Antiretroviral therapy (ART) allows suppressed viremia to reach less than 50 copies/mL in most treated persons living with HIV (PLWH). However, the existence of PLWH that show events of persistent low-level viremia (pLLV) between 50 and 1000 copies/mL and with different virological consequences have been observed. PLLV has been associated with higher virological failure (VF), viral genotype resistance, adherence difficulties and AIDS events. Moreover, some reports show that pLLV status can lead to residual immune activation and inflammation, with an increased risk of immunovirological failure and a pro-inflammatory cytokine level which can lead to a higher occurrence of non-AIDS defining events (NADEs) and other adverse clinical outcomes. Until now, however, published data have shown controversial results that hinder understanding of the true cause(s) and origin(s) of this phenomenon. Molecular mechanisms related to viral reservoir size and clonal expansion have been suggested as the possible origin of pLLV. This review aims to assess recent findings to provide a global view of the role of pLLV in PLWH and the impact this status may cause on the clinical progression of these patients. Human Immunodeficiency virus (HIV) viremia is related to increased AIDS events and death . NonetheTransient episodes of detectable viremia (blips) have been described in around 1/5 of HIV-infected patients undergoing suppressive treatment, whereas 4–10% of PLWH show persistent events of low-level viremia (≈50–500 copies/mL) . ClinicaToday, the role of pLLV in PLWH remains unclear and a lot of unresolved questions complicate management of these individuals. The aim of this paper is to review the possible causes and origins of pLLV in PLWH and the impact that pLLV may have on the clinical progression of these patients according to recent findings.The scientific community has reached no definition regarding pLLV patients. In general, treated patients with HIV persistently presenting viremia from 50 to 1000 copies/ml have been considered pLLV patients . Howevervirological failure (VF) has been previously observed  due to one or more mutations in the genetic structure of HIV that prevents the blocking of virus replication by a specific drug or a combination of drugs ,44. The By contrast, other studies have not shown any association between pLLV and viral resistance or inadequate drug concentrations ,49. Pereintensification of ARV is not associated with a reduction in the incidence of pLLV in PWLH. Two studies that intensify ART with Raltegravir in patients with pLLV found no benefit when compared to control patients  [The egravir) ,52.switch to a second-line ART based on PI may improve virological suppression (<50cp/mL) in a high percentage of pLLV (from 55% to 83.3%) [By contrast, the optimization of ART related with a o 83.3%) ,53–56 alo 83.3%) .Given that most published data belong to the pre-integrase inhibitors (INIs) era, the potential role of INIs as a treatment backbone remains unclear in the clinical management of pLLV. According to Taramasso et al. (2020), INI-based therapies could lead to lower pLLV over time and therefore to the achievement of more effective virological control . More stmortality and AIDS events also remains uncertain  entails the movement of commensal microbial products from intestinal lumen into circulation in the absence of bacteremia. In 2006, this mechanism was described for the first time in PWLH . HIV infWhile AIDS events are no longer the principal problem in treated PLWH, new complications called Non-AIDs-Defining Events (NADEs) have become the main cause of morbi-mortality . NADEs aThe main studies on NADEs have been related to cardiovascular diseases, where increases in C-reactive protein (CRP) and D-dimer biomarkers have been found in PLWH compared to healthy controls ,110. HowOverall, no consensus has been reached as to the clinical consequences of pLLV. While some studies claim that persistent LLV increases the risk of future virological failure, others have not even found a significant impact on AIDS events and mortality. While the worst impacts may be associated with VL above 200 cp/ml, it is less clear if there is any negative impact on virological failure and morbi-mortality when LLV is between 50 and 200 copies. Different methodologies and a lack of standardization in the number and characteristics of populations studied make it difficult to compare results . FurtherMost studies published suggest that factors such as ART adherence difficulties and viral genotype resistance could be the main cause of pLLV in HIV patients, as we have previously reviewed ,40,50. HThe HIV viral reservoir is the main barrier to curing HIV infection [nfection . HIV resnfection ,121–124.nfection , the infnfection . Indeed,nfection .Despite the unknown origins of low-level viremia, in 2015, Samarti et al.  proposedMore recently, Jacobs et al. (2019) reviewed the issue and found a generally direct association between HIV-DNA levels and persistent viremia, despite the differences observed regarding techniques used and findings . This coClonal expansion also complicates HIV clearance and contributes to the maintenance of reservoirs [servoirs , probablservoirs . This reservoirs ,138,139 servoirs . This hyservoirs . This woservoirs ,142. Accservoirs ,144. Indservoirs .Determining the role of the viral reservoir and the mechanism of clonal expansion in PLWH with pLLV remains crucial for the design of therapies that achieve HIV elimination (54).Further knowledge of the continuous presence of the virus in treated PLWH is needed to design treatments that achieve a cure for HIV infection. Reported data regarding the possible causes and origins of pLLV and its impact on clinical progression are rather discordant. While some studies point to a higher risk of developing virological failure and different AIDS/mortality events related to pLLV status, others have not made such findings. Moreover, the emergence of viral resistance in pLLV patients and its direct association with ART adherence have been only partially observed .Table 4.On the other hand, patients with pLLV seem to have an elevated risk of immunovirological failure and increased levels of proinflammatory cytokines, and there seems to be a general consensus as to the association of pLLV with persistent immune system activation. Indeed, it has been speculated that the phenomenon of pLLV, which leads to residual immune activation and inflammation, may influence the morbidity and mortality of NADEs.Related to the origin of this phenomenon, the clonal expansion in HIV-infected cells and its impact on the maintenance of the viral reservoir have been previously described and may be related to the appearance of pLLV in treated HIV patients . A lack


Anaemia is common in patients with retroviral disease. New or worsening anaemia after initiation of antiretroviral (ARV) treatment has a broad differential diagnosis.We describe six patients who developed transfusion-dependent anaemia on first-line therapy  and, by exclusion, implicated emtricitabine in the aetiology of the anaemia.We conducted a retrospective chart review of patients seen at the Infectious Diseases specialist clinic at King Edward VIII Hospital in KwaZulu-Natal between 2014 and 2016. We focused on patients with isolated, refractory and transfusion-dependent anaemia occurring after initiation of ARVs, in whom bone marrow biopsies were consistent with pure red cell aplasia (PRCA) without an identifiable secondary cause.3, respectively. Before presenting with symptomatic anaemia, the duration on emtricitabine was 4.5 (2–8) months. At presentation, all patients had an HIV viral load of < 1000 copies/mL and a CD4 cell count of 314 (213–389) cells/mm3. The median time to recovery following the discontinuation of emtricitabine was 2 (1–4) months. After a median of 12 months, all patients were successfully rechallenged with emtricitabine and remained well for a follow-up period of 24 (7–36) months.All the patients were female, with a median (range) age and baseline CD4 cell count of 42.5 (23–61) years and 237 (83–329) cells/mmThis study provides strong circumstantial evidence that emtricitabine plays an important role in the pathogenesis of reversible PRCA. The mechanisms through which emtricitabine induces PRCA remain unclear and require further study. Anaemia is common in persons living with HIV (PLWH). New onset or worsening anaemia on initiation of antiretroviral treatment (ART) has a wide differential diagnosis. Toxicity from antiretroviral drugs such as the nucleoside analogues zidovudine (AZT) and lamivudine (3TC) must be considered.5 Initially, 3TC was thought to potentiate the haematological toxicity of AZT, following reports of two patients who presented with profound anaemia while on both drugs.1 Later, 3TC was shown to cause anaemia independently of AZT.2In 1998, several case reports implicated 3TC as a cause of pure red cell aplasia (PRCA).7 They share similar toxicities, are active against the hepatitis B virus and select the same resistance mutations. Emtricitabine, however, has a longer half-life, a higher binding affinity for the reverse transcriptase enzyme and demonstrates a greater synergy with tenofovir in inhibiting HIV replication.8 The most common mechanism of nucleoside reverse transcriptase inhibitor (NRTI) toxicity is inhibition of the human mitochondrial DNA polymerase γ enzyme, which leads to mitochondrial dysfunction. The structural differences between FTC and 3TC reduce the affinity of FTC for the γ polymerase enzyme 100-fold.9 This likely explains the reduced toxicity of FTC compared to 3TC.9There are several similarities between 3TC and emtricitabine (FTC). Both are cytosine deoxyribonucleoside analogues that target the HIV reverse transcriptase enzyme by acting as a chain terminator of viral DNA synthesis, with the only difference in their chemical structure being a fluorine atom bound to carbon 5 of the FTC pyrimidine ring .6,7 TheyBecause of the striking similarities between 3TC and FTC and the development of severe anaemia soon after ART initiation, in the absence of another cause, we suspected that FTC might be responsible for the PRCA. We present observational data from six patients with probable FTC-induced transfusion-dependent anaemia following the initiation of a fixed-dose combination of tenofovir, FTC and efavirenz.10 The department has a long-standing interest in PLWH with PRCA secondary to parvovirus B19 infection. As a result, patients with unexplained, transfusion-dependent anaemia are actively recruited for further evaluation.This study was based at the Infectious Diseases specialist clinic at King Edward VIII Hospital, KwaZulu-Natal. We conducted a retrospective chart review of all patients presenting to the clinic between 2014 and 2016 with a haemoglobin (Hb) level of < 7 g/dL following the initiation of first-line ART.Patients were included if they were aged > 18 years, infected with HIV, on an FTC-containing regimen and had isolated anaemia with a bone marrow examination consistent with PRCA, without an alternate explanation. There had to be a temporal relationship between anaemia and the use of FTC with at least 3 months’ follow-up at the clinic.All patients underwent comprehensive investigations to determine the cause of their anaemia, including iron studies, folate and vitamin B12 levels, viral studies, a connective tissue screen and an examination of the bone marrow. The information captured included the baseline and most recent CD4 cell counts, HIV viral load, previous history of ART, comorbidities and concomitant medication use, including herbal medication. Secondary causes of red cell aplasia were excluded clinically and by directed laboratory investigations. These included pregnancy, thymoma, lymphoma, systemic lupus erythematosus, rheumatoid arthritis, juvenile chronic arthritis, multiple endocrine neoplasms and drugs such as AZT and 3TC. Infection with the following viruses was excluded: parvovirus B19, Epstein-Barr virus, human T-cell lymphotropic virus 1, and hepatitis A, B and C. Bone marrow aspirate and trephine biopsies were performed on all patients.Patients were considered for a rechallenge with FTC once they became transfusion independent. For the rechallenge, the following criteria had to be met:Stable normal Hb for at least 3 monthsFully suppressed HIV viral load for at least 3 monthsInformed consent from the patient.This study was approved by the University of KwaZulu-Natal Biomedical Research Ethics Committee . This was a retrospective chart review. Because of the study design, patients’ consent was not required.3. The median Hb at the time of ART initiation was 9 g/dL  age of 43 (35–61) and CD4 cell count of 237 (83–329) cells/mms 9 g/dL . All patAt the time of referral to investigate the anaemia, all patients had an HIV viral load of < 1000 copies/mL. Bone marrow biopsies on all patients revealed a reduction in the erythroid series, with normal to increased myeloid series. All histopathology findings were consistent with PRCA. Bone marrow culture for mycobacteria was negative for all patients.All patients were switched from a fixed drug combination containing FTC to single agents consisting of abacavir, tenofovir and efavirenz. Following this change, all patients made a complete recovery. The median time to recovery of the Hb to 10 g/dL without blood transfusions was 2 months. Four patients did not require any further transfusions after the switch. Patient 4 required a once-off transfusion of three units of packed red blood cells within 2 weeks of the switch, and Patient 5 required a total of seven units of packed red blood cells over two admissions within the first 3 months of FTC discontinuation. Patient 6 was initially switched to abacavir (ABC) and 3TC because of a stock-out of single-agent tenofovir. Despite this, she continued to require transfusions. However, when the patient was switched to tenofovir and abacavir with permanent discontinuation of 3TC and FTC, no further blood transfusions were required, and there was a complete recovery of the Hb.After stable recovery of the Hb and consistent good control of the HIV disease monitored over a range of 4 months to 16 months (median: 12 months), all patients were offered a rechallenge with FTC as a component of a fixed drug combination. All patients tolerated the rechallenge without consequence with up to 36 months of follow-up  .11 Based on at least three of these four factors, this case series provides a compelling argument for an association between FTC, a commonly used NRTI, and the development of reversible PRCA. It is not surprising that rare toxicities only manifest in clinical practice following widespread use of the drug. This underscores the importance of ongoing pharmacovigilance after introducing a drug into clinical practice (Phase IV studies).12Four fundamental factors are usually considered when implicating a drug as a causal agent of an adverse event: (1) a temporal relationship between commencing a drug and the onset of the adverse reaction, (2) biological plausibility, (3) a relationship between discontinuation of the drug and the resolution of toxicity and (4) recurrence of the toxicity on rechallenge.13 Of interest, the patients in that report were all female with a median time to toxicity of 3 months, similar to our findings of 4.5 months. Interestingly, the PRCA described with the related drug 3TC has been noted in male and female patients.2,5Our findings build on a recent report of four cases from Cape Town, South Africa, implicating FTC as the cause of transfusion-dependent anaemia.14 This patient’s persistent anaemia was initially thought to be the result of parvovirus B19 infection based on a positive parvovirus B19 PCR test. Despite multiple rounds of intravenous immunoglobulin and attaining an undetectable HIV viral load with significant recovery of the CD4 cell count from 83 cells/mm3 to 237 cells/mm3, this patient remained transfusion dependent. She received 53 units of packed red blood cells over 11 months. Impressively, within 2 months of discontinuing FTC, her Hb improved to 11.5 g/dL and remained normal at the last follow-up, 2 years later. This case illustrates the importance of considering other entities when a suspected disease does not behave as expected. It is worth noting that this patient’s parvovirus B19 PCR cycle threshold, performed several times, varied between 32.97 and 37.38 cycles, suggesting a low viral load, which in retrospect was more consistent with infection than the disease.15 Of interest, her parvovirus B19 PCR assay remains positive more than a year after recovery at similar cycle thresholds, further supporting the unlikely role of this virus in her anaemia.Patient 5 was previously published as a case report.13The response of Patient 6 to treatment manipulation is worth noting. The initial switch to ABC and 3TC did not substantively impact the anaemia or transfusion requirements; however, following a switch to abacavir and TDF, there was a prompt and complete recovery of the anaemia, with no further transfusions required. This suggests cross toxicity between FTC and 3TC, which is not surprising and is consistent with other reports.16; and frequent stock-outs of single agents, meaning that an uninterrupted supply of alternates to FTC would be a challenge.Several factors led us to consider rechallenging the patients with FTC after full recovery. These included the following: our observation of a prompt recovery following removal of the offending drug; FTC playing an important role in the three-drug combination treatment of HIV; FTC being a common component of most fixed drug combinations available in the stateFailure of the recurrence of the toxicity following rechallenge makes for interesting speculation on the pathogenesis. We posit that the marrow requires a double hit, the first being bone marrow that has been made vulnerable by pre-existing anaemia or uncontrolled HIV with immune dysregulation, and the second hit being the drug, which, together with the appropriate host genetic background, leads to toxicity. Uneventful rechallenge following adequate recovery of the bone marrow suggests that the presumed genetic predisposition is necessary but not sufficient for the toxicity to manifest and that uncontrolled viral replication or immune dysregulation play an important role.The limitations of this report include its retrospective design and small case numbers. The inferences about causality are strengthened by the temporal relationships with onset and recovery of the toxicity; however, it is important to note that this remains an uncontrolled observation.This study provides strong circumstantial evidence that FTC plays an important role in the pathogenesis of reversible PRCA in a subset of patients with HIV commencing ART. This entity should be considered when common causes of refractory anaemia are excluded. The mechanisms through which FTC induces PRCA remain unclear and require further study.


Human immunodeficiency virus-1-associated neurocognitive disorder is a known complication in individuals treated with antiretroviral therapy. Cerebrospinal fluid escape, which is defined as discordant higher cerebrospinal fluid viremia than plasma, may occur in antiretroviral therapy-experienced individuals. Different cerebrospinal fluid versus plasma mutation patterns have been observed in individuals with cerebrospinal fluid escape.A 46-year-old adult African male with human immunodeficiency virus-1 infection and acquired immunodeficiency syndrome based on cerebral toxoplasmosis and a chronic hepatitis B virus infection developed cerebrospinal fluid escape. A different human immunodeficiency virus-1 genotypic drug resistance profile was observed in plasma compared with cerebrospinal fluid. Brain biopsy and cerebral magnetic resonance imaging indicated the development of human immunodeficiency virus encephalopathy. A discordant protease inhibitor mutation/wild-type T74PT in plasma but not in cerebrospinal fluid indicated poor central nervous system penetration due to the selective pressure of drug therapy. An intensified antiretroviral therapy regimen including dolutegravir with good central nervous system penetration improved conditions.This case shows the importance of measuring human immunodeficiency virus drug resistance in cerebrospinal fluid, which might differ from resistance detected in plasma samples and target effective antiretroviral therapy treatment accordingly. The management of human immunodeficiency virus (HIV) drug resistance is challenging . Few stu3. During the first years, ART consisted of two nucleoside(tide) reverse-transcriptase inhibitors (NRTIs) and a non-nucleoside reverse transcriptase (NNRTI). The HIV-1 pol gene genotypic resistance analysis showed development of the NRTI M184V mutation, and NNRTI K103N and E138EK mutations in plasma, respectively. Poor compliance, increasing viral loads, falling CD4 cell count levels, and mutation development led to therapy changes. The lowest nadir CD4 count was zero cells/mm3. The NRTI M184V mutation results in high-level in vitro resistance to lamivudine (3TC) [A 46-year-old male from Togo with HIV-1 and acquired immunodeficiency syndrome (AIDS) presented with confusion despite receiving antiretroviral therapy (ART) for more than a decade. AIDS was due to previous cerebral toxoplasmosis complicated with epilepsy and a chronic hepatitis B virus co-infection. ART was initiated at a baseline cluster of differentiation 4 (CD4) count of 330 cells/mmDuring subsequent years, the plasma resistance pattern reverted to susceptible for the NRTI/NNRTIs; however the PI mutation L89V appeared, only later to revert to fully susceptible again. The PI L89V mutation may contribute to reduced PI susceptibility. Strengthened therapy included an integrase inhibitor (INI).3 (98% mononuclear), with an elevated protein level , no erythrocytes present, and a normal glucose level (2.5 mmol/l). Cerebrospinal fluid was negative for bacterial culture, syphilis, toxoplasmosis, Mycoplasma pneumoniae, and polymerase chain reaction (PCR) diagnostics for John Cunningham (JC) polyomavirus, enterovirus, herpes simplex virus, varicella zoster virus, and cytomegalovirus. The CSF Epstein–Barr virus (EBV) level was 11,871 copies per ml. The HIV viral load in CSF and plasma were 1.2 million and 10,874 HIV RNA copies per ml, respectively. Cerebral magnetic resonance imaging (MRI) showed toxoplasmosis sequelae and unspecific changes in the white matter. A brain biopsy confirmed a diagnosis of HIV encephalopathy with cerebral toxoplasmosis sequelae.After more than a decade on ART therapy, HIV RNA levels and CD4 cell counts deteriorated and the condition was complicated by unspecific neurological symptoms and convulsions. The CSF cell count was increased with 99 (>5) cells per mm3, and both plasma and CSF harbored the same NRTI M184V mutation. However, discordantly, the accessory nonpolymorphic PI T74TP mutation mixed with wild type appeared only in the plasma but not CSF. Intensified therapy included changing raltegravir with the more potent integrase inhibitor dolutegravir, which resulted in a marked improvement of CD4 cell counts and suppression of viral levels.At the point of CSF escape diagnosis, the CD4 cell count was 180 cells/mmin vitro 50% inhibitory concentrations in the CSF [Cerebral MRI and histopathology indicated HIV encephalopathy. The blood–brain barrier may hinder the passage of ART into the brain parenchyma. Reduced penetration achieving lower CNS concentrations leads to virus compartmentalization and selection of drug-resistant mutants . The dis the CSF . PI regi the CSF . A large the CSF .Our case had CSF viral escape with a CSF HIV-RNA level more than 100 times higher than that observed in plasma. This could lead to speculation on the adherence level. Although the T74P mutation is described as nonpolymorphic, the T74TP mutation was mixed with wild type, which has sporadically been reported. This partial reversion to wild type might be explained by prolonged periods of nonadherence. Intensified ART with good CNS penetration drugs, including the integrase inhibitor dolutegravir, which has the highest CPE score, markedly improved neurological symptoms and regression of cerebral findings on repeated MRI scans. Although less neurotropic, the findings of elevated EBV in the CNS may also have contributed to the HIV encephalopathy observed. This case shows the importance of measuring HIV viral load and drug resistance in CSF fluid in patients with neurological symptoms, allowing for effective therapy adjustments and improved management of HIV-associated neurocognitive disorders.Complete control of HIV replication in the CSF as well as in plasma is necessary.


Loss to follow-up (LTFU) from antiretroviral therapy (ART) reduces treatment benefits and leads to treatment failure. Hence, this study was aimed at determining the incidence of loss to follow-up and predictors among HIV-infected adults who began first-line antiretroviral therapy at Arba Minch General Hospital.  We carried out an institutional-based retrospective cohort study, and data were collected from the charts of 508 patients who were selected using a simple random sampling technique. All the data management and statistical analyses were conducted using STATA version 14. Cumulative survival probability was estimated and presented in the life table, and the Kaplan-Meir survival curves were compared using the log-rank test. The Cox proportional hazard model was used to identify the independent predictors.  We followed 508 patients for 871.9 person-years. A total of 46 (9.1%) experienced loss to follow-up, yielding an overall incidence rate of 5.3 (95% CI: 3.9-7.1) per 100 person-years. The cumulative survival probability was 90%, 88%, 86%, and 86% at the end of one, two, three, and four years, respectively. The predictors identified were age less than 35 years ), rural residence , baseline body weight greater than 60 kilograms , a fair level of adherence , and a poor level of adherence .  In this study, the incidence rate of loss to follow-up was low. Younger adults below the age of 35 years, living in rural areas, with a baseline weight greater than 60 kilograms, which had a fair and poor adherence level were more likely to be lost from treatment. Therefore, health professionals working in ART clinics and potential stakeholders in HIV/AIDS care and treatment should consider adult patients with these characteristics to prevent LTFU. Acquired immune deficiency syndrome (AIDS) is the major global public health problem that affected an estimated 36.9 million people with a global adult prevalence of 0.8% in 2018 [In Ethiopia, the gradual decline in new HIV infections in adults was reported by the Ethiopian Public Health Institute (EPHI) HIV-related estimates and projections from 13,394 for the year 2016 to 11,613 in 2019 [Effective ART utilization controls and prevents the transmission of HIV and increases the life expectancy of HIV-infected individuals by reducing the mortality rate secondary to HIV . ART hadIn ART service utilization, loss to follow-up (LTFU) refers to a patient who had no contact for three consecutive months or longer after the last appointment for antiretroviral (ARV) refills . DespiteAccording to the reports of different studies, the magnitude of LTF among patients living with HIV was estimated to be high. The report of the systematic review in sub-Saharan Africa showed an estimated LTFU from 20% to 40% , 4.1% inLoss of follow-up from ART service has a great negative impact on HIV patients. It can negatively affect the immunological benefits of ART and increase AIDS-related morbidity, mortality, and hospitalization, and it also results in serious consequences such as drug toxicity, treatment failure due to poor adherence, and drug resistance. It also poses a serious challenge to program implementers and constitutes an inefficient use of scarce resources like treatment –28. BesiμL [2) [Different studies revealed that LTFU from the ART service is associated with baseline sociodemographic factors and clinical and treatment-related factors. From the sociodemographic variables: young age , 21, 30,μL , 20, 33,μL , 33, takμL , 38, havμL , 20, 39,μL , 20, 40,μL , 20, lowμL [2) , suboptiμL [2) , and havμL [2)  were repThough few studies were done in Ethiopia, the incidence rate of loss to follow-up and predictors has not been investigated in this study setting. Therefore, this study assessed the level of incidence of loss to follow-up and its predictors among adult HIV patients on ART in Arba Minch General Hospital. The results of this study will provide necessary inputs for policymakers and program planners who are working at different levels of HIV/AIDS control programs. Besides, early identification of the problem is important to know the vital intervention areas and improve the lives of people living with HIV (PLHIV) through improved viral suppression. In resource-limited settings like Ethiopia, evidence-based interventions that prevent the loss to follow-up will improve treatment outcomes and adherence in a cost-effective approach.We conducted an institutional-based retrospective cohort study in Arba Minch General Hospital. Arba Minch town, the capital of the Gamo zone, is located in Southern Ethiopia about 444 kilometers away from Addis Ababa, the capital city of Ethiopia. Arba Minch General Hospital provides free diagnosis, treatment and monitoring, and follow-up for HIV patients, and nowadays, 1,699 adult HIV patients are actively following AR. This study included those enrolled from January 1, 2014, to December 31, 2018. Treatment and follow-up were based on the national FMOH ART treatment guidelines for HIV infections in adults and adolescents .All HIV-infected adults, aged 15 years and above, who were registered for HIV/AIDS care and put on ART from January 1, 2014, to December 31, 2018, in the Arba Minch General Hospital ART clinic, were the study population. Patients who initiated ART, but without at least one ART follow-up visit, with an incomplete patient record and those who transferred in from another facility were excluded from the study.μL from the previous study conducted in Gondar, Northern Ethiopia, [The sample size was calculated by using STATA version 14 based on the following assumptions: 5% alpha, 80% power, allocation ratio 1, and adjusted hazard ratio 1.3 for CD4 count < 200 cells/thiopia, , and by In this study, the dependent variable was the LTFU from ART service utilization, whereas sociodemographic factors such as sex, age, education level, marital status, occupation status, residence, disclosure status , substance use; treatment-related factors such as eligibility criterion (test–start/not), initial ART regimen type, comedication, treatment duration, drug side effects, number of pills per day, cotrimoxazole prophylactic treatment (CPT) at the start of ART, and the level of adherence; and clinical and immunological-related factors like baseline body weight, WHO clinical stage, CD4 count, opportunistic infections (OIs) at the start of an initial regimen, comorbidity other than OIs, baseline ALS, HGB, creatinine, and functional status were considered as the independent variable.This study considered LTFU when a patient is not seen at the ART clinic for at least 90 days or 3 months after the last missed appointment, but not transferred out from the facility to another facility or dead , 42–44. The data collection tool was prepared by reviewing various kinds of literature in the English version that included sociodemographic characteristics, clinical characteristics, treatment-related characteristics, and the information related to the time of ART initiation and end date of LTFU and censored. The data were collected by three BSC nurses who had previous exposure to data collection and training on comprehensive HIV care and supervised by two master's holders in public health who had experience in data management.To assure the quality of data, the data extraction format was designed carefully and we appropriately recruited data collectors who had experience in data collection. And also, training was given for data collectors and supervisors. A pretest was performed on 5% of the populations before data collection in the same setting in Arba Minch General Hospital because the source of data was secondary. Intensive supervision was done on a daily basis by the principal investigator and supervisors during the whole period of data collection.The principal investigator reviewed a random sample of registration forms to confirm the reliability of data before the data collection period, and the investigator and supervisors made random crosschecking for the completeness, accuracy, and consistency of data at the end of each day, and accordingly, corrective discussion was made with all data collectors. To minimize errors and take corrective actions, remarks were given during morning times. Then, the data were checked for completeness and consistency and coded and entered into the computer using EpiData version 4.6.Data were cleaned, edited, coded, and entered into EpiData version 4.6 and exported to STATA version 14 for analysis. Exploratory data analysis was carried out to check the missing values. Results are presented using numerical summary measures, frequency, and percentages and also using survival curves and tables. The incidence rate of loss to follow-up was calculated by dividing the numbers who experienced the loss to follow-up in the overall follow-up period by person-time at risk contributed throughout the observation period. A life table was used to estimate the cumulative survival time in each time interval. The Kaplan–Meier survival curve together with the log-rank test was used to estimate the median time and to compare the overall survival experience of two or more categories of variables.p ≤ 0.25 levels in the bivariable analysis which had improved model adequacy compared with the null model were entered into the multivariable Cox regression analysis. Model adequacy was checked via the maximum likelihood with the assumption of the higher is the better. The backward variable selection method was applied to get significantly associated predictors, and the adjusted hazard ratio (aHR) with corresponding 95% confidence interval (CI) and the p value were used to assess the strength of association and statistical significance, respectively. The statistical significance was considered at a p value < 0.05. The reasonability of proportional hazard assumptions was tested graphically and by using the Schoenfeld residuals test (phtest) by using a post estimation command “estat phtest” and “estat phtest, detail” for the final model and each variable, respectively. In the final model, the global test of the Schoenfeld residuals test gave χ2(df) = 13.15 with a p value = 0.4361; this supports the null hypothesis which states that hazards are proportional and the iteration of log-likelihood was −266.084 in the first step and −228.4955 in the last iteration of log-likelihood with LR x2 = 75.18 and a p value < 0.001.A Cox proportional hazards model was applied to identify the factors that predicted LTFU. Bivariable Cox regression analysis was used to identify candidate variables in the multivariable Cox regression. Those variables with A total of 508 charts of HIV patients were reviewed and analyzed, giving a 100% response rate. The mean age at initiation of ART ± SD (standard deviation) was 35.1 ± 8.2 years. A majority, 219 (43.1%), were in the age groups between 25 and 34 years. A total of 289 (56.9%) were females. Regarding the educational status of the patients, a majority, 195 (38.4%), completed the primary education level and about 63 (12.4%) had tertiary and above educational statuses. A total of 375 (73.8%) were urban dwellers but the rest were rural dwellers. A total of 485 (95.5%) disclosed their HIV status to either their family or other relatives, but the rest did not disclose their HIV status .A total of 238 (46.9%) patients started ART by test and start eligibility criteria, but 270 (53.1%) were not by test and start. Initially, a majority, 498 (98.1%), of HIV patients have prescribed a combination of tenofovir (TDF) + lamivudine(3TC) + efavirenz (EFV), followed by tenofovir (TDF) + lamivudine(3TC) + nevirapine (NVP), zidovudine (AZT) + lamivudine(3TC) + efavirenz (EFV), and zidovudine (AZT) + lamivudine(3TC) + nevirapine (NVP). A majority of patients, 491 (96.7%), started by taking one ART pill per day whereas the rest started by taking more than one ART pill and 284 (55.9%) of the patients took CPT prophylaxis at the start of ART .3 (IQR: 144.5–407.0) and it was 457.3 cell/mm3 (IQR: 400–485.8) at the end of the follow-up period, and above half, 306 (60.2%), of study subjects started ART at a HGB level of between 10 and 12.9 g/dL. A total of 84 (16.5%) of the study participants have been diagnosed with tuberculosis (TB) at the initiation of ART, and about 85 (16.73%) had an opportunistic infection (OIs) other than TB. From the total study subjects, about 157 (30.9%) experienced at least one ART drug side effect , were in WHO clinical stage I at the initiation of ART and 395 (77.8%) of the participants were on a working functional status at baseline. The median weights of the study participants at the initiation of ART and at the end of the follow-up period were 55.0 kg (interquartile range (IQR): 48–60) and 57.6 kg (IQR: 52–60), respectively. The median CD4 count at initiation of ART was 281.5 cell/mme effect .A total of 508 patients on ART were followed for a minimum of 0.5 and a maximum of 54.1 months of the follow-up period. The total follow-up period was 10,462.5 person-months (871.9 person-years) of observation, and the median follow-up period was 16.1 months . At the end of the follow-up period, a total of 46 (9.1%) patients experienced loss to follow-up, 16 (3.2%) died and were defaulters, 55 (10.8%) transferred out, 292 (57.48%) were kept on an initial regimen, and 99 (19.5%) of patients changed their initial regimen. Hence, the overall incidence of loss to follow-up was estimated to be 5.3 (95% CI: 3.9-7.1) per 100 person-years of observation (PYs). From the total incidence rate of loss to follow-up, 4.0/100 PY, 40.5/PY, and 54.1 attributed to good, fair, and poor levels of adherence, respectively .p value = 0.002)  .p value less than 0.05. There was a marginal significant difference within categories of occupational status and baseline WHO clinical staging (The log-rank (Mantel-Cox) estimate of the loss to follow-up among variables was estimated for sociodemographic-, clinical-, immunological-, and treatment-related variables. Among all variables, the age, residence, level of adherence, disclosure status, regimen change, side effect, and treatment duration had a  staging .p values less than or equal to 0.25 were considered as the candidate variables for multivariable cox regression analysis. These were age, residence, occupational status, disclosure status, substance use, baseline weight, baseline functional status, level of adherence, baseline WHO stage, and the eligibility criteria at the start of ART (test start). In multivariable Cox regression analysis, the age, residence, level of adherence, and baseline weight were significantly associated predictors of LTFU. However, variables like a history of TB, OIs, history of cotrimoxazole prophylactic therapy, baseline CD4 count, WHO stage, and disclosure status were not significantly associated with loss to follow-up in ART . Regarding the residence of ART patients, those patients who were from rural areas had approximately two times higher risk of loss to follow-up as compared with counterparts . Keeping other variables constant, baseline body weight had also a significant association with the incidence of loss to follow-up. Those ART patients with baseline body weight greater than 60 kilograms had a 2.19 times higher risk of LTFU as compared with counterparts with a baseline body weight less than 60 kilograms . The hazard of LTFU was also higher among adult ART patients who had fair and poor levels of adherence. Those patients who had a fair level of adherence were 11.5 times at higher risk of loss to follow-up as compared to those with a good level of adherence , and also, patients with a poor adherence level were 12.03 times at higher risk of loss to follow-up when compared with those patients with a good level of adherence  .Loss to follow-up is the major difficulty to treatment success and it complicates the evaluation of HIV care and treatment programs . This stBut, this finding is lower than the study conducted in different parts of Ethiopia, in Gondar, Ethiopia, 12.26 per 100 person-years , in JigjThis variation in the incidence rate might be due to the differences in setting, time variation, the difference in the follow-up period, health-seeking behaviors, and difference in the sociodemographic characters of the study participants, and the commencing of test and start ART criteria may be the other possible reason; in this study, 46.9% patients initiated their treatment by test and start eligibility criteria as compared to those of other studies. The lower incidence rate of this study from many reports that are listed above also might be due to an improvement in ART adherence, tracing back of HIV patients who lose their follow-up, and early initiation of treatment has been adapted recently to get the expected good clinical outcomes and improve the quality of life of HIV patients ultimately .Regarding the characteristics of cohorts, in present study, a majority (77.8%) of study participants were in working functional status at baseline, and also, about (53.4%) were in WHO clinical stage one, (60.2%) having a hemoglobin level between 10 and 12.9 g/dL, and the median CD4 count at baseline was 281.5 cell/mm3. And also, only 16.5% of the study participants had been diagnosed with tuberculosis at the start of ART and about 16.73% had another opportunistic infection when compared with the previous studies. This all might make the lowest level of LTFU in present study. This recent study can reflect the implementation of different stakeholders' strategies.In this study, from the total patients who experienced loss to follow-up, a majority, 34 (93.9%), lost from ART service within the first year of treatment initiation. The probability of cumulative survival was 90%, 88%, and 86% at the end of one, two, three, and four years, respectively. In this study setting, we found that a progressive decrease in the incidence rate of LTFU of HIV patients within each year after initiation of ART. This finding is in agreement with the study finding from Jigjiga town, Ethiopia . This prIn this study, patients whose age less than 35 years had a 1.96 times higher risk of loss to follow-up when compared with those patients whose age is above 35 years. In agreement with this study, younger age groups were more likely to lose to follow-up from ART service as compared to older age categories in the report of studies in Gondar, Ethiopia , Pawi GeRegarding the residence of HIV patients following the ART clinic, those patients who had rural residence were 1.98 times at higher risk of loss to follow-up as compared with their counterparts. This result is congruent with different studies done in the Oromia region, Ethiopia . This miFurthermore, baseline body weight had also a significant association with loss to follow-up in this study. Those ART patients with baseline weight greater than 60 kilograms were 2.19 times at higher risk of LTF as compared with those with baseline weight less than 60 kilograms. The possible reason could be, even though BMI was not computed in this study, those patients with higher body weight might face noncommunicable diseases which have been associated with overweight and obesity and this could affect their retention in care, and due to these chronic noncommunicable diseases, they might have a suboptimal (fair/poor) adherence level which is a predictor of LTFU in the present study. Another reason might be that patients with normal body weight would like to maintain their good wellbeing  by taking ART so that they stay longer in the program when compared to those whose body weight is not normal .The adherence status had a statistically significant association with the incidence rate of LTFU. The risk of LTFU was higher among adult ART patients with fair and poor levels of adherence. Those patients who had a fair level of adherence were 11.5 times at higher risk of loss to follow-up as compared to those with a good level of adherence, and patients with a poor adherence level were 12.03 times at higher risk of loss to follow-up when compared with those patients with a good level of adherence. This finding is in agreement with a study done in Gondar, Ethiopia , Oromia Variables like alcohol/drug use and prescription of many pills/day were not statistically significant in this study. The possible reasons might be that the number of substance users in present study was only 1.5% and those patients who were receiving two and more pills per day were only 0.3%.As limitations, due to the nature of the secondary source of data, some missed variables like the BMI, status of mental illness, stigma and discrimination, viral load, distance from the health facility, cell phone possession, and having a caregiver might be predictors. In addition to these, charts with an incomplete record of 20% and transferred outpatients were excluded; this might lead to underestimating or overestimating the incidence rate of loss to follow-up.In this study, the incidence rate of loss to follow-up was estimated to be low when compared with a majority of previous studies. A majority of loss to follow-up occurred within the first year of ART initiation. Younger adults below the age of 35 years, living in rural areas, had a baseline body weight greater than 60 kilograms, had a fair and poor adherence level, and were more likely to be lost from treatment. Therefore, health professionals working in ART clinics and potential stakeholders in HIV/AIDS care and treatment should give emphasis for above characteristics. They should give health education about the effects of LTFU and the benefits of retention in the ART program for adult patients below the age of 35 years, visits to ART clinic from the rural (distant) areas, having baseline body weight above 60 kilograms, and having a suboptimal (fair and poor) adherence level. Furthermore, a prospective cohort study needs to be conducted and a qualitative study should be applied to obtain information from LTFU patients themselves by tracing them and the health service quality and satisfaction level of patients need to be addressed.


Sub-optimal adherence to antiretroviral therapy (ART) is reportedly worse amongst young people living with HIV (YPLHIV). Group adherence counselling can be useful to improve adherence.We evaluated an enhanced adherence counselling group intervention (EACGI) amongst YPLHIV failing a non-nucleoside reverse transcriptase (NNRTI)-based first-line ART regimen.This was a retrospective cohort study using routinely collected data of YPLHIV failing NNRTI-based first-line ART. Patients with confirmed virological failure were referred for EACGI, a 12-week curriculum of weekly, 1.5-h sessions accommodating 8–15 people per group. It aimed to facilitate readiness to switch to second-line ART and improve adherence through a mental health intervention. Viral loads of HIV were measured pre-EACGI; at baseline; 3, 6 and 12 months post switch.Fifty-seven patients aged 13–25 years were invited to EACGI and followed for up to 48 weeks. Thirty-three (58%) patients attended at least four sessions, whilst 24 (42%) attended none. Amongst those who attended none, two (8%) were transferred out, three (13%) were lost to follow-up and two (8%) had died by week 48 of follow-up, whilst all who attended were still in care. By week 48, amongst patients still in care, 29%, 44% and 67% of those who attended no sessions, 4–9 and 10–12 sessions, respectively, had viral loads of < 50 copies/mL.An EACGI is a promising intervention for YPLHIV failing ART prior to treatment switch, leading to improved adherence. This study’s findings support the need for further enquiry into rigorous, evidence-based multilevel adherence interventions that are acceptable and effective for YPLHIV. One of the major challenges that healthcare professionals face is helping young people adhere to ART despite its well-known benefits in improving the overall health and quality of life.8 Globally, HIV is a leading cause of death amongst young people, which is associated with inadequate adherence support and poor retention in care.11 Given the high risk of VF, disease progression, drug resistance, limited treatment options and the ultimate threat to survival, understanding and examining adherence strategies that delve beyond a traditional clinical approach is imperative.12 This is more so in countries in sub-Saharan Africa, where more than 80% of the world’s 2.1 million adolescents infected with HIV live.4Sub-optimal adherence to antiretroviral therapy (ART) amongst people living with HIV (PLHIV) is the leading cause of virological failure (VF).14 The fundamental goal of regimen switching is to achieve and sustain virological suppression without compromising future treatment options.14 Although treatment switching is an established clinical practice, there are limited data on the virological status of young people following a treatment switch.15Part of young people’s HIV management and care involves treatment switching from a failing ART regimen to a different class of antiretrovirals when VF occurs, most often because of inconsistent adherence.16 Studies have shown mixed results in its effectiveness and were mainly conducted in adult populations.11 A randomised controlled trial in Thailand found a statistically significant difference in treatment outcomes in 15- to 24-year-olds for the intervention group,17 whilst in South Africa there was no difference in treatment outcomes for a group adherence strategy delivered to young people and their caregivers.18 Experiences and outcomes of group psychotherapy as an adherence support intervention in young people have not been widely documented. In this study, we report virological suppression outcomes amongst adolescents and young people who were invited to an Enhanced Adherence Counselling Group Intervention (EACGI) after failing a non-nucleoside reverse transcriptase (NNRTI) based first-line ART regimen.Group adherence counselling is often utilised as an intervention to improve adherence in routine HIV care.19 Psychological support offered by a psychologist and peer counsellor is provided for patients struggling to cope with issues that affect their treatment success. The clinic had 1102 patients aged 13–25 years in care as of 31 December 2020.This was a retrospective cohort study using routinely collected data of adolescents and young PLHIV (13–25 years) failing NNRTI-based first–line ART at Newlands Clinic during the period 2015–2016. This study sought to evaluate an EACGI for young PLHIV on ART adherence. Newlands Clinic is an urban HIV treatment centre in Zimbabwe and a referral outpatient clinic providing comprehensive HIV care, which is supported by the Ruedi Luethy Foundation, a private voluntary organisation. The model of care is nurse-led, doctor supervised, with four nurses and two doctors dedicated to the care of over a 1000 adolescents and young people predominately from marginalised communities.® Ampliprep®/Taqman48® platform and the Roche HIV1 version 2.0 assay. According to the clinical guidelines, virological treatment failure was defined as two consecutive viral load measurements > 200 copies/mL at least 3 months apart. Virological suppression was defined as achieving a viral load < 50 copies/mL. Patients with low-level viraemia (51 copies/mL – 200 copies/mL) were managed by their respective nurses and were not referred to EACGI. Once virological treatment failure on first-line ART was confirmed, patients were referred for the EACGI, which was part of routine care, aimed to facilitate readiness to switch treatment to second-line ART, and improve adherence through phenomenological, motivational interviewing and cognitive behavioural therapy principles. All patients who were referred for EACGI were included in the study. The EACGI was a 12-week curriculum of weekly, 1.5-h sessions that accommodated 8–15 people per group during the period 2015–2016. The intervention was developed locally in the clinic by the psychologist through adapting the past experiences of clinicians, peer counsellors and patients. These experiences were then used to design the intervention to best meet the needs of adolescents failing treatment. Participants were conveniently selected to a group based on their respective ages (13–17 years and 18–24 years). Participants were informed and invited to attend EACGI by their respective nurse and peer counsellor. Group sessions were facilitated by a resident psychologist and a peer counsellor in English, the local dialect (Shona) and a youth friendly language. The peer counsellor was trained under the Africaid’s Community Adolescent Treatment Support programme.20 Each session began with an icebreaker to help to establish rapport, and create a positive group atmosphere and cohesion. Participants were offered bus fare and refreshments after each session. All participants who missed the initial EACGI sessions were followed up telephonically or at their clinic visit by their peer counsellor to establish barriers to attendance. Reasons for missing visits for those who attended the EACGI were asked during the individual interviews or at group session recaps. An overview of the EACGI curriculum is displayed in 21Viral load measurements were conducted using the COBASAfter undergoing EACGI, the patients who achieved virological suppression continued their current regimen, whilst those who were unsuppressed were switched to a second-line protease inhibitor-based regimen. Viral loads of HIV were measured pre-EACGI at the end of the 12-week sessions (time of switching to second-line ART), and at 3, 6, 9 and 12 months post switch to assess virological outcomes.All patient data were recorded in the clinic’s electronic medical record (EMR), which is only accessible to authorised personnel and is password protected.t-tests. We used Stata version 13.1  and DABEST package (version 0.3.0) in R studio (R version 4.0.4 [2021 Feb 15]) for statistical analysis.22We used frequencies and proportions to describe patient distributions in categories. For the description of central tendency, we used medians and interquartile ranges for variables not normally distributed. We measured normality of continuous variables using the Shapiro–Wilk test. Attendance rates were analysed as no attendance, < 75% and at least 75% attendance. The initial nine EACGI curriculum sessions covered the fundamental aspects of treatment literacy, whilst the final sessions reinforced taught material. We used logarithm transformed viral load measurements before comparing using two-sample This study was approved by the Newlands Clinic Research Unit and the Medical Research Council of Zimbabwe (MRCZ/E/205).All participants aged 18 years and older provided written informed consent before participating in this study. Participants younger than 18 years provided written assent, and their parents or guardians provided written informed consent.n = 34, 60.0% female) aged 13–25 years were invited to the EACGI and followed up for 48 weeks. The median duration of first-line ART was 6 years (interquartile range [IQR]: 4–8) at the time of invitation to EACGI. Thirty-three (57.9%) patients attended at least four EACGI sessions, whilst the other 24 (42.1%) patients did not attend any session. Of the 33 patients who attended the EACGI, 25 (75.8%) were female patients, whilst 15 (62.5%) of those who did not attend were male patients. The main reasons for not attending the EACGI include a lack of interest and school or work commitments. Main reasons reported by patients for a low attendance rate to EACGI amongst those who attended were hopelessness, family dysfunction, perception of not having an illness, an aversion to a daily routine attached to stigma and prior experience of medication side effects. Amongst those who did not attend the EACGI, two (8%) were transferred out, three (13.0%) were lost to follow-up and two (8.0%) had died by week 48 of follow-up, whilst all who attended were still in care (Fifty-seven patients ( in care .As shown in p < 0.001). Those who attended EACGI had the highest decline of 1.24 log copies/mL  compared with 0.76 log copies/mL  amongst those who did not attend.Overall, there was a mean decline in the viral load of participants after EACGI before switching to second-line ART by 1.03 log copies/mL  are mainly from low-resourced communities such as those in the current study and, therefore, it is plausible that income-generating opportunities may interfere with attending facility-based interventions. These findings highlight the importance of offering differentiated adherence interventions. This phenomenon may affect male patients more as observed in this study where fewer male patients attended the EACGI regularly. Group counselling interventions may not always achieve similar results in young men living with HIV, highlighting the need for further research in this area.As already highlighted, group attendance was associated with viral response. Not all adolescents chose or were able to regularly attend sessions. This is reflective of young people’s realities where competing factors, such as seeking autonomy, an active social life, and educational and financial responsibilities, contend with HIV care engagement.32 Adolescents receiving care and enrolled in teen clubs in Windhoek, Namibia, did not show improved treatment outcomes compared, with the standard of care.33 Whilst there was marginal improvement in adherence  to ART in a Malawian study utilising teen clubs.32 The introduction of an EACGI, which has shown positive results in the Zimbabwean setting, could very well complement the differentiated models being rolled out for young people requiring adherence support.There are some differentiated treatment strategies that have been developed to try and improve HIV treatment outcomes in adolescents and young people. Teen clubs are one such model that have achieved mixed outcomes in different settings. These clubs have been rolled out and evaluated in a few treatment programmes around Africa.The strength of this work was that adherence behaviour change was measured by viral load, an objective clinical marker of adherence and clinical outcomes. The strength of this study’s results also lies in the ability to measure viral progression longitudinally in young people after group counselling intervention, which is difficult to conduct in low- and middle-income countries. One of the limitations with this approach is that the observed viral suppression after switching to second-line ART could be as a result of switching to a more potent treatment regimen.34 This study’s findings support these recommendations and provide a possible preliminary framework on support for young people being prepared for a treatment switch post treatment failure.Biomarkers are not the only important factors in making clinical decisions in routine HIV management, especially in key populations.31 The EACGI can be included in HIV treatment programmes with the inclusion of trained personnel.This study was conducted using routinely collected data where patients were not randomised into groups. Willingness to attend group sessions may have affected the rate of attendance and virological outcomes. The EACGI referrals were initiated by clinicians’ judgement and could have introduced a selection bias. However, this is reflective of typical HIV primary care. This study focused on individual-related factors of adherence; yet, adherence is complex with multiple interacting adherence risk factors.Adherence support interventions, which include a mental health framework such as EACGI, in preparing young adult patients for second-line treatment seems to be a promising tool, increasing the likelihood of improved adherence and treatment outcomes. All participants who attended EACGI were retained in care. This study’s findings support the need for further enquiry into rigorous, evidence-based multilevel adherence interventions that are acceptable and effective for diverse young PLWHIV.


In the era of anti-retroviral therapy (ART), the plasma HIV viral load (VL) is an important primary indicator for monitoring the HIV treatment response. To optimize the clinical management of HIV/AIDS patients, we investigated VL high-risk events related to virological failure (VF) and further explored the preventive factors of VL high-risk events.The data were derived from China’s HIV/AIDS Comprehensive Response Information Management System. HIV infected patients who initiated or received ART in Guangxi between 2003 and 2019 were included. The contributions of VL after 6 months of ART to VF and AIDS-related death were analysed by Kaplan-Meier curves, log-rank tests and Cox regression analyses. Both descriptive analyses and bivariate logistic regression were employed to further explore the preventive factors related to VL high-risk events of VF.χ2 = 18.45; P <  0.001) and non-suppressed group  were significantly higher than those in the viral suppression (VS) group. Therefore, the VL high-risk events of VF was defined as highest VL > 200 copies/ml after 6 months of ART. Compared with the VS group, the adjusted hazard risk was 7.221  in the high LLV group and 8.351  in the non-suppressed group. Compared with single patients, married or cohabiting  and divorced or separated  patients were negatively associated with VL high-risk events. So were patients acquired HIV homosexually . However, patients who had ART modification were 1.728 times  more likely to have VL high-risk events, and patients who used cotrimoxazole during ART were 1.843 times  more likely to have VL high-risk events.The cumulative rates of VF in the high low-level viremia group (high LLV) (A VL greater than 200 copies/ml is a VL high-risk event for VF. Intervention measurements should be adopted to optimize the surveillance of ART in patients who are single or widowed, who have ART modification, and who use cotrimoxazole during ART. Human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) are threats to public health worldwide. The World Health Organization (WHO) estimated that 38 million individuals worldwide were living with HIV by the end of 2019 . At the Since the first ART drug was approved, the survival of ART-treated individuals living with HIV has improved because the ART regimens developed reduced HIV viral loads and delayed disease progression. Combination ART was developed to substantially arrest viral replication by targeting and interrupting different stages of the virus life cycle , 6. As rAdhering to the ART regimen is crucial to achieve and maintain viral suppression to prevent further HIV transmission and the progression of HIV infection , 10. FurIn clinical practice, the plasma HIV viral load (VL) is an important and primary indicator to monitor the HIV treatment response. Additionally, VL can indicate adherence to ART by showing the therapeutic response. According to the China National Handbook on Free Anti-retroviral Therapy for AIDS (4th edition), two consecutive confirmed viral loads > 400 copies/ml after 24 weeks of ART could be defined as virological failure (VF) . HoweverTo optimize the clinical management of HIV/AIDS patients, we investigated the risk events related to VF and AIDS-related death based on the data of patients who initiated or received ART in Guangxi between 2003 and 2019 exported from China’s HIV/AIDS Comprehensive Response Information Management System (CRIMS). Furthermore, to prevent VL risk events as early as possible and block the occurrence of subsequent adverse events during ART, we explored the preventive factors of risk events.A retrospective follow-up study was conducted among HIV/AIDS patients who initiated or received ART in Guangxi, China between 2003 and 2019. The follow up period was the time between ART initiation and a certain outcome was confirmed. We utilized data from China’s HIV/AIDS CRIMS. The patients’ inclusion criteria were as follows: a) available baseline VL data before treatment initiation; b) ART for 6 months and longer; c) two or more viral load records during follow-up; and d) the interval between viral load tests not exceeding 12 months. Figure Mycobacterium tuberculosis (Mtb) infection in the recent year, opportunistic infections (OIs) in the recent 3 months, AIDS-related symptoms, WHO clinical stage, and VL. VL, duration on ART (months), ART regimen and ART regimen switch or interruption during the ART follow-up period were collected.Demographic information was collected from the baseline of ART initiation, such as sex, marital status, age at HIV diagnosis, age at ART initiation and registered permanent residence. At ART initiation, HIV infection-related information was also collected, such as the transmission route, Based on the 4th edition of the China National Handbook of Free Antiviral Therapy for AIDS, VF was defined as a viral load greater than 400 copies/ml two or more consecutive times during ART, whereas VS was defined as a VL below the minimum detection threshold of the detection reagent . VLs between 20 copies/ml and 400 copies/ml were divided into two subgroups: low LLV (20 copies/ml ≤ VL ≤ 200 copies/ml) and high LLV (200 copies/ml < VL ≤ 400 copies/ml). Therefore, the outcome of VF was defined as VL > 400 copies/ml two or more consecutive times after 6 months of ART. The VLs after 6 months of ART were records of VL detected between 6 months after ART and the time of first VL > 400 copies/ml of VF or death or the last VL detection. VLs after 6 months of ART were divided into four groups, including VS ; low LLV (20 copies/ml ≤ VL ≤ 200 copies/ml); high LLV (200 copies/ml < VL ≤ 400 copies/ml) and non-suppressed (VL > 400 copies/ml).chi-square test or the Mann-Whitney U test. Variables significantly different between the groups were further entered into a bivariate logistic regression model to identify independent factors correlated with LLV occurrence. All statistical analyses were performed using IBM SPSS statistics 23.0 . All the tests were two-sided, and P <  0.05 was considered to be significant.To determine the contribution of VL after 6 months of ART to VF and AIDS-related death, the cumulative rates of VF and AIDS-related death were evaluated by Kaplan-Meier curves and tested by the log-rank test. Cox regression analyses were performed to investigate whether different VLs were associated with VF. Hazard ratios were adjusted for demographic information, HIV infection-related information and ART follow-up data. Based on the results of analysis above, we define that a VL greater than 200 copies/ml after 6 months of ART (high LLV group and non-suppressed group) as VL high-risk event for VF. To further explore the preventive factors related to VL high-risk events of VF, patients after antiviral therapy were divided into two groups: patients who experienced VL high-risk events of VF (HR) and those who did not (non-HR). Demographic information, HIV infection-related information and ART follow-up data were compared between these groups by We recruited 1860 HIV-infected patients based on the inclusion criteria. They were followed up for a total of 6455.34 person years. After 6 months of ART, VF and AIDS-related death were set as the outcome indicators when following HIV patients. Additionally, the VL between 6-month ART and VF was recorded. Patients were divided into four groups based on the recorded VL, including the viral suppression group , low LLV group (20 copies/ml ≤ VL ≤ 200 copies/ml), high LLV group (200 copies/ml < VL ≤ 400 copies/ml), and non-suppressed group (VL > 400 copies/ml).Kaplan-Meier analysis and were further compared among groups by log-rank tests. The cumulative incidence rates of VF and AIDS-related death were significantly different among the four groups . However, the cumulative rates of VF in the high LLV group  and non-suppressed group  were significantly higher than those in the VS group. The cumulative incidence of AIDS-related death was highest in the high LLV group  and low LLV group . However, no significant difference was found in the cumulative incidence of AIDS-related death between the high LLV and non-suppressed group .The cumulative rates of VF and AIDS-related death were calculated by Univariate and multivariate Cox regression models were used to determine the effect of VL after 6 months of ART on VF. The time variable was the interval between ART initiation to the outcome (VF or not). Compared with the VS group, the adjusted hazard risk was 7.221  in the high LLV group and 8.351  in the non-suppressed group  comprised patients who had a VL greater than 200 copies/ml after 6 months of ART, while the non-high-risk group (non-HR) comprised patients whose VL was not greater than 200 copies/ml after 6 months of ART.χ2 = 10.812; P = 0.029; Table According to the sociodemographic characteristics of the patients at baseline, most were male (70.70%) and married or cohabiting (56.88%), with a median age at the HIV diagnosis of 39 years and a median age at ART initiation of 40 years. Sex and age at HIV diagnosis and ART initiation were not significantly different between the HR and non-HR groups. However, compared with the non-HR group, the marital status of the HR group was significantly different . The rate of OIs in the last 3 months in the HR group was significantly higher than that in the non-HR group . Most of the patients were WHO stage I (Table P = 0.015). Additionally, the CD4+ T-cell count of the HR group was significantly lower than that of the non-HR group (P <  0.001), while the VL at baseline of the HR group was much higher than that of the non-HR group (P = 0.001). However, no significant difference was found in the rates of Mtb infection in recent years, positive AIDS-related symptoms or cotrimoxazole use before baseline between the HR and non-HR groups.Most of the included patients were infected by HIV heterosexually. However, the HIV transmission routes of patients in the HR group were significantly different from those in the non-HR group . Additionally, the percentage of cotrimoxazole use during ART in the HR group was much higher than that in the non-HR group  and divorced or separated  patients were negatively related to VL high-risk events. Patients who acquired HIV homosexually showed a negative relationship with VL high-risk events . However, patients who had ART modification were 1.728 times  more likely to have VL high-risk events, and patients who used cotrimoxazole during ART were 1.843 times  more likely to have VL high-risk events.To determine the independent factors related to VL high-risk events for VF, variables significantly different between the two groups were entered into a bivariate logistic regression model, such as the marital status, transmission route, OIs in the last 3 months, WHO clinical stage, baseline CD4RT Table . The occAOR = 0.591; 95% CI: 0.408, 0.856) or divorced or separated  and acquired HIV homosexually  were less likely to have VL high-risk events, while those who had ART modification and used cotrimoxazole during ART were 1.728 times  and 1.843 times  more likely to have VL high-risk events.Our study reported that HIV patients with a VL greater than 200 copies/ml were at a higher risk of VF and AIDS-related death. Among the ART-treated HIV patients, those who were married or cohabiting  predicted VF [In this study, we reported that patients with VL reaching 200 copies/ml after 6 months of therapy were at a higher risk of VF and AIDS-related death. A retrospective cohort study indicated that among patients with persistent LLV , a PLV > 400 copies/mL  . A largePatients who had ART modification were more likely to have VL high-risk events. Some cohort studies have reported high rates of change in the first ART –34. ART 3 or at clinical stage 3 or 4 or lifelong cotrimoxazole for any CD4 count in settings with a high prevalence of malaria or bacterial infections. In China, a national free ART programme was officially launched in 2003, and the first guidelines on cotrimoxazole were released in 2005 [+ T-cell count less than 200 cells/μL or a total lymphocyte count less than 1200 cells/μL, WHO stage 4 disease or a history of oropharyngeal candidiasis [+ T-cell counts less than 200 cells/μL and/or a high VL. Therefore, patients who used cotrimoxazole during ART were more likely to have VL high-risk events in this study. To the best of our knowledge, continued cotrimoxazole prophylaxis therapy can significantly reduce the risk of severe opportunistic infection in ART patients [Cotrimoxazole, a fixed-dose combination of trimethoprim and sulfamethoxazole, is widely used against opportunistic infections in patients with advanced HIV disease –43. Incr in 2005 . Currentdidiasis . In thispatients . Howeverpatients . Sisay Mpatients  reportedThis study has several limitations. First, because the interval between the viral load tests of all the included patients did not exceed 12 months, some patients who did not undergo viral load testing within 12 months were excluded. Thus, the representativeness of the participants was affected. Second, we did not collect the data of non-AIDS-related deaths in this study, which may be associated with VL high-risk events too. Third, some unmeasured potential confounders could also result in the difference between groups. What’s more, we did not collect data to evaluate ART adherence, which may be associated with VL high-risk events, VF and AIDS-related death. Finally, an ART drug resistance test was not performed to determine its impact on VL high-risk events.This study demonstrated that a VL greater than 200 copies/ml is a VL high-risk event for VF. To better prevent VF and AIDS-related death, intervention measures should be adopted to optimize the surveillance of ART in patients who are single or widowed, who have ART modification, and who used cotrimoxazole during ART.


N), reflecting the quality of immune reconstitution, as a function of the timing of ART initiation (early (<6 months) versus late (≥24 months of age)).The early initiation of antiretroviral therapy (ART) in HIV-1-infected infants reduces mortality and prevents early CD4 T-cell loss. However, the impact of early ART on the immune system has not been thoroughly investigated in children over five years of age or adolescents. Here, we describe the levels of naive CD4 and CD8 T lymphocytes (CD4/CD8TThe ANRS-EP59-CLEAC study enrolled 27 children (5-12 years of age) and nine adolescents (13-17 years of age) in the early-treatment group, and 19 children (L-Ch) and 21 adolescents (L-Ado) in the late-treatment group. T lymphocytes were analyzed by flow cytometry and plasma markers were analyzed by ELISA. Linear regression analysis was performed with univariate and multivariate models.N percentages , and a marginally higher CD4TN . In adolescents, early ART was associated with low CD4TN percentages and less differentiated memory CD8 T cells. CD4TN and CD8TN levels were inversely related to cellular activation and gut permeability.At the time of evaluation, all patients were on ART and had a good immunovirological status: 83% had HIV RNA loads below 50 copies/mL and the median CD4 T-cell count was 856 cells/µL (interquartile range: 685-1236 cells/µL). In children, early ART was associated with higher CD8TN were clear after long-term ART. The impact of early ART on CD4TN appears to be modest, because pediatric patients treated late respond to HIV-driven CD4 T-lymphocyte loss by the de novo production of TN cells in the thymus. Our data also suggest that current immune activation and/or gut permeability has a negative impact on TN levels.In children and adolescents, the benefits of early ART for CD8TClinicalTrials.gov, identifier NCT02674867. N)  face a lifetime of chronic disease due to this virus . Early AN)  and CD4/N) . Early AN) –12. OverSeveral gaps in our knowledge of the long-term impact of early versus late ART remain. Few studies have investigated the immunological benefits of early ART initiation in children over the age of five years and those without sustained viral suppression. The benefit of early ART for CD4 T-cell levels may persist or decrease over longer periods of long-term effective ART. Finally, unplanned treatment interruptions frequently occur during early childhood and adolescence, and it remains unclear whether the deleterious impact of viral rebound on the benefits of early ART is transient or irreversible –15.vs. ≥ 24 months of age). We included participants with an initial period of viral suppression but without any criteria on the persistence of viral control  HIV-1 infection after vertical transmission, (2) participant aged 5 to 17 years at the time of the study, (3) ART initiation for therapeutic purposes before six months of age or after two years of age, (4) with initial virological success (HIV-1 RNA < 400 copies/mL achieved within 24 months of treatment initiation), regardless of the subsequent course of viremia. Between 2016 and 2019, two 15 mL blood samples were collected for biological evaluations, at two consecutive routine clinical follow-up visits.N), central memory (TCM), transitional memory (TTM), effector memory (TEM) and effector (TE) cells; CD31 and CD95 expression was used to define recent thymic emigrants (TRTE) and stem cell memory cells (TSCM); and HLA-DR and CD38 expression was used to define activated T cells  or peptide diluent (DMSO). The cells were then cultured for 24 h. Spot-forming cells (SFCs) were counted with an ImmunoSpot S6 UV Image Analyzer .C-reactive protein (CRP), interleukin-6 (IL-6), CXCL10, soluble CD14 (sCD14), soluble CD163 (sCD163), and intestinal fatty acid-binding protein (iFABP) were quantified by ELISA . During the first few weeks of life, 30 children received prophylactic ART consisting of zidovudine (n=21), zidovudine+lamivudine (n=5), zidovudine+lamivudine+lopinavir (n=2) or zidovudine+lamivudine+nevirapine (n=2). For the last four of these children, the date of first HAART (ART1) initiation was the date of prophylactic ART initiation, as treatment was continued without interruption after diagnosis. At the time of the study, all but one of the children were on HAART, the remaining child being on two nucleoside reverse transcriptase inhibitors and having an undetectable viral load.The patients were either included at birth in The Agence Nationale de Recherche sur le SIDA et les Hépatites Virales (ANRS) EPF/ANRS CO10 national prospective multicenter cohort or were managed at the centers of the ANRS/CO10 cohort and diagnosed before the age of 13 years . Wilcoxon-Mann-Whitney, Kruskal-Wallis and the Fisher’s exact tests were used to compare the characteristics of children and adolescents between the early and late treatment initiation groups. The corrplot package of R was used to display Spearman’s rank correlation coefficients. Univariate and multivariate analyses were performed by linear regression, with CD4/CD8TP = .07), and had higher CD4 T-cell counts than adolescents . Immunovirological status was good in most patients at the time of the study.We prospectively enrolled 27 children (E-Ch) and nine adolescents (E-Ado) in the early ART (E) group, and 19 children (L-Ch) and 21 adolescents (L-Ado) in the late ART (L) group Table 1.N percentages were not significantly higher in E-Ch than in L-Ch . E-Ado had significantly lower CD4TN than L-Ado . The interaction between age and treatment group was significant (P = .008) and we performed analyses separately for children and adolescents.Blood CD4TRTE, 27.2% vs. 41.4%, P = .03) and CD31negTN , and higher levels of transitional memory (TTM) cells  than L-Ado. CD4 T-cell counts were positively correlated with CD4TN and CD4TRTE, and negatively correlated with the levels of most memory subsets , inflammation (CRP and IL-6) and gut permeability (iFABP) , but was inversely correlated with activated CD4TM percentage (model 2).In children, higher CD4Tcentages Figure 2N percentages were associated with late treatment, younger age, higher CD4 T-cell counts, and lower plasma CRP and iFABP levels, but not with either sex or geographic origin (N percentages were associated with late treatment and higher CD4 T-cell counts (model 1). Multivariate models including other variables were not robust to outliers (data not shown).In adolescents, higher CD4TN percentages in children, and was associated with lower CD4TN percentages in adolescents. In both groups, CD4TN percentages were associated with CD4 T-cell count and levels of immune activation and/or intestinal permeability.In conclusion, early ART was not significantly associated with higher CD4TN percentages than L-Ch , and lower percentages of the most differentiated effector memory cells  , and similar levels of CD8TN  , and with higher CD4/CD8 ratio and lower HIV DNA levels (model 2). The associations with CMV serostatus and sCD163 were not significant in multivariate models (data not shown).In children, higher CD8TN percentages were not associated with early ART, sex or geographic origin, but were significantly associated with younger age, higher CD4/CD8 ratio, lower normalized cumulative viremia, and lower levels of activated CD4 and CD8TM cells, IL-6 and iFABP (N percentages were associated with younger age and higher CD4/CD8 ratio (model 1), or with younger age and lower activated CD4TM cell levels (model 2).In adolescents, higher CD8TN percentages in children, but not in adolescents. In both groups, higher CD8TN percentages were associated with higher CD4/CD8 ratio and stronger immune activation.In conclusion, early ART was significantly associated with higher CD8TN level in E-Ado than in other groups was unexpected. One patient had <5% CD4TN and this very low value was confirmed on the second blood sample. Relative to the reference values for Spain, a second patient had a CD4TN percentage below the 10th percentile, two had values above the 90th percentile, and five had CD4TN percentages between the 10th and 90th percentiles . Two patients in each group were diagnosed on the basis of suggestive symptoms (P = .25). Two of nine E-Ado and five of 27 E-Ch had at least one CDC stage C event (P = .99); these events occurred before the age of six months in both groups. Graphical analyses of CD4TN values as a function of early clinical events and early HIV diagnosis revealed no obvious relationship . Thus, the low CD4TN levels in E-Ado may reflect limited HIV-driven TN production by the thymus.HIV replication leads to a depletion of CD4 T cells and drives the patients –23. We cnificant Table 3.N levels being driven by an expansion of CMV-specific lymphocytes. E-Ado and L-Ado had similar levels of cellular and plasma markers of immune activation, inflammation, and gut permeability  and low HIV-DNA levels  between E and L groups definitively to the timing of first ART, because data from an observational study necessarily reflect differences in care according to chronological time and place of birth. Nevertheless, pathophysiological description according to the timing of ART initiation is worthwhile, because it reflects the diversity of patients managed in France and other high-income countries.N cells. Children in whom treatment was initiated late had high CD4TN levels, probably because of their robust thymic activity. They achieved CD4 T-cell counts similar to those of their peers receiving early treatment, whilst on suppressive therapy. Thus, CD8TN levels, and their principal clinical correlate, CD4/CD8 ratio, are valuable indicators for use in long-term immune reconstitution studies in pediatric patients.In conclusion, we report that, in children over five years of age and adolescents, early ART clearly has a beneficial effect on CD8TThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Comité de protection des personnes Île-de-France V. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.PF, JLC, CD, VA-F, JW and FB conceived the study and analyzed the data. PF supervised the clinical study. VA-F supervised the virological study. JW supervised the study methodology and statistical analyses. FB supervised the immunological study. TM, DB, and IF performed the immunological tests and analyzed immunological data. JLC performed the statistical analyses. PF, CD, AF, SB, AC, CF, IH, ML, NM, VM, M-DT and FV followed the patients and contributed to clinical data. AH participated to data collection, TW managed the database. FB wrote the manuscript. All authors contributed to the article and approved the submitted version.ANRS (France Recherche Nord et Sud SIDA-HIV Hépatites) funded this study.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.