Logistic regression analysis showed that an increase in age of ten years (OR 2.48 (95% CI 1.58–3.89), p < 0.0001) and the presence of HBcAb positivity (OR 2.7 (5% CI 1.05–6.9), p = 0.038) increased the risk of detectability of HIV RNA by nearly three-fold after switching to 2DR-3TC.The aim of this study was to evaluate whether the presence of anti-hepatitis B (HBV) c antibodies (HBcAb positivity) could influence the control of Human Immunodeficiency Virus (HIV) viremia in patients living with HIV (PLWH) who switch a to two-drug antiretroviral therapy (2DR) containing lamivudine (3TC) (2DR-3TC). A retrospective observational multicenter study was conducted on 166 PLWH switching to the 2DR-3TC-based regimen: 58 HBcAb-positive and 108 HBcAb-negative patients. The HBcAb-positive PLWH group demonstrated a significantly higher percentage of subjects with very low-level viremia at all time points after switching (6th month: <31% vs. 17.6%,  Occult B infection (OBI) is characterized by the persistence of hepatitis B virus (HBV) DNA in the liver, regardless of its presence in serum. Patients with OBI may or may not have serological signs of a previous HBV infection; however, the presence of antibodies against an HBV c antigen (HBcAb) is usually considered a surrogate marker of an OBI condition . ImmunosThe current triple ART includes HBV-active drugs in its composition; the choice of a third drug with potent anti-HBV activity, such as tenofovir (TDF) or tenofovir alafenamide (TAF), is strongly recommended in the treatment of HIV/HBV-coinfected patients . In PLWHIn our recent paper, we demonstrated that HBcAb positivity was associated with a delay in achieving HIV undetectability and the onset of viral rebound in HBcAb-positive PLWH after triple ART initiation , thus suIn recent years, interest has grown in two-drug ART regimens designed to improve adherence and compliance by reducing ART toxicity but maintaining its efficacy. Many of these therapies are considered to be nucleoside reverse transcriptase inhibitor (NRTI)-sparing treatments, which essentially means that they eliminate HBV active molecules or, in some cases, use 3TC as a second drug, which is no longer recommended for HBV treatment. In HBsAg-positive PLWH, the use of NRTI-sparing treatments or a two-drug ART regimen with 3TC is not recommended; however, to date, no restrictions have been instituted regarding switching HBcAb-positive PLWH to dual-therapy.We retrospectively evaluated HIV viremia values two years before and two years after the switch to two-drug antiretroviral therapy (2DR) containing 3TC (2DR-3TC) in a cohort of HBcAb-positive and HBcAb-negative PLWH to assess whether the elimination of HBV active drugs or their replacement with 3TC worsened the control of HIV viremia in HBcAb-positive PLWH.A retrospective observational study was conducted on 187 PLWH switched to the 2DR-3TC-based regimen and followed up thereafter. Patients were enrolled at different clinical sites: The Infectious Diseases Clinic of the Tor Vergata Polyclinic in Rome, the Department of Molecular Medicine of the University of Padua, the Units of Infectious Diseases of Vicenza, and the Venezia and Treviso hospitals. For this study, a database was built which included all patients’ data at HIV infection diagnosis (baseline), at the start of ART treatment, and at follow-up visits. In particular, the following data were collected for all patients: demographic information; HBV serology at baseline; CD4+ cell count at baseline and at the time of the 2DR-3TC switch; calendar year of the HIV infection diagnosis; ART composition before the 2DR-3TC switch; and HIV-RNA viral load at 6, 12, 18, and 24 months before the 2DR-3TC switch, at the time of the switch, and at 6, 12, 18, and 24 months after.As shown in HBV serological markers were measured using immune-enzymatic assays .Plasma HIV-RNA levels were measured using a commercial test with 20 cp/mL HIV RNA as the lower limit of quantification . The test allows for the detection of the presence of HIV RNA without quantifying it under 20 copies/mL, which is defined as HIV-RNA detected or target detected .All patients enrolled in the study had an undetectable HIV viral load  at the time of the switch to 2DR-3TC treatment. Levels of HIV RNA detectable below the limits of commercial assays have been found to be associated with an increased risk of virological failure, virological rebound, and the development of resistance ,18,19. TThe endpoint of the study was to evaluate differences in the maintenance of HIV viremia suppression between the two PLWH populations of HBcAb-positive and HBcAb-negative patients 6, 12, and 24 months after the 2DR-3TC-based switch.The data were collected, and the dataset was assembled using Excel 2019 v. 16.3. All statistical analyses were conducted using STATA 14.2 , and graphs and confirmation analyses were performed using GraphPad Prism.v. 8.2.1.p < 0.1 in univariable analysis were included in a full model and were then excluded in a backwards-stepwise fashion if p < 0.05 using the likelihood ratio test.The study population is described using proportions and percentages for categorical values and median measurements and interquartile ranges (IQRs) for continuous values. The comparison between HBcAb-positive PLWH and HBcAb-negative PLWH was performed with the Kruskal–Wallis test for continuous variables and with the chi-squared test or Fisher’s exact test, when appropriate, for categorical variables. Univariable odds ratios (ORs) associated with a lack of HIV-RNA undetectability at T24 and their 95% confidence intervals (CIs) were calculated using logistic regression. A multivariable model was constructed in which risk factors with The study protocol and related informed consent were submitted and approved by the Independent Ethics Committee at Policlinico Tor Vergata ; the study was structured with respect to privacy. Personal information was treated in a confidential manner, and clinical data were anonymized in accordance with the Helsinki Declaration (October 2013 version). All included patients signed an informed consent for inclusion in the observation.3 (IQR 172–414), while the median CD4+ cell count at the time of the switch was 695/mm3 (IQR 547–880). Approximately one-third of the patients  tested positive for HBcAb. Triple ART treatment before the switch to 2DR-3TC showed a balance in the choice of drug classes used: 65 patients (39.2%) were on two NRTIs plus a protease inhibitor (PI), 38 (22.9%) were on two NRTIs plus a non-nucleoside reverse transcriptase inhibitor (NNRTI), 56 (33.7%) were on two NRTIs plus an integrase inhibitor (INI), and 7 (4.2%) were on other non-conventional therapeutic regimens (four-drug therapy or triple ART with PI + INI + 3TC). Most patients  reached viral load undetectability 24 months after the start of triple ART, with three adjunctive subjects at 12 months . At the time of the switch to 2DR treatment, 36 (31.7%) subjects showed a very low level of viremia (<20 copies/mL with a target detected).The full description of the study population is shown in The 2DR-3TC simplification schemes were distributed as follows: 59 patients (35.5%) moved to 3TC plus PI (atazanavir (ATV) or darunavir (DRV) regardless of whether boosted with ritonavir (RTV) or cobicistat (COBI)), and 107 (64.5%) moved to 3TC plus dolutegravir (DTG). All patients maintained virological suppression at 6 and 12 months after the switch, although with different proportions of subjects with very low-level viremia: at the 6th month, 77.7% had <20 copies and no detectable target, while at the 12th month (data available for only 144 patients), only 50.4% had <20 copies and no detectable target, almost 30% had a very low level of viremia, and 18.7% showed a detectable viremia > 20 copies/mL. At month 24 (data available only for 125 patients), the proportion of patients with a very low level of viremia grew to 35.2%, while 22.4% of subjects were viremic with HIV-RNA load values above 20 copies/mL.p = 0.0007) and had a longer history of HIV infection  and were likely more frequently on PI-containing triple ART regimens . Conversely, HBcAb-negative patients were more frequently treated with regimens containing INIs . No statistically significant difference in switch reasons was found in the study population (p = 0.44), furthermore, in both subpopulations the main reason was the medical choice of pre-emptive switch (43 HBcAb-positive patients (74.1%) and 70 HBcAb-negative patients (64.8%)).A comparison between HBcAb-negative and HBcAb-positive patients in the study cohort is reported in 3 (IQR 145–341) versus 316 cells/mm3 (IQR 201–446), respectively, in the HBcAb-positive and HBcAb-negative groups, p = 0.047); however, there was no difference in CD4+ cell count between the two groups of patients at the time of switching to 2DR-3TC (p = 0.58). The proportions of subjects with a history of therapeutic failure were similar, and no differences in the proportions of patients with different viremia determinations  were observed in the two groups 24 and 12 months before the switch and at the time of simplification to 2DR-3TC .The HBcAb-positive group showed a significantly lower CD4+ cell nadir value (251 cells/mmp = 0.047), and a progressive reduction of patients with undetectable viremia was present at all time points . Moreover, progressive increases in patients with detectable viremia above 20 copies/mL were shown after 12 months  (data available for 144 patients) and 24 months  (data available for 125 patients).No difference in the 2DR-3TC composition was observed in the two groups of patients, and higher proportions of patients in both groups resulted in a 2DR-3TC regimen containing DTG . Less control of HIV replication was demonstrable in the HBcAb-positive group at all time point assessments after simplification. In the HBcAb-positive group, a higher proportion of subjects with a very low level of viremia was demonstrated six months after the switch  and 24 months  after the switch. In addition, a higher proportion of subjects in the HBcAb-positive group showed very low-level viremia  and a detectable viremia above 20 copies  (p = 006). No difference in viremia values were detected between the two groups of patients at six months from the switch , switch to 2DR-3TC containing DTG, and HBcAb positivity. The analysis showed that 24 months after simplification to a 2DR-3TC regimen, a ten-year increase in age (OR 2.48 (95% CI 1.58–3.89), p < 0.0001) and the presence of HBcAb positivity (OR 2.7 (95% CI 1.05–6.9), p = 0.038) increased the risk of HIV-RNA detectability more than two-fold (very low-level viremia and detectable viremia above 20 copies/mL).A logistic regression analysis  was perfp = 0.038).In our cohort of virologically suppressed PLWH who switched to a 2DR-3TC regimen, HBcAb positivity was significantly associated with the worst HIV replicative control at all time points of follow-up and correlated with a nearly three-fold increase in the risk of HIV-RNA detectability at 24 months after the 2DR-3TC switch (OR 2.7 (95% CI 1.05–6.9), Achieving HIV suppression below the detection limits of laboratory tests remains the main goal of ART, and its maintenance throughout the duration of therapy is the best guarantee of its effectiveness. However, the observation of occasional or persistent viremia above the test threshold in patients on ART is common and has often been associated with virologic failure ,18,20,21In a previous study , we descStudies on HBcAb-positive PLWH treated with a 2DR regimen are lacking, and published papers on HIV/HBV ART simplified subjects are mainly focused on HBV replication control. Abdullahi et al.  describeIn this regard, it is emphasized that all patients whose HIV viremia was poorly controlled during the 2DR-3TC-based switch did not undergo therapeutic failure, the appearance of resistance mutations, or the onset of AIDS events. Furthermore, of the patients included in the study, 15 returned to triple therapy more than 24 months after the switch unrelated to the aforementioned reasons.Regarding the choice of 3TC in simplified treatment schemes, its use has been proven to be ineffective in the control of HBV replication even in HIV HBcAb-positive patients treated with triple ART. A recent South African prospective study investigating the impact of 3TC-containing ART regimens on the trend of HBV viremia during 24 months of follow-up demonstrated that 25% of patients with proven OBI had detectable HBV DNA at 24 months after the introduction of 3TC . In addiBefore drawing conclusions, a number of study limitations need to be stated. First, the retrospective nature of this study may introduce selection and information biases, such as lack in follow-up data or anamnestic data, in particular HCV serostatus and risk factors for HIV transmission. Second, the reasons for switching  are not homogeneous for all patients, and different simplification schemes were taken into consideration (PI- or INI-based). Third, we did not evaluate ART adherence, and the follow-up of patients in the present study might have been too short to observe treatment failures.In conclusion, to the best of our knowledge, this is one of the first studies investigating the role of HBcAb positivity in the control of HIV RNA in PLWH switched to 2DR-3TC. Based on the presented results, the condition of potential OBI should be carefully considered when selecting PLWH candidates for 2DR switching, as they are potentially at risk of possible future therapeutic failure. In addition, an increase in serological screening of HBV infection and periodic HBV-DNA monitoring in HBcAb-positive PLWH should be encouraged to better monitor occasional HBV viremia appearance and to prevent frank HBV reactivation.


Although the United Nations program on HIV/AIDS 90–90-90-targets recommends achieving 90% of viral suppression for patients on first-line antiretroviral therapy by 2020, virological failure is still high and it remains a global public health problem. Therefore, assessing the incidence and predictors of virological failure among adult HIV patients on first-line ART in Amhara regional referral hospitals, Ethiopia is vital to design appropriate prevention strategies for treatment failure and preventing the unnecessary switching to second-line regimens.P-value < 0.05 in the multivariable analysis were taken as significant predictors of virological failure.An institution-based retrospective follow-up study was conducted on 490 adult HIV patients. The simple random sampling technique was used, and data were entered into Epi data Version 4.2.0.0 and was exported to Stata version 14 for analysis. The proportional hazard assumption was checked, and the Weibull regression was fitted. Cox-Snell residual was used to test the goodness of fit, and the appropriate model was selected by AIC/BIC. Finally, an adjusted hazard ratio with a 95% CI was computed, and variables with 3  and 201–350 cells/mm3  respectively, and NVP based first line drug regimen  were significantly associated with virological failure.The overall incidence rate of virological failure was 4.9 events per 1000 person-month observations (95%CI: 3.86–6.38). Users of CPT , poor adherence , CD4 Count <=200 cells/mmThe incidence rate of virological failure was high. CPT, poor adherence, low baseline CD4 count and NVP based first-line drug regimen were independent risk factors associated with virological failure. Therefore, strengthening HIV care intervention and addressing these significant predictors is highly recommended in the study setting. Globally, it has been estimated that out of 36.9 million people living with HIV, 59% of them received Anti-retroviral Therapy (ART) . EthiopiIdentifying and handling the determinants of virological failure and reducing its incidence is used to realize the 90–90-90 treatment target and achieve sustainable development goal 3. To create an HIV free generation and stop HIV epidemic, early detection of virological failure on first-line ART patients is very important for better preservation of the efficacy of second-line regimens. Maintaining a low viral load is important for patients to prevent the progression of AIDS and associated co-infections; yet, there is only limited evidence on the incidence of virological failure and its predictors. Therefore, this study aimed to estimate the incidence of virological failure and identify its predictors among adult HIV patients on first-line ART in Amhara regional referral hospitals.An institutional-based retrospective follows up study was conducted from September 2015 to December 2018 in three Amhara regional referral hospitals including; the University of Gondar comprehensive specialized hospital, Bahirdar Felegehiwot referral hospital and Deberemarkos referral hospital. As part of the national AIDS control Program, in Amhara regional referral hospitals have been providing free ART services from 2005 to date. The hospitals provide clinical care, including laboratory and pharmacy services , poor adherence (HR = 3.25), duration of ART (HR = 6.62) and ART regimen change (HR = 3.95) from retrospective follow up study done in Adama medical college [The dependent variable was incidence of virological failure, whereas the independent variables were socio-demographic characteristics , anti-retroviral medication related and Clinical characteristics .Survival time was defined as time in month from the start of first line ART treatment to the development of virological failure. Event was defined as patients who developed virological failure during the follow up time. Virological failure is defined as during the follow up time viral load above 1000 copies/ml based on two consecutive viral load measurements in 3–6 months, with enhanced adherence support following the first viral load test [: Good , Fair (85–94% or 4–9 doses was missed per month), or Poor  was calculated for the events of virological failure. The Kaplan Meier (KM) failure curve and log-rank test were used to describe the survival experiences of categorical variables. The proportional hazard assumption was checked both graphically and using a Schoenfield residual test. The goodness of model fitness was also checked using the Cox-Snell residual plot.P-values ≤0. 2 in the bi-variable analysis were entered into the multivariable analysis and variables with P-value ≤0. 05 and an adjusted hazard ratio (AHR) with a 95% confidence interval (CI) were considered as statistically significant predictors of virological failure.The appropriate model for the data was selected based on the Akaike Information Criterion (AIC), Bayesian Information Criterion (BIC) and log-likelihood ratio (LL). Hazard Ratio (HR) was used as a measure of association. Parametric survival models were fitted by assuming baseline hazard distribution. The frailty model was taken into account by introducing the random effect model for time-to-event data, by adding a frailty term “H”. Thus, both univariate and shared frailty models were tested by considering different parametric distributions and the frailty distribution (gamma and inverse Gaussian). A more parsimonious model was chosen using BIC and AIC. The model with the smallest AIC was considered as an appropriate fitted model. Variables having About 2251 adult HIV patients on first-line ART were enrolled between September 2015 and December 2018 in northwest Amhara referral hospitals. Based on our sample size determination, 513 medical charts were included of which 23 medical charts were excluded due to missed charts and incomplete data. As a result a total of 490 patients were included in the analysis  took Cotrimoxazole preventive therapy (CPT). The majority, 437(89.18%), of the patients were treated for first-line Efavirenz (EFV) based ARV drug regimen. Nearly two-thirds (62.04%) had baseline WHO clinical stage I/II and 414(84.49%) had good ART adherence status. Almost three –fourths 265(74.49%), took Isoniazid preventive therapy (INH); 398(81.22) had no TB/HIV co-infection; only 106(21.63%) were anemic, while 385(78.57%) could perform routine activities (Table 1% took CFour hundred ninety (490) adult HIV patients in the first-line ART were followed for different periods with a total of 12,281.53 person-months (PM) of observations. Patients were followed for a minimum of 8.9 and a maximum of 40.33 months; 61(12.4%) of patients developed virological failure during the follow-up period (95%CI: 9.7–15.6). Hence, the overall incidence rate of virological failure in this follows up was 4.9  per 1000 PM of observations. The cumulative hazard of virological failure at 12, 24 and 36 months was03, 7.75 and 7.65 per 1000 PM observations, respectively.The overall IR of virological failure at the University of Gondar comprehensive specialized hospital, Deberemarkos referral hospital, and Feleghiowt referral hospital was 5.63 , 5.3  and 4.1  cases per 1000 PM observations, respectively.A graph of the Kaplan Meier (KM) failure function was used to describe the cumulative IR of virological failure over the follow-up period. The cumulative probability of surviving or being free from the event of interest at the end of 10, 20, 30 s and 40 months was 98.9, 92, 80, and 59%, respectively  and in those who were in poor and Good adherence (P < 0.001)  Fig. .Fig. 4Kp = 0.65) .The proportional hazard assumption states that the risk of failure of the study subjects must be the same no matter how long they are followed. The global test of the proportional hazards assumption based on the Schoenfeld residuals was done, and it was found that all of the covariates and in the full model satisfied the proportional hazard assumption  and log-likelihood were used to select the most parsimonious models for the data set.AIC = 313.15, BIC = 405.32) model was more efficient than Cox proportional hazard and other parametric models.Based on this, the Weibull regression with the . This result was higher than that of a retrospective study done in Adama, Ethiopia  2.1 evenThe incidence of virological failure in this study was slightly higher than that of an observational cohort study conducted in South Africa  . RCT by itself increases the attrition rate of the patients but the method of analysis used in the Southeast Uganda study was intended to treat. Intent to treat analysis considers all patients assigned at the beginning of an event despite the follow-up time with the first viral load result which is greater than 500 copies/ml. Regarding cut off points of virological failure, in Southeast Uganda, virological failure was defined as viral load above 500 copies/ml, and a high proportion (78% Vs 10.82%) of patients have treated in NVP based regimen .3.The other possible reason might be the inclusion criteria used. For example, the study participants in Southeast Uganda were WHO stage IV or late-stage III disease or CD4 count below 200 cells/mmAlso, higher sample size was used in Southeast Uganda compared to this study. When the sample size increases, the probability of getting a high number of events also increases. Thus, all these differences could overestimate the incidence rate of virological failure in southeast Uganda.3 and 201–350 cells/mm3) were significant predictors of virological failure.According to the Weibull regression model, non-user CPT, fair/poor ART adherence, NVP based first-line regimen, and baseline lower CD4 count  and (201–350 cells/mm3) were nearly four times at higher hazard of developing virological failure compared to patients with more than 500 cells/mm3 CD4 count. This result was similar to those of studies done in Myanmar [Another important predictor of virological failure was baseline CD4 count in which patients with a CD4 count of  was incomplete and didn’t incorporated as a predictors and also didn’t studied behavioral characteristics like smoking, alcohol and psychosocial, emotional factors like stigma, depression and anxiety.3 and 201–350 cells/mm3) were independent predictors associated with increased risk of virological failure. Patients with this condition need to be carefully observed during the follow up time. Furthermore, since NVP based regimen is associated with virological failure. This is very important to facilitate shifting NVP based regimen to the recommended drug (DTG based).The incidence rate of virological failure was high among HIV patients on the first line ART at northwest Amhara referral hospitals, Northwest, Ethiopia. Non users of CPT, poor adherence, NVP based regimen and lower CD4count (<=200 cells/mm


In 2015, Zimbabwe introduced third-line antiretroviral therapy (ART) through four designated treatment centers; three government clinics in Harare and Bulawayo, and Newlands Clinic (NC), operated by a private voluntary organization in Harare. We describe characteristics of patients receiving third line ART and analyzed treatment outcomes in this national programme as of 31 December 2018.We described the population using proportions for categorical variables, and medians and interquartile ranges for continuous variables. Patients from NC, where data were more complete, were followed from the date of starting third-line ART until death, transfer, loss to follow up or 31 December 2018.A total of 209 patients had ever received third-line ART: 124 at NC and 85 from the three government clinics. HIV genotype results were available for 89 (72%) patients at NC and fourteen (16.5%) patients in the government clinics. Median duration of third line ART (years) in the government clinics was 2.3 (IQR:0.6–3.4), 1.3 (IQR: 0.7–1.7) and 1 (0.6–1.9). Of the 67 patients who received third line ART in the government clinics for at least six months, 53 (79%) had most recent viral load (VL) < 1000 copies/ml. Data on other treatment outcomes from government clinics were incomplete.From NC: a total of 109 (88%) patients were still in care, 13 (10.5%) had died and 2 (1.5%) were transferred. Median duration of third-line ART was 1.4 years (IQR: 0.6–2.8). Among the 111 NC patients who had received third-line ART for at least 6 months, 83 (75%) had a VL <50 copies/ml and 106 (95.5%) had a VL <1000 copies/ml.Our findings demonstrate that, with comprehensive care, patients failing second-line ART can achieve high rates of virological suppression on third-line regimens. There is need to decentralize the provision of third-line ART in Zimbabwe. More needs to be done to improve completeness of data in the government clinics. Zimbabwe has one of the highest burdens of HIV infection in the world with an adult prevalence of 14.2% and approximately 1.4 million people living with the infection [2016 Zimbabwe HIV Estimates]. As the national programme continues to grow, it is expected that the numbers of patients failing current first-line non-nucleoside reverse transcriptase inhibitor (NNRTI)-based antiretroviral therapy (ART) and needing second-line protease (PI)-inhibitor-based ART will increase . Third-lThe provision of third-line ART in resource limited sub-Saharan Africa (SSA) has many challenges. Access to routine VL measurements among patients on ART is low and this leads to late diagnosis of ART treatment failure . PreviouDocumentation of outcomes of third-line ART in RLS is scarce, yet very important to enable improvement of patient care. Due to the high costs of third-line regimens it is crucial to assess the effectiveness of these regimens to ensure optimal use of the limited resources. A few studies have reported encouraging early treatment outcomes for patients receiving third-line ART in RLS ,11–13. RWe set out to describe the cohort of patients receiving third-line ART in Zimbabwe as well as assess treatment outcomes. We describe the following: demographic characteristics of patients, proportion of patients who were still in care, died and those lost to follow up. We further report on the virological outcomes among patients who had access to routine VL monitoring at one of the main treatment centers. We have previously reported week 24 third-line treatment outcomes for patients receiving care at Newlands Clinic (NC) .The study was conducted at the four designated national third-line ART treatment centers. Three of the centers are government run opportunistic infections (OI) clinics and the fourth center, NC, is operated and funded by a private foundation. Three of these centers,  are in the capital city, Harare. The fourth center is in the second largest city, Bulawayo. All four clinics use standard national HIV treatment guidelines for the care of patients.Unlike the other three centers, NC has had an effective electronic monitoring system from its inception. Furthermore, the clinic provides HIV genotyping, six monthly routine viral load monitoring, and other necessary laboratory and radiology services at no cost to the patient. Details of the model of care are published elsewhere .Following the WHO recommendations, Zimbabwe adopted a public health approach to its HIV program using standardized treatment regimens. Since the inception of the HIV treatment program in 2004, there have been several guideline changes in when to start patients on ART and what regimens to use. Until beginning of April 2019, adult first line regimens included an NNRTI (Nevirapine or Efavirenz) plus two nucleoside / nucleotide reverse transcriptase inhibitors (N(t)RTIs). In April 2019, the preferred first-line regimen was changed to a dolutegravir-containing regimen as recommended by WHO. Second line regimens include a ritonavir boosted PI (Lopinavir or Atazanavir) and two N(t)RTIs. All patients received triple therapy for the management of HIV infection except earlier in the program (2004–2015) when single dose nevirapine or nevirapine plus zidovudine dual combination was used for prevention of mother to child transmission (PMTCT).Third-line ART was introduced in Zimbabwe in 2015 through four designated national third-line treatment centers. All the four centers are designated specialist HIV treatment clinics with access to laboratory and radiology support. Patients failing second-line ART are transferred to the nearest third-line center by their treating physicians. These patients are supposed to receive at least three months of enhanced adherence support before being offered HIVDR testing. National standard operating procedures recommend that patients must have confirmed good adherence to second-line ART to become eligible for HIVDR testing. The Stanford HIV Drug Resistance Database is used to assess resistance to ART. HIVDR testing is not available in the public sector and hence patients need to access testing in the private sector at a prohibitive cost. Second-line treatment failure is confirmed by the presence of any level of resistance to atazanavir and lopinavir. Third-line ART for adults and children is composed of boosted darunavir, dolutegravir / raltegravir  and sometimes two additional N(t)RTIs (based on the HIVDR test results).Monitoring for ART treatment success was previously predominantly done using clinical events and routine CD4 measurements. Routine VL measurements became available in the public sector in 2015. ART regimen failure is defined as at least two VL results greater than 1000 copies /ml with good adherence to treatment in a patient who has been treated for at least six months. A VL test is mandatory to confirm diagnosis of second-line ART failure.We conducted a cross-sectional analysis using data from all four national third-line treatment centers. We included all patients who initiated third-line therapy between 01 January 2015 and 31 December 2018. We defined third-line therapy to be any treatment regimen that included darunavir and raltegravir or dolutegravir after documented PI based second-line failure. A data collection form was used to abstract individual patient level data  from clinic files at Harare and Parirenyatwa Hospitals. Data from Bulawayo were accessed using the clinic’s cohort report. The data collected included demographic variables, ART treatment history, viral load and CD4 count results.We analyzed data from NC in greater detail than data from the three hospitals because of completeness. Patient data were obtained from the clinic’s electronic records. We described the population using proportions for categorical variables, medians and corresponding interquartile ranges (IQR) for continuous variables. Patients were followed from the date of third-line initiation until death, transfer, loss to follow up or data set closure, whichever occurred earlier.We assessed the proportion of patients receiving third-line ART who achieved virological suppression (VL<1000 copies/ml) after 24 and 48 weeks. Database was closed on 31 December 2018.This study was approved by the Medical Research Council of Zimbabwe, approval number: MRCZ/E/196. The ethics committee waived the requirement of informed consent as the study used routinely collected clinic data.A total of 209 patients have ever received third-line ART through the national program as of 31 December 2018. Bulawayo clinic (Mpilo). Forty-nine patients had ever been initiated on third-line ART in Bulawayo and only 8/49 (16%) were initiated based on HIVDR test results. The HIVDR test results were not available for review. The rest were initiated after assessment by clinicians and consultations with senior doctors at the hospital. Among the 35 patients with available data on treatment duration, median duration of third line ART was 2.3 years (IQR: 0.6–3.4). Patients received second-line ART for a shorter duration  compared to first-line ART (5.2 years). As of 31 December 2018, 7/49 (14%) had died, 3 were lost to follow up (LTFU) and 1 transferred out to South Africa.The total number of patients in care as at 31 December 2018 was 38, and 33 of them had received third-line ART for more than 6 months. Of the 33 on treatment for more than 6 months, 25/33 (76%) had a documented VL result during the last 12 months and 22/25 (88%) had a VL below 1000 copies/ml. Two patients had low level viremia of between 200 and 1000 copies/ml.Harare clinics. Thirty-six patients  were commenced on third-line ART from the two government treatment centers in Harare  as of 31 December 2018. Only five patients had available documented HIVDR results and all 5 patients had triple class  resistant HIV. The median duration of third-line ART was 1.3 years (IQR: 0.7–1.7) at Parirenyatwa hospital and 1 year (IQR: 0.6–1.9) at Harare Hospital. Thirty-four patients had been receiving routine VL monitoring, and for 31/34 (91%) patients their most recent VL was < 1000 copies/ml after at least six months of third-line ART.3 (IQR:27–245) and 78,845 copies/ml  respectively. Patients had received first- and second-line ART for a median duration of 4.5 years (IQR: 2.8–6.4) and 3.3 years (IQR: 2.2–5.4) respectively.Since inception of the program at NC, 124 patients  had started third-line ART. Only 9/124 (7.3%) patients commenced first-line ART at NC and the remaining 115/124 (92.7%) were transfers from other HIV treatment centers from across the nation for either first, second- or third-line ART. The median age at third-line commencement was 42.1 years (IQR: 27.6–48.5). The youngest and oldest ages at third-line commencement were 7.7 years and 71 years respectively. Median CD4 cell count and VL at third-line commencement were 116 cells/mmA total of 89 patients (72%) had documented HIV genotyping results and 65/89 (73%) had at least one major PI resistance associated mutation (RAM). The most prevalent PI RAM was V82A/L/M/C/F which was present in 42.7% of the 89 patients. The commonest NNRTI RAM was G190A/S/E which was prevalent in 32.6% of the 89 patients and the M184V mutation was the commonest NRTI RAM present in 91% of the 89 patients. As at 31 December 2018, 88% (109/124) of patients who commenced third line ART were still in care, 10.5% (13) had died and 1.5% (2) were transferred to other treatment centers. Median duration of third-line ART was 1.4 years (IQR: 0.6–2.8). Among the 111 patients who had received third-line ART for at least 6 months, 105 (95%) had a achieved a VL of < 1000 copies/ml  Among the 51 patients who had week 48 VL results, 48 (94%) patients had a VL < 1000 copies/ml. One patient, a 19-year-old adolescent girl, failed third-line ART and HIVDR testing confirmed high level resistance to all protease inhibitors, reverse transcriptase inhibitors and integrase inhibitors including dolutegravir. The patient was switched to a holding regimen of zidovudine, lamivudine and abacavir and details have been published as a case report .At the time of death, the 13 deceased patients  patients had received third-line ART for a median duration of 7.7 weeks (IQR: 3–23.2). The causes of death were as follows: 3 patients died of renal failure and 3 patients died of Non-Hodgkin’s Lymphoma. Other causes of death were (one patient per cause): liver failure, anemia, gastroenteritis, milliary tuberculosis, chronic pancreatitis , unknown, and deep vein thrombosis. At the time of death three patients had achieved virological suppression on third-line ART.We present the findings of the outcomes of the Zimbabwe national public sector third-line ART cohort. These findings are important because very few countries in sub-Saharan Africa provide third-line ART in public sector programs, hence there is scarcity of data on third-line ART in these settings. We show that there is poor access to HIVDR testing among patients failing second-line ART in the government led treatment centers. Among patients with access to HIVDR testing, there was a high prevalence of RAMs affecting PIs, NNRTIs and NRTI drug classes. Patients receiving third-line ART at NC have high virological suppression rates, with 94.5% being suppressed to below 1000 copies per milliliter. Despite the lack of complete patient level data, good treatment outcomes were achieved among patients receiving third-line in the public sector clinics.The poor access to HIVDR testing for patients failing PI-based second-line ART in the government clinics is of great concern. While Newlands Clinic had higher rates of HIVDR testing, rates were still not 100%, which indicates a more universal issue regarding access to HIVDR testing, rather than an issue that is isolated to the public sector.Previous studies of second-line ART outcomes in adults in SSA found that acquired resistance associated with protease inhibitors was infrequent and treatment failure was mainly due to poor adherence ,10,16–18Our data demonstrated the effectiveness of third-line ART in a programme where the predominant subtype was C. Our findings are in line with other studies from the region that demonstrated good virological suppression rates among patients receiving third-line ART ,12,23. FThe Zimbabwe national third-line ART program is facing several challenges. In our view the challenges are mainly because the program is centralized to the two largest cities in the country. This increases costs for third-line patients who are seen more frequently compared to those on first- and second-line treatment. HIVDR testing is not available in the public sector and hence patients need to access this test from the private sector at high costs unaffordable to most public health patients. Due to this prohibitive cost, management of patients is negatively affected as some end up being switched on clinical grounds without genotypic testing which overestimates those eligible and has cost implications to the program. Low VL testing coverage as reported by the national ART coordinator (44% at the end of 2018) is a challenge and impacts negatively on patient monitoring. We anticipate similar challenges in other national ART programs in SSA as countries scale up the provision of third-line ART. There is need to decentralize the provision of third-line ART to the provinces and districts to increase accessibility. Lessons can be learned from the South African third-line program were decentralization has been achieved through the aid of a well-coordinated national third-line committee .The main limitations of our study are the relatively small sample size, the short duration of follow up and the missing individual patient data from the three government linked clinics. The lack of complete data regarding the number of patients failing second-line ART makes it difficult to contextualize the need for third-line ART in Zimbabwe. However, the lack of complete data is an important finding that highlights the need for the national program to invest in better and more user-friendly electronic monitoring systems. Regardless of these limitations, we find these data useful in helping national programs in the region improve care of patients post second-line ART.Our findings highlight the need for national ART programs especially those in resource limited settings to strengthen access to HIVDR testing for patients failing second-line ART. HIVDR testing is essential for the identification of patients who have acquired clinically relevant HIV resistance associated mutations, furthermore, it helps to optimize third-line regimens. This study has also demonstrated that with comprehensive care, patients who have failed on PI based second-line ART can achieve high rates of virological suppression on third-line ART. As more patients are likely to fail second-line ART, national programs must ensure that third-line ART is available through decentralization of care. Healthcare workers must be trained and equipped to identify and manage patients failing second-line therapy early.S1 Dataset(DTA)Click here for additional data file.


Early initiation of combination antiretroviral therapy (ART) with long‐term viral suppression may lead to seronegativity in grown‐up children with perinatally acquired HIV (PHIV). This study aimed to determine the frequency and associated factors of seronegativity in Thai children, adolescents and young adults with PHIV.A cross‐sectional HIV serological study was performed in children, adolescents and young adults two years or older who were receiving ART with undetectable HIV‐RNA for at least one year from August 2018 to August 2019. Medical records were extracted for multivariate analysis of independent factors for seronegativity.p = 0.045; and shorter median (range) duration from ART initiation to viral suppression: 16.8 (7.2 to 42.0) versus 55.2 (6.0 to 214.8) months, p = 0.036. Multivariate analysis identified younger age at ART initiation  and shorter time to viral suppression after ART initiation  as independent factors associated with HIV seronegativity. Of the infants who initiated ART < 3 and between three and six months of age, 50% and 26.7% became seronegative respectively.Of 110 patients, 50 male, median (range) age was 18.4 (4.8 to 26.6) years, 8 (7.3%) were seronegative, and 1 (0.9 %) was inconclusive. The seronegative group had a younger median (range) age at ART initiation: 3.0 (1.0 to 12.0) versus 40.0 (2.0 to 207.0) months, HIV seronegativity was observed in children and adolescents with PHIV who initiated ART early in infancy and had rapid and sustained virological response. Awareness of this phenomenon will help avoid inappropriate treatment interruption on the basis of negative antibody testing. Several) counts . Given tThe new fourth‐generation HIV serological tests include the detection of p24 antigen allowing very early detection of HIV acquisition. Also, these newer assays are more sensitive which could result in a longer time to detect seroreversion in HIV‐exposed uninfected infants . Today, The aim of this study was to determine the frequency of seronegativity or seroreversion in children, adolescents and young adults with perinatally acquired HIV (PHIV) who have been receiving effective ART with undetectable HIV‐1 RNA  and the factors that potentially contribute to seronegativity or seroreversion.22.1A single‐centre cross‐sectional study was conducted at the paediatric HIV clinic, Department of Paediatrics, Siriraj Hospital, Mahidol University, Bangkok, Thailand, from August 2018 to August 2019. Children, adolescents and young adults with HIV since childhood, confirmed by two positive HIV DNA PCR assay in infancy, and/or high HIV RNA , and/or with AIDS defining condition(s); who were receiving ART and had viral suppression (VL < 50 copies/mL) for at least one year (based on at least two consecutive measurements), were invited to participate in the study. Only children perinatally infected with HIV were included. Perinatally acquired infection was based on history of maternal HIV‐infection and no other evidence of alternative modes of HIV acquisition. The primary objective was to determine the rate of negative HIV serology and the secondary objective was to identify factors associated with HIV seronegativity.2.2The study was reviewed and approved by the Siriraj Institutional Review Board, Faculty of Medicine Siriraj Hospital, Mahidol University, Certificate of approval SIRB Protocol No: 250/2561(EC2). After informed consent, and assent in children aged between seven and eighteen years, a single blood drawn was taken to test for HIV serology.Case record forms were filled using data extracted from medical records. Per standard of care, VL was checked every six months during the first year of treatment and then every 12 months thereafter if virologically suppressed. CD4 cell counts were monitored every six months. Data collected included: demographic data, medical history including prenatal and perinatal history, maternal ART use, age of ART initiation, CD4 cell counts at the time of diagnosis, CD4 cell counts on the day of enrolment (or within one year if result missing), nadir CD4 cell counts, duration of ART, time from ART initiation to first report of viral suppression, duration of viral suppression, history of viral blip, ART regimens received, and ART compliance.® Architect i2000, IL, USA; Roche® Cobas E601, IN, USA; Vidas® PC, Marcy l’Étoile, France). If the HIV serology test result was inconclusive, the test was repeated six months after the first test.The HIV serological test was performed at the hospital’s central lab using fourth‐generation test kits , PI (protease inhibitors) and INSTI (integrase strand transfer inhibitor) containing regimens.2.4p < 0.1 in the univariate model were included in the stepwise multivariate model. All analyses were carried out using Stata® software version 11.2 .The rate of HIV seropositivity and seronegativity were calculated. Associated factors were compared between the seropositive and seronegative groups using logistic regression. Variables with 3A total of 115 children were enrolled. Five children were excluded, one child due to a detectable viral load at enrolment and four children after a review of medical records found that their mode of HIV acquisition was sexual. Among 110 patients, 101 (91.8%) were HIV seropositive, eight (7.3%) were seronegative, and one (0.9%) was inconclusive (repeated). Details of the nine (8.2%) seronegative child are shown in Table p = 0.001), Table p = 0.045). The duration from ART initiation to viral suppression was significantly shorter in the seronegative children, 16.8 (7.2 to 42.0) months, compared to 55.2 (6.0 to 214.8) months in the seropositive children (p = 0.036). There were no differences in nadir CD4 cell counts, CD4 counts at enrolment or at time of diagnosis. No significant differences between groups were also observed for the duration of viral suppression before testing, presence of viral blip, premature birth, route of delivery, birth weight, maternal antiretroviral treatment before or during pregnancy, adherence to ART, duration of ART and ART regimens.At enrolment, the median (range) age in the seronegative children was lower compared to the seropositive children, 12.8 (4.8 to 17.2) versus 18.6 (6.7 to 26.6) years , p = 0.019, were independently associated with seronegativity. Among the six children who initiated ART before three months of age, 3/6 (50%) became seronegative. Seronegative rates were lower in children who initiated ART after three months: 4/15 (26.7%) children who initiated ART between three to six months of age were seronegative and 2/89 (2.2%) children who initiated ART after six months were seronegative  0.69 (0.49 to 0.98), Several recent reports have shown that seroreversion does occur in children living with HIV who initiate very early ART , 2, 3, 4Consistent with previous reports, the seronegative children in our cohort were younger, which is a reflection of the current clinical practice of earlier diagnosis, earlier ART initiation, and improved immunological and virological profiles following treatment initiation.A previous study found that approximately 40% of children who initiated ART before two and three months of age had negative HIV serology using a third‐generation HIV serology assay . FactorsEarly initiation of ART can lead to a rapid decline in viral replication and improvement in host immune responses, leading to attenuated or defective virus , 13. It Though not statistically significant, seronegative children did have higher nadir CD4 cell counts and CD4 cell counts at time of diagnosis, reflecting the earlier state of HIV infection at the time of ART initiation. This finding is in agreement with other studies that found a higher CD4 percentage prior to ART initiation was predictive of seronegativity .We used a fourth‐generation HIV serology test in our study. While the fourth‐generation tests have been proven to better at detecting very early HIV infection, a study has found decreased sensitivity of fourth‐generation tests in detecting fading antibody in adults who received effective ART during acute infection . HoweverSeronegativity may reflect the smaller size of CD4 cells infected with HIV and the overall viral reservoir . These iThis study is the first study reporting the frequency of seronegativity and the factors that potentially contribute to seronegativity in children, adolescents and young adults with PHIV in Asia. A seronegative test result can potentially eliminate stigmatization in some certain situations; however, seronegative may also lead to inappropriate treatment interruptions.There are several limitations to our study. This was a small single‐centred study and fourth‐generation assays were used to test HIV serology, therefore, the results may not reflect paediatric populations in other settings. Due to infrequent VL monitoring in routine practice in Thailand, the time to viral suppression was longer than that reported in other studies. Clearly, the exact duration from ART initiation to viral suppression was certainly shorter than the time to first test report of viral suppression; however, both seronegative and seropositive groups had similar frequencies of routine VL monitoring.4Seroreversion or seronegativity is not rare in children and adolescents with PHIV. Early initiation of ART in infancy and shorter time to viral suppression after initiation of ART may predict seronegativity in children and adolescents with PHIV who are receiving effective ART. Seronegativity or seroreversion does not equal to HIV cure. Withholding or discontinuing ART could lead to viral rebound and disease progression. On the other hand, seronegativity may help reduce stigmatization, particularly when HIV testing is performed for other non‐medical purposes. Further study is required to prove the association between seronegativity and post‐treatment virological control.All authors declare no conflict of interest.KL, KC and PW designed the research study. PW, KL, NK and BK established the cohort including subject finding, invitation and inform consent process. PW, KL, SR, OW and WP performed the study. PW, KL and AM analysed the data. PW, KL and KC wrote the primary draft of the manuscript. All authors contributed to subsequent drafts and approved the final manuscript.


Routine viral-load (VL) measurements along with enhanced adherence counselling (EAC) are recommended to achieve virological suppression among people living with HIV/AIDS (PLHA) on anti-retroviral therapy (ART). The Mumbai Districts AIDS Control Society along with Médecins Sans Frontières has provided routine VL measurements and EAC to PLHA on ART at King Edward Memorial (KEM) hospital, Mumbai since October-2016. This study aims to describe the initial VL results and impact of EAC on viral suppression and factors associated with initial viral non-suppression among patients with an initial detectable VL, in a cohort of patients tested between October-2016 and September-2018.This is a descriptive study of PLHA on ART who received VL testing and EAC during October-2016 to September-2018. Log-binomial regression was used to identify factors associated with a high VL.Among 3849 PLHA who underwent VL testing, 1603(42%) were female and median age was 42 years (IQR:35–48). Majority were referred for routine testing (3432(89%)) and clinical/immunological failure (233(6%)). Overall, 3402(88%) PLHA had suppressed VL at initial testing. Among 3432 tested for routine monitoring, 3141(92%) had VL suppressed. Of 291 with VL>1000c/ml, 253(87%) received EAC and after repeat VL, 70(28%) had VL<1000c/ml. Among 233 referred for clinical/immunological failure, 122(52%) had VL>1000c/ml and 109 have been switched to second-line ART.CD4 count<500 (aOR-5.0[95%CI 3.8–6.5]), on ART for<5 years (aOR-1.5[1.1–2.0]) and age<15 years (aOR-5.2[3.0–8.9]) were associated with an initial VL>1000c/ml. Factors associated with follow-up VL suppression included EAC (p<0.05) and being on second-line ART (p<0.05).Results from a routine VL program in public sector in India were encouraging and in line with UNAIDS 90-90-90 targets. Routine VL monitoring along with EAC resulted in early switch to alternative optimised regimens while also preventing unnecessary switches. Along with the vital scale up of routine VL monitoring, implementation of enhanced adherence strategies for patients with detectable viral load should be ensured. The HIV/AIDS epidemic continues with 36.9 million people living with HIV/AIDS (PLHA) globally in 2017 .To achieve this viral suppression, routine HIV viral load (VL) monitoring is necessary. The World Health Organization (WHO) recommends VL as the preferred approach to ART monitoring compared to clinical or immunological criteria . This isFrom a drug-resistance perspective, early detection of unsuppressed viral load and treatment failure through routine VL measurement can contribute to prevent accumulation of thymidine analogue mutations, which have the potential to reduce the effectiveness of second-line ART regimens –12. DeveAlong with identifying failures, routine VL has also been shown to help with adherence ,16–18. IRoutine VL testing in India is was launched in 2018 . The NatThis is a descriptive study using routinely collected programme data.Mumbai is a megacity in Maharashtra, India with a population of about 12.5 million people . The citThe ART centre at King Edward Memorial (KEM) hospital is a high burden centre providing services to about 4200 PLHA. The centre provides first- and second line ART. All regimens are designed as per national guidelines . The cenSince October 2016, MDACS along with MSF has been providing VL monitoring along with enhanced adherence counselling for PLHA on ART at KEM hospital. PLHA on ART for more than 6 months or those with signs of clinical failure were eligible for VL measurement. In case the VL was more than 1000 c/ml, then the PLHA was referred to a counsellor for enhanced adherence counselling spread over three months before VL was retested. It was recommended that at least one EAC session be conducted with the patient upon receiving a high viral load result and before retesting. The first session would be offered the same day the viral load result was received. The second session was offered one month later and before the 2nd viral load. More sessions could be offered, according to the patient’s needs.Enhanced adherence counselling followed the motivation-information-behaviour skill model. During the first session, patients with high viral load were invited during the counselling sessions to assess the barriers they face in adherence to their treatment. The counsellor helps the patient assess the information and motivation level of the patient and serves as a facilitator to fill the relevant gaps. In addition to providing information about HIV and viral load, providing emotional support is a very important component of EAC, as many patients report facing stigma, feeling depressed/or suffering from other mental health problems. Keeping all this in mind, an individualized adherence plan is developed which further enables the patient to take their treatment successfully. The second EAC session focuses on reviewing the plan with the patient and supporting them, where required. The end goal for EAC is to ensure that patients take their medication timely and in an effective manner.Post EAC, the VL was retested, three months after the first measurement. In case the VL result was still more than 1000c/ml, then the patient was referred to the District AIDS Clinical Expert Panel (DACEP) in KEM hospital. The panel would decide on the appropriate ART regimen based on national guidelines. Patients may be referred directly to DACEP in case of clinical/immunological failure. Patients referred for presumptive clinical/immunological failure also underwent viral load testing. However, their regimen could be changed by DACEP even before EAC and repeat VL testing, based on clinical criteria under the national guideline.For all patients with supressed VL, national guidelines now recommend routine VL monitoring, to be repeated once a year. Standard WHO definitions were used for defining clinical, immunological and virological failure  24]..24].VL were done using Xpert HIV-1 Viral Load (Cephid) platform.All PLHA tested for HIV-VL, irrespective of the reason for testing , between October 2016 and September 2018 were included in this study.Details of all patients who underwent VL testing were captured by a nurse in patient cards at the ART centre. The data then was entered into a Microsoft Excel 2010 database by a dedicated data encoder. Socio-demographic variables, ART regimen and CD4 counts were captured from patient cards. VL result was entered from lab reports. Dates of EAC were provided by the counsellor to the data encoder and were entered in a Microsoft Excel 2010 database. A cut-off date of 31 December 2018 was used for follow-up viral load and regimen switches.Data was imported into SPSS  for analysis. Categorical variables among the socio-demographic characteristics of the study participants were described using numbers and proportions, and continuous variables described using median and inter quartile range (IQR). Bivariate analysis was conducted to study the relationships between demographic and select variables with VL>1000c/ml. Those with a p-value of less than 0.2 were included in the multivariate model along with factors considered clinically and epidemiologically significant. Log binomial regression was used to identify factors associated with VL>1000c/ml. A p-value of 0.05 or below was considered statistically significant.th February 2018). This research also fulfilled the exemption criteria set by the Médecins Sans Frontières Ethics Review Board  for a posteriori analyses of routinely collected clinical data and thus did not require MSF ERB review. It was conducted with permission from Medical Director, Operational Centre Brussels, Médecins Sans Frontières. All data was annonymised before it was obtained for analysis.Approval was obtained from the Mumbai Districts AIDS Control Society for conducting this study  and 42% were female. Socio-demographic and clinical characteristics of the patients are described in Among all the viral load tests, 3432 (89%) were done for routine monitoring, 233 (6%) were done for presumptive clinical/immunological failure, while 184 (5%) were done for other reasons. The viral load testing cascade has been described in In bivariate analysis, age (p <0.001), time on the ART (p<0.001), CD4 count (p<0.001) and reason for referral (p<0.001) were significantly associated with high initial viral load. Sex (p = 0.179) was not seen to be significantly associated with initial VL.In multivariate analysis , age <15Among those referred for routine VL testing and who had a baseline VL of more than 1000c/ml, post EAC, 253 had a repeated VL testing after 3 months . Number The study shows a virological suppression of 88% in the KEM hospital cohort at the beginning of the intervention, while a suppression of 92% was observed among the subgroup of patients tested for routine monitoring. These are very encouraging findings and in line with the target of 90% virological suppression set by UNAIDS. Among patients tested for routine monitoring and who had VL>1000c/ml, 28% had a follow-up VL<1000c/ml and their ART regimen was maintained, while the rest were referred for switch to second-line ART regimen. Almost 77% of those referred were switched during the study period. Among those tested for clinical/immunological failure, almost half had VL<1000c/ml and their regimens were maintained, as per national guidelines, thus preventing unnecessary switches. The role of routine viral load in earlier identification of failures and, earlier switches to second-line ART and improved treatment outcomes, while at the same time preventing unnecessary switches has been reported by many studies around the world –19,25–31Multivariate analysis revealed that age less than 15 years was significantly associated with a higher VL. Many studies around the world have reported lower age as a risk factor for higher VL ,32,33. MAmong those with baseline VL>1000c/ml, follow-up viral suppression was significantly associated with EAC. Many studies around the world have proved effectiveness of EAC in helping patients adhere to their treatment and thus leading to a decreased VL. A study from Swaziland had reported 61% suppression post-EAC , while aThe strengths of this study include that it reports a large cohort of PLHA on ART at a high burden public ART centre. The participants in this study received access to routine VL before the release and implementation of national guidelines, and thus represent one of the earliest cohorts in the country to receive access to routine VL. While patients received VL testing, they were also adequately supported to improve their adherence by a trained counsellor. However, the follow-up period for the patients was short, which is a limitation of this study. Providing routine VL and EAC over a longer period should inform about the long term efficacy and effectiveness of EAC in the population.In conclusion, viral suppression among PLHA on ART was in line with the UNAIDS 90-90-90 targets in the study cohort. The use of routine viral load led to early identification of treatment failures and referrals to second- and third-line regimens, while also preventing unnecessary switches. Enhanced adherence counselling played a significant role in viral load suppression among those identified with a high initial viral load. While scaling up the essential access to viral load monitoring and ensuring rapid switch to second- and third-line ART regimens for failing patients, national HIV programmes should put efforts in the integration of adherence support strategies for the best results and adequate resource utilisation.


Tuberculosis (TB) is associated with systemic inflammation and anemia, which are aggravated in persons living with HIV (PLWH). Here, we characterized the dynamics of hemoglobin levels in PLWH coinfected with TB undergoing antitubercular therapy (ATT). We also examined the relationships between anemia and systemic inflammatory disturbance as well as the association between persistent anemia and unfavorable clinical outcomes. Data on several blood biochemical parameters and on blood cell counts were retrospectively analyzed in a cohort of 256 TB/HIV patients from Brazil during 180 days of ATT. Multidimensional statistical analyses were employed to profile systemic inflammation of patients stratified by anemia status  prior to treatment and to perform prediction of unfavorable outcomes, such as treatment failure, loss to follow up and death. We found that 101 (63.63%) of patients with anemia at pre-ATT persisted with such condition until day 180. Such individuals exhibited heightened degree of inflammatory perturbation (DIP), which in turn was inversely correlated with hemoglobin levels. Recovery from anemia was associated with increased pre-ATT albumin levels whereas persistent anemia was related to higher total protein levels in serum. Multivariable regression analysis revealed that lower baseline hemoglobin levels was the major determinant of the unfavorable outcomes. Our findings demonstrate that persistent anemia in PLWH during the course of ATT is closely related with chronic inflammatory perturbation. Early intervention to promote recovery from anemia may improve ATT outcomes. Tuberculosis (TB) remains as a leading cause of death from infection by a single pathogen and also among people living with human immunodeficiency virus (HIV) . PersonsAnemia is also a global public health problem and is diagnosed based on concentration of hemoglobin (Hb), specifically when it falls below established cut-off values; 12.0 g/dL for women and 13.5 g/dL for men . Several+ T-cell count and HIV viral load values  during the study follow up . This fiThe study was approved by the Institutional Review Board of the Instituto Nacional de Infectologia Evandro Chagas (INI) (CAAE: 71191417.8.0000.5262). Written informed consent was obtained from all participants, and all clinical investigations were conducted according to the principles expressed in the Declaration of Helsinki.Mycobacterium tuberculosis (Mtb) detection was positive in any sample collected . In cases without bacteriological confirmation, the diagnosis was established by suggestive imaging analysis, histopathological examination, together with clinical and epidemiological findings consistent with TB. For those who had a negative culture, a positive therapeutic test with TB drugs was considered, after excluding other opportunistic diseases for differential diagnosis. Patients that initiated TB treatment and were diagnosed later with non-tuberculous mycobacteria as well as those who showed rifampicin and isoniazid resistance (multidrug resistance) were excluded. Patients with bone, mammary, renal or ocular TB were excluded, since these clinical forms can have very subtle, asymptomatic presentations, making it difficult to be compared to the other forms.A prospective cohort has been followed at the Clinical Research Laboratory on Mycobacteria (LAPCLIN-TB) of the INI Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil, since 2000. The present study is a retrospective assessment performed between 2008 and 2016, with data obtained from this cohort. Data were collected from electronic medical records based on standardized information of a defined template used in each patient’s visit for the whole cohort. PLWH 18 years and older, with clinical signs and symptoms of TB were included. The diagnosis of TB was made when Anemia was defined according to World Health Organization (WHO) guideline criteria: Hb value < 13.5 g/dL for men and <12 g/dL for women.Tuberculosis was classified as pleuropulmonary (when restricted to the lungs and/or pleura), extra-pulmonary (when just one extra-pulmonary site was identified) or disseminated .Discharge due to cure, with or without etiologic confirmation of the diagnosis of TB, was considered a favorable outcome. Patients were defined as cured through clinical and/or radiologic improvement. Unfavorable outcome was defined as death, loss to follow up and treatment failure following the WHO guidelines. The cause of death was determined after thorough review of relevant clinical, microbiological and pathological data of each deceased patient.Highly active antiretroviral therapy was offered according to contemporary Brazilian National Guidelines that were periodically updated . The fir+ T-cell count and HIV VL among other variables. At baseline and in the follow up timepoints, patients underwent blood tests according to the INI’s clinical laboratory routine, with complete blood count and biochemical tests .Visits included in this study were done at baseline, 60 and 180 days after TB therapy initiation. HAART were initiated after TB treatment according to decision from each physician and following the Brazilian TB treatment Guidelines . Informan = 06) who abandoned TB treatment (ATT loss to follow up) had recorded data on Complete Blood Count (CBC) and biochemical assessments in blood after the date of the outcome established by the present study (non-compliance), because those patients had been following up at INI by other specialties outside the TB outpatient clinic.Some patients (U test (for two unmatched groups), the Wilcoxon matched pairs test (for two matched groups), the Kruskal–Wallis test (for more than 2 unmatched groups) or the Jonckheere-Terpstra permutation and asymptotic test (for time series) were used to compare continuous variables. The Spearman rank test was used to assess correlations between indicated markers, conditions and timepoints. A multivariable logistic regression analysis model was used to identify independent determinants of persistent anemia and unfavorable treatment outcomes. The results were presented in the form of adjusted odds ratio (aOR) and 95% confidence intervals (CI).Three timepoints were considered: baseline, day 60 (D60) and day 180 (D180) of ATT. To perform baseline analysis, were used data from 256 patients. Due to lack of data in the subsequent timepoints (6.6% were missing data at D60 and 25.4% at D180), only 191 (74.6%) patients with complete laboratory data at all timepoints were considered for longitudinal analysis. Descriptive statistics was used to present data, use the median values with interquartile ranges (IQR) as measures of central tendency and dispersion, respectively, for continuous variables. Categorical variables were described using frequency (no.) and proportions (%). The Pearson chi-square test was used to compare categorical variables between study groups. The Mann–Whitney The degree of inflammatory perturbation (DIP) is based molecular degree of perturbation (MDP) , an adapHierarchical cluster analysis (Ward’s method) using values of z-score normalized data was employed to depict the overall expression profile of indicated markers in the study subgroups. In this analysis, the dendrograms represent the Euclidean distance (inferring degree of similarity).p-values below 0.05 after adjustment for multiple comparisons (Holm-Bonferroni) were considered statistically significant. The statistical analyses. were performed using mdp (version 1.8.0), rstatix (version 0.4.0), stats (version 3.6.2), and caret (version. 6.0.86) R packages.All analyses were pre-specified. Differences with + T-cell counts and higher HIV viral loads than those non-anemic at the study baseline  were anemic and 37 (14.4%) were not anemic at baseline. The vast majority of study participants were male (71%), and the median age was 37 years old (IQR: 31–46). Individuals with anemia at baseline were similar to non-anemic participants with regard to, age, sex, overall frequency of comorbidities and life-habits . Anemic baseline . Frequen+ T-cell counts increased in both study groups, but values in the group of participants who were anemic at the study baseline persisted substantially lower than those measured in non-anemic patients . Thus, 191 patients were further considered, out of whom 161 (84.3%) were anemic and 30 (15.7%) were not anemic at baseline. The median TB treatment period was 189 days for both groups. At day 180 of treatment, CD4The overall differences in cell counts and values of biochemical parameters measured at pre-ATT for anemic and non-anemic TB patients are described in In regard to biochemical parameters, statistically significant differences were found in levels of ALT, AST and GGT, which were all higher in anemic patients at baseline, whereas the levels of albumin were lower . Additior = −0.27; p < 0.001) and levels of ALT , AST , GGT , Alkaline Phosphatase , and Urea . Furthermore, frequency of lymphocytes  and monocytes , as well as levels of albumin  were increased proportionally to elevations in Hb levels , whereas such levels did not substantially change in those who were not anemic at baseline. Curiously, 11 (36.6%) patients who were non-anemic at baseline developed anemia at day 60, from whom 8 (26.6% of the non-anemic group) were also anemic at day 180 of ATT   individuals recovered from anemia at day 60 (early recovery), 36 (22.36%) recovered only by day 180 (late recovery), and 5 (3.1%) recovered at day 60 but were once again anemic at day 180 (transient recovery). The characteristics of these subpopulations are shown in the  < 0.05) .r = −0.74; p < 0.001) and at day 180 , highlighting that the degree of anemia and activation of inflammation are concurrent processes.Given that the majority of anemic patients persisted with anemia during the time of ATT regardless of the gradual increase in hemoglobin levels, we tested whether such condition was related to a chronic and unresolved inflammatory disturbance. To do so, we employed a mathematical maneuver named Molecular Degree of Perturbation (MDP), which has been used by our group and others to estimate the overall degree of inflammation and/or immune activation –20. In tAdditional analyses demonstrated that, as expected, patients who had an early recovery from anemia exhibited significantly higher baseline values for erythrocytes, Hb, hematocrit, neutrophils  and albup = 0.04) whereas increases in total proteins were directly associated with persistent anemia   are able to predict recovery from anemia. Results demonstrated that increases in concentrations of albumin were directly associated with recovery from anemia  . Similarn = 3; death attributed to HIV: n = 2; ATT failure: n = 1; ATT loss to follow up abandonment: n = 12). The majority of the cases of unfavorable outcomes was composed by individuals who experienced persistent anemia  (p < 0.001) but did substantially change in those who has unfavorable outcomes  developed unfavorable outcomes  . In factoutcomes . A hieraoutcomes  and biocoutcomes  demonstrp = 0.052), albumin (p = 0.035), uric acid (p = 0.001), urea (p = 0.006), and creatinine (p = 0.008) than those who were further successfully treated (p = 0.04) independent of the other factors . The patients/participants provided their written informed consent to participate in this study.FD, CS, FS’A, and VR contributed to conception and design of the study. FD also collected the data and organized the database. MA-P and MA performed the statistical analysis and data visualization. FD, MA-P, and BA wrote the first draft of the manuscript. VR and BA supervised the project execution. All authors contributed to the article and approved the submitted version.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.


Etravirine (ETR) is approved as a component of second or third-line antiretroviral treatment (ART) for children living with HIV. We assessed the outcomes of ETR-based ART in children in routine care in Europe and Thailand.Data on children aged <18 years at ETR start were pooled from 17 observational cohorts. Characteristics at ETR start, immunological and virological outcomes at 12 months, discontinuations, adverse events (AEs) and serious adverse events (SAEs) were described. Follow-up was censored at ETR discontinuation, death or last visit.3, 70% had exposure to ≥3 ART classes and 20% had viral load (VL) <50 copies/mL. 95% received ETR in combination with ≥1 potent drug class, mostly protease inhibitor-based regimens. Median time on ETR was 24  months. Amongst those on ETR at 12 months (n=141), 69% had VL<50 copies/mL. Median CD4 increase since ETR start (n=83) was 147  cells/mm3. Overall, 81 (46%) discontinued ETR by last follow-up. Median time to discontinuation was 23  months. Common reasons for discontinuation were treatment simplification (19%), treatment failure (16%) and toxicity (12%). Eight children (5%) had AEs causally associated with ETR, all dermatological/hypersensitivity reactions. Two were SAEs, both Stevens–Johnson Syndrome in children on regimens containing ETR and darunavir and were causally related to either drugs; both resolved following ART discontinuation.177 children ever received ETR. At ETR start, median [IQR] age was 15  years, CD4 count 480  cells/mmChildren receiving ETR were predominantly highly treatment-experienced, over two-thirds were virally suppressed at 12 months. Second- and third-line antiretroviral treatments (ART) are needed for children and adolescents living with HIV who experience treatment failure and have limited ART options, due to multidrug resistance or drug intolerance –3. EtravClinical outcome data for ETR in treatment-experienced children and adolescents are limited to single-arm trials and observational studies with <50 patients. These reported 33%–78% viral suppression <50 copies/mL at 48 weeks –14. Commwww.hicdep.org) and included demographics, clinical and ART history, CD4, viral load (VL), biochemistry results and adverse events (AEs).Individual patient data were pooled from 17 cohorts from 11 European countries and Thailand, for children/adolescents starting ETR aged <18 years, with followed-up data until 31/01/2018. Individual cohorts gained local ethics approval. Data were collected using the HIV Cohort Data Exchange Protocol  licenced; (2) unlicensed; (3) off-label, ART inexperienced (no prior protease inhibitor (PI) or NNRTI exposure); 4) off-label, age < 6 years; and (5) missing weight/dose. Treatment-experienced children ≥6 years, receiving an ETR dose within ±20% of European dose recommendations for weight at ETR start (twice daily ETR dosing: 100 mg (≥16 to <20 kg), 125 mg (≥20 to <25 kg), 150 mg (≥25 to <30 kg) and 200 mg (≥30 kg)) were as-signed to the ‘licenced’ group  age was 15  years and 99% were treatment-experienced . Median n=141), 69% (85/124 with data) had VL<50 copies/mL and 80% (99/124) <400 copies/mL, median CD4 (n=103) was 658  cells/mm3 and median CD4 change from ETR start (n=83) was 147  cells/mm3 (p<0.001).Median follow-up after ETR initiation was 24  months. Amongst patients on ETR at 12 months (DAIDS grade ≥3 rates of laboratory AEs for the licenced dose group are shown in Amongst 138 (78%) patients with clinical data, eight clinical AEs (in eight patients), were reported as possibly, probably or definitely causally related to ETR. All were cutaneous/hypersensitivity reactions occurring within 1 month of ETR start in the licenced group. Two were serious, both Stevens–Johnson Syndrome (SJS), of which one was considered life-threatening. Both patients were on regimens containing ETR and darunavir and were reported as causally related to either drugs. Both events resolved after temporary discontinuation of all ART. The remaining AEs were five rash/erythema and one generalised hypersensitivity/urticaria reaction. Of these, five events resolved (two patients stopped ETR due to the event) and one had unknown resolution status. Amongst patients with clinical data, 5.8%  reported skin/hypersensitivity reactions whilst on ETR, of which two  were SJS, occurring at a rate of 0.5/100 person-years .Three patients died, two whilst on ETR and one within 3 weeks of stopping. Two were AIDS-associated events and one was an HIV-related metastatic adenocarcinoma. None were considered ETR-related.By last follow-up 81 patients (46%) discontinued ETR. Median [IQR] time to discontinuation was 23  months, the majority (69%) discontinuing at >12 months. Common reasons for discontinuation were: treatment simplification (19%), treatment failure (16%), toxicity (12%), physician’s decision (10%) and unknown reason (21%) . Of thosn=101) [3. A Spanish observational cohort (N=23) of treatment-experienced children/adolescents reported similar findings; 78% had VL<50 copies/mL at a median of 48 weeks [The World Health Organization has highlighted the need for more data on outcomes on paediatric second and third-line ART . This con=101) . At 48 w48 weeks .Approximately half of the participants in our study discontinued ETR by end of follow-up. The most common reason was treatment simplification reflecting availability of new drugs, including integrase inhibitors .DAIDS grade ≥3 laboratory events occurred infrequently, and clinical AEs were uncommon. Two 1.4%) patients experienced Stevens–Johnson Syndrome, a severe and potentially life-threating hypersensitive reaction. Both were taking darunavir concomitantly and the events were reported as causally related to either/both drugs. Both events resolved after temporary discontinuation of ART. Previous studies have reported associations between both ETR and darunavir and SJS/other cutaneous hypersensitivity reactions ,19. The % patientThis study has some limitations. The median duration of follow-up on ETR was relatively short at ∼2 years and we did not have data on HIV drug resistance to assess how this may affect treatment response. However, our study includes data from cohorts across Europe and Thailand and contributes important information on outcomes in children/adolescents on advanced therapy. ETR is now approved for children aged ≥2 years, although there remains scarce data in this younger age group and further monitoring is needed. Paediatric ETR use has some disadvantages including twice-daily dosing, lack of a fixed-dose combination formulation and multiple interactions with other anti-retrovirals ,8. Nonet


Background: Mitochondrial genome has been used across multiple fields in research, diagnosis, and toxicogenomics. Several compounds damage mitochondrial DNA (mtDNA), including biological and therapeutic agents like the human immunodeficiency virus (HIV) but also its antiretroviral treatment, leading to adverse clinical manifestations. HIV-infected and treated patients may show impaired mitochondrial and metabolic profile, but specific contribution of viral or treatment toxicity remains elusive. The evaluation of HIV consequences without treatment interference has been performed in naïve (non-treated) patients, but assessment of treatment toxicity without viral interference is usually restricted to in vitro assays.Objective: The objective of the present study is to determine whether antiretroviral treatment without HIV interference can lead to mtDNA disturbances. We studied clinical, mitochondrial, and metabolic toxicity in non-infected healthy patients who received HIV post-exposure prophylaxis (PEP) to prevent further infection. We assessed two different PEP regimens according to their composition to ascertain if they were the cause of tolerability issues and derived toxicity.Methods: We analyzed reasons for PEP discontinuation and main secondary effects of treatment withdrawal, mtDNA content from peripheral blood mononuclear cells and metabolic profile, before and after 28 days of PEP, in 23 patients classified depending on PEP composition: one protease inhibitor (PI) plus Zidovudine/Lamivudine  or PI plus Tenofovir/Emtricitabine .Results: Zidovudine-containing-regimens showed an increased risk for drug discontinuation  due to adverse effects of medication related to gastrointestinal complications. In the absence of metabolic disturbances, 4-week PEP containing PI plus AZT + 3TC led to higher mitochondrial toxicity (−17.9 ± 25.8 decrease in mtDNA/nDNA levels) than PI plus TDF + FTC . MtDNA changes showed a significant and negative correlation with baseline alanine transaminase levels (p < 0.05), suggesting that a proper hepatic function may protect from antiretroviral toxicity.Conclusions: In absence of HIV infection, preventive short antiretroviral treatment can cause secondary effects responsible for treatment discontinuation and subclinical mitochondrial damage, especially pyrimidine analogs such as AZT, which still rank as the alternative option and first choice in certain cohorts for PEP. Forthcoming efforts should be focused on launching new strategies with safer clinical and mitotoxic profile. Currently recommended PEP regimens show less mitochondrial toxicity than the old ones containing pyrimidine analogs such as AZT and 3TC. However, AZT is still used in certain clinical and geographical settings.- AZT-containing regimens showed a higher risk of drug discontinuation.- Reduction of mitochondrial toxicity of PEP regimens may improve tolerability and toxicity issues.- Current and forthcoming efforts to elaborate global policy guidelines should consider mitochondrial toxicity of PEP as an important issue for compliance and patient care.in vivo.- PEP-treated patients convey an outstanding opportunity to assess antiretrovirals toxicity - mtDNA is confirmed as the gold standard for mitochondrial toxicogenomics in antiretroviral management.Mitochondria are the energy and heat power plants of the cell  and its antiretroviral treatment (ART) , the prototype NRTI class drug, is a pyrimidine analog linked to long-term secondary effects. Included in this group, and combined with AZT is Lamivudine (3TC), with lesser harmful effects  emerged , which have also been associated with metabolic alterations  development, major concerns have been ascribed to its mitochondrial and metabolic toxicity, especially primary ART  or PI plus TDF + FTC (n = 14).We performed a multicentric observational study in HIV-1-exposed and uninfected patients to evaluate mitochondrial and metabolic disturbances before and after a 28-day PEP treatment comparing two different regimens: PI plus AZT + 3TC  and the Hospital of Granollers .All participants initiated their PEP regimen within 48 h after a non-occupational sexual exposure to HIV and provided informed consent to be enrolled in the study, which was approved by the Ethical Committee of our institutions.per-protocol analysis).The inclusion criteria were adults over 18 years old with no clinical evidence of primary mitochondrial disease, or concomitant treatment with potential toxic drugs for mitochondria  and the full completion of the 28-day treatment , PEP regimen, and treatment intervention were gathered during the study. Similarly, data regarding tolerability, adherence, and reasons for PEP discontinuation were collected in the follow-up on account of clinical interviews.Glucose, lipid, and hepatic profile data included information about blood glucose (measured using the glucose-oxidase method), triglycerides, and total cholesterol (by enzymatic approaches), as well as aspartate and alanine aminotransferase hepatic enzymes (AST and ALT), which were quantified by atomic absorption spectrophotometry .Fasting samples of 20 ml of venous blood were collected in Vacutainer™ EDTA tubes. For each subject of the study (and for both groups), two sets of samples were obtained, one just after HIV exposure and before PEP, and another after a 28-day course of treatment. Blood was first centrifuged at room temperature for 15 min at 1,500g to reduce platelet contamination through plasma removal. Peripheral blood mononuclear cells (PBMCs) were immediately isolated by means of Ficoll density gradient centrifugation procedure   in a 96-well plate and results were expressed in relative units as the ratio between mtDNA to nuclear DNA (mt12SrRNA/nRNaseP), as previously validated  or in percentage of change ± SEM with respect to the baseline measurement. Longitudinal differences between both study time points (in each treatment arm) and cross-sectional differences between treatment intervention groups (PI plus AZT + 3TC vs. PI plus TDF + FTC) were determined with the non-parametric Kolmogorov–Smirnov test for paired and independent measures, respectively. Correlation analysis between all quantitative parameters was determined using the non-parametric Spearman test. Statistical analysis was performed using the Statistical Package for Social Sciences version 23.0 . Statistical significance was set at a As previously stated, from the initial 30 participants of the study, 7 discontinued PEP before 4 weeks due to gastrointestinal secondary effects including bloating, diarrhea, nausea, and/or vomiting. Consequently, longitudinal mitochondrial and metabolic toxicity profile could not be assessed in these 7 patients due to lack of follow-up. From these patients, 6 were treated with PI plus either AZT + 3TC and 1 with a PI plus TDF + FTC .n = 23) remained uninfected and blood analysis for HIV antibodies were all confirmed as negative.After 6 months of HIV exposure, all subjects that continued the study  regardless of the PEP regimen  have been postulated as the etiopathological basis of several side effects in HIV-infected and chronically treated patients , serious complications were raised: the low compliance, the appearance of several secondary or toxic effects, and the little commitment of some patients led to further discontinuation of AZT-containing regimens, herein demonstrated. As previous reported, the main secondary effects for both of these regimens that led to discontinuation were gastrointestinal symptoms , it was difficult to gather all the participants for the study in a short period of time. In fact, we needed to perform a multicenter study to include the minimum sample size required to reach our aim. However, we cannot discard a type II error due to the small sample size of the cohorts herein tested, which may be bypassed in further studies with bigger sample sizes and controlled designs. Additionally, the fact that male patients exclusively composed our sample may be considered as the second limitation of the study. However, in current clinical settings, this characteristic may reflect the differences in prevalence of HIV infection according to gender in general population and eradicates potential gender interference in observed results. Regarding the source of sample, we acknowledge that mitochondrial parameters may be exacerbated in more energy-dependent tissues than PBMCs. Likewise, we are aware that assessing specific PBMC composition would be of interest to assess potential interference of cell populations in observed findings, as well as preventing platelet contamination , where toxicity of PEP regimens should be considered and AZT should be discouraged.in vivo and mtDNA is confirmed as the gold standard for mitochondrial toxicogenomics in antiretroviral management.PEP-treated patients convey an outstanding opportunity to assess antiretroviral toxicity The datasets generated for this study are available on request to the corresponding author.The studies involving human participants were reviewed and approved by Ethical Committee of Hospital Clinic of Barcelona. The patients/participants provided their written informed consent to participate in this study.We also acknowledge the contribution of each author: GG, along with EM, FC, EP, and ÒM, who conceived the study and supervised the data collection and analysis. JR and AL participated in patient inclusion and supervised the clinical aspects of this study, in collaboration with JM and EM. Each author participated in the recruitment of epidemiological, clinical, and metabolic data of patients. GG, MB, MG-M, and IG-C managed the collection of samples and isolation of cells. EL, JC-S, DJ, CM, and MB were responsible for experimental analysis of mitochondrial DNA content, under the supervision of GG. ET provided technical assistance for reagent preparation. A database was also created by MB and SB to collect all the clinical and experimental parameters to perform the statistical analysis of the data, under the supervision of GG. All authors participated in drafting and critical revision of the manuscript, especially MB, SB, EM, and GG.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.