatment with first line HAART but relative to the non-failing group the rate significantly decreases at a later period, notably between 6 months and 12 months. Median rate of CD4 cells recovery in the period between 6 and 12 months of first line treatment was significantly different in the two groups. Though its validation might require a large study, it could be a potential area for predicting immunological treatment failure in resource limited setting, where viral load testing is not routinely done.


The current guidelines recommend 21-day adjunctive corticosteroid therapy for HIV-1-infected pneumocystis pneumonia patients (HIV-PCP) with moderate-to-severe disease. Whether shorter adjunctive corticosteroid therapy is feasible in such patients is unknown.2 on room air of <70mmHg or A-aDO2 ≥35 mmHg.We conducted a retrospective study to elucidate the proportion of patients with moderate and severe HIV-PCP who required adjunctive corticosteroid therapy for 21 days. The enrollment criteria included HIV-PCP that fulfilled the current criteria for 21-day corticosteroid therapy; PaO2 35–45 mmHg) received steroids for >14 days, whereas 35% of the patients with severe HIV-PCP  required corticosteroid therapy for ≥21 days. Four (13%) of the severe cases died, whereas no patient with moderate disease died. Among patients with severe HIV-PCP, discontinuation of corticosteroid therapy within 14 days correlated significantly with higher baseline CD4 (p = 0.049).The median duration of corticosteroid therapy in the 73 study patients was 13 days (IQR 9–21). Adjunctive corticosteroid therapy was effective and discontinued within 10 and 14 days in 30% and 60% of the patients, respectively. Only 9% of the patients with moderate HIV-PCP (n = 22, A-aDOShorter adjunctive corticosteroid therapy was clinically effective and adjunctive corticosteroid could be discontinued within 14 days in 60% of moderate-to-severe HIV-PCP and 90% of moderate cases. However70 mmHg] . Moreove1) to elucidate the proportion of HIV-1-infected patients with moderate and severe PCP who fulfilled the criteria for use of adjunctive corticosteroid for 21 days who actually needed corticosteroid use for 21 days from retrospective chart review, and 2) to investigate the factors associated with shorter (<21 days) duration of steroid use among such patients. In this retrospective review, the CDC guidelines were not always followed but instead use of adjunctive corticosteroids was modified based on the hospital protocol and treating physician's judgment. Thus, this study discussed what has been done in actual clinical practice and was both a discussion of actual clinical practice and patient outcomes.Based on above background, this study was designed 1) history of shortness of breath, dyspnea on exertion, and cough; and 2) histological or cytological evidence of Pneumocystis jirovecii in bronchoalveolar lavage fluid, or probable PCP based on 1) history of shortness of breath, dyspnea on exertion, and cough and 2) abnormal CT scan findings compatible with PCP, and 3) initiation of specific anti-pneumocystis therapy  were also collected from the medical charts. Patients were followed up for one year, and prognosis by one year after the diagnosis of PCP was collected.2 ≥45 mmHg) and moderate disease group (A-aDO2 <45 mmHg) based on American CDC Guidelines , short corticosteroid therapy was associated with significantly higher CD4 count, and marginally associated with lower LDH value. The results of the present study might suggest that systemic corticosteroid therapy could be discontinued within 14 days in the majority of HIV-infected PCP with moderate-to-severe disease, rather than 21 days, and most (90% in this study) PCP with moderate severity could discontinue corticosteroid within 14 days. A large-scale prospective study, desirably randomized controlled trial that compares shorter versus longer courses of adjunctive corticosteroids in patients with moderate to severe disease, is warranted to confirm the results of the present study.This single-center study described the length of systemic corticosteroid therapy in PCP patients with HIV-1 infection who fulfilled the criteria of the American CDC guidelines for systemic corticosteroid therapy of 21-days. The median duration of corticosteroid therapy of the study patients was 13 days (IQR 9–21); corticosteroid therapy was discontinued in <15 days in 59% of the patients, and even within 9 days in 30% of the patients. Of the moderate group , although the corticosteroid was discontinued within 14 days in the majority of moderate-to-severe PCP and most moderate PCP. Third, the study patients included clinically-diagnosed (probable) PCP cases without histological or cytological evidence. However, all probable cases underwent chest CT and serum β-D glucan, both of which have high diagnostic value for PCP , presentIn conclusion, the present study suggested that adjunctive corticosteroid therapy for only 14 days or less was clinically effective in 60% of HIV patients with moderate-to-severe PCP and 90% of moderate cases who fulfilled the criteria for use of corticosteroids for 21 days. Because short-term corticosteroid therapy is desirable in order to avoid various side effects of systemic corticosteroid, it is important to note that the majority of such patients can discontinue corticosteroid within 14 days.


This study explores factors associated with virological detectability, and viral re-suppression after enhanced adherence counselling, in adults and children on antiretroviral therapy (ART) in Swaziland.This descriptive study used laboratory data from 7/5/2012 to 30/9/2013, which were linked with the national ART database to provide information on time on ART and CD4 count; information on enhanced adherence counselling was obtained from file review in health facilities. Multivariable logistic regression was used to explore the relationship between viral load, gender, age, time on ART, CD4 count and receiving (or not receiving) enhanced adherence counselling.From 12,063 patients undergoing routine viral load monitoring, 1941 (16%) had detectable viral loads. Children were more likely to have detectable viral loads , as were adolescents , patients with last CD4<350 cells/µl  or WHO Stage 3/4 disease , and patients on ART for longer . At retesting, 450 (54% of those tested) showed viral re-suppression. Children were less likely to re-suppress , as were adolescents , those with initial viral load> 1000 copies/ml , and those with last CD4<350 cells/µl . Receiving (or not receiving) enhanced adherence counselling was not associated with likelihood of re-suppression.Children, adolescents and those with advanced disease were most likely to have high viral loads and least likely to achieve viral suppression at retesting; receiving adherence counselling was not associated with higher likelihood of viral suppression. Although the level of viral resistance was not quantified, this study suggests the need for ART treatment support that addresses the adherence problems of younger people; and to define the elements of optimal enhanced adherence support for patients of all ages with detectable viral loads. In 2013 the World Health Organisation (WHO) recommended routine annual viral load (VL) monitoring for all patients on antiretroviral therapy (ART), as the most accurate available measure of effective treatment response. was performed in a backward, step-wise manner, from an initial model which included all explanatory variables with a p-value of <0.1 on bivariate analysis, until a best-fit model was found. Data entry was carried out with EpiData 3.1, and data analysis was performed using Stata/SE  Version 12.1.Since the study was carried out using only routine data sources, there was a substantial proportion of missing data. For each variable of interest, we assessed whether having a missing value was associated with the outcome of interest (detectability or re-suppression) and whether the missing values were disproportionately distributed among certain groups . Many patients with missing values came from the same few health facilities, so clustering by health facility was controlled for in the analysis. In the final model regression models, analysis was restricted to records for which all relevant variables were available. This decision was made after exploring the potential impact on the findings of including these extra records in the analysis  of the patients. For those patient records that could not be linked, information could thus not be obtained on time on ART, CD4, WHO stage, TB status and ART regimen; these patients were more likely to have detectable VLs see . AmongstCharacteristics of patients at time of VL testing are shown in Tables On bivariate analysis, males, patients under 20 yrs old, those with WHO stages 3 or 4 disease or advanced immuno-suppression (CD4<350 cells/µl), and those managed in primary rather than secondary care locations, were more likely to have detectable VL . Patients with detectable VL tended to have been on ART for longer than patients with undetectable VL, although this was not statistically significant (p = 0.08). ART regimen and TB co-infection status were not associated with virological detectability. Patients undergoing VL testing for early adherence (at six months) were no more likely to have a detectable VL than patients attending for routine annual monitoring.In the final adjusted model, the key predictors of detectability were: being an adolescent or a child, longer time on ART, WHO Clinical Stages 3 and 4, and recent CD4<350 cells/µl. Crude and Adjusted Odds Ratios are shown in Of the original 12,063 patients, 1,930 (16%) had a detectable VL, of whom 835 had a follow-up VL during the study period; this represents approximately 60% of those eligible for follow-up testing during the study period, on the basis of the timing of their first test. The median time to follow-up was four months. All 835 patients with a follow-up VL test were included in the “predictors of virologic failure” analysis, of whom 451 (54%) showed viral suppression at re-testing. Again, not all patients had complete data for all explanatory variables of interest, but no patient was excluded on this basis.The review of 200 patient files to obtain information on EAC yielded 180 files with information recorded: 35 (19%) had received no EAC; 145 (81%) had received at least one session of counselling, and 36 (20%) had received all three sessions. In 20 files it was unclear whether the patient had received EAC or not. There was no difference in the rates of re-suppression among the sample of 180 patients for whom information on EAC was collected, and the rest of the cohort.On bivariate analysis, patients younger than 20, those with VL >1000 at initial test, and those with CD4 count <350 cells/µl were more likely to show virologic failure at retesting (p<0.01 in each case). Gender, WHO clinical stage, TB co-infection status, time on ART, type of facility and ART regimen were not associated with likelihood of virologic failure. Patients who had a detectable VL at their early adherence test (at six months) appeared as likely to re-suppress as those who were detectable at routine annual monitoring. There was no difference in re-suppression rates between those who underwent EAC and those who did not. Restricting analysis to patients with a first detectable VL of over 1000 had no effect on these findings.In the final multivariate regression model, the factors associated with virologic failure were: being a child or an adolescent, having an initial VL between 1000 and 50,000 copies/ml and recent CD4 <350 cells/µl. Crude and Adjusted Odds Ratios are shown in This programmatic study demonstrated that children and adolescents on ART were more likely to have raised VLs, and less likely to achieve viral suppression at retesting when compared with the adult cohort. Receiving EAC did not appear to increase the likelihood of viral suppression, relative to receiving a detectable VL result from the health worker.Overall, 84% of patients in the cohort had an undetectable VL, and of those with detectable VLs, 54% resuppressed following planned adherence counselling. Likelihood of viral detectability increased with time on ART and advanced disease; virologic failure was more likely in advanced disease (as indicated by CD4 cell count). This is consistent with other studies, and suggests that these groups are more likely to have resistance mutations.Children and adolescents were significantly more likely to have a detectable VL, and less likely to re-suppress at retesting. This is consistent with the limited available evidence on VL monitoring in children, and evokes the specific barriers to adherence faced by children and adolescents, that are unlikely to be addressed successfully through counselling., 11 Due In our study patients with raised VLs who received EAC by lay counsellors were no more likely to have a subsequent suppressed VL than those who did not receive counselling. Although factors such as age and sex were controlled for in the analysis, there may be other factors that could explain why patients who did not undergo counselling tended also to suppress their VL at re-testing. For example, these patients may be more empowered (or employed) and may have chosen not to attend counselling, instead managing to improve their adherence autonomously; likewise the health worker may have made more effort to persuade those most in need of counselling to attend counselling, which may explain the poorer than expected virologic outcomes in the counselling group Secondly, the lack of apparent difference between the counselling and non-counselling groups may reflect a weakness in counselling training and supervision. Thirdly, whilst the WHO recommends an adherence intervention for patients with detectable VL, it does not specify what form that intervention should take. We must recognise that the act  of explaining to a patient that their VL is detectable constitutes an intervention in itself; indeed, we can assume that all retested patients were notified of their initial result, even if they did not subsequently receive counselling. If it is this intervention that results in re-suppression, then efforts must focus on improving ‘treatment literacy’ amongst patients on ART, including awareness of the role and importance of VL testing. Finally, viral resistance was not measured in this study, and thus the possibility that rates of resistance were higher in the counselling group cannot be excluded.Patients with an initial low detectable VL (<1000copies/ml) were more likely to resuppress; this may reflect a ‘return to mean’ phenomenon, or virologic ‘blips’, rather than indications of poor adherence or resistance. Raising Our final database had a substantial amount of missing data, predominantly where we were unable to link the VL laboratory records with the national ART database. These patients appeared more likely to have detectable VLs. It is possible that they started ART prior to the implementation of the electronic register (which explains why we could not link their laboratory records), and have thus been on ART for longer, with consequent higher likelihood of treatment failure due to acquired resistance. If this is the case, our analysis may underestimate the effect of time on ART on likelihood of viral detectability. However, we also noticed that many of these patients came from the same few health facilities, which could suggest that these facilities are delivering poorer quality of care. We controlled for clustering by health facility in order to minimise the impact this would have on our estimations.This study has several strengths: the sample was relatively large and included a large number of children, with good overall testing coverage of the ART cohort. For the planned adherence counselling, we verified if counselling was actually received, which has not been reported in other similar studies to our knowledge. STROBE guidelines were followed in the reporting of the study.However, since the study uses routine programme data, conclusions are limited by issues of data quality and missing values. Where possible we have controlled for this in the analysis. For the re-suppression analysis, 40% of the ‘detectable’ patients failed to undergo retesting during the study period; it is possible that this 40% are more likely to remain detectable than the 60% who successfully underwent retesting. Since the Swaziland VL programme is new, this analysis included patients having their first VL test at six months, as well as patients having a first test after many years on ART; once the programme is well established, it will be possible to compare these early adherence tests results with the results from patients undergoing annual monitoring who are known to have been virally suppressed at previous VL monitoring. Due to operational constraints we only collected data on counselling for a sub-sample of the detectable cohort; but since rates of re-suppression in this sub-sample were similar to those in the whole detectable cohort, this is unlikely to affect the overall results. Finally, this study does not look at clinical outcomes or make use of viral genotyping of patients with virologic failure to confirm the presence of resistance mutations. Whilst this would certainly be of programmatic interest, it would require a prospective cohort study and is outside the scope of this descriptive analysis.VL monitoring has the potential to improve ART treatment support, but clinicians should take into account the patient’s age and disease status when interpreting the VL results, and should make efforts to exclude ongoing adherence problems before considering second line therapy. This is especially the case in young people, as the adherence barriers they face may not be amenable to adult-oriented counselling; tailored treatment support with more regular VL monitoring may be helpful in this group.For patients with elevated VLs, the act of communicating (and explaining) their result, which can be seen as improving ‘treatment literacy’, may be a key element of any adherence intervention. Further operational research should aim to define the other components of effective adherence support for patients with detectable VL.S1 Table(DOC)Click here for additional data file.S1 Dataset(XLS)Click here for additional data file.S2 Dataset(XLS)Click here for additional data file.


It is uncertain if plasma HIV-1 tropism is an independent predictor of short-term risk of clinical progression / death, in addition to the CD4 count and HIV RNA level. We conducted a nested case-control study within EuroSIDA to assess this question amongst people with current HIV RNA level >1000 copies/mL, including both people on ART and those ART naïve.People with an AIDS diagnosis or who died from any causes for whom there was a stored plasma sample with HIV-1 RNA (VL)≥1,000 copies/mL available in the time window of 3–12 months prior to the event were identified. At least one control was selected for each case matched for age, VL and HCV status at the time of sampling. Controls were event-free after a matched duration of time from the date of sampling. Plasma HIV tropism was estimated using 454 and population sequencing (PS). Non-R5 HIV was defined as: (a) ≥2% of sequences with a Geno2Pheno (G2P) FPR≤3.75% by 454, and (b) a G2P FPR≤10% by PS. We also compared CD4 slopes over the 12 months following the date of sampling using a linear mixed model with random intercept according to HIV tropism and ART status.3 and 4.81 log c/mL, respectively. Baseline characteristics were well balanced by tropism. Factors independently associated with clinical progression or death were female gender , CD4+ count , being on ART  and calendar year of sample . Baseline plasma tropism was not an independent risk factor for clinical progression or death by either 454 or PS. No significant interaction was observed between tropism and ART status. There were no significant differences in the CD4+ slope within or between tropism groups.The study included 266 subjects, 100 cases and 166 controls, with sample taken on average in 2006; 23% and 24% had non-R5 HIV by 454 and PS respectively. There were 19% women, 25% MSM, 92% Caucasians, 22% HCV+. At the time of sampling, 26% were ART-naïve, 25% had started but were off ART and 49% were receiving ART. The median age, CD4 and viral load was 41 years, 350 cells/mmPlasma HIV-1 tropism does not appear to add to the ability of CD4 count and viral load to predict the short term risk of AIDS and death outcomes, even with 454 sequencing.


Limited data are available from the developing world on antiretroviral drug resistance in HIV-1 infected children failing protease inhibitor-based antiretroviral therapy, especially in the context of a high tuberculosis burden. We describe the proportion of children with drug resistance mutations after failed protease inhibitor-based antiretroviral therapy as well as associated factors.Data from children initiated on protease inhibitor-based antiretroviral therapy with subsequent virological failure referred for genotypic drug resistance testing between 2008 and 2012 were retrospectively analysed. Frequencies of drug resistance mutations were determined and associations with these mutations identified through logistic regression analysis.10, IQR 5.34;6.47) and frequent tuberculosis co-infection (66%) at antiretroviral therapy initiation. Major protease inhibitor mutations were found in 49% of children and associated with low weight-for-age and height-for-age ; longer duration of protease inhibitor regimens and virological failure ; unsuppressed HIV viral load at 12 months of antiretroviral therapy (p = 0.001); tuberculosis treatment at antiretroviral therapy initiation (p = 0.048) and use of ritonavir as single protease inhibitor (p = 0.038). On multivariate analysis, cumulative months on protease inhibitor regimens and use of ritonavir as single protease inhibitor remained significant .The study included 65 young children  with mostly advanced clinical disease (88.5% WHO stage 3 or 4 disease), severe malnutrition , high baseline HIV viral load (median 6.04 logMajor protease inhibitor resistance mutations were common in this study of HIV-1-infected children, with the timing of tuberculosis treatment and subsequent protease inhibitor dosing strategy proving to be important associated factors. There is an urgent need for safe, effective, and practicable HIV/tuberculosis co-treatment in young children and the optimal timing of treatment, optimal dosing of antiretroviral therapy, and alternative tuberculosis treatment strategies should be urgently addressed. Treatment of HIV-infected children with antiretroviral therapy (ART) is challenging. Children’s higher HIV-1 viral load (VL), poor tolerability of antiretroviral medication, complex adherence issues and previous exposure to ART through prevention of mother-to-child transmission (PMTCT) strategies potentially contribute to the more rapid development of HIV-1 drug resistance in children compared to adults . The sitProtease inhibitor (PI)-based ART is becoming more important in the management of HIV-1 infected children in the developing world. The CHER trial demonstrated that early treatment of infants with boosted PI-based regimens reduce early infant mortality by 76% and HIV progression by 75% in a developing world setting . PI-baseThe feasibility of large-scale implementation of PI-based regimens in resource-limited settings is, however, questionable. LPV/r is the only co-formulated PI available in a paediatric formulation  in the developing world. LPV/r liquid is expensive, unpalatable and requires refrigeration while LPV/r tablets are relatively large and have uncertain bioavailability when broken ,2. QuestThis study assessed the proportion of paediatric patients failing PI-based ART in a public sector setting in South Africa–a high TB burden country–with major PI drug resistance mutations and determined factors associated with these mutations.The study population consisted of children who initiated PI-based ART in the Tshwane District, South Africa, and had a genotypic HIV-1 drug resistance test done between 2008 and 2012. ART regimens were prescribed according to national guidelines  at ART initiation and a male-to-female ratio of 1.95. The clinical characteristics of the cohort, as shown in Of the 61 children with reliable TB data, 77% had received co-treatment for TB and HIV disease; 66% of whom were on TB treatment at the time of ART initiation. TB treatment was started at a median of 42 days before ART initiation . The majority of the children (64.6%) were initiated on a combination of d4T, lamivudine (3TC) and LPV/r, while the second most common regimen was d4T, 3TC and RTV-sPI (24.6%). At time of genotyping, 44 patients were still on a PI-based regimen , while 19 had been switched to NNRTI-based regimens and had not been on a PI for a median of 25.5 months . One patient was on both a PI and NNRTI and one was not on any ART. The majority were still on d4T (76.9%) and 3TC (90.8%), while 13.8% were now on ABC, 10.8% on didanosine (ddI) and 7.7% on zidovudine (AZT).10 at time of genotyping was 4.15 . Genotypic drug resistance testing was successful in all 65 patients. All viruses belonged to HIV-1 subtype C and had at least one drug resistance mutation. All but two of the genotypes (97%) had NRTI mutations and, as expected, the M184V mutation, which confers resistance to 3TC/emtricitabine, was the most common, occurring in 89%. Thymidine analogue mutations (TAMs) were found in 25%, with half (50%) of these genotypes showing multiple (≥3) TAMs and the majority  following the TAM2 pathway. The K65R mutation was rare in this patient population, occurring in only 3%. Furthermore, evidence of resistance to NNRTIs was found in 45% genotypes and the most common NNRTI mutations were K103N (23%), P225H and Y188C (9% each). NNRTI mutations predictably occurred more commonly in patients on an NNRTI at the time of genotype (67.9% versus 32.1%).The median VL logThirty-two of 65 (49%) genotypes had major and 51% minor PI mutations  with theUnivariate analysis  showed t10 VL 4.45 vs 3.79; p = 0.021). There was no difference in clinically documented ART interruptions .There was no difference in the number of children in each group who ever had viral suppression . Among patients who achieved virological suppression to lower than detectable levels (LDL) (n = 28), 57% were suppressed at a single visit, 14% at 2 visits, and the remainder (29%) at ≥3 visits. Time to a first episode of suppression to LDL was significantly longer for patients with at least one major PI mutation , while failure to suppress to LDL by 12 months was associated with a higher risk of developing PI mutations (p = 0.001). While the VL at genotype was equivalent between children with and without major PI mutations (p = 0.35), patients with ≥2 major PI mutations had a significantly higher VL at time of genotype than those with ≤1 major PI mutation (logCo-treatment for TB and HIV significantly increased the risk for major PI mutations (p = 0.036), with children on TB treatment at the time of ART initiation significantly more likely to develop PI mutations (p = 0.048). There was no difference between the groups if TB treatment had been started later while on PI (p = 0.12). After adjusting for baseline anthropometry, TB disease at ART initiation and malnutrition were found to be independently associated with the development of PI mutations  and this association held even after further adjustment for total time on PI.+ and the development of PI mutations. There was no evidence of confounding or co-linearity between failure to achieve virological suppression and exposure to RTV-sPI, suggesting that both were independently associated with the development of major PI resistance mutations. However, restricting the analysis to only children who had been on TB treatment at the time of ART initiation showed that patients on RTV-sPI were less likely to achieve virological suppression by 12 months  and took longer to achieve such suppression (p = 0.043) . Among the 39 children with no RTV-sPI exposure there was a trend for risk of major PI mutation if they also received TB treatment; however, the numbers were small and did not reach statistical significance OR = 2.0 [95% CI 0.5 to 9.8]. There was no evidence of an association between the use of either ddLPV/r or super-boosted LPV/R= 0.043) . MultivaThis study of children failing ART shows that all children who had genotypic drug resistance testing had at least one HIV-associated drug resistance mutation and that resistance patterns were generally severe. In contrast to previous studies ,23–31, aEven though some studies have shown that age is a risk factor for treatment failure –39 and dMalnutrition increases hospitalisation and mortality in HIV-infected children –45, but High pre-initiation VL and/or low CD4 count have been associated with a lower probability of durable viral suppression during PI-based treatment –55 as weAn unexpectedly slow virological response after treatment initiation may occur due to drug intolerance, toxicity, inadequate absorption, resistance, non-adherence and possibly some unknown factors, and such patients should be assessed for adherence to therapy, and if available, drug levels and the presence of resistance . PrimarySlow and incomplete virological suppression was, however, associated with the timing of TB co-treatment and the type of PI boosting strategy used. Children who initiated ART while on TB treatment were almost 5 times more likely to develop major PI mutations than children without TB or who had completed TB treatment prior to ART initiation. Several studies have demonstrated worse virological outcomes in children who received TB co-treatment at the time of ART initiation, but this had not been linked to the presence of drug resistance ,58–60. TRTV, when used as a single PI, is not significantly affected by concurrent rifampicin treatment and was used for co-treatment until data on LPV boosting strategies in children became available . Our stuModifying TB treatment, by excluding a rifamycin, is an option but may be sub-optimal in HIV-infected patients with active TB and is currently not recommended . RifabutMajor PI mutations have been associated with adverse clinical outcomes. Children with a lopinavir mutation score of ≥6 are less likely to achieve an undetectable VL and to remain virally suppressed . In our Notwithstanding the lack of validated adherence tools in children, our study is limited by the absence of more objective measures of adherence such as pill counts and LPV levels in hair. Other limitations include incomplete data on PMTCT exposure, no denominator data and the absence of drug resistance testing at ART initiation. In addition, the retrospective nature of this study limited the results to testing of associations and not causation. Nevertheless, our study contains significant strengths, such as the relatively large study population, uniform and simple treatment regimens, and robust clinical data.This study identified children at high risk of developing major PI drug resistance mutations. Children on TB treatment at ART initiation, suboptimal ART regimens, malnutrition, and an unexpectedly slow rate of initial viral suppression should be identified and targeted for more intensive monitoring and adherence support. In addition, even though use of RTV-sPI is no longer recommended, children with previous exposure to such a regimen are at high risk of failure and should be provided with frequent VL monitoring and early access to drug resistance testing. Further research into ART dosing in very young and malnourished children should be a priority. Finally, there is an urgent need for safe, effective, and practicable HIV/TB treatment strategies in young children with emphasis on the optimal timing and dosing of ART and potentially alternative TB treatment strategies.


To investigate human immunodeficiency virus (HIV) virologic suppression and drug resistance among HIV-infected patients receiving first-line antiretroviral treatment (ART) in hospitals while community care and outreach through local health workers in Guangxi, China.This was a series of cross-sectional surveys from 2004 to 2012 in Guangxi, supported by the Chinese National HIVDR Surveillance and Monitoring Network Working Group.Guangxi, China.+ cell count, viral load, and drug resistance) were analyzed. Factors associated with virologic suppression were identified by logistic regression analysis.Demographic, ART, and laboratory data (CD4P = 0.002).A total of 780 patients were included in this study. The median treatment duration was 20.6 months (IQR 6.6–35.9). Of 780 study participants, 95.4% of patients (744/780) had HIV virologic suppression. Among these, of the 143 patients who were infected through drug injection, only 10 (7.0%) experienced virologic failure, and the overall prevalence of HIV drug resistance was 2.8% (22/789). Factors associated with virologic suppression in the final multivariate models included self-reported missing doses in the past month  and initial ART regimen without 3TC . Moreover, the trend chi-square test showed that the proportion of virologic suppression increased over time from 2004 to 2012 (This study first demonstrated that HIV patients infected through various transmission routes can achieve an excellent treatment outcome in hospitals at or above the county level for free first-line ART in Guangxi. It is an important of ART education and adherence to intervention for achieving better treatment outcomes. Highly active antiretroviral therapy (HAART) has led to a dramatic increase in sustained suppression of human immunodeficiency virus (HIV) replication. Since HAART was developed in the early 1990s, there has been a rapid improvement in prognosis of patients infected with HIV and reduction in AIDS-related mortality . In resoThe China’s National Free Antiretroviral Treatment Program (NFATP) began in 2002 and rapidly scaled-up. In 2008, China’s NFATP changed the threshold of initiating free ART access to more patients . By the 3 before 2008, and <350/mm3 since 2008, (2) total lymphocyte count <1200/mm3 before 2008, and/or (3) WHO stage III or IV disease  of the National Center on HIV/STD Control and Prevention (NCAIDS), China CDC approved this study.+ T-lymphocyte count (CD4 count), HIV viral load (VL), and HIVDR mutations. The CD4 count was determined by flow cytometry within 24 h after collection in the provincial CDC. The Plasma HIV RNA was quantified with real-time NASBA  or COBAS  according to the manufacturer recommendations. In samples with a viral load ≥1000 copies/ml, HIVDR was determined by using an in-house polymerase chain reaction (PCR) (http://hivdb.stanford.edu/) was used to analyze drug resistance mutation and viral subtype determination. Low-, intermediate-, and high-level drug resistance were defined as HIVDR  , 21. Theas HIVDR , 23.P < 0.05 were retained in multivariate logistic regression models using stepwise selection and results were presented with adjusted odds ratio (AOR) and 95% CIs. Hypothesis testing was two-sided with α = 0.05.Questionnaire and laboratory data were double entered and compared with Epidata 3.1 , and then were analyzed by Statistical Analysis System . Demographic variables were described with descriptive statistics. Factors associated with virologic failure  were identified by univariate and multivariate logistic regression models. Variables with Seven hundred eighty patients were included in this study. Among these, 221 patients were investigated in 2004–2006, 114 patients were investigated in 2006–2007, and then 291 patients were surveyed in 2007–2009, whereas 154 patients were included in 2011–2012. The demographic characteristics of the subjects are shown in Table Initial HAART regimens used were AZT + 3TC + EFV (12.2%), AZT + 3TC + NVP (32.1%), D4T + 3TC + EFV (5.1%), D4T + 3TC + NVP (34.7%), and DDI-based regimens (15.9%). The median of the duration of ART was 20.6 months. At the time of the survey, 36 (4.6%) patients had a viral load ≥1000 copies/ml. Among these subjects, 35 were successfully genotyped. CRF01_AE was the most common HIV viral subtype . Of these, 22 had detectable HIVDR mutations.Among the 35 subjects successfully genotyped with viral load ≥1000 copies/ml, 22 patients were identified with HIVDR mutations, and the overall prevalence of HIVDR was 2.8% (22/789) among HIV-infected patients receiving first-line ART. Approximately 54.5% (12/22) of patients were resistant to non-nucleoside reverse transcriptase inhibitor (NNRTIs) drugs, 90.9% (20/22) of patients were resistant to nucleoside reverse transcriptase inhibitor (NRTIs) drugs, and 4.5% (1/22) of patients had drug resistance to protease inhibitors (PIs). In addition, 45.5% (10/22) of patients were identified as multi-drug resistance to NNRTIs and NRTIs. The most frequent NNRTIs mutations occurred at position 101 in the RT (reverse transcriptase) region, NRTIs mutations occurred at position 184 in the RT region, and PI mutations occurred at position 84 in the PR (protease) region (Table P = 0.002).Of 780 study participants, 744 (95.4%) had HIV virologic suppression. Univariate logistic regression models were used to examine the factors associated with HIV virologic suppression Table . EthniciIn this study, we found significant low virologic failure 4.6%) and drug resistance (2.8%) among HIV-infected patients receiving first-line ART with the median duration of treatment of about 20-month in Guangxi, China. Also, virologic suppression increased over time. A recent systematic review and meta-analysis showed that the pooled prevalence of HIVDR was 11.1% , which increased to 22.92% at 61–72 months  among Chinese HIV-infected patients receiving first-line ART in China . Definin.6% and dThere are several reasons to explain low virologic failure and drug resistance among HIV-infected patients receiving first-line ART in Guangxi. First, there are three levels of AIDS hospitals providing ART for HIV patients, including provincial, prefecture, and county hospitals. One provincial hospital provides technical supports and training to each prefecture hospital, which then provides technical assistance to each county hospital. Second, although HIV patients receive treatment in hospitals at or above the county level, health staff at village clinics or township hospitals are responsible for community care and outreach, such as home visits or telephone calls for reminding of ART adherence, and making an appointment if patients did not see doctors at AIDS hospitals for ART management every 3-month follow-up. Third, all doctors and health staff for ART and care management receive comprehensive HIV/AIDS medical training. Fourth, initial ART regimen with 3TC can increase virologic suppression. Our previous studies found HIV patients who received ART at village clinics, township hospitals, or local CDCs had poor virologic outcomes, whereas treatment counseling and instruction through telephone and 3TC-based regiments were significantly associated with HIV RNA suppression , 29, 30.Despite successful HIV virologic suppression in this study, patients with missed doses in the past month and initial ART regiments without 3TC were found to be at increased risk for poor virologic response. This indicates that measures should be continuously taken to train local medical staff, and educate patients and enhance adherence monitoring. Due to the poor outcome of patients that received DDI-based treatment, the NFATP’s first-line antiretroviral regimens have been changed to exclude the use of didanosine (DDI) and to include the use of lamivudine (3TC) for all new patients beginning treatment since 2008 .The prevalence of HIVDR among patients who experienced virologic failure was 62.9% (22/35). Of 22 patients with HIVDR, the proportions of NNRTI mutations, NRTI mutations, and PI mutations were 54.5, 90.0, and 4.5%, respectively. In addition, 10 (45.5%) were identified to be resistant to multi-drugs. M184I/V was the most common NRTI mutations and other studies in China showed similar results , 29. OneThe limitations can be summed up as follows. First, these results may not represent all patients in Guangxi because of the exclusion criteria and limited geographic distribution of the surveillance sites. Also, the surveys did not include all patients who have met the inclusion criteria in Guangxi, so when we draw the conclusion we should be cautious. Second, considering diverse HIV epidemic conditions in different districts in Guangxi, the difference among those districts should be considered.In summary, this study in Guangxi demonstrates that HIV-infected patients receiving first-line treatment achieve an excellent treatment outcome and we can summarize those factors associated with virologic suppression as increasing the proper use of 3TC-based regimens and strengthening the importance of adhering to treatment.In this study, we found significant low virologic failure and drug resistance among HIV-infected patients receiving first-line ART with the median duration of treatment of about 20-month in Guangxi, China. Our study demonstrated that HIV-infected patients receiving first-line treatment can achieve an excellent treatment outcome in hospitals at or above the county level for free ART in Guangxi, and we can conclude that the increasing the proper use of 3TC-based regimens and the strengthening the importance of adhering to treatment are associated with virologic suppression.JY and SL wrote the main manuscript text and FL, ZT, YS, and WL prepared Tables The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Nevirapine extended-release (NVP-XR) taken once daily remains an effective antiretroviral agent for patients infected with HIV-1 strains that do not harbor resistance mutations. Presence of tablet remnants of NVP XR in stools was reported in 1.19% and 3.05% of subjects in two clinical trials. However, the prevalence may have been underestimated because the information was retrospectively collected in the studies.t)ide reverse-transcriptase inhibitors. Patients were invited to participate in therapeutic drug monitoring of plasma concentrations of NVP 12 or 24 hours after taking the previous dose  of NVP XR using high-performance liquid chromatography. The information on clinical characteristics, including plasma HIV RNA load and CD4 lymphocyte count, at baseline and during follow-up was recorded.Between April and December 2014, we prospectively inquired about the frequency of noticing tablet remnants of NVP XR in stools in HIV-1-infected patients who switched to antiretroviral regimens containing NVP XR plus 2 nucleos and a similar mean plasma HIV RNA load  on switch. At about 12 and 24 weeks after switch, patients who noticed tablet remnants continued to have a similar mean plasma HIV RNA load , but had a lower median NVP C12 , and a similar median NVP C24  when compared with those who did not notice tablet remnants.During the 9-month study period, 272 patients switched to NVP XR-based regimens and 60 (22.1%) noticed tablet remnants of NVP XR in stools, in whom 54.2% reported noticing the tablet remnants at least once weekly. Compared with patients who did not notice tablet remnants, those who noticed tablet remnants had a higher mean CD4 lymphocyte count (629 vs 495 cells/mmThe presence of tablet remnants of NVP XR in stools is not uncommon in HIV-1-infected Taiwanese patients receiving NVP XR-based antiretroviral regimens, which does not have an adverse impact on the virological and immunological outcomes. The 2NNTo reduce the pill burden and enhance convenience and adherence, NVP IR was replaced by NVP extended-release (NVP XR) tablet that contains 400 mg of NVP in a single tablet to be taken once daily. The NVP XR tablet contains hydrophilic polymer hydroxypropyl methylcellulose, which provides extended, controlled release of NVP in the gastrointestinal tract. Although the NVP XR formulation had a lower bioavailability than NVP IR, trough plasma concentration with NVP XR was similar to that of NVP IR and no virological failure was reported in patients treated with NVP XR formulations .In two clinical trials (VERxVE and TRANxITION), the NVP XR formulation has demonstrated non-inferiority of efficacy and similar safety to NVP IR formulation, although the exposure to NVP and the peak NVP concentration are lower in patients taking NVP XR than those taking NVP IR ,7. PreseIn this prospective cohort study, we aimed to determine the prevalence of tablet remnants of NVP XR in stools and to evaluate its impact on virological and immunological outcomes in HIV-1-infected patients who switched to NVP XR-based antiretroviral regimens. Therapeutic drug monitoring of plasma NVP concentrations was performed in a subgroup of patients switching to NVP XR-based regimens.t)ide reverse-transcriptase inhibitors. These patients were interviewed with the use of a face-to-face questionnaire to inquire about the frequency of noticing tablet remnants of NVP XR in stools  or hepatitis C virus (HCV), frequency of noticing NVP XR remnants in stools, backbone antiretroviral therapy, duration of NVP XR before the study, concurrent medications, plasma HIV RNA load and CD4 lymphocyte count on and after switch to NVP XR-based regimens. Patients were invited to participate in therapeutic drug monitoring of plasma NVP concentrations with the use of high-performance of liquid chromatography (HPLC) 12 or 24 hours after taking the previous dose. Clinical characteristics, plasma NVP concentrations, and immunological and virological outcomes were compared between patients with and those without noticing tablets remnants of NVP XR in stools. The study was approved by the Research Ethics Committee of the hospital  and the patients gave written informed consent before participating in the study.After switch to NVP XR-based regimens, plasma HIV RNA load and CD4 lymphocyte count were followed every 3 to 6 months. CD4 lymphocyte count was determined using flow cytometry . Plasma HIV RNA load was quantified using the Cobas AmpliPrep/Cobas TaqMan HIV-I test  with a lower detection limit of 20 copies/mL.Since 2009, we started to conduct therapeutic drug monitoring of plasma concentrations of efavirenz, nevirapine and atazanavir among HIV-infected patients . Patientt test. Categorical variables were expressed as percentage of the total number of patient analyzed, and compare with chi-squared test. Plasma NVP concentrations of patients who noticed tablet remnants and those who did not were expressed by median and interquartile range (IQR) and were compared by Kruskal-Wallis test. A P value less than 0.05 was considered statistical significance.Statistical analyses were performed using SPSS software version 17.0 . Continuous variables were reported as mean ± standard deviation, and compare with Student’s t)ide reverse-transcriptase inhibitors were identified from the Department of Pharmacy of the hospital; 272 patients (87.7%) agreed to participate in the questionnaire interview, in whom 60 patients (22.1%) reported noticing tablet remnants of NVP XR in stools on face-to-face or cell phone questionnaire interview. The baseline clinical characteristics, virological and immunogical outcomes of HIV-1-infected patients with or without tablet remnants of NVP XR in stools are summarized in During the 9-month study period, 310 patients who had switched to NVP XR plus 2 nucleos(P = 0.02), and had similar mean plasma HIV RNA load , a higher mean CD4 lymphocyte count  on switch to NVP XR-based regimens, and a similar duration of exposure to NVP XR before enrollment into this study   .10 copies/mL, P = 0.43), a similar percentage of virological suppression , and a higher mean CD4 lymphocyte count  compared with those who did not notice tablet remnants. Second clinical follow-up, at a mean duration of 213 days after switch, also demonstrated a similar mean plasma HIV RNA load , percentage of virological suppression (<50 copies/ml) , and mean CD4 lymphocyte count  between the patients who noticed and those who did not notice tablet remnants , while the median plasma NVP concentrations at 24 hours of the previous dosing were similar between the two groups   participated in therapeutic drug monitoring of plasma NVP concentrations: 44 patients noticing tablet remnants  and 45 patients not noticing remnants . The clinical characteristics were similar between the two subgroups of patients who underwent therapeutic drug monitoring of plasma NVP concentrations . The med = 0.84) .This is the first prospective cohort study to determine the frequency of noticing tablet remnants of NVP XR in stools and its impact on virological and immunological outcomes in HIV-1- infected patients. Using a face-to-face and cell phone questionnaire interviews, we found that the prevalence of noticing tablet remnants of NVP XR in stools was significantly higher than those reported in two previous clinical trials  –8; the pP = 0.06).While the frequencies of tablet remnants of NVP XR in stools differ between our study and the study by Stephan and colleague , our finTherapeutic drug monitoring of NVP concentrations was recommended for efficacy and safety in patient care . At a doPassage of tablet remnants in stools is not an unusual phenomenon in clinical practices, which may occur whenever patients receive certain pharmaceutical agents that are designed to prolong the rate of drug release . The actOur study has several limitations. First, we did not request the patients to bring along the tablet remnants to the clinics for confirmation. Residues of other concurrent medications or undigested materials may have been mistakenly identified as remnants of NVP XR. Second, we were not able to identify the risk factors predisposing to passage of tablet remnants of NVP XR in stools. Passage of tablet remnants of NVP XR may be related to bowel movement, which may have wide day-to-day variation with dietary habits and other factors among individuals. Third, the number of our patients participating in therapeutic drug monitoring of plasma concentrations of NVP remains small and metabolism of nNRTIs may vary with genetic polymorphisms among different ethnicities ,17,18. TWe conclude that the presence of tablet remnants in stools of NVP XR was not uncommon in HIV-1-infected Taiwanese patients, which did not have an adverse impact on immunological and virological outcome of the patients who switched from NVP IR to NVP XR.