Modelling suggests that early diagnosis and immediate antiretroviral therapy (ART) among key populations would have a substantial impact in reducing HIV transmission and mortality in Vietnam. An implementation research project of “test‐and‐treat” among people who inject drugs (PWID) was developed to inform effective roll‐out of such interventions.3.“Test‐and‐treat” was offered to PWID in two high burden provinces, Thai Nguyen and Thanh Hoa. The interventions comprised the offer of biannual HIV testing and immediate ART, irrespective of CD4 count. PWID were enrolled between April 2014 and July 2015 and followed up for 12 months, and retention, HIV viral load (VL) and risk behaviours were assessed. Retention in care of this prospective cohort was compared with the retention among men enrolled in care in the preceding period (April 2012 to March 2013) at the same clinics when ART was initiated at CD4 cell count ≤350 cells/mm3. After 12 months, 238 participants (83%) were retained on ART, and 205 achieved viral suppression (<1000 copies/mL) . Baseline CD4 count ≤100 cells/mm3 and history of imprisonment were associated with lower retention and viral suppression, while engagement in methadone maintenance was associated with higher retention. Retention in care was higher in the “test‐and‐treat” cohort (83%) compared with men enrolled in care in the preceding period (78%), primarily because lost‐to‐follow‐up during pre‐ART care was eliminated. No decline in consistent condom use and clean needle use was observed.In total, 287 HIV positive PWID started immediate ART. The majority (98%) were men; median age was 34; and median (interquartile range) CD4 count was 199 (50 to 402) cells/mmEarly ART initiation resulted in successful treatment outcomes among PWID, with no observed increase in self‐reported risk behaviours, suggesting feasibility and potential effectiveness of “test‐and‐treat” approach. The results also call for differentiated care for PWID, including promoting early diagnosis and engagement in methadone maintenance therapy while enhancing care for those with advanced HIV disease and history of imprisonment. Concerns were raised among national stakeholders to offer ART irrespective of CD4 count among asymptomatic PWID, with regard to adherence, retention and potential increase in risk behaviours. In reality, a number of studies have shown that access to ART for HIV‐positive PWID remains a challenge globally However, the programmatic experiences of “test‐and‐treat” had been limited, especially in key populations in resource‐limited settings In such context, this implementation research project was designed with aims to assess feasibility and potential effectiveness of providing “test‐and‐treat” among PWID and to inform optimization of related policy development and programme implementation.22.1The study used a prospective cohort design, with viral suppression, retention and self‐reported risk behaviours as primary outcomes of interest, and sample size needed for prospective cohort was initially estimated as 306. Historical comparison of care retention before and after the introduction of “test‐and‐treat” was conducted, where data prior to “test‐and‐treat” were obtained retrospectively.The study was conducted in Thai Nguyen and Thanh Hoa provinces in Vietnam. HIV prevalence in PWID has been high in both provinces, with some decline in Thai Nguyen (from 38.8% in 2012 to 23.0% in 2016) and fluctuation in Thanh Hoa (11.0% in 2012 to 13.0% in 2016), according to the national HIV sentinel surveillance. HIV testing twice a year was recommended among PWID in both provinces. Immediate ART was offered at 13 HIV outpatient clinics  self‐reporting ever injecting any illicit drug and having a visible injection site on the body, (2) self‐reporting injecting illicit drugs in the past month, or (3) receiving MMT. Other eligibility criteria included: ART naïve; aged ≥18 years; living in one of the two study provinces; and no plan to move outside the province for at least one year. Exclusion criteria were: unable to provide consent; acute clinical condition ; or participation in another study with a similar research focus. Participants were recruited from April 2014 to July 2015 among those newly diagnosed HIV positive and linked to study clinics, and those who had previously diagnosed and were receiving care but had not been on ART at the clinics.2.22.2.1HIV testing services (HTS) was offered at healthcare facilities and MMT services and through community outreach at selected hot‐spots and remote communes. To promote early HIV diagnosis, healthcare workers and peer educators were trained to promote knowledge of ART and potential benefits and risks for immediate ART among PWID. PWID were recommended to seek HTS once every six months. PWID diagnosed HIV positive were referred to the HIV clinics by healthcare workers or peer educators.2.2.2People were assessed for the eligibility at the study clinics, and if eligible, they received baseline assessment and counselling upon written informed consent. The importance of using prevention measures was emphasized, including condoms, clean needles and MMT as appropriate. Participants then received CD4 cell count and viral load (VL) tests.2.2.3Upon study enrolment, participants were provided ART irrespective of CD4 count. Tenofovir, lamivudine and efavirez, as a fixed‐dose combination, was the preferred first‐line regimen. The study followed participants for 12 months from the date ART was started, or until they were recorded as attrition ), whichever occurred earlier. In instances when a participant reported moving to another province (transfer‐out), was arrested or was taken to compulsory drug treatment centres (06 centres) 2.3® AmpliPrep®/COBAS® TaqMan® 48 analyser  at National Institute of Hygiene and Epidemiology. Behaviour assessment was offered through counselling sessions, using the standard questionnaire at three, six and 12 months.Data on key dates  and treatment outcomes  are recorded on study specific logbook. VL was measured at six and 12 months after ART initiation. The quantitation of HIV‐1 viral ribonucleotide (RNA) were performed using COBASTo compare retention in care (including pre‐ART and ART care) before and after the introduction of “test‐and‐treat,” data of pre‐“test‐and‐treat” cohort were retrospectively extracted from medical charts at the study clinics. The data on attrition  during the first 12 months after care enrolment, together with injection drug use status if documented on the chart, were obtained for patients who were newly enrolled in care at the study clinics from April 2012 to March 2013. This timeframe was selected to ensure 12 month follow‐up period before “test‐and‐treat” was introduced in April 2014. Individuals who were transferred out or arrested were excluded from the analysis to ensure the consistent inclusion criteria with the prospective cohort.2.4Data were entered into Epi Info™ 7.0  and analysed using STATA 12.1 . The proportion of viral suppression, defined as VL <1000 copies/mL following the national and WHO guidelines a priori based on prior knowledge of potential correlates. Chi square test or Fisher's exact test were used to compare the status at 12 months after the care enrolment between the pre‐ and post‐“test‐and‐treat” cohorts.Cox proportional hazard models, using scaled Schoenfeld residuals to test the proportional hazard assumptions, was applied to analyse correlates for treatment retention, and Poisson regression analysis, with robust error variances In the historical comparison, to compare with the prospective cohort, two comparators were defined for the pre‐“test‐and‐treat” cohort: all the male patients, and those with injection drug use status documented in their medical chart. This was because under‐reporting of the injection drug use status has been common in Vietnam, due to stigma, discrimination and fear of being arrested 2.5The study protocols were reviewed and approved by the Institutional Review Board of Hanoi University of Public Health, and the Ethical Review Committee of the World Health Organization Regional Office for the Western Pacific.33.1Three hundred sixty‐seven persons were assessed for potential enrolment in the study, among whom 322 individuals met the eligibility criteria, and consented for enrolment; 30 were excluded as per protocol due to transfer‐out, arrest, or withdrawal from the study, resulting in 292 persons included in the comparison of care retention before and after introduction of “test‐and‐treat.” An additional five cases were excluded, due to attrition before ART initiation, resulting in 287 individuals for the analysis of treatment retention, viral suppression and risk behaviours of the prospective cohort Figure .3 with 34% having a CD4 count <100 cells/mm3. Median (IQR) VL was 61,200  copies/mL. Median (IQR) time from study enrolment to ART initiation was 2 (0 to 14) days. The characteristics at care enrolment of PWID in “test‐and‐treat” cohort and men and self‐reporting PWID enrolled in care before “test‐and‐treat” were shown in the Table Table 3.23 (N = 93) and between 101 and 350 cells/mm3 (N = 92) had significantly higher retention  than those with baseline CD4 count ≤ 100 cells/mm3 . Forty‐nine persons had attrition (28 deaths and 21 LTFU), with the majority of deaths (20 cases) occurring in the first six months, while majority of LTFU (17 cases) being recorded in the second six months.Of the 287 individuals starting ART, 83% were still on treatment 12 months after ART initiation   than those with ≤100 cells/mm3 (63.7%) , the proportion VL suppressed (<1000 copies/mL) was 8%, 87% and 92% respectively. There was no significant difference in the proportion achieving viral suppression at 12 months among the groups with different baseline CD4 count levels   and >350 cells/mm3  compared with CD4 ≤ 100 cells/mm3 and engagement in MMT  were associated with lower attrition, and history of imprisonment was associated with greater attrition   and >350 cells/mm3  compared with CD4 < 100 cells/mm3 were associated with lower risk of lack of viral suppression , and history of imprisonment were associated with lack of viral suppression  , a high proportion reported using clean needles at their last injection . Of respondents reporting sexual intercourse with their regular partner in the past three months , the proportion reporting consistent condom use in the past three months showed an increasing trend .3.5p = 0.004) . Figure n = 2, 0.7%) in the former than the latter  (p < 0.001). The result was consistent when those with PWID status documented was used as the comparator .Retention was significantly higher among PWID in “test‐and‐treat” cohort (N = 292), than among the males enrolled in care prior to introduction of “test‐and‐treat”  Figure a. When t4In this demonstration project, conducted in two Vietnamese provinces affected by heroin injection and associated HIV transmission, PWID were able to achieve relatively high retention (83%) and viral suppression (92% among tested) in the first 12 months of ART without increasing self‐reported risk behaviors. The “test‐and‐treat” approach also significantly reduced LTFU associated with pre‐ART care. These results suggest that “test‐and‐treat” among PWID will provide programmatically feasible and potentially high impact interventions, and likely contribute in effectively controlling HIV epidemic. Based on the interim results of this study, combined with other emerging evidence, the Ministry of Health of Vietnam decided to recommend provision of ART irrespective CD4 count for key populations from July 2015.Our study provided some of the first data on viral suppression among PWID in Vietnam. The level of viral suppression in the present cohort was comparable to outcomes reported by the other previous studies conducted in Vietnam among people on ART in general, including cohort studies 3). Attrition (deaths and LTFU) and lack of viral suppression at 12 months were associated with low baseline CD4 count (<100 cells/mm3). Late presentation for care and late initiation of ART have been common in Vietnam Our data confirmed that many PWID start ART at an advanced stage of HIV infection  and it unlikely affects the overall conclusions. Third, the outcomes of patients lost to care are unknown, and could include both positive outcomes (e.g. self‐transfers) and negative outcomes (e.g. deaths). Forth, our study recruited only a few females, and was unable to provide data on female PWID. Finally, our study followed the PWID only for the first 12 months of ART, and further study is needed to assess long‐term durability of immediate ART.5In conclusion, our study demonstrates that “test‐and‐treat” among PWID is a feasible and effective intervention in Vietnam. Early ART initiation resulted in relatively high retention and viral suppression among PWID without increasing self‐reported risk behaviors, while the “test‐and‐treat” approach reduced the risk of patients being lost during pre‐ART care. The interim results of this study informed revision of the national guidelines to recommend immediate ART among key populations in 2015. In order to achieve full therapeutic and preventive benefits of immediate ART in line with the global and Vietnam's goal to reach 90‐90‐90 by 2020 None to declare.MK, TTTD, HHN, VTTN, LMG, DDB, SMN and NTD designed the study, with advice from Y‐RL, NF, LHN and inputs from other co‐authors. Intensive monitoring of project implementation was conducted by HHN, TTTD, LQP, VTTN, THT, THP, SMN, ABS, NTD with support from DDB, LHN, LMG and MK. Data were managed and analysed by LQP, SMN, THT, THP and MK with advice from NF. MK drafted manuscript, with extensive feedback from other co‐authors.Table S1. List of members of the team for the implementation research project “Vietnam HIV early antiretroviral therapy with regular HIV testing (V‐HEART).”Table S2. List of study sites.Table S3. Characteristics at care enrolment of people who inject drugs in “test‐and‐treat” cohort and men enrolled in care before “test‐and‐treat.”Click here for additional data file.


ART) patients may improve retention in care and reduce facility workload. We assessed long‐term retention among clinically stable ART patients attending six‐monthly clinical consultations (SMCC) with three‐monthly fast‐track drug refills, and estimated the number of consultations “saved” by this model of ART delivery in rural Malawi.Longer intervals between clinic consultations for clinically stable antiretroviral therapy  were eligible for SMCC, with three‐monthly drug refills from community health workers. Early enrollees were those starting SMCC within six months of eligibility, while late enrollees started at least 6 months after first eligibility. Kaplan–Meier methods were used to calculate cumulative probabilities of retention, stratified by timing of their enrolment and from first six‐monthly clinical consultation. Cox regression was used to measure attrition hazards from the first six‐monthly clinical consultation and risk factors for attrition, accounting for the time‐varying nature of their eligibility and enrolment in this model of care.Stable patients  initiated this model of care. The median time from eligibility to enrolment was 12 months and the median cumulative time on SMCC was 14.5 months. Five years after first SMCC eligibility, cumulative probabilities of retention were 85.5% (95% CI: 84.0% to 86.9%) among early enrollees and 93% (95% CI: 92.8% to 94.0%) among late enrollees. The cumulative probability of retention from first SMCC was 97.0% (95% CI: 96.7% to 97.3%) and 86% (95% CI: 85% to 87%) at one and five years respectively. Among eligible patients initiating SMCC, the adjusted hazards of attrition were 2.4 (95% CI: 2.0 to 2.8) times higher during periods of SMCC discontinuation compared to periods on SMCC. Male sex, younger age, more recent SMCC eligibility and WHO Stage 3/4 conditions in the past year were also independently associated with attrition from SMCC. Approximately 26,000 consultations were “saved” during 2014.From 2008 to 2015, 22,633 clinically stable patients from 11 facilities were eligible for SMCC was high, especially among women and older patients, and its scale‐up could facilitate universal access to ART.After five years, retention among patients attending  In Malawi, substantial progress has been made towards achieving the The Joint United Nations Programme on HIV/AIDS (UNAIDS) 90‐90‐90 targets, with data from a household‐based national survey conducted in 2015 to 2016 indicating that 73% of people living with HIV aged 15 to 64 years reported knowing their HIV status, of whom 89% self‐reported current use of ART, and of whom 91% were virally suppressed Differentiated models of HIV care have been advocated as a strategy for managing clinically stable patients by reducing the number of consultations in HIV clinics, which would free up health worker time to initiate new patients onto ART, and better address the needs of patients needing additional monitoring Differentiated models of ART delivery can be broadly classified into individual models (facility or out‐of‐facility) and group models  To date, there is a dearth of evidence from African settings on the effectiveness of facility‐based individual models of differentiated care, including data on long‐term retention rates and risk factors for attrition from care among patients enrolled in these models 22.1MSF has supported the Malawian MoH provision of HIV and tuberculosis services to around 270,000 persons in Chiradzulu district in southern Malawi since 1997 2.2From January 2008, adult patients attending any HIV clinic in the district's health facilities were screened by a clinical officer, and those meeting eligibility criteria  after first eligibility date, stratified by enrolment status  or late enrollee (enrolled at least 6 months after first eligibility date)) and (ii) after first SMCC appointment. Attrition was defined as either reported death, or loss to follow‐up, with lost to follow‐up recorded for patients more than 60 days late for their last scheduled appointment. Cox proportional hazards regression was used to estimate crude and adjusted hazard ratios for attrition up to five years after first SMCC, and to identify risk factors for attrition. Eligibility and enrolment onto the SMCC schedule were considered as time‐dependent variables since patients could become ineligible for periods of time, for example if they became pregnant, but could later return to being eligible. Similarly, SMCC‐enrolled patients could leave and re‐enter the six‐monthly schedule, either due to changing eligibility status or for other reasons including a desire to return to shorter durations between appointments.In five health centres, routine viral load monitoring was implemented from August 2013 in line with MoH protocols . Among patients attending these health centres, the proportions with an undetectable viral load (defined as <1000 copies/mL) and the median time from SMCC initiation to viral load test were reported.In order to calculate the total number of clinical appointments that were “saved” per year since SMCC introduction, we classified each patient visit as being either eligible or ineligible for SMCC. Eligible visits were further classified as: (a) a SMCC visit; (b) a drug refill visit with an HSA; or (c) routine visit (i.e. a non‐SMCC clinic visit among an SMCC‐eligible patient) and aggregated over a 12‐month period. The estimated number of appointments per category per year was then presented graphically. We defined the annual number of drug refill visits with an HSA as the annual number of clinical consultations that were saved. The total number of clinical appointments saved since the introduction of SMCC was calculated by summing these annual totals over the years of SMCC implementation.2.5Ethical approval was provided by the National Health Sciences Research Committee in Malawi. As this is a secondary analysis of routinely collected programme data which were anonymized prior to analysis, consent for participation from patients was not sought. This research fulfils the exemption criteria set by the Médecins Sans Frontières Ethics Review Board for a posteriori analysis of routinely collected clinical data.33.1In total, 47,904 patients aged 18 years and over were seen between January 2008 and July 2015, of whom 26,081 ever met the eligibility criteria for SMCC . The mos3, with a median duration since the CD4 count measurement of eight months. The median number of months from first eligibility for SMCC to starting the SMCC schedule was 12 months [interquartile range (IQR): 3 to 27 months].Of the 22,633 individuals in the analysis , 19% never enrolled, 31% were early enrollees and 50% were late enrollees ).Following first eligibility for SMCC, patients who never initiated the SMCC schedule spent a median cumulative time of 12 months being eligible for SMCC and 10 months being no longer eligible for SMCC  among those who never enrolled, 97.3% (95% CI: 96.8% to 97.6%) among early SMCC enrollees and 99.8% (95% CI: 99.7% to 99.9%) among late SMCC enrollees, while the corresponding figures at five years were 47.4% (95% CI: 45.0% to 49.7%), 85.5% (95% CI: 84.0% to 86.9%) and 93.4% (95% CI: 92.8% to 94.0%) respectively . Patients with recorded WHO Stage 3/4 conditions in the past year had higher attrition hazards compared to those who did not .In the adjusted models, patients had 2.6 times higher hazards of attrition (95% CI: 2.2 to 3.1) during periods when patients were eligible but no longer on SMCC, and 2.4 (95% CI: 1.9 to 3.0) times higher hazards of attrition during periods when patients were not eligible and off SMCC, compared to periods when they were both eligible and enrolled on SMCC There was no difference in adjusted hazards of attrition among patients during periods when they were not eligible and on SMCC compared to periods when they were eligible and on SMCC (adjusted hazard ratio (aHR) = 1.2; 95% CI: 0.8 to 1.8). In the adjusted models, there was an increased hazard of attrition among patients aged 18 to 24 years  and in those aged 25 to 34 years  compared to patients aged 35 to 44 years, and among men compared to women . There was a trend in increased attrition hazards with more recent calendar years of SMCC eligibility  individuals. Of these, 93% (n = 1619) of viral load measurements were <1000 copies/mL. The viral load test was done a median of 21 months following first SMCC enrolment [IQR: 14 to 28].3.6In 2008, when the strategy was first introduced, a total of 110,389 clinic visits were recorded across the 11 facilities among patients ≥18 years of age  times higher during periods of SMCC discontinuation compared to periods on SMCC, suggesting the need for careful patient monitoring among patients who discontinue SMCC. As with traditional models of ART delivery in many settings Although 81% of all eligible patients were initiated on to SMCC, there was a median time of 12 months from first eligibility to first SMCC. Furthermore, the cumulative median time on SMCC was relatively short at 14 months among early and late enrollees, suggesting that efforts are needed to reduce the delay between becoming eligible for SMCC and moving to this schedule. Although further research is needed to understand and address patient and health systems barriers to SMCC uptake, it is likely that further health worker training on application of the SMCC protocols and ensuring patient readiness may reduce delays in SMCC initiation following eligibility.This model of differentiated ART delivery in this setting saved just under 62,000 clinical consultations over seven years, despite the slow pace of the rollout. Assuming that a typical clinical officer conducts around 500 consultations per month, the total savings equates to almost 118 clinician‐months or approximately 10 clinician‐years for the health facilities in this district over the study period. During 2014, approximately 26,000 appointments had been moved outside the clinic during the year as a result of SMCC, corresponding to approximately sixty clinician‐months or five clinician‐years, and representing a substantial saving in health worker time in a country with severe workforce shortages.These findings demonstrate that SMCC can play a key role in enabling ART programmes to continue their expansion as test and treat policies are introduced, by freeing up health worker time to initiate new patients on ART, and manage complicated cases such as patients with suspected treatment failure, opportunistic infections, or those taking second‐line regimens. Furthermore, this model of care is likely to be scalable in Malawi, and elsewhere, because the strategy requires fewer formally trained health workers and no additional resources than the current standard of care.The findings from our analysis are consistent with studies investigating the effectiveness of community‐based or group‐based ART delivery strategies for clinically stable patients in other settings There are various limitations that need to be considered when interpreting these findings, including those inherent to using routinely collected programmatic data such as missing information that could influence classifications of SMCC eligibility, or result in residual confounding . In particular, better documentation of reasons for delayed initiation and non‐initiation of SMCC among apparently eligible patients would help to understand the poorer outcomes among this group which precluded us from using them as a comparison group in our analyses, due to selection biases that this would introduce Previous studies reporting retention rates among patients receiving ART through other models of differentiated care have had shorter follow‐up periods While these findings provide a much‐needed and widely called for contribution to the evidence base on differentiated models of ART delivery 5In conclusion, our findings demonstrate that SMCC with fast‐track refills for clinically stable, first‐line ART patients represents an effective and feasible strategy for delivering treatment, enabling substantial savings in terms of health worker input, providing more flexible access to care and achieving excellent outcomes under routine programme conditions. Further scale‐up of facility‐based consultation‐spacing strategies with three‐monthly fast‐track ART refills from community health workers should be encouraged, accompanied by ongoing programme monitoring and evaluation in other settings, as an important step towards achieving universal access to ART and a future free of AIDS.None to declare.AW, SN and CC designed the study; CM, CC and SN oversaw the data management; SN, CC and AW designed or undertook the analysis; AW, SN, CC, ES, LS and EP interpreted the data; AW and CC wrote the first draft of the manuscript. All authors provided comments which were incorporated into subsequent drafts by AW.Figure S1. Flow chart showing inclusion and exclusion for the analysis.Click here for additional data file.


Simplification strategies of antiretroviral treatment represent effective tools for the reduction of drug-induced toxicity, resistance mutations in case of virological failure and costs.rtv) or unboosted atazanavir (ATV400) plus lamivudine, and if low plasma or intracellular ATV Ctrough influence virological outcomes.To assess the effectiveness of simplification to atazanavir/ritonavir  were allowed if the resistance tests showed major resistance mutation neither to ATV nor to lamivudine. VF was defined as two consecutive plasma HIV-RNA >200 copies/mL. Effectiveness was assessed by intention-to-treat and on-treatment analyses. Plasma and intracellular ATV Ctrough were measured by LC-MS/MS.Ambispective observational study in patients with undetectable HIV-RNA who were switched to ATVrtv and ATV400 groups were 85.9%  versus 87.6%  by intention-to-treat analysis (p = 0.684), and 97.7%  versus 98.8%  by on-treatment analysis (p = 0.546), respectively. Plasma and intracellular Ctrough were significantly higher with ATVrtv than with ATV400 (geometric mean (GM), 318.3 vs. 605.9 ng/mL; p = 0.013) and , respectively. Only 14 patients had plasma Ctrough below the suggested effective concentration for ATV (150 ng/mL). No relationship between plasma or intracellular Ctrough and VF or blips were found.A total of 246 patients were included. At week 48, the Kaplan–Meier estimation of efficacy within the ATVtrough observed with ATV400 do not compromise the effectiveness of these simplification regimens in long-term virologically suppressed HIV-1-infected patients.Boosted or unboosted ATV plus lamivudine is effective and safe, and the lower plasma C In the group of ATV400 the numbers of non-virological failures were 1 (1%) for AEs , 6 (6.2%) for loss to follow-up, and 4 (4.1%) for change of treatment by medical decision. All patients had an undetectable viral load at the time of the last available HIV-RNA assessment on ATV.In addition to VF, other treatment failures in the ATVrtv experienced blip episodes , while only eight (8.2%) patients on ATV400 experienced nine blip episodes (p = 0.148), with a median HIV-RNA of 129 copies/mL .During the 48 weeks of follow-up, 20 (13.4%) patients on ATV+ T cell counts from baseline to week 48 was 20 cells/μL  and 50 cells/μL  in the ATVrtv and ATV400 groups, respectively, being inversely proportional to the baseline CD4+ T cell counts The median increase in CD4rtv group , three of them suffered chronic hepatitis C, and in 1 patient in the ATV400 group (grade 1), who was also coinfected by hepatitis C virus. These alterations were transient and improved without treatment modification in all cases. Regarding changes in lipid profiles between baseline and week 48, no significant differences between the ATVrtv and ATV400 groups were observed, with median changes (mg/dL) of 8  versus -12  in fasting total cholesterol, 1  versus -2  in HDL-cholesterol, 12  versus -12  in LDL-cholesterol, and 4  versus -25  in triglycerides, respectively.Aminotransferase level elevations throughout the follow-up period occurred in 4 patients in the ATVrtv and ATV400 group, respectively. ATV Ctrough were determined in 339 plasma samples , and in 35 PBMCs samples of each group  for ATVrtv and from 45.1 to 1755.0 ng/mL  for ATV400 (p <0.001). Whereas in PBMCs samples, the corresponding values were 2659.2  vs. 811.3 ng/mL  (p <0.001) for ATVrtv and ATV400, respectively. Likewise, the mean intracellular penetration, evaluated as intracellular/plasma Ctrough ratios was higher in the ATVrtv group than in the ATV400 group . There was a correlation between the plasma and intracellular Ctrough in patients taking ritonavir-boosted ATV , but not in those on unboosted ATV .The pharmacokinetics study was conducted in a sub-group of 63 and 78 patients in the ATVch group . In bothrtv group and 43 (17.7%) samples from 12 patients of the ATV400 group. Given the low number of VF, it was not possible to establish any relationship between VF and plasma or intracellular concentrations, however, none of the patients with plasma ATV Ctrough below 150 ng/mL had VF. No association between blip episodes and a low ATV Ctrough was observed. Likewise, there were no relationships between plasma and intracellular ATV concentrations and weight or body mass index, and there were no differences in plasma and intracellular ATV concentrations with respect to gender or the presence of cirrhosis.ATV concentrations below the suggested minimum effective concentration of 150 ng/mL were detected in two (1.8%) samples from 2 patients of the ATVrtv and ATV400 groups, the median intra-subject variability for ATV was 32.3% and 44.6% in plasma samples and 34.5% and 40.3% for intracellular ATV. The corresponding median inter-subject variability was 197.23% and 99.23% in plasma, and 118.8% and 97.2% for cellular samples.For the ATVIn the last years, several ART simplification strategies have been studied in order to reduce the severity or even avoid AEs from chronic drug exposure, lower the risk of HIV-1 drug resistance, and achieve more cost-effective regimens. Among them are dual therapies based on ritonavir-boosted PIs in combination with 3TC or other drugs that have shown good efficacy rates and safety profiles, being this simplified regimen an option in low resource settings or when clinicians prefer the least number of drugs possible for their patients. , 28–30. rtv-based regimen before switching to dual therapy. Our results are similar to those reported by the ATLAS-M clinical trials [95, 84.3–94.7%) and 90.1%  respectively, and even better than those in the SALT trial [rtv  +  2 plus two NRTIs in long-term supressed patients. To our knowledge, only two studies of dual therapy comprising ATV400 plus 3TC [400 plus two NRTIs were switched to ATV400 plus 3TC or emtricitabine, without any VF or discontinuation after 48 weeks. In the other study, treatment-experienced HIV-infected patients were switched from triple therapy to boosted or unboosted ATV plus 3TC with no VF. However, the latter study only analyzed the first six months after switching to dual therapy, and sample sizes were as low as 40 and 20 patients, respectively.In spite of being a study performed in the routine clinical practice, a high effectiveness of ATV plus 3TC was observed at 48 weeks, although it should be taken into account that most of patients of the study were virologically suppressed for a long time. Furthermore, less than 2% of the population presented AEs that led to treatment discontinuation, which may partly be explained by the large proportion of patients who were already on an ATVl trials , where tLT trial  that fouplus 3TC –20 are atrough in the non-boosted regimen as compared with the ritonavir-boosted regimen both in plasma and on intracellular level [et al. [trough lower than 150 ng/mL was associated with a high probability of VF in PI-experienced patients, most of them showing plasma HIV-RNA loads higher than 1000 copies/mL. In contrast, none of the patients with a plasma ATV Ctrough below 150 ng/mL had VF in the present study, although it is to note that the clinical condition of the herein analyzed populations was different regarding their virological and immunologic status.In accordance with previous pharmacokinetic studies, the herein presented work finds lower ATV Car level –33. The ar level –35. In t [et al.  found thrtv is progressively decreasing since it is being replaced by a co-formulation including the pharmacokinetic enhancer cobicistat, which is not analyzed in the present study. However, two randomized, crossover bioequivalence studies have shown that ATV/cobicistat (300/150 mg) provides bioequivalent ATV exposures as compared to ATVrtv, both in healthy volunteers and treatment-naïve adults infected with HIV-1 [400 may be a good alternative. Another limitation is the low number of blood samples for pharmacokinetics study, since this substudy was only conducted in the prospective part. However, the determination of ATV plama levels was not the primary aim of the study and furthermore, still a considerably number of samples were obtained.One of the limitations of this study is that in the last years the use of ATVth HIV-1 –37. Althtrough is observed with ATV400, this does not appear to compromise the effectiveness of these regimens in virologically suppressed patients. However, the lasting efficacy of this regimen would need further investigation with clinical trials.In conclusion, our data suggest that boosted or unboosted atazanavir plus lamivudine represent comparable simplification strategies regarding effectiveness and safety in HIV-infected patients with long-term virological suppression. Although lower plasma and intracellular ATV CS1 TableM (IQR), Mean (interquartile range). ATVrtv, atazanavir boosted with ritonavir. ATV400, unboosted-atazanavir. ART, antiretroviral treatment. PIrtv, ritonavir-boosted protease inhibitor. NRTIs, nucleoside reverse transcriptase inhibitors. INSTI, integrase strand transfer inhibitor.(DOCX)Click here for additional data file.


Zimbabwe, like other resource limited countries, manages HIV infection using the public health approach with standard antiretroviral therapy (ART) regimens for first, second and third-line treatment. Third-line ART is the last available treatment option and is based on dolutegravir and darunavir use after HIV drug resistance testing.We report here a 17-year-old patient on dolutegravir (DTG) and Darunavir based third-line antiretroviral therapy (ART) previously exposed to raltegravir who develops multidrug resistance HIV to the four ART classes available in Zimbabwe.A trophism assay revealed that patient has CXCR4 trophic virus and hence will not benefit from Maraviroc. Patient is currently stable and receiving a holding regimen of abacavir, lamivudine and lamivudine.This is the first documented case of multiclass resistance to the four available ART classes in Zimbabwe. The development and transmission of multiclass HIV drug resistance in resource limited settings has potential to undo the gains of national ART programs. There is need to ensure optimum adherence to ART even in the era of DTG. To date, no cure exists for HIV, and hence patients must remain on effective ART for the rest of their lives, that makes the development of drug resistance a major public health concern. Sustained viral suppression is of paramount importance if drug resistance is to be prevented. Strategies to ensure optimal adherence to ART are, therefore, an important component of HIV care and treatment. Antiretroviral therapy resistance limits further treatment options, increases treatment programme costs and drug resistance may even be transmitted to others.4 Treatment guidelines have periodically changed and are guided by the World Health Organization (WHO). In 2015, Zimbabwe introduced third-line ART in the national programme. Patients failing second-line ART are referred for specialist assessment that includes viral load (VL) and genotype testing prior to recommending third-line medicines. Adherence needs to be reinforced at all times.4HIV treatment in Zimbabwe is based on a public health approach using standard national treatment guidelines.We report the first case of documented four-class HIV drug resistance in Zimbabwe that highlights the possibility of third-line ART failure and transmission of untreatable HIV in resource-limited settings.We report the case of an adolescent girl born in July 2000. She tested positive for HIV infection in 2009 and was enrolled into care at Newlands Clinic on 30 July 2009. She is the last born in a family of three children, a paternal orphan and stays with her mother. She was vertically infected, and her mother is accessing ART at the same treatment centre. Both her siblings are HIV negative. She commenced first-line ART on 28 August 2009. Monitoring for ART treatment success was done clinically and immunologically since the initiation of treatment. Routine VL monitoring was added in January 2014. A genotypic resistance test was performed on 31 March 2015 after second-line ART failure. Results of the test were interpreted using the Stanford HIV drug resistance guide. We found four major protease inhibitor (PI) resistance-associated mutations (RAMs), that is, M46I, I54V, L76V and V82A. The PI RAMs conferred high-level resistance to atazanavir (ATV), lopinavir, indinavir and saquinavir.There were three nucleoside reverse transcriptase (NRTI) RAMs, that is, M41L, M184V and T215F, and three non-NRTI RAMs, that is, A98G, K103N and E138A. The RAMs conferred intermediate resistance to abacavir, zidovudine, stavudine, didanosine and rilpivirine. There was high-level resistance to emtricitabine, lamivudine, efavirenz and nevirapine. The virus had low-level resistance to tenofovir and etravirine. She was started on third-line ART in August 2015. She has had challenges with treatment adherence because of the high pill burden, and received 3TC monotherapy as a holding therapy from March 2017 (VL was 255 397 copies/mL) to January 2018. She was treated for pulmonary tuberculosis (TB) from 08 August 2017 to 23 January 2018. The TB diagnosis was made based on loss of weight and suggestive chest X-ray findings. She improved clinically on TB treatment, and after completing 6 months of therapy, she recommenced third-line therapy with ritonavir-boosted darunavir, lamivudine and dolutegravir (DTG). She came daily to the clinic for a nurse to observe her and to take third-line medicines for 16 weeks, but her VL remained very high.An integrase strand transfer inhibitor (INSTI) resistance test was then performed on 14 June 2018. Results showed three integrase inhibitor major RAMs, that is, E138K, G140A and Q148R. The RAMs conferred high-level resistance to DTG, raltegravir (RAL) and elvitegravir (ELV). Trophism assay was performed, and results showed that unfortunately the patient is CXCR4 trophic and hence maraviroc is unlikely to work. The recently approved post-attachment inhibitor, ibalizumab, is not available in the country. She was commenced on a holding regimen of ABC, 3TC and AZT, and her latest VL done on 12 November 2018 was 771 334 copies/mL. Her mother is virologically suppressed on a second-line ART regimen of ATV or ritonavir, AZT and 3TC.Analysis of routine clinical data is approved by the Medical Research Council of Zimbabwe as part of a larger study, International Epidemiological Databases to Evaluate AIDs (IeDEA Collaboration) . Verbal assent from adolescent and written informed consent from parent were obtained.5 and a similar case was reported earlier in South Africa.6 Multi-drug resistant HIV could have developed because of a variety of factors, including poor adherence to ART and inadequate psychosocial support – issues which are frequently encountered among adolescents living with HIV.7 In this case, poor adherence was mainly because of poor family support and lack of motivation for ART when the patient felt clinically well. Poor adherence to previous ART regimens could have led to exposure to DTG monotherapy. Previous studies have shown that monotherapy with DTG has a high rate of resistance selection in the integrase gene through different pathways in case of virologic failure.8To our knowledge, this is the first report of a patient with a virus that has developed multi-class drug resistance to all four standard classes of ART, including INSTIs, in Zimbabwe. This patient has HIV with high-level resistance to DTG after previous exposure to RAL. Recently, a case of multi-drug resistant HIV, including resistance to INSTIs, was reported from Botswana10 Zimbabwe has not yet adopted the use of DTG as part of the preferred first-line ART regimens.Integrase strand transfer inhibitors are one of the newest class of antiretroviral drugs to be approved for HIV treatment and act by inhibiting the essential HIV protein integrase from inserting the viral DNA genome into the host cell’s chromatin. Raltegravir and EVG have been successful in clinical settings, but have low genetic barriers to resistance. Dolutegravir is known to have a very high genetic barrier to resistance and retains activity against RAL- and EVG-resistant viruses.This is the first case of recorded four-class HIV drug resistance in Zimbabwe. This adolescent girl cannot be effectively treated with any of the currently available ART regimens in Zimbabwe. Prevention measures such as family planning intervention and safe sex counselling are being taken to minimise the risk of transmission of this multi-class resistant virus.This case emphasises the need for health workers to continue providing adherence counselling and support for patients who are on ART. Transmission of four-class-resistant HIV is a potential public health disaster.


Pharmacists have demonstrated the ability to improve patient adherence to antiretroviral therapy (ART).To determine the clinical and economic effects of a pharmacist-administered ART adherence clinic for patients living with human immunodeficiency virus (HIV).This pilot study with a pretest-posttest design examined the effect of a pharmacy adherence clinic on patient HIV viral load and CD4 count over a 6-month period. Patients with documented adherence problems were referred to the clinic. The pharmacist counseled patients at baseline and met with patients 1-2 weeks, 6 weeks, 3 months, and 6 months after starting ART. A societal perspective net cost analysis of the pharmacy adherence clinic was conducted to assess the economic efficiency of the intervention.P = 0.001). In the 3 months following the intervention, we estimated that it prevented approximately 0.13 secondary HIV infections among the sexual partners of the 16 participants who completed the intervention. The total cost of the intervention was $16,811 , which was less than the future savings in averted HIV-related medical care expenditures .Twenty-eight patients were enrolled in the study, and 16 patients reached completion. Median HIV RNA significantly decreased from 48,000 copies/mL  to undetectable (< 20 copies/mL) at 6 months for all study participants who completed the full intervention (A pharmacy adherence clinic that focused on early and sustained ART adherence interventions helped patients with documented medication adherence problems achieve an undetectable HIV RNA. The intervention was highly cost saving, with a return of nearly $3 in future medical care savings per dollar spent on the intervention. What is already known about this subjectAdherence to human immunodeficiency virus (HIV) antiretroviral therapy (ART) yields quality of life and survival benefits to the person living with HIV and reduces the chance of transmission of HIV to other individuals.Adherence counseling, before and after ART initiation, has been shown to improve ART adherence.Multidisciplinary care teams that include pharmacists have a positive effect on ART adherence in HIV-infected patients.What this study addsThis study demonstrated that a pharmacist-led ART adherence clinic operating within a multidisciplinary care clinic can help HIV-infected patients with documented medication adherence problems achieve HIV viral suppression.In addition to the positive clinical effect, this intervention was highly cost saving, with a return of $2.96 in future medical care savings for each dollar spent on the adherence intervention.Under conservative assumptions of the durability of this intervention, the adherence clinic also showed significant prevention of HIV transmission to the partners of the adherence clinic participants.3). Early ART initiation and viral suppression, or maintaining an undetectable HIV viral load, is critical to the health and longevity of persons living with HIV (PLWH).2 Moreover, PLWH who achieve an undetectable viral load are less likely to transmit HIV to their sexual partners than are PLWH with unsuppressed virus.3 Viral suppression therefore has significant benefits for the individual patient and for public health. Unfortunately, only 30% of the approximately 1.2 million PLWH in the United States have achieved viral suppression.4Nearly all persons living with human immunodeficiency virus (HIV) who adhere to antiretroviral therapy (ART) active against their virus attain an undetectable HIV RNA viral load  evaluate the clinical effect  of a pharmacist-led ART adherence clinic that focused on early and sustained adherence counseling and (b) assess the economic efficiency from a societal perspective of this adherence intervention.A pharmacist-led ART adherence clinic was held 2 half-days per week at the University of New Mexico Truman Health Services (THS), a primary care clinic providing multidisciplinary services to approximately 1,200 HIV-infected patients. Pharmacists did not work in the clinic outside of the 2 half-days per week on which the adherence clinic was held. The adherence clinic was staffed by licensed pharmacist clinicians with prescriptive authority who provided medication adherence counseling to patients referred to the clinic by their primary care providers (PCPs).THS PCPs referred patients to the adherence clinic for 1 or more of the following reasons: (a) initiation or reinitiation of ART; (b) ART failure, defined by a viral load > 400 copies/mL at 24 weeks or following previous viral suppression; (c) high risk for treatment failure; (d) potential or diagnosed adverse drug reaction; or (e) other adherence or pharmaceutical care issues, as determined by the PCP. Patients at high risk for treatment failure included those who had previously failed to adhere to ART or other medications, as well as patients with polypharmacy, a busy life schedule, active substance abuse, mental illness such as depression, and/or homelessness.Adherence clinic patients were eligible for study inclusion if they were (a) referred to the clinic by their PCPs for medication adherence concerns between December 1, 2011, and June 1, 2013; (b) aged ≥ 18 years; (c) without HIV dementia as determined by their PCPs; (d) consented to participation in the study; and (e) were able to read and understand English. This study was approved by the University of New Mexico Human Research Review Committee and conforms to the Declaration of Helsinki.18Sociodemographic and clinical characteristics of participants were recorded from the electronic medical record and patient interviews at baseline and included age, gender, race/ethnicity, HIV risk factor, ART adherence barriers, highest level of education completed, and any comorbid psychiatric conditions. Participants also completed the Substance Abuse and Mental Illness Symptoms Screener (SAMISS) questionnaire to screen for mental illness and/or substance abuse. The SAMISS is part of the standard of care in the adherence clinic and has been shown to be a good initial screening tool for substance abuse and mental illness in an outpatient HIV clinic.19 The focus on early and sustained adherence counseling was applied to all patients initiating ART during the study period, regardless if they had been prescribed ART in the past. In this context, “early” is used in reference to each patient’s ART initiation during the study period. The initial adherence clinic visit lasted approximately 1 hour, after which participants were prescribed ART. Patients returned to the adherence clinic for 30-minute follow-up visits with the pharmacist at 1-2 weeks, 6 weeks, 3 months, and 6 months. Standard-of-care visits with PCPs at the THS did not occur until at least 6 weeks after ART initiation. Participants were allowed a grace period of ± 1 week when making follow-up appointments.The adherence clinic was designed to ensure a regularly scheduled, initial patient follow-up by a pharmacist, allowing for early identification and management of ART-related side effects and adherence barriers following ART initiation or reinitiation, in order to improve long-term medication adherence and clinical outcomes.Pharmacists in the adherence clinic focused their efforts on medication and disease state education. During each appointment, pharmacists performed the following as indicated or appropriate: medication reconciliation; screening for opportunistic infection prophylaxis; assessing patient adherence to ART; screening for ART adherence barriers; managing ART side effects and drug interactions; discussing patient CD4 counts, HIV viral loads, and the goals of ART therapy; using motivational interviewing techniques to encourage ART adherence; using patient recall and repetition rather than informational handouts; ordering laboratory tests and immunizations; providing management recommendations to PCPs; developing patient ART regimens with the PCPs; prescribing and/or refilling medications as necessary; and making referrals to specialists.Baseline patient-level sociodemographic and clinical characteristics were compared between the entire study population and the subpopulation of participants who completed the final 6-month follow-up visit to assess differential loss to follow-up using Pearson’s chi-square test and the Wilcoxon signed-rank test. Wilcoxon signed-rank tests were used to compare participants’ CD4 counts and HIV viral load obtained at ART initiation (baseline) and 6 weeks, 3 months, and 6 months after ART initiation. Statistical analyses were performed using SPSS version 20.0 .20 All costs were expressed in 2015 U.S. dollars. Univariate sensitivity analyses and scenario analyses were conducted on key variables.The net cost analysis was conducted from the societal perspective and included a valuation of patient time and travel expenses, as well as costs incurred by the adherence clinic to implement the intervention.The cost to the THS of implementing the adherence intervention included salaries and fringe benefits for the pharmacists and receptionists who staffed the clinic, together with a 25% clinic operations overhead charge, which also included costs related to any social workers or supportive services to assist with obtaining ART. The time pharmacists spent with adherence clinic patients was obtained from study records. An additional 40 minutes of pharmacist time was added to each patient encounter  to account for time pharmacists spent reviewing patient records before each appointment and recording notes after the encounter. Clinic receptionists spent an estimated 10 minutes checking in each patient and scheduling follow-up appointments.21 Total travel time consisted of a patient’s driving time plus 20 additional minutes to park, walk from the clinic parking area to the clinic, and then walk back again. Time at the clinic included the actual time spent receiving the adherence intervention from the pharmacist; 5 minutes to check-in before the clinic appointment and 5 minutes after to schedule the next appointment; and 10 minutes of wait time. Time spent by patients traveling to and from the clinic and time spent at the clinic was valued at the New Mexico minimum wage. We valued participants’ time at minimum wage based on the low per capita income of Albuquerque residents  and the large proportion (41.7%) of HIV-positive Ryan White Program enrollees in New Mexico who were below 200% of the federal poverty level.22Patient records were used to determine residential ZIP codes, which then were used to estimate a patient’s travel distance and time to the clinic using Google Maps. Patient transportation costs were calculated using the government reimbursement rate of $0.575 per mile.The cost analysis adopted an intent-to-treat approach in which the total intervention cost estimate included costs for all study patients (n = 28), regardless of whether they completed the full intervention. The effectiveness analysis conservatively assumed that patients who failed to complete the intervention received no benefit from the intervention. The average cost per patient who completed the intervention also was calculated.23 and with the findings of the HIV Prevention Trials Network 052 study,3 our analysis assumed that PLWH who maintain an undetectable viral load through adequate ART adherence are 84%-96% less likely than PLWH with detectable virus to transmit HIV to a sex partner during a given time period—that is, the HIV transmission rate is 84%-96% smaller for PLWH with undetectable virus than for those with detectable virus.24 While this HIV transmission rate pertains directly to sexual HIV transmission, evidence suggests that ART is also associated with reduced HIV transmission among persons who inject drugs.25 Given the small number of injection drug users in this study sample, our analysis assumed an 84%-96% reduction in transmission for all patients.The economic analyses focused on the HIV prevention benefits of the ART adherence intervention, a main goal of which was to help patients with detectable virus reduce their viral load to undetectable levels and then maintain it there. Consistent with a modeling study by Granich et al. (2009)26 Two different estimates of the expected number of secondary infections were calculated for each participant with undetectable virus at the 6-month follow-up: the first estimate, S1, assumed that the participant would maintain an undetectable viral load throughout the 3-month period, whereas the second estimate, S2, assumed that, had the participant not received the adherence intervention, his or her viral load would have remained at detectable levels. The total number of secondary HIV infections prevented by the intervention then was estimated as A = N * (S2 – S1), where N denotes the number of study participants with undetectable viral load at the 6-month follow-up.The analysis used an HIV transmission rate model to estimate the number of secondary HIV infections that would be expected among each study participant’s sex partners during the 3-month period directly following the 6-month follow-up clinic visit.27 Each secondary HIV infection prevented by the intervention saves society the lifetime medical care costs, T, associated with treating a case of HIV infection. The net cost of the intervention is therefore Cnet = Cintv – A * T, where Cintv is the total cost of the intervention from an intention-to-treat perspective.28 If the net cost is negative  then the intervention is considered cost saving.The corresponding savings in averted future HIV-related medical care expenditures and lost quality-adjusted life-years (QALYs) were estimated using previously described methods.Twenty-eight THS patients were screened for the study and subsequently enrolled . Most paSixteen of the 28 participants (57.1%) attended all follow-up visits, including the 6-month final follow-up visit. Four (14.3%) of the remaining participants attended at least 1 follow-up visit, and 8 participants (28.6%) did not attend any follow-up visits. Six of the patients who missed 1 or more follow-up appointments were reachable by telephone at the end of the study. The reasons cited by these participants for missing appointments centered around living and social issues. There were no statistically significant differences in patient-level characteristics between patients who completed and who did not complete the study.P = 0.001), whereas median HIV RNA viral load decreased from 48,000 copies/mL  at baseline to all participants having an undetectable HIV RNA level at 6 months .Findings from the longitudinal analysis of clinical outcomes for patients who completed all follow-up visits indicated statistically significant differences in CD4 counts and viral load levels between baseline and the 6-week, 3-month, and 6-month follow-up assessments . SpecifiThe total cost of the adherence intervention as implemented (intention-to-treat cost) was $16,811, or $1,050.68 for each of the 16 patients who completed the intervention; noncompleters accounted for 22% of the intention-to-treat cost. The true mean cost per patient who completed the 5-visit intervention was $819.74. This total includes $139.24 in costs borne by patients and $680.50 in clinic-borne costs. Compensation for pharmacists’ time  accounted for 78% of the total cost to the clinic for each patient who completed the adherence intervention.The transmission rate modeling analysis indicated that the adherence intervention prevented approximately 0.134 secondary HIV infections among the sexual partners of the 16 PLWH who completed the full intervention during the 3 months following the 6-month assessment. The corresponding savings in averted future HIV-related medical care expenditures and lost QALYs were $49,702 and 0.772, respectively. Thus, the intervention was highly cost saving, with a return (savings-to-cost ratio) of $2.96 in future medical care savings for each dollar spent on the intervention.The results of the sensitivity and scenario analyses are summarized in The main analyses conservatively assumed that the 16 patients who completed the intervention  would remain virally suppressed during the following 3-month period, but no longer. If instead, all 16 patients remained suppressed for 6 months, the savings-to-cost ratio would increase to 5.92. Conversely, even with all parameters set to their least favorable value, the intervention would remain cost saving provided that patients remained virally suppressed for the 2 months following the 6-month visit.30 This study evaluated the clinical and economic effects of an existing pharmacist-led adherence intervention in New Mexico, the results of which support the role of clinical pharmacists within multidisciplinary care teams working with HIV-infected patients.Multidisciplinary care teams, including care teams with pharmacists, have a positive effect on the ART adherence of HIV-infected patients.Clinically, all participants who completed the study experienced virologic suppression. The positive clinical results observed in this study were likely a function of timing of the pharmacist visits before and shortly after ART initiation and the quantity of time pharmacists spent with patients. The 12 patients who did not complete the study were lost to follow-up from the adherence clinic, and no additional patient-level data were recorded for these patients during the study period. The large number of patients who were lost to follow-up may be reflective of the high-risk patient population seen in the adherence clinic.3 Therefore, obtaining ART adherence shortly after ART initiation is crucial. The adherence clinic was designed to ensure that pharmacists met often with patients following ART initiation. These initial visits allowed pharmacists to manage promptly any ART-related side effects or adherence barriers in order to secure optimal ART adherence from patients early in therapy. Standard of care for patients suggests that the first follow-up visit to check HIV viral load be within 2-4 weeks (and no later than 8 weeks) after ART initiation.1 However, this high-risk group of patients might have required more immediate adherence assistance and may not have received enough one-on-one time with their PCPs to address all of their questions or barriers. Early adherence counseling following ART initiation within the first month, in addition to adherence counseling before ART initiation, has been shown to improve ART adherence, as well.19Early initiation and adherence to ART yield quality of life and survival benefits to PLWHs and reduce the chance of HIV transmission to other individuals.31 Education and counseling before ART initiation by a pharmacist working as part of a multidisciplinary team also improved ART adherence.13 This intervention focused on lengthy counseling sessions involving medication and disease state education that emphasized participant recall rather than informational handouts. All pharmacists who participated in this study had training in infectious diseases pharmacotherapy and several years of experience working with HIV-infected patients. Pharmacists in this study addressed patients’ social issues, such as homelessness or substance abuse, that could be barriers to adequate ART adherence. Pharmacists also helped providers select optimal, participant-specific ART regimens based on previous medication experiences of the patient and psychosocial issues. To improve comprehension of difficult adherence concepts, pharmacists used language appropriate for the participant’s education level and repeated all of the ART adherence counseling points numerous times during each appointment.Pharmacists spent approximately 3 hours with each participant who completed the study over the course of 6 months, which is much more contact than most patients would have had with their PCPs. During these 3 hours, pharmacists used motivational interviewing techniques, which has been shown to increase ART adherence.In addition to the positive clinical effect, this intervention was highly cost saving, with a return of $2.96 in future medical care savings for each dollar spent on the adherence intervention. The economic analyses were conducted on an intention-to-treat basis and therefore included costs (but no benefits) for the 12 patients who failed to complete the intervention. At a cost of $308 per patient, these noncompleters accounted for 22% of the total cost of the intervention. This finding suggests that more intensive efforts to retain patients in clinic-based adherence interventions could be a cost-effective or cost-saving adjunct to these interventions.Not only are pharmacists well positioned to administer a medication adherence intervention because of their unique skillset, but most are compensated at a lower rate than physicians, which further increases the cost-effectiveness of pharmacist-led adherence interventions. Under conservative assumptions of the durability of this intervention, the adherence clinic also showed significant prevention of HIV transmission to the partners of the adherence clinic participants. Given the relatively low cost of the intervention and the positive effect on the participant’s virologic suppression and prevention of future transmission, we strongly recommend the inclusion of pharmacists on multidisciplinary care teams to improve patient ART adherence.Although many medication adherence studies measure adherence directly as their primary outcome, this study used the more clinically relevant outcome of viral suppression. Viral suppression is a laboratory-based measure, is not subject to biases associated with self-reported medication adherence measures, and directly measures the health and infectiousness of a PLWH.This study has some limitations to consider. While this study demonstrates the positive effect of pharmacist medication adherence interventions on the viral load of HIV-infected patients, low external validity is a concern because of the single center study design. However, with an increasing number of pharmacists caring for HIV-infected patients in similar adherence clinics across the United States, our results should have strong external validity, unless our study participants were different from other U.S. HIV-infected patients, and/or pharmacists were not performing similar interventions in other clinics.32The sample size is also a limitation. THS underwent numerous changes during the course of this study, which decreased the number of patients referred to the adherence clinic for the 6 months of the study. These changes included a relocation of the clinic, a change in clinic administrative leadership and nursing, and support staff turnover. Also, because we relied solely on provider referral for study participation, it is possible that physicians were more likely to refer patients to the study if they felt they would be adherent following the intervention. Thus, it is possible that our results do not apply to all nonadherent patients, but only to the types of patients referred to the clinic by physicians. The number of patients who were lost to follow-up is a testament to how difficult it is to retain patients with documented adherence problems in HIV care.This study demonstrated that a pharmacist-led ART adherence clinic operating within a multidisciplinary care clinic can help HIV-infected patients with documented medication adherence problems achieve HIV viral suppression, which, in turn, decreases the likelihood of HIV transmission by these patients and leads to future savings in averted HIV-related treatment costs. In this study, the savings in future treatment costs far outweighed the cost of the pharmacist-led adherence intervention. Future large-scale studies should further investigate the effect of early and sustained pharmacist ART adherence interventions on patient health and HIV transmission. In addition, HIV clinics serving patients with ART adherence problems that do not employ a pharmacist should consider hiring a pharmacist to assist these patients with ART adherence.


We analysed the relationship between PI susceptibility and outcome of second-line ART in Nigeria, where subtypes CRF02_AG/G dominate the epidemic.Previous work showed that in vitro phenotypic susceptibility testing, with PI susceptibility expressed as IC50 fold change (FC) relative to a subtype B reference strain.Individuals who experienced second-line failure with ritonavir-boosted PI-based ART were matched  to those who achieved virological response (‘successes’). Successes were defined by viral load <400 copies of HIV-1 RNA/mL by week 48. Full-length Gag-protease was amplified from patient samples for 50 FC was 4.04 (2.49–7.89) for virological failures and 4.13 (3.14–8.17) for virological successes (P = 0.94). One patient had an FC >10 for lopinavir at baseline and experienced subsequent virological failure with ritonavir-boosted lopinavir as the PI. There was no statistically significant difference in single-round replication efficiency between the two groups (P = 0.93). There was a moderate correlation between single-round replication efficiency and FC for lopinavir (correlation coefficient 0.32).The median (IQR) lopinavir ICWe found no impact of baseline HIV-1 Gag-protease-derived phenotypic susceptibility on outcomes of PI-based second-line ART in Nigeria. They were matched to ‘controls’, who had achieved virological suppression lasting up to 12 months (HIV-1 RNA <400 copies/mL) with a similar age, sex, baseline CD4 count and duration of treatment. Baseline (pre-PI) plasma samples from these matched pairs were retrospectively retrieved.,gag-protease was amplified and cloned into a subtype B-based (p8.9NSX+) vector. Clonal sequencing of up to 10 plasmids (where possible) was performed by standard Sanger sequencing. The variant that most closely represented the consensus (obtained via next-generation sequencing as previously describedhttp://www.bluetractorsoftware.co.uk) and MEGA v7.0 software.https://hivdb.stanford.edu).HIV-1 RNA was manually extracted from archived plasma samples using the QIAamp viral RNA extraction kit. Using previously described techniques,gag-protease sequences, pMDG expressing vesicular stomatitis virus envelope glycoprotein (VSV-g), and pCSFLW .PI susceptibility and viral infectivity were determined using a previously described single assay. Briefly, 293T cells were co-transfected with a Gag-Pol protein expression vector (p8.9NSX+) containing cloned patient-derived 50 was calculated using GraphPad Prism 5 . Susceptibility was expressed as a fold change in IC50 compared with the subtype B reference strain (p8.9NSX+). Replicative capacity of these viruses was assessed by comparing the luciferase activity of recombinant virus with that of the WT subtype B control virus in the absence of drug. Equal amounts of input plasmid DNA were used, and it has previously been shown that percentage infectivity correlates well with infectivity/ng p24 in this system.PI drug susceptibility testing was carried out as previously described.Informed consent was obtained from all subjects and ethics approval for virological testing was obtained from the National Research Ethics Committee of Nigeria (NHREC/01/01/2007).Differences in PI susceptibility were compared with the Wilcoxon rank-sum test , which is robust to data that are not normally distributed.3. All but one pair was treated with lopinavir-based ART (atazanavir was used in one pair). Table Six matched pairs of patients were included. Table P = 0.94), as described in Figure P = 0.47). The median (IQR) darunavir FC was 1.234 (0.84–2.05) for virological failures and 1.529 (1.14–2.319) for successes (P = 0.47).The median (IQR) lopinavir fold change (FC) was 4.04 (2.49–7.89) for virological failures and 4.13 (3.14–8.17) for virological successes (gag-protease-containing pseudoviruses derived prior to initiation of second-line boosted PI treatment from patients who either did (success) or did not (failure) suppress viral replication after 48 weeks .One patient had an FC >10 for lopinavir at baseline and experienced subsequent virological failure on boosted lopinavir as the PI. We also measured the single-round replication efficiency of patient-derived Finally, we analysed the relationship between single-round replication efficiency and FC to lopinavir in all viruses tested. There was a moderate correlation between these parameters  was not statistically different between the virological failures (cases) and virological successes (controls) for any of the PIs tested: lopinavir, atazanavir or darunavir.This negative result could be due to the influence of adherence, in that second-line therapy is used in patients for whom first-line therapy has failed, usually as the result of incomplete adherence. Therefore, the patient group was enriched for poor adherers, which could have overcome the effects of small differences in susceptibility.Interestingly, we previously showed that 2/2 patients with FC >10 prior to PI monotherapy went on to virological failure.gag and partial protease genes.We also showed here that replication efficiency over a single round was correlated with lopinavir susceptibility prior to initiation of the bPI. We have previously reported similar findings in replication-competent subtype C viruses that contained patient-derived Limitations of our study include the relatively small sample size, the inclusion of more than one subtype and the possibility of viral recombination through our PCR and cloning strategy. In addition, the process of mapping next-generation sequencing reads to a consensus reference sequence to generate a patient consensus can introduce biases against variation, which may affect the identification of novel drug resistance mutations. Finally, our assay system did not incorporate the native gp160 envelope.,Despite introduction of second-generation integrase inhibitors such as dolutegravir as first-line therapy in areas where pre-treatment resistance is >10%,


Liver disease is a common cause of non‐AIDS morbidity and mortality in people living with HIV (PLHIV), but the prevalence and significance of liver function test (LFT) abnormalities in early HIV infection is unknown. This study aimed to characterize LFTs in a large cohort of participants with acute HIV infection initiating immediate antiretroviral therapy (ART) and examine the association between LFTs and biomarkers of HIV infection and inflammation.We measured LFTs at the time of HIV diagnosis and at 4, 12, 24 and 48 weeks after ART initiation in 426 Thai individuals with acute HIV infection from 2009 to 2018. A subset of individuals had data available at 96 and 144 weeks. We excluded individuals with concomitant viral hepatitis. Alanine aminotransferase (ALT) was the primary outcome of interest; values greater than 1.25 times the upper limit of normal were considered elevated. Analyses utilized descriptive statistics, non‐parametric tests and multivariate logistic regression.p = 0.001) and baseline HIV RNA >6 log10 copies/mL (p = 0.012). Baseline elevations resolved by 48 weeks on ART in 59 of the 66 individuals (89%). ALT elevations at 24 and 48 weeks correlated with Fiebig stages I to II at diagnosis (p < 0.001), baseline plasma HIV RNA levels <6 log10 copies/mL (p < 0.001), abnormal baseline ALT (p < 0.001), baseline CD4 >350 cells/μL (p = 0.03) and older age (p = 0.03). Individuals initiating efavirenz‐based regimens were more likely to have elevated ALT levels at 48 weeks compared with those on non‐efavirenz‐based regimens (p = 0.003).Sixty‐six of the 426 individuals (15.5%) had abnormal baseline ALT levels; the majority  had Grade 1 elevations. Elevated baseline ALT correlated with Fiebig stages III to V (One in six people with acute HIV infection have elevated LFTs. Clinical outcomes with ART started in acute HIV are generally good, with resolution of ALT elevations within 48 weeks on ART in most cases. These results suggest a multifactorial model for hepatic injury involving a combination of HIV‐associated and ART‐associated processes, which may change over time. Screening for AHI was performed using pooled nucleic acid testing (NAT) and sequential HIV enzyme immunoassay (EIA) in accordance with previously published methods This analysis took place within the SEARCH010/RV254 cohort (thG) acute infection staging The stage of HIV infection was determined using the fourth‐generation (4Participants initiated ART within 24 to 72 hours of the baseline assessment. From 2009 to 2016 the standard first‐line ART regimen was efavirenz plus two nucleoside reverse transcriptase inhibitors (NRTIs). Subsets of participants were randomized to receive “mega‐ART,” composed of standard ART with the addition of maraviroc or maraviroc plus raltegravir. In February 2017, the standard first‐line ART regimen was changed to dolutegravir plus two NRTIs. Substitutions could be made in individual drugs for clinical indications such as intolerance or resistance. Because of the association between non‐nucleoside reverse transcriptase inhibitor (NNRTI)‐based regimens and drug‐induced liver injury + and CD8+ T lymphocyte count, complete blood count (CBC), alanine aminotransferase (ALT), gamma‐glutamyl transferase (GGT), total and direct bilirubin. Values of ALT, GGT and bilirubin were compared with the reference value for the upper limit of normal (ULN) for the assay . The ULN values were determined in a representative Thai population at the Chulalongkorn Hospital laboratory Plasma HIV RNA was measured using either the Roche Amplicor HIV‐1 Monitor Test v1.5 or the Roche COBAS AmpliPrep/COBAS TaqMan HIV‐1 Test v2.0 . Lower limits of detection were 50 and 20 copies/mL respectively; analyses utilized 50 copies/mL as the lower limit of detection. Standard laboratory tests included CD4Participants were considered to manifest acute retroviral syndrome (ARS) if they demonstrated at least three clinical features consistent with this diagnosis P‐values were adjusted for multiple comparisons using the Bonferroni method where appropriate.Statistical analyses included descriptive statistics and non‐parametric correlative analyses. The Mann‐Whitney test was used to compare characteristics between the sub‐groups with normal and abnormal baseline ALT. Dunn's pairwise comparison was used to compare continuous outcomes across Fiebig stages and ART regimens. Spearman correlation was used to identify the soluble immune markers significantly correlated with clinical measures, with FDR adjustment (BH procedure) for multiple comparisons applied. A multivariate logistic regression model was used to identify factors associated with elevated ALT at baseline. Random effects models were used to identify factors associated with elevated ALT at 24 and 48 weeks. We used Stata 15.0  and R 3.6.0  for statistical analyses. Figures were created using GraphPad Prism 7.0 . All participants provided informed consent. The cohort study was approved by the Institutional Review Boards at Chulalongkorn University in Bangkok, Thailand, and the Walter Reed Army Institute of Research, MD, USA.3+ T cell count was 364 cells/μL and median plasma HIV RNA was 5.9 log10 copies/mL.Demographics of the participants are described in Table 3.1Sixty‐six of the 426 individuals 15.5%) exhibited elevated baseline ALT levels  and abnormal (n = 66) baseline ALT levels, there was no difference in age, risk group, education level, HIV subtype, syphilis seropositivity, alcohol use, recreational drug use or baseline CD4nt Table . CD4/CD83.2p < 0.001; Table Individuals enrolled during Fiebig stages I to II had lower baseline ALT compared with those enrolled during Fiebig stages III to V Table a. Those p < 0.001; Figure + T lymphocyte count, and plasma HIV RNA, only Fiebig stages III to V and baseline HIV RNA >6 log10 copies/mL were independently associated with elevated baseline ALT levels . In a subsequent model limited to Grade 2 or greater ALT elevations (n = 23), both Fiebig stages III to V and baseline HIV RNA >6 log10 copies/mL remained independently associated with elevated baseline ALT levels .Those with higher baseline plasma HIV RNA had higher baseline ALT Figure c, and bap < 0.001), soluble CD30 , TNF‐alpha , soluble CD163 , T‐cell immunoglobulin and mucin domain (Tim)‐3  and interferon gamma‐induced protein (IP)‐10  receptor II , this difference resolved by four weeks after ART initiation , abnormal baseline ALT , and baseline plasma HIV RNA less than 6 log10 copies/mL  in a multivariate model . Other factors associated with week 48 ALT elevation included older age, abnormal baseline ALT and baseline CD4 count >350 cells/μL  according to the presence of abnormal baseline ALT. There was a trend towards association between abnormal baseline ALT levels and lower rates of virologic suppression (defined as plasma HIV RNA <50 copies/mL) at week 4 , week 12  and week 24 , even when adjusted for the baseline plasma HIV RNA value; this trend was no longer present at week 48 . There was no association between baseline ALT abnormality and CD4+ T cell count, magnitude of CD4+ T cell change from baseline, or CD4/CD8 ratio at week 4, 12, 24 or 48 follow‐up time points.We investigated clinical outcomes  with longitudinal data available at these time points. There were no clear trends after the first year on ART based upon initial Fiebig stage Figure a. When t3.6p < 0.001; Figure p < 0.001; Figure Sixty‐six of the 425 individuals (15.5%) had elevated GGT at baseline. As with ALT, the greatest proportion and highest magnitude of GGT elevation was seen in Fiebig stages III to V , IP‐10 , soluble CD30 , Tim‐3  and CD27 . An inverse correlation with the protein regulated on activation, normal T cell expressed and secreted  was also identified .3.710 copies/mL  had elevated total bilirubin at baseline. Interestingly, most bilirubin elevations occurred during Fiebig stages I to II , IP‐10 , monocyte chemoattractant protein (MCP)‐1 , soluble CD14 , interferon‐alpha  and vascular endothelial growth factor (VEGF)‐D  found that 65% of individuals with primary HIV infection had elevated ALT levels + T lymphocyte count, and ART regimen. Longitudinal trends showed that individuals diagnosed in Fiebig stages III to V tended to have stable or downtrending ALT levels following ART initiation. Individuals diagnosed in earlier Fiebig stages tended to have a subsequent increase in ALT levels despite early ART initiation. In general, these elevations resolved. Further understanding of these trends is important in the light of a recent study that demonstrated that most biopsies performed for transaminase elevations in HIV‐monoinfected individuals showed nonspecific pathology There were several notable trends with regard to ALT elevations in this cohort. At baseline, elevated ALT levels concentrated in individuals diagnosed in later Fiebig stages, when the HIV viral load peaks and the immune response is most active. At later time points (week 24 and week 48), ALT elevations were predicted by higher baseline ALT, earlier Fiebig stages at enrolment, lower baseline HIV RNA and higher baseline CD4Taken together, our findings suggest a multifactorial model for hepatic injury involving a combination of HIV‐associated and ART‐associated processes. HIV‐associated hepatocellular injury due to immune‐associated processes may be the dominant process driving ALT perturbations in later Fiebig stages, causing baseline elevation with subsequent normalization of ALT levels. Earlier diagnosis and ART initiation in Fiebig stages I to II may prevent the HIV‐associated hepatocellular injury that arises in later stages of AHI, but may also preserve vulnerable hepatocytes (i.e. those that are most susceptible) for injury due to drug toxicity, a slower process that becomes apparent over the first six to twelve months of ART A multifactorial model involving differential risk to HIV‐associated and ART‐associated hepatic effects is supported by several observations. First, a significant proportion of those treated in earlier Fiebig stages do not develop the robust immune response that characterizes the later stages + and CD8+ T lymphocytes, regulatory T cells, and innate immune cells. In chronic HIV, the Tim‐3 receptor may be associated with T cell dysfunction and exhaustion This analysis provides some clues as to potential mechanisms driving HIV‐associated hepatic injury. A previous study found a correlation of similar magnitude between plasma HIV RNA and elevated ALT in a smaller cohort (n = 59), and hypothesized that this could be related to the apoptotic properties of HIV viral proteins In this cohort, baseline total bilirubin levels inversely correlated with markers of general inflammation , macrophage activation  and chemokines targeting macrophages and lymphocytes . In addition, regardless of Fiebig stage, total bilirubin decreased between baseline and week 4 before plateauing. Bilirubin is known to have anti‐inflammatory effects and may reduce oxidative stress, and recent data have shown that hyperbilirubinemia is associated with decreased cardiovascular disease risk in PLHIV This study had several notable limitations. While the sample size was large, the cohort examined in this study is relatively homogeneous and comprised of young Asian MSM without significant comorbidities. These participants therefore might not be representative of the general population and may also demonstrate greater physiological reserve or a more robust inflammatory response than older individuals and those with intercurrent illnesses. The clinical significance of small differences in LFTs is also unclear. For example, although differences in median baseline ALT levels between those with and without ARS were statistically different, the median in those with ARS was still within the normal range. The clinical significance of these findings is supported by the fact that most abnormal values  tended to be associated with certain characteristics . Furthermore, even small differences between groups may provide clues regarding HIV pathogenesis and the mechanisms by which the virus affects hepatocytes.5We have shown that abnormal serum LFTs are common during acute HIV infection in our population and are associated with the stage of infection and markers of inflammation. These data provide insight into potential mechanisms of liver injury during the first year of infection and demonstrate that most individuals do well from this perspective following ART initiation. They also support testing for HIV infection in the setting of a viral illness with associated LFT perturbations. Further research is necessary to better determine the mechanisms that underlie LFT elevations in AHI , their relationship to the systemic inflammatory process, and their prognostic implications.JA has received honoraria for participating in advisory meetings for ViiV Healthcare, Gilead, Merck, Roche and AbbVie. SS directs a study through the AIDS Clinical Trials Group for which study medications are provided by Viiv Healthcare.EK, JA, SS, NP, PP, MLR, DJC and MJP designed the study. EK, JA and NP led the study, with management support from DJC, JI, NC and PP. MJP, SP and NJ designed and performed the statistical analyses. SU, RT, BMS and SJK performed and interpreted laboratory assays. MJP and EK drafted the manuscript, which was reviewed and approved by all other authors.Table S1. Factors associated with ALT>1.25 ULN at baselineTable S2. Factors associated with ALT>1.25 ULN at 24 weeksTable S3. Factors associated with ALT>1.25 ULN at 48 weeksClick here for additional data file.


We identified a HIV-positive cohort in virologic failure (VF) who re-suppressed without drug switch. We characterized their drug resistance mutations (DRM) and adherence profiles to learn how to better manage HIV drug resistance.A retrospective cohort study utilizing clinical data and stored samples. Patients received ART at three Nigerian treatment centres. Plasma samples stored when they were in VF were genotyped.Of 126 patients with samples available, 57 were successfully genotyped. From ART initiation, the proportion of patients with adherence ≥90% increased steadily from 54% at first high viral load (VL) to 67% at confirmed VF, and 81% at time of re-suppressed VL. Sixteen (28%) patients had at least one DRM. Forty-six (81%) patients had full susceptibility to the three drugs in their first-line (1 L) regimen. Thirteen (23%) were resistant to at least one antiretroviral drug but three were resistant to drugs not used in Nigeria. Ten patients had resistance to their 1 L drug(s) and six were fully susceptible to the three drugs in the recommended second-line regimen.This cohort had little drug resistance mutations. We conclude that if adherence is not assured, patients could exhibit virologic failure without having developed mutations associated with drug resistance. For treatment of HIV-1 in resource-limited settings, the World Health Organization (WHO) specifies that if viral load (VL) is > 1000 copies per millilitre (cp/mL) after 6 months on treatment, virologic failure (VF) is suspected [The emergence of HIV drug resistance mutations (DRMs) is influenced by many factors, foremost of which is adherence to antiretroviral therapy (ART) , 3. AdheWe discovered a cohort of patients who met the criteria for virologic failure but surprisingly re-suppressed VL without a change of regimen. At present, there is little data regarding DRMs in patients that re-suppress VL following confirmed VF, particularly in the context of adherence patterns. Thus, we conducted this evaluation to examine the range of HIV DRMs, drug resistance and adherence patterns in this cohort. We believe findings will guide management of HIV drug resistance, especially in resource-constrained settings that have limited drug options.p = 0.042), none of the other variables were significantly associated with drug resistance in the bivariate analyses  had at least one HIV-1 DRM Table . Four pa1); F1 to the second VL ≥ 1000 cp/mL (FC); FC to VL re-suppression, the proportion of patients with adherence ≥90% increased steadily  as six of eight patients with drug resistance to at least one drug had 70–89% adherence. This association was specifically with only NRTI resistance and the M184 V mutation  were fully susceptible to their 1 L regimens, including six patients with detectable DRMs. Of all the 16 patients with DRMs, only thirteen (23% of 57) patients had resistance to any ARVs (Table n = 1), low-level resistance (n = 1) to susceptible  patients in this cohort had at least one HIV DRM, but only 13 (23%) were resistant to at least one drug. Of the 13 patients with resistance to at least one drug, all were susceptible to the PIs recommended for 2 L regimens in Nigeria.We find that most patients failed and re-suppressed without developing DRMs. In addition, those who had DRMs were still able to re-suppress VL. Firstly, it is not surprising that patients without DRMs re-suppressed VL. Secondly, we note that some patients with functional monotherapy were still able to re-suppress VL, reiterating that the presence of DRMs itself does not necessarily predicts VF. However, its noteworthy that all four patients with dual-class DRMs (NRTI and NNRTIs), with only their NRTI backbone being sensitive, had the M184 V mutation. The M184 V mutation reduces viral replication, increases susceptibility to AZT and TDF, and thus slow emergence of VF to these drugs. These effects could be partly responsible for viral re-suppression especially in these four with several DRMs.Improved adherence appears to have helped them achieve re-suppression, given that adherence before suppression improved for over 80% of participants. We could not perform further statistical analysis due to the small study sample size. Some patients had lower confirmatory VLs than their initial failing VL, which may be due to improved adherence. Although lower confirmatory VL levels (still above 1000 cp/mL) were recorded for half of the patients with confirmed DRMs, a drop in VL levels may not indicate that DRMs are not being developed as mutant viruses may have a fitness cost, resulting in lower viral replication capacity and/or hyper-susceptibility to other ARVs [Given that this cohort re-suppressed VL after confirmation of VF and in the absence of a drug switch, it is not surprising that they had low levels of DRMs and only 23% had confirmed resistance to at least one drug. Our findings reiterate the utility of VL and DRM monitoring, as reported in other studies, and show these may be best utilised in combination with the adherence profile especially when considering drug switch –13. An ePatients suspected to be failing treatment clinically are required to undergo intensified adherence counselling while the result of repeat VL is awaited –16. CounThere are limitations in this study. Firstly, the population were selected retrospectively from electronic medical records and may not be representative of the population. Secondly, we are not certain why these patients with confirmed VF were not switched at the various ART centres and if adherence was considered at the time. Given this is a retrospective study, data were not captured on the reasons why each patient was not switched. It is possible patients were not switched due to other issues, such as logistics challenges or delays in data availability for clinical decision-making. Secondly, the small sample size, due to over half of the samples failing genotyping, reduced the power for statistical analysis outcomes. The failure to genotype might be caused by the degradation of RNAs in the stored plasma samples.Despite the limitations of the study, our results reveal that in the absence of a regimen switch, patients who re-suppressed their VL following confirmed virologic failure had few underlying DRMs and remained largely susceptible to the current 1 L regimens. We surmise that when consistent adherence is not assured, patients could exhibit virologic failure, with two VLs above 1000cp/mL, without developing mutations associated with drug resistance.As part of a larger evaluation on DRMs in patients experiencing virologic failure (VF) , we condAdult ART patients with the following characteristics were included in the study: 1) provided consent for use of data and samples in future research studies; 2) received 1 L ART, either AZT + 3TC + NVP/EFV or TDF + 3TC/FTC + NVP/EFV, between the years of 2004–2009 for at least 6 months; 3) met World Health Organisation VF criteria for 1 L treatment failure (two consecutive VL measurements greater than 1000 cp/mL); and 4) re-suppressed VL to ≤400 cp/mL following confirmation of VF. These patients may not be representative of their various population being selected from electronic medical records for meeting the criteria above. In addition, we report here findings from the second aim of a study, see Additional file 1). If the first attempt for genotyping was not successful, a plasma sample collected at the confirmatory VF time point (FC) was used for repeat genotyping. In brief, HIV ribonucleic acid (RNA) was extracted from the plasma samples using the Qiagen Viral RNA Kit . Reverse transcriptase-polymerase chain reaction (RT-PCR) and nested PCR were performed using the ATCC® HIV-1 Drug Resistance Genotyping kit module 1. The nested PCR products were purified using ExoSAP-IT enzyme and used for cycle sequencing with the kit module 2. The sequencing was performed with Genetic Analyser 3130xL  and AB1 files were used to generate consensus sequences using ReCall 2.25 software . Sequence identity matrices were performed using BioEdit software  to check for contamination and the quality-confirmed sequence files were analysed with Stanford HIVDB Calibrated Population Resistance “QA details” to confirm base calls [Data on VLs were accessed from existing clinical databases (EMRS). VL were earlier determined using the Roche Cobas Amplicor Monitor assay, version 1.5  and the Roche Cobas Ampliprep/COBAS TaqMan HIV-1 Test, v2.0 kits . Stored frozen plasma samples collected from patients who met the inclusion criteria were retrieved for HIV drug resistance testing using ATCC® HIV-1 Drug Resistance Genotyping Kit   was used for continuous variables while chi-squared or Fisher’s exact tests was used for categorical variables as appropriate. The deidentified study database is available as Additional file Patient characteristics at ART initiation, including estimated adherence and VL measurements were examined using univariate methods. Adherence was estimated as medicine possession ratio (MPR) using pharmacy drug refill data. MPR was computed by dividing the total number of pills provided by the number of days in the period between drug pick-ups and then multiplied by 100. Average adherence was computed for the time from ART initiation to FEthical approval for this study was obtained from ethics committees of NIMR, JUTH, UCH and the Harvard T. H. Chan School of Public Health. The study was reviewed according to the Centers for Disease Control and Prevention (CDC) human research protection procedures and was approved as research, but CDC was not engaged. At these tertiary facilities, HIV-positive persons at enrolment either deny access or provide written consent for further use of their samples for research purposes. Only patients who consented and gave documented approval for use of their samples for research purposes were included in this study.Additional file 1. Study Population. Gives greater details about the study population and how the participants were selected.Additional file 2. Study Database. Unlinked database without personal identifiable data.