The implications of bariatric surgery (BS) on virologic and metabolic outcomes in people with human immunodeficiency virus  on antiretroviral therapy (ART) are unknown.Here, we report a retrospective analysis up to 18 months post-BS in PWH from the AIDS Therapy evaluation in The Netherlands (ATHENA) cohort with data from all dutch HIV treating Centers. Primary end points were a confirmed virologic failure (2 consecutive HIV-RNA measurements >200 copies/mL) and the percentage of patients who achieved >20% total body weight loss up to 18 months post-BS. Switches from baseline ART and trough plasma concentrations of antiretrovirals were also reported post-BS. Metabolic parameters and medication usage were compared pre- and post-BS.P < .01) post-BS. Total medications and obesity-related comedications declined from 203 to 103 and from 62 to 25, respectively, at 18 months post-BS.Fifty-one patients were included. One case of confirmed virologic failure and 3 cases with viral blips were detected in this cohort up to 18 months post-BS. Eighty-five percent of patients achieved >20% total body weight loss at 18 months post-BS, with a mean difference from baseline  of −33.5% (−37.7% to −29.3%). Trough plasma concentrations of measured antiretroviral agents were all above minimum effective concentrations, except for 1 sample of darunavir. Lipid profiles, but not serum creatinine and blood pressure, improved significantly (BS was an effective intervention for weight loss and lipid control in PWH using ART in this cohort with no clear link to poor virologic outcomes. Data from a Dutch cohort of people with HIV on antiretrovirals demonstrate that bariatric surgery is a beneficial intervention for weight loss and lipid improvement with no clear worsening of virologic control up to 18 months post-surgery. Femaght gain , 9.To date, bariatric surgery (BS), commonly sleeve gastrectomy (SG) and gastric bypass (GBP), is a durable intervention when diet and lifestyle modifications fail to achieve weight goals. BS improves obesity-related complications and overall health, with high rates of remission in obesity comorbidities seen in the general population . LimitedBS significantly manipulates the anatomy and the environment within the gastrointestinal tract; this could profoundly impact the absorption and metabolism of orally administered medications including antiretrovirals , 12. CurTherefore, we conducted a retrospective national cohort study in the Netherlands in PWH post-BS. The primary objectives were to evaluate the virologic response of different ART regimens up to 18 months post-BS and to assess weight reduction in PWH post-BS. Secondary objectives included the number of ART switches post-BS, the plasma concentrations of several antiretrovirals post-BS, and the impact of BS on the metabolic status in PWH. Medication usage was also compared before and 18 months after BS.Eligible participants were selected from the Dutch AIDS Therapy evaluation in the Netherlands (ATHENA) cohort database for which data are routinely collected from all consenting PWH treated at 1 of the 24 Dutch HIV treating centers . The ATHBaseline was defined as the documented date of BS. For plasma HIV-1 RNA viral load (VL), the latest available measurement within ≤6 months prior to the BS date was considered baseline. HIV VL, CD4+ T-cell count, and treatment history were collected at baseline and at all available time points up to 18 months post-BS. Demographics including age, weight, BMI, blood pressure, low-density lipoprotein cholesterol (LDL-c), high-density lipoprotein cholesterol (HDL-c), triglycerides, and serum creatinine were collected at baseline and at 3 follow-up visits 6, 12, and 18 months (±2 months) post-BS, if available.Medications were stratified as obesity-related medications  and total medications . Prescribed vitamin/mineral supplements were also retrieved from medication records.Results of therapeutic drug monitoring (TDM) were collected if monitoring was performed by individual physicians up to 18 months post-BS. TDM results were reported if they were collected at trough concentrations (≥16 hours post-intake for once-daily and ≥8 hours post-intake for twice-daily medications) to enable comparison with the minimum effective concentration of each drug at the end of the dosing interval. Values of minimum concentration targets of each drug were extracted from the related clinical trials.The primary end point was a confirmed virologic failure (VF) defined as 2 consecutive VL measurements ≥200 copies/mL up to 18 months post-BS. We also report the incidence of developing a single viral blip (detectable HIV-1 RNA of >40–200 copies/mL) after being virologically suppressed at baseline (VL <40).BS efficacy was defined as a >20% loss of total body weight at 18 months post-BS. Currently, no definition exists for successful weight loss post-BS. However, the American Society for Metabolic and Bariatric Surgery has defined insufficient weight loss as <50% of excess weight loss or a corresponding <20% total body weight loss at 18 months post-BS . The 20%The secondary end points for ART performance were the number of drug switches from the baseline ART regimen and the incidence of trough plasma concentrations below the minimum effective concentration for each antiretroviral with an available TDM. ART switches are defined as any addition to or deletion from the prescribed ART regimen at baseline.The secondary outcome for BS efficacy was a significant improvement in the metabolic parameters including systolic and diastolic blood pressure, LDL-c and HDL-c, and creatinine clearance at 6, 12, and 18 months post-BS compared with baseline. Since there is no consensus on the improvement goals for metabolic parameters post-BS, we calculated the mean difference and statistical significance for each metabolic parameter before vs 6, 12, and 18 months after surgery. The number of obesity-related medications and the total number of medications were compared before and at 18 months after BS.P value of .01 instead of .05 to correct for the increased rate of false-positives in multiple testing as previously recommended for disease-associated studies [Virologic changes (VF or blips) and drug switches from the baseline ART regimen were described without statistical analysis due to the expected low number of events compared with the number of available ART regimens. Demographics with continuous variables were presented as medians and interquartile ranges (IQRs); n (%) was used for categorical data. A linear mixed-effects model for repeated measures was used to compare the mean differences and 90% confidence intervals (CIs) of the continuous metabolic parameters before vs 6, 12, and 18 months after BS (fixed effect). Patient number was set as a random effect. Due to the multiple testing performed on the continuous health parameters, we used a  studies . Data anFifty-eight patients who underwent BS between January 2004 and January 2022 were identified; 7 were excluded , respectively. Eighty-four percent (n = 43) of patients were virologically suppressed (plasma HIV-1 RNA <40 copies/mL) at the last measured VL prior to BS. The remaining patients (n = 8) had a detectable HIV-1 RNA level <200 copies/mL, except for 1 patient who had a VL of 6000 copies/mL before BS . At baseline, 49% of patients were on INSTI + 2 nucleo(s/t)ide reverse transcriptase inhibitors (NRTIs), and 29% used dolutegravir as an anchor drug. A full description of ART regimens used is provided in The median age at baseline was 46 years , 55% were women, and 76% underwent GBP. Median weight (IQR) and BMI pre-BS were 121 kg (109–133) and 39.8 kg/mOf 43 patients with full virologic suppression at baseline, 1 developed VF with 2 consecutive VL measurements of 487 and 420 copies/mL at month 8 post-BS . This pa3). There were no VF or blips detected in 3 patients who were on a dual ART regimen  and had SG. Four of 8 patients who had detectable VL pre-BS (VL >40 copies/mL) became fully suppressed by the end of the follow-up period; 4 patients had no VL by the end of the follow-up period including the patient with high VL at baseline (6000 copies/mL).In 3 patients who had undetectable HIV-1 RNA at baseline, 3 viral blips occurred at 6, 7, and 7 months post-BS, respectively . These patients were on different ART regimens that contained tenofovir disoproxil fumarate (TDF) and emtricitabine combined with nevirapine, raltegravir, or darunavir/ritonavir. Due to the low VL, no resistance testing was done on the blip samples. Previous resistance tests did not show PI resistance, and INSTI resistance was not tested. No VFs or viral blips were reported in the 12 patients who had SG in this cohort. None of the patients on dual therapy (n = 3) showed VF or blips, and their VL remained undetectable up to 18 months post-BS with good immune response (CD4 >500 T cells/mmP < .001), with a mean difference of −33.5 (95% CI: −37.7 to −29.3) at 18 months post-BS. Interestingly, a group analysis showed no significant difference in weight reduction at 18 months among patients who continuously took INSTI without TAF, or INSTI plus TAF versus non-INSTI/non-TAF regimens in this cohort  of 27% (21.4%–34.0%). Mean differences in weight were significantly lower at all post-BS time points compared with baseline  decreased significantly post-BS P < .01; . SystoliPost-BS, the total number of medications and obesity-related medications dropped from 203 to 103 and from 62 to 25, respectively . Twelve This is the first cohort study on PWH who underwent BS for which virologic, pharmacologic, and metabolic parameters were analyzed. We did not detect insufficient virologic control in those with suppressed VL at the time of BS, and we did not detect multiple ART drugs with subtherapeutic plasma concentrations in this cohort post-BS. Additionally, the magnitude of weight loss and the decreased number of concomitant medications post-BS in PWH on ART was comparable to that observed in the general population .The single VF seen in 1 individual was thought to be driven mainly by noncompliance with ART. Calcium carbonate was prescribed to this patient to prevent vitamin deficiency post-BS. Raltegravir is known to form a complex with divalent cations in mineral supplements, such as calcium, that prevents its absorption into the gastrointestinal tract. Nevertheless, this was not hypothesized to be the main driver of the VF in this patient due to their history of multiple VFs pre-BS. Moreover, the patient was on twice-daily raltegravir (400 mg), and this is known to compensate for the lower exposure to raltegravir when given with calcium carbonate compared with once-daily 1200 mg . GeneralWeight reduction was the major end point for BS efficacy in our study and was demonstrated to be high at 12 months with a slight increase at 18 months post-BS. These findings in PWH are consistent with data from the general population that demonstrate an accumulative weight loss up to 1 year after SG or GBP before weight loss plateaus or continues modestly . Thus, aOur, albeit limited, results of plasma concentrations indicate that BS had no detrimental effect on elvitegravir, dolutegravir, emtricitabine, and tenofovir plasma concentrations. The latter 3 drugs are particularly important because their combination is listed as a preferred first-line treatment option in most HIV treatment guidelines. Two patients were switched post-BS due to expected low darunavir (+ cobicistat) plasma levels following SG or GBP (concentrations were not provided). Additionally, 2 of 3 trough plasma concentrations of darunavir/ritonavir in our analysis did not suggest a subtherapeutic exposure post-BS . The avaP < .01) for blood pressure measurements. The overall decline in body weight and reduction in medication usage in our cohort is consistent with the outcomes of the GAstric Bypass to Treat obEse Patients With steAdy hYpertension (GATEWAY) randomized trial on obese patients with hypertension who underwent GBP. This trial reported significant reductions in LDL-c and triglycerides at 12 months post-GBP [Lipid measurements improved significantly post-BS in this cohort. Systolic blood pressure improved post-BS but not to a statistically significant level. Nevertheless, data on medication usage showed a 50% decrease in the use of antihypertensive medications in the same cohort during the same period. One explanation is the small sample size in our cohort, which might have hindered achieving the significance cutoff (post-GBP . The stupost-GBP . One pospost-GBP . Importapost-GBP .The current analysis has some limitations. Although this is the largest analysis to date on PWH who underwent BS, the sample size was not sufficient for a comprehensive comparison of health improvement in PWH vs the general population. Furthermore, TDMs were not performed at VFs and viral blips, and available TDM samples did not involve all current antiretrovirals, including doravirine, atazanavir, and rilpivirine. The latter 2 have acid-dependent absorption and were considered not suitable post-BS on a theoretical basis with limited clinical data . MedicatTogether, these initial data from a small cohort indicate that BS is a beneficial intervention in obese PWH using ART and that there is no clear worsening of virologic control. Weight and lipid profiles improved significantly post-BS in PWH. Caution should be used in people with a history of VF or ART nonadherence at the time of BS to avoid the risk of subtherapeutic exposure to ART and the subsequent poor virologic control.Clinical Infectious Diseases online. Consisting of data provided by the authors to benefit the reader, the posted materials are not copyedited and are the sole responsibility of the authors, so questions or comments should be addressed to the corresponding author.ciad404_Supplementary_DataClick here for additional data file.


In HIV infection, dysregulation of cytokines, including interleukin 18 (IL-18), has been linked to poor clinical outcomes in studies mainly conducted in resource-rich countries. This phenomenon has not been well-studied in resource-limited settings where outcomes could be confounded by exposure to endemic infections and genetic factors.Therefore, the influence of immunological and virological status of HIV-infected, antiretroviral therapy (ART)-naïve patients on serum IL-18 levels at baseline (pretreatment) and 24 weeks following initiation of combination ART (cART24) in a resource-limited setting was investigated.Using the cross-sectional and longitudinal mixed method design, a total of Forty-four (44) newly diagnosed consenting HIV patients were consecutively recruited during routine clinic visits at the Nasara Treatment & Care Centre of the Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, Nigeria between December 2016 to January 2018, and followed up for 24 weeks on initiation of first-line cART.were determined at baseline and cART24. There was little CD4+ count gain in both <200 and ≥ 200 cell/mm3subgroups despite the high proportion of subjects having virological suppression  at cART24. However, at cART24 there was a more than a threefold decrease in the level of IL-18 concentration compared to baseline in patients with <200 cells/mm3 and a significant decrease in the median plasma IL-18 concentration in patients with HIV1 RNA <1000 cp/mL at cART24. A multivariate logistic regression model shows IL-18 intermediate quartile to be more related to immunological poor gain as compared to the highest quartile.Serum IL-18 concentrations, CD4+ T-cell counts (CD4+) counts, and HIV1 RNA levels Our study found high baseline and significantly low levels of IL-18 at cART24 in virologically suppressed subjects but not among virological non-suppressed responders despite comparable IL-18 levels by CD4+ T cell count strata at cART24. These findings have implications for risk stratification and treatment outcomes in HIV-positive persons. Sub-Saharan Africa (SSA) alone accounts for approximately 60% of the daily HIV infection worldwide . In low-ountries . Despiteountries . The mosountries ,6. It isountries . A multiountries . One sucountries ,8,11–13.Cytokines are crucial to cellular signaling pathways and intercellular communication, with pleiotropic effects in various organs, and thus play a critical role in modulating the immune response ,17. InduIn general, immune responses enhance the capacity of the host’s cellular immunity, particularly against viral infections . HoweverThe role of cytokines in immuno-virological pathology in HIV infection is relatively well documented in developed countries, environmental exposure to endemic pathogens may affect the basal repertoire of inflammatory status and induce a cytokine storm that drives unique pathologies in resource-limited settings ,35. TherThis was a pilot prospective study that evaluated serum IL-18 levels at baseline and cART24 in newly diagnosed HIV-positive patients without previous antiretroviral medication and compared changes in their CD4+ counts and plasma viral loads over the study period. The study was carried out at Nasara Treatment & Care Centre of the Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, Nigeria, which is a U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)-supported HIV treatment facility. The study was conducted in December 2016 and January 2018 followed up for 24 weeks on the initiation of first-line cART. This centre has been cumulatively responsible for screening and providing treatment as well as ART adherence counseling to PLWH.The participants included confirmed HIV-positive adults aged ≥18 years) who were ART-naïve at baseline. ART-experienced patients, sex workers, and pregnant women were excluded. Patients with apparent co-morbidities were also excluded. Eligible participants were consecutively selected and followed up for 6 months 24 weeks). All participants were on a first-line cART regimen for 24 weeks in line with the “test and treat” WHO strategy [8 years w4 weeks. The study protocol was approved by the research ethics committee of the ABUTH, Zaria, Nigeria . All study procedures were conducted per the Declaration of Helsinki. Written informed consent was obtained from participants before participation; voluntariness and strict confidentiality were maintained throughout the study.Relevant socio-demographic characteristics and clinical data  were obtIL-18 was assayed using Quantikine, an antigen-based, solid phase, sandwich Enzyme-Linked Immunosorbent Assay (ELISA) for the Human IL-18 BPa. The assay was performed according to the manufacturer’s instructions. The kit has a sensitivity of 7.52 pg/ml and a specificity of 10.0 pg/ml.The plasma HIV-1 RNA was determined using the COBAS® Ampliprep/COBAS® Taqman® HIV-1 Test, v2.0. . Specimen preparation and assay were all performed according to the manufacturer’s instructions. The dynamic range was from 20 to 10.000.000 copies/mL.Clusters of differentiation (CD) 4+cell count in whole blood were determined using Partec™. Cyflow analyzer  based on manufacturer’s instructions.3). HIV viral load <1000 copies/mL was considered virologically suppressed, while ≥1000 copies/mL were considered virologically non-suppressed. Low CD4+ recovery following cART initiation was defined as CD4+ increase <50 cells/mm3 at cART24 despite HIV RNA <1000 copies/mL [CD4+ decline was stratified by CD4+ T-lymphocyte count , or percentage (frequency) after failing normality checks. Interleukin 18 levels were parameterized into quartiles  and their median values were used to represent each quartile. Following the longitudinal and cross-sectional research design, data were compared using Wilcoxon rank-sum test also known as Wilcoxon unpaired two-sample test statistic  and the Wilcoxon matched-pair signed rank test to analyze the longitudinal component. Multiple comparisons of ranks were followed by the Bonferroni correction test which allows the adjusting of P-values to correct for the occurrence of false positives. The level of significance was set at a 95% confidence interval (CI), assuming p ≤ 0.05.3) at baseline and 24 weeks (ART24) were computed. The Chi–Square test was used to determine statistical association. To account for potential confounders, a multivariate logistic regression model was used to control for the biologically plausible variables included in our study design: age, sex, baseline BMI, baseline WHO clinical, and baseline HIV RNA level. In this model, baseline IL-18 quartiles were used as determinants, and CD4+ counts at cART24 as the response variable. The robust standard errors for the parameter estimates were adopted to control for mild violation of homoscedasticity. We use the R package sandwich to obtain the robust standard errors and calculated the p-values accordingly. Together with the p-values, a 95% confidence interval using the parameter estimates and their robust standard errors was calculated. p-value was set as p ≤ 0.05.To evaluate the response to cART, the proportion of patients’ IL-18 levels achieving a plasma HIV viral load (below and above 1000 copies/ml) and the absolute CD4+ cell count . Among individuals with CD4+ count ≥200 cells/mm3 at baseline, there was an approximately 2-fold reduction at cART24  at both time points  and virological suppression at cART24. This finding is consistent with previous studies [Early observations have shown that the selective depletion of the CD4+ T cells is accompanied by aberrant immune activation of all the components of the immune system in patients with HIV infection . Althougbaseline . Despitebaseline . This ob studies ,23 that in situ data analysis (baseline) when compared with similar cohort studies in Zambia–North America and Baltimore, Maryland . Although the interleukin-18 levels were of subjects with high viral load and reduced CD4 count, they did not use similar stratification. Racial and genetic diversity, along with social and environmental factors may contribute to the varying association of IL-18 levels which is also seen in many settings [et al [There is a growing body of evidence  that marsettings ,37,38. Ts [et al  reportedIn contrast to previous studies that consistently used baseline upper quartile (Q3: 75th quartile) as predictors of immunological failure and clinical progression of HIV infection, our study shows, for the first time, that an intermediate quartile (Q2: 50th percentile) was a stronger predictor of immunological failure in our study population. This observation is further strengthened by the lack of cART suppression of baseline IL-18 level despite lower baseline median IL-18 level in virologically non-suppressed subjects (>1000 cp/mL) as compared to virologically suppressed subjects. However, baseline IL-18 concentration within the 25th quartile was suggestive of a preserved immune function. This variability may reflect heterogeneous virus-host dynamics and cART treatment status, including socioeconomic variability across geographies, the use of appropriate normative data, and the handling of confounders ,38. FurtOur study also found a positive correlation between serum IL-18 and HIV-1 viral, a negative correlation between serum IL-18 and CD4+ T cell count, and decreased serum IL-18 concentrations following effective anti-retroviral therapy. These findings are consistent with other studies investigating the clinical significance of IL-18 suppression as a measure of cART response and monitoring of HIV progression .Some of the limitations of our study include the relatively small sample size and short follow-up period which limits the generalizability of our findings. Laboratory screening for concomitant infections other than HIV-1 was not carried out. Also, ART adherence among study participants was not analyzed. This could potentially affect the determination of serum IL-18 levels. Despite these limitations, our study provides useful findings of clinical relevance that can be built upon. A scale-up to involve a larger sample size, as well as mechanistic investigations, would be needed to further elucidate the clinical relevance of the trend observed in this study.Our study highlights some of the dynamics of IL-18 levels at various stages of CD4+ T cell counts and HIV RNA status in HIV-positive patients at baseline and at 24 weeks after commencing cART. Our findings have relevance for early identification and stratification of patients at risk of virological or immunological failure (non-response), with implications on treatment outcomes in HIV-positive persons. Future studies should focus on therapeutic strategies focused on not only viral suppression but immunological reconstitution of HIV-infected patients to avoid clinical progression to AIDS. Further reduction of IL-18 to a comparable level in healthy subjects should be explored as a pharmacological target for the achievement of such immunological reconstitution.The data sets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.


Public health behaviours, such as retention in HIV care and adherence to antiretroviral therapy (ART) pose major challenges to reducing new Human Immunodeficiency VirusWe evaluated 6-month retention in care, and clinical outcomes of an ART cohort comprising of SDI and delayed ART initiators. We conducted a 6 months’ observational prospective cohort study of 403 patients who had been initiated on ART. A structured questionnaire was used to abstract data from patient record review which comprised the medical charts, laboratory databases, and Three Interlinked Electronic Registers.Net (TIER.Net). Treatment adherence was ascertained by patient visit constancy for the clinic scheduled visit dates. Retention in care was determined by status at 6 months after ART initiation.Among the 403 participants enrolled in the study and followed up, 286 (70.97%) and 267 (66.25%) complied with scheduled clinics visits at 3 months and 6 months, respectively. One hundred and thirteen (28.04%) had been loss to follow-up. 17/403 (4.22%) had died and had been out of care after 6 months. 6 (1.49%) had been transferred to other health facilities and 113 (28.04%) had been loss to follow-up. Among those that had been lost to follow-up, 30 (33.63%) deferred SDI while 75 (66.37%) initiated ART under SDI. One hundred and eighty-nine (70.79%) participants who had remained in care were SDI patients while 78 (29.21%) were SDI deferred patients. In the bivariate analysis; gender , number of sexual partners , age , ART start date , partner HIV status  and the number of hospitalizations after HIV diagnosis . were significantly associated with viral load detection. Furthermore, SDI patients who defaulted treatment were 2.4 (95% CI: 1.165–4.928) times more likely to have increased viral load than those who had been returned in care.Viral suppression under SDI proved higher but with poor retention in care. However, the results also emphasise a vital need, to not only streamline processes to increase immediate ART uptake further, but also to ensure retention in care. Availability of Antiretroviral therapy (ART) to individuals diagnosed with Human Immunodeficiency Virus (HIV) has led to improved disease prognosis, healthier quality of life and reduction of HIV transmission . HoweverThe Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO) introduced the 95-95-95 initiative to further decrease new infections globally . The iniThe 2022 South Africa report on 95-95-95 targets indicates relative success with HIV testing, ART initiation and viral suppression, achieving 94% and 76% success rates and 89% respectively . It is wIn the field of HIV medicine, patients who receive regular medical care and attend scheduled clinic visits are considered retained in care . RetentiThis prospective cross-sectional study was conducted at 4 clinics in eThekwini municipality KwaZulu-Natal (KZN), South Africa between June 2020 to December 2020. The study sites were Ithembalabantu, Pinetown, D, and Qadi clinic. KZN has 1.9 million people living with HIV of which only 1.1 million are on ART . Of the We enrolled 403 participants from June to November 2020 meeting the eligibility criteria for the national guidelines on ART initiation. The guidelines state that all HIV-positive diagnosed individuals should rapidly initiate on ART regardless of CD4 count, receive treatment adherence counselling, those not ready to start ART and Tuberculosis asymptomatic awaiting for TB results initiate later as per program guidelines. The study participants were followed up for a period of six months after ART initiation from December 2020 to May 2021.A structured questionnaire was used to extract information on patient adherence to treatment, and retention in care and clinical outcomes using patient chart reviews. Data were collected electronically using the Kobo Collect application on Android mobile devices . Data waAdherence to treatment was ascertained by consistently attending scheduled patient visit dates for collection of medication both in the clinic and external medication pick up points. Retention in care was determined by clinic visits status at 6 months after ART initiation. Lost to follow-up was defined as no documented death or transfer and no clinical visit or pharmacy pick-up during the last 90 days according to the South Africa guidelines. Data collected was analysed using Stata version 17.0 . Descriptive and bivariate analysis were used to summarize socio-demographic characteristics of the participants as well as evaluating their association with the study outcome which was viral load detection and retention in care. Bivariate associations between each independent variable and viral load detection were determined using unadjusted logistic regression model, and variables associated with viral load detection at the level of p ≤ 0.2 were included in the multivariable logistic model. Viral load detection was associated to a number of factors with some of the factors also correlated with CD4 count. Therefore, our analysis considered all these factors in the model to minimize confounding effects. To achieve this, we estimated a step-wise model building for our outcome on the initial model by adding more controls at each stage (First level model: unadjusted (socio-demographic characteristics of participants); Second level model: added health outcomes and haematology laboratory results weight; Final-model: adjusted for date of start of ART. We also tested for interaction and for clustering by hospital site in order to fit it as a random effect. However, when site was included as our random effect to allow for robust estimate of viral load detection within and between the study clinics there, was no evidence of interaction. Goodness of fit and model adequacy were tested using the fit is the Hosmer–Lemeshow test . The prip=0.343) of association between viral load suppression and time of ART initiation when controlled for remaining in care or not.All 403 study participants were followed up using routine health data collected in TIER.NET and medical charts for 6 months from the date of HIV diagnosis. Two hundred and eighty-six (70.97%) and 267 (66.25%) visited scheduled clinics at 3 months and 6 months, respectively. Among those that had missed their scheduled visit dates after six months, 17 (4.22%) had died, 6 (1.49%) had been transferred to other health facilities and 113 (28.04%) had been loss to follow-up. Among those that had been lost to follow-up, 30 (33.63%) deferred SDI of ART while 75 (66.37%) initiated ART under SDI. Participants who had remained in care, 189 (70.79%) were SDI patients while 78 (29.21%) were SDI deferred patients (Table p=0.820), most respondents aged between 29- 39 years 71.8% (n=92) years had an undetectable viral load. We also observed a significant association with gender with 75.8% (n=138) of the females had suppressed viral load. The majority 69.1% (n=98) of the respondents were single and of these, 69.0% (n=98) had an undetectable viral load. Among the (n=142) unemployed patients, we observed that 71.1% (n=101) had an undetectable viral load. We observed that there was a correlation between viral load and the number of sexual partners, those with one sexual partner were more likely to have a suppressed viral load compared to those with more than two sexual partners (p=0.027). There was a significant association between having no knowledge of UTT and a detectable viral load (p=0.001). Participants who initiated ART on the same day of HIV diagnosis were more likely to have an undetectable viral load compared to those who delayed ART initiation (p-0.000). Factors such as HIV status of partner, scheduled clinic visits at 3 months after initiation, remaining in care (6 months after initiations), number of hospitalisations after testing were all associated with viral load suppression (p<0.05)  of the respondent had contracted another disease during the six months’ follow-up period. Of the 403 56.5% (n=104) were SDI deferred patients while 43.5 (n=80) (p=0.001) were SDI. The most common coinfection contracted by both the SDI (n=44) and SDI deferred patients (n=49) was STI shingles. On the other hand, 42.3% (n=44) of the SDI deferred patients had TB while only 1.25% (n=1) of the SDI patients had TB. We also observed that 9.78% (n=18) of the SDI patients had contracted hypertension while non-of the SDI deferred patients had contracted the same. Furthermore, 12.5% (n=10) and 7.5% (n=5) of the SDI patients had contracted Covid-19 and Cryptococcus Meningitis respectively while 5.8% (n=6) and 2.9% (n=3) of the SDI deferred patients had contracted the same diseases.Forty-five point seven percent  had a CD4 count of >350 copies/ml and 34.8% (97%) had a CD4 count of <350 copies/ml. On the other hand, among the SDI deferred patients, 37.9% (n=47) and 62.1% (n=77) had >350 copies/ml and <350 copies/ml CD4 count respectively. We also observed that of the 78 SDI deferred patients who had remained in care, 33.3% (n=26) had a CD4 count of >350 copies/ml while 66.7% (n=52) had a CD4 count <350 copies/ml. On the other hand, of the 189 SDI patient, 82% (n=155) had a CD4 count above 350 copies/ml while 18% (n=34) had a CD4 count below 350 copies/ml.In addition, we observed that among the SDI patients, 65.2 , more than two sexual partners , 18-28 years of age , ART start date  and partner HIV status  were significantly associated with viral load detection. Missing clinic scheduled visits at 3 months  and not remaining in care   they reported having co-morbidities during the period of the study  which was a predictors of viral load detection. We also observed that the odds of viral load surge were 2.313 (95% CI: 1.591–4.987) higher among those not remaining in care than those who remained in care. In addition, patients with chronic conditions such as hypertension were 0.082 (95% CI: 0.008–0.257) times more likely to have reduced viral load than those with Covid-19  trial and the Simplified Algorithm for Treatment Eligibility (SLATE) study in South Africa and Kenya, demonstrated that SDI improved viral suppression rates but showed limited evidence for improved retention in care .The increase in loss of patients to follow up among participants who initiated ART on the same day of HIV diagnosis we observed corroborates with results from the SLATE trial conducted in South Africa and Kenya that in that same-day treatment initiation increased rapid ART uptake but not necessarily retention in care especially in the early months after initiation . Trends Intensified patient education focussing on the benefits of ART initiation and consistent treatment is crucial to increase patient retention , 32. FurOur findings indicate that substantial effort is required to encourage treatment adherence and further sustain retention of PLHIV in care, especially during the first six months of ART initiation. Several, socio-demographic characteristics such as sex, gender, marital status, and employment status must be considered when developing policy and HIV care interventions since these pose technical hitches in effective policy implementation and sustainability on public health benefits.We found that individuals who remained in care were more likely to have a suppressed viral load at 6 months. Unsuppressed viral load at 6 months was associated with sub-optimal ART adherence, and this is corroborated by findings in studies conducted in Nigeria and Malawi amongst individuals attending a public ART programme , 35. AccWe identified that SDI individuals were more likely to be virally suppressed compared to those that deferred ART at 6 months after ART initiation. We also found that individuals who deferred same day ART initiation had greater odds of getting opportunistic infections with the common infection being TB. This might have been caused by low CD4 count results in the deferred SDI group. These findings were consistent with a study conducted in Johannesburg South Africa which showed that individuals who delayed to initiate on ART later on presented with advanced HIV disease, co-infections and low CD4 counts which were complicated to manage  .Some of the strengths of our study include; i) being done in an urban and peri‐urban communities of KwaZulu-Natal, a province with large numbers of patients on treatment thus providing a reasonable basis for generalizability for many people living with HIV in South Africa and sub-Saharan Africa, ii) being able to analyse at 6 months after ART initiation which is crucial in clinical assessments to observe if patients are responding well to treatment. However, some of the weaknesses of our study include that the population comprised of adults only hence the results on retention in care, viral suppression and clinical outcomes may not apply to infants and children and the Tier.Net is individualised per facility implying that some patients might have self-transferred themselves to other clinics or migrated and not actually lost to follow up. This is because patients exiting care from the ART initiating clinic may re-enter care elsewhere  and appear as lost to follow-up when they are still in care.rd 95% of the UNAIDS 95-95-95 target. However, the results also emphasise a vital need, to not only streamline processes to increase immediate ART uptake, but also ensure retention in care. There is need to review the same day ART initiation policy considering the amount of time some individual require to process and accept a positive HIV diagnosis before committing to lifelong treatment. Given the high HIV prevalence in eThekwini municipality and South Africa in general, adequate staff provision especially trained professional healthcare workers need to be addressed to reduce time taken initiating ART and effective continuous treatment management including adherence counselling services.We found evidence of a significant relationship between SDI and viral suppression but poor retention in care during the first 6 months of ART initiation. Individuals who initiated ART on the same day of HIV diagnosis and remained in care showed clinically meaningful outcomes. The CD4 count results, suppressed viral load, and reduced incidence of co-infections supported “proof of principle” for same day ART initiation algorithm. This study also provides much needed evidence on the relationship between adherence and viral suppression in this setting and supports the 3


Due to the high prevalence of resistance to NNRTI-based ART since 2018, consolidated recommendations from the WHO have indicated dolutegravir as the preferred drug of choice for HIV treatment globally. There is a paucity of resistance outcome data from HIV-1 non-B subtypes circulating across West Africa.We characterized the mutational profiles of persons living with HIV from a cross-sectional cohort in North-East Nigeria failing a dolutegravir-based ART regimen.WGS of plasma samples collected from 61 HIV-1-infected participants following virological failure of dolutegravir-based ART were sequenced using the Illumina platform. Sequencing was successfully completed for samples from 55 participants. Following quality control, 33 full genomes were analysed from participants with a median age of 40 years and median time on ART of 9 years. HIV-1 subtyping was performed using SNAPPy.Most participants had mutational profiles reflective of exposure to previous first- and second-line ART regimens comprised NRTIs and NNRTIs. More than half of participants had one or more drug resistance-associated mutations (DRMs) affecting susceptibility to NRTIs  and NNRTIs . Almost a quarter of participants  had one or more DRMs affecting tenofovir susceptibility. Only one participant, infected with HIV-1 subtype G, had evidence of DRMs affecting dolutegravir susceptibility—this was characterized by the T66A, G118R, E138K and R263K mutations.This study found a low prevalence of resistance to dolutegravir; the data are therefore supportive of the continual rollout of dolutegravir as the primary first-line regimen for ART-naive participants and the preferred switch to second-line ART across the region. However, population-level, longer-term data collection on dolutegravir outcomes are required to further guide implementation and policy action across the region. The continuing rollout is aided by the availability of a low-cost, generic fixed-dose co-formulation of tenofovir disoproxil fumarate, lamivudine and dolutegravir, called TLD.6Due to the increasing prevalence of pre-treatment NNRTI drug resistance,7 However, due to economic and other factors, there is no routine virological or resistance testing in Nigeria. Therefore, the majority of HIV-1-infected participants transitioned to dolutegravir-based regimens without prior viral load (VL) or resistance testing. Data from the ADVANCE and NAMSAL clinical trials,9 which recruited ART-naive participants exclusively in SSA, showed no evidence of emergence of drug resistance-associated mutations (DRMs) amongst participants on dolutegravir-based ART. Data on treatment outcomes of ART-experienced participants transitioning to TLD are limited, though some literature is beginning to emerge.10 Despite this, there are almost no data available from West Africa.Dolutegravir-based ART has been commercialized and distributed in Nigeria since late 2019. As of 2020, national Nigerian treatment guidelines recommend the transition to dolutegravir-based ART in both virally suppressed and unsuppressed participants.11 data on resistance outcomes following long-term use of dolutegravir are highly valuable. In this study, we present resistance outcomes and drug-resistance genotypes using next-generation HIV-1 sequencing, from participants in a small, Nigerian, treatment-experienced cohort failing dolutegravir-based ART following rollout.Given the high prevalence of ART resistance amongst treatment-experienced, HIV-1 participants following virological failure whilst on previous first- and second-line ART regimens,This was a cross-sectional study performed at the University of Maiduguri Teaching Hospital, Borno State, Nigeria, between January and June 2021. Assessing virological and resistance outcomes in this region of Nigeria has been challenging due to ongoing and long-term armed conflict caused by the Boko Haram insurgency, which has turned the area into a conflict zone. Inclusion criteria for this study was as follows: participants with virological failure (two consecutive HIV-1 RNA VL >1000 copies/mL) whilst following a dolutegravir-based ART regimen for >6 months, ≥18 years of age, attending routine clinic visits and able to provide informed consent for participation in the study. All participants included in this study provided informed consent prior to sample and data collection. Available demographic data including age, gender, ART regimen, duration on ART and current CD4 count were collected from clinical files and recorded in Microsoft Excel .12 protocol on 61 plasma samples with VL > 1000 copies/mL and stored prior to confirmation of VL.Plasma was separated from whole venous blood in EDTA within 2 h of collection and stored immediately at −80°C. Plasma VL testing and CD4+ counts were performed at the Defence Reference Laboratory, Asokoro Abuja using the COBAS AmpliPrep/COBAS TaqMan HIV type 1 (HIV1) v2.0 test . WGS was performed retrospectively using the ve-SEQ-HIVBriefly, total RNA was extracted from plasma samples, washed in ethanol, and eluted using the NUCLISENS easyMAG system (bioMérieux). Libraries were prepared using the SMARTer Stranded Total RNA-Seq Kits v2  according to the manufacturer’s protocol. Total RNA was denatured, and reverse-transcribed to cDNA and a total of 500 ng of pooled libraries were hybridized to custom HIV-specific biotinylated 120-mer oligonucleotides . Captured libraries were then amplified by PCR to produce a final pool for sequencing with an Illumina MiSeq  to produce up to 300-nucletoide paired-end reads.14 BAM files were quality controlled by determining the read depth at each position of the HIV-1 genome. Sequences with a depth of <50 reads were excluded from further analysis. Resistance genotyping was performed using an in-house script that utilizes the Stanford HIV drug resistance algorithm (v9.1) but is adapted to calculate the prevalence of DRMs from all available sequencing data rather than just consensus-level mutations. The script calls mutations with an absolute minimum read count of 50 reads, and minimum frequency of 2%, 10% and 20%. Haplotypes were reconstructed using CliqueSNV v2.0.315 using the -fdf extended, -m snv-illumina and -tf 0.05 flags. Phylogenies were inferred with IQ-TREE2 v2.2.215 using a GTR + F + I + R4 model with 1000 rapid bootstraps. Inference of transmission was made with phyloscanner v1.8.113 using overlapping windows of 150 bp across the whole genome. Phylogenies were rooted on an HIV-1 subtype G reference sequence, downloaded from the curated HIV-1 alignment from the Los Alamos National HIV Database. HIV-1 subtyping was performed using SNAPPy v1.0.0.16 Prediction of co-receptor usage was made using TROPHIX .FastQ files were trimmed of all sequencing adapters, and mapped iteratively to the best available reference sequence, from a curated alignment of 3000 HIV-1 genomes downloaded from the Los Alamos HIV sequence database, using SHIVER.The study was approved by the University of Maiduguri Teaching Hospital Ethics Committee (UMTH/REC/21/714). All participants provided written informed consent.JAC Online), 28 samples were excluded from further analysis. This resulted in a population of 33 participants with a fully intact whole genome, from which the prevalence of DRMs and minority variants were calculated.Virological assessment revealed that of 4263 HIV-1-positive participants on dolutegravir-based ART for ≥6 months, 452 (11%) had a detectable VL (>400 copies/mL), yielding a population-level suppression rate of 89%. Amongst those participants with a detectable VL, 281 had a VL of >1000 copies/mL; plasma collection was successful in 61 participants. Following quality control of the WGS, due to poor coverage and depth across most of the genome . Only two participants were initiating first-line dolutegravir-based regimens; the remainder were switched to dolutegravir as their second-line regimen. We did not observe from clinical records, any previous exposure to an INSTI in our study population.This population Table  was a la18 Using a minimum threshold of 20%, NRTI, NNRTI, PI and INSTI DRMS occurred in 17 (52%), 24 (73%), 4 (12%) and 1 (3%) of samples, respectively ; this mutation compensates for the fitness defect induced by M184V.20 The most prevalent NNRTI DRM was K103N, reflective of prior exposure to nevirapine and efavirenz in this cohort of treatment-experienced persons living with HIV (PLWH). The frequency of detected DRMs was similar across the different interpretive thresholds of 2%, 10% and 20%  settings.24 The second-generation INSTI dolutegravir has been systematically adopted and rolled out across SSA since 2018, though there are concerns regarding the emergence of DRMs following virological failure in these limited-monitoring settings. In a recent analysis of pooled evidence on virological and resistance outcomes following dolutegravir failure in SSA, there was an overall high rate of virological response to dolutegravir: 88.5% (95% CI: 73.8–97.8). Participants in these studies experienced an exceptionally low rate of virological failure,10 and there was minimal evidence of the emergence of DRMs during short observation periods. However, prolonged virological failure is expected to eventually lead to the selection of DRMs within viral quasispecies, as a result of intrahost evolution.25Following the initial rollout of previous first-line, NNRTI-based ART regimens, DRMs were first observed within the first year of virological failure in ∼15%–35% of participants, characterized by resistance to lamivudine, tenofovir disoproxil fumarate and NNRTIs.26 However, other studies conducted in various countries in SSA have reported similar virological and resistance outcomes in both ART-naive28 and ART-experienced participants30 (without evidence of DRMs), as well as in ART-experienced individuals with a history of NRTI mutations, particularly M184V/I.33 Nonetheless, it is important to acknowledge that resuppression can occur after a viral rebound, but DRMs accumulated during that rebound can lead to high-level resistance against second-line ART components.34It is worth noting that the presence of pre-existing DRMs, prior to switching to dolutegravir-based ART regimens may have a significant impact on both virological and resistance outcomes. Previous studies suggest that NNRTI mutations acquired before treatment can reduce the effectiveness of dolutegravir-based ART regimens.35In this study, we conducted a cross-sectional analysis to determine the prevalence of DRMs, using WGS, in a small cohort of HIV-1-positive participants who were experiencing virological failure on dolutegravir-based ART regimens (defined as a VL > 1000 copies/mL). This study is particularly relevant as the majority of HIV-1 in Nigeria is subtype G or AG recombinants, rather than the commonly investigated subtype C from many other parts of SSA. Many of the viraemic participants were ART-experienced, having previously been on PI-based regimens before being switched to TLD. We attribute the high rate of virological failure amongst these participants to poor adherence. Despite this, we observed a low incidence of individuals with TDF or dolutegravir resistance despite experiencing viraemia on TLD. This is reassuring as it suggests that adherence counselling would likely result in resuppression of viraemic participants, similar to those rates observed with PI-based ART.36 Further, the G118R and R263K mutations observed in this patient, conferring between 2- and 15-fold reductions to dolutegravir susceptibility,38 have also been observed in participants experiencing virological failure on INSTI-based regimens in non-B HIV subtypes42 and is known to reduce long terminal repeat DNA binding, replication capacity, infectivity and viral fitness.43 It is likely that the G118R mutation emerged first and led to the accumulation of other mutations including the E138K compensatory mutation, as G118R has been described as a dolutegravir-resistance pathway in non-B subtypes.44 Research on non-B subtype drug resistance is therefore important, especially as polymorphisms in the integrase gene may have a negative effect on impact on resistance outcomes to other INSTIs.45Amongst the 33 participants with sequencing data of sufficient quality, the observed mutational landscape was reflective of exposure to previous first-line NNRTI-based regimens, with only a single participant having DRMs reducing the efficacy of dolutegravir or other PIs. This participant was vertically infected, likely at a young age, due to the length of ART treatment. The participant had a number of DRMs conferring high-level resistance to dolutegravir and other INSTIs, i.e. T66A, G118R, E138K (accessory) and R263K. The T66A mutation is non-polymorphic and primarily selected by elvitegravir and raltegravir, resulting in an ∼9-fold reduction in susceptibility to elvitegravir but minimal impact on other INSTIs. The E138K mutation has negligible effect on susceptibility to INSTIs; however, when found in combination with other DRMs, this results in further decreased susceptibility to dolutegravir.47 To ensure that this was a true finding, investigation of read coverage shows that there was sufficient depth to determine DRMs at this site, though there was a complete absence of it (Figure 48 and that the occurrence of NRTI and PI mutations is relatively uncommon during viraemia on PI-based ART.50We note that there was a complete absence of the NRTI mutation K65R, along with low-level resistance to tenofovir disoproxil fumarate. This phenomenon has also been described in other Nigerian cohorts.t Figure . We note51 Despite this, this study has provided additional evidence to support favourable outcomes when providing long-term ART services in areas of conflict and civil unrest. However, several factors may increase the risk of dolutegravir resistance emerging in the region, including prolonged virological failure due to the lack of routine virological monitoring53 as well as suboptimal treatment adherence,54 which is an independent determinant of virological outcomes in these settings.Given the increasing use of dolutegravir in clinical practice, the most effective strategy for managing participants with persistent viraemia whilst on dolutegravir-based ART regimens remains uncertain. This is especially true in resource-limited settings such as Nigeria, where the capacity for drug resistance testing is limited.55 highlighting the benefits that can be gained through outreach and tracing efforts. Given that INSTI-based long-acting injectables are being considered as pre-exposure prophylaxis,56 it is crucial to conduct further analyses of resistance across SSA over extended periods and to monitor newly diagnosed individuals for INSTI resistance.Disengagement from care is also a significant problem, although it is possible to re-engage with a substantial proportion of cases,This study was subject to limitations. Study sample size was small, with only 33 samples generating high-quality sequences for analysis despite sample collection from 61 participants. We speculate this could be due to human-related factors, which may include shipping and storage conditions. We did not collect data on adherence although the mutational landscape and profile of patients are consistent with prior treatment with NNRTI-based first-line regimens and with evidence of virological failure on dolutegravir. Nonetheless, given the paucity of data across this region, this study provides critical outcome and resistance data including highlighting the need for larger and more comprehensive population-level cohort studies to further understand the emerging trends and prevalence of DRMs in individuals failing dolutegravir-based ART in resource-limited settings.Finally, given the potential for dolutegravir resistance to emerge due to suboptimal treatment adherence and prolonged virological failure, efforts to improve adherence and increase access to routine virological monitoring should be prioritized to minimize the emergence and spread of drug resistance. Further research is needed to evaluate the effectiveness of different strategies for managing individuals experiencing persistent viraemia on dolutegravir-based ART in resource-limited settings, particularly in the context of ongoing conflict and civil unrest.dkad195_Supplementary_DataClick here for additional data file.


Prevalence of asymptomatic cryptococcal antigenemia was estimated by facility and geopolitical zone. Logistic regression was conducted to identify risk factors for cryptococcal antigenemia. In total, 1,114 patients with AHD were screened. The overall prevalence of asymptomatic cryptococcal antigenemia was 3.9% with wide variation across facilities (range: 0/75 [0%]– 15/122 [12.3%]) and geopolitical zones (range: 0/75 [0%]–19/279 [6.8%]). Prevalence of antigenemia was highest in the South-West (19/279 [6.8%]) and lowest in the North-East (0/75 [0%]). Prevalence was 5.2% (26/512) and 3.2% (18/561) in patients with CD4<100 and CD4 of 101–200, respectively. Of all patients with antigenemia, 50% were on antiretroviral therapy (ART) at the time of having a positive CrAg test. In adjusted analysis, cryptococcal antigenemia was significantly less in patients on ART and patients who had completed any formal education. The survey showed a high overall burden of cryptococcal antigenemia in Nigeria, with variable prevalence across geopolitical regions. We provided valuable evidence for implementing routine CrAg screening of AHD patients in Nigeria which has commenced in selected centres.As of 2018, cryptococcal antigen (CrAg) screening in patients with advanced human immunodeficiency virus (HIV) disease (AHD) was not routinely implemented in Nigeria despite being recommended in the national HIV treatment guidelines. Our aim was to determine the prevalence and risk factors for asymptomatic cryptococcal antigenemia in adult people living with HIV (PLHIV) in Nigeria to advocate for the implementation of routine CrAg screening. A descriptive cross-sectional study and CrAg screening of consecutive adult PLHIV with CD4 counts ≤200 cells/ Over the last decade there has been a significant increase in access to antiretroviral therapy (ART) for people living with HIV (PLHIV) in resource limited settings . However3 followed by pre-emptive antifungal therapy to prevent CM in patients with antigenemia in whom concurrent CM is ruled out [A first episode of cryptococcal antigenemia indicates disseminated infection and cryptococcal antigen (CrAg) can be detected in a patient’s blood weeks to months prior to onset of CM . Routineuled out . HoweverThis descriptive cross-sectional study was conducted across eleven ART clinics located in all six geopolitical zones of Nigeria; . The sites within the zones were selected mostly based on confirmation of a high burden of AHD from the national database but also because of the availability of suitably qualified site investigators with an established working relationship. Institutional ethical approval was obtained at each site before commencement of the study.The studied population consisted of adult (18 years and above) patients with AHD patients who had CD4 count less than 200 cells/μL or clinical stage 3–4 disease. CD4 count testing is done per routine at the participating sites, with all ART naïve patients eligible for baseline CD4 while CD4 monitoring is done every 6 months for patients on ART. Patients in these two categories were eligible for the study if their CD4 count was less than 200 cells per microlitre. Patients who were currently pregnant or breastfeeding, had previously been treated for cryptococcosis, or who had clinical liver disease  were excluded from the study. All eligible patients were screened for CrAg regardless of ART status.Eligible patients were enrolled consecutively until the end of the study period.We selected a minimum sample size of 120 participants per site based on the minimum number recommended to establish a reference interval using the the non-parametric percentile method . This isDemographic data and clinical history were collected using a pre-tested, semi-structured questionnaire. Blood samples were obtained and transported to the laboratory at each site where CD4 and CrAg testing were conducted on patients’ serum samples. CrAg testing was performed by laboratory personnel previously trained to conduct the test using the CrAg lateral flow assay (LFA)  per manufacturer’s instructions. The same lot of testing kits was sent to all the sites, however to rule out false positives or negatives, duplicate samples were shipped to the Principal Investigator’s laboratory where they were retested. There was very good correlation between the results. However, a couple of samples had prozone reactions which was discovered by serial dilutions. These samples were recorded as positive for cryptococcal antigen. Relevant clinical and laboratory data was obtained from the enrolled patients’ records. CrAg screening was conducted from April 2018 –April 2019.All final clinical and treatment initiation decisions  for enrolled patients were made at the discretion of the clinicians at the participating facilities based on the standard of care at the time of the pilot. However, we recommended that patients who tested positive for CrAg and were asymptomatic for cryptococcal meningitis be commenced on Fluconazole 800mg daily for 2 weeks, then deescalated to 400mg daily for 8–10 weeks, followed by 200mg daily until immune reconstitution according to Nigerian Ministry of Health HIV treatment guidelines . PatientEthical approval was obtained from ethical committees at all participating enrolment sites prior to implementation of patient enrolment and screening activities. . A 5% significance level was used throughout the study unless otherwise specified. Chi-squared and Fisher’s exact tests were used to compare proportions between groups and Wilcoxon rank sum tests were used to compare continuous variables. Bivariable and multivariable logistic regression was conducted to identify factors associated with higher odds of cryptococcal antigenemia. Any variable with a p-value ≤0.2 in bivariable analysis was considered in the initial adjusted model. The final model included all variables for which adjustment was necessary to account for potential confounding (assessed by impacts on effect size and precision when removing variables in backward model selection). Collinearity and correlation were assessed prior to conducting regression analysis.From April 2018 to April 2019, 1,114 patients with advanced HIV disease (AHD) were enrolled and screened for CrAg . Of thos3, 512 (46.0%) had a CD4≤100 cells/mm3, 561 (51.2%) had a CD4 of 101–200, and 22 (1.9%) had a CD4>200 cells/mm3 and were tested due to clinical stage 3–4 illness. CD4 count did not differ significantly by ART status at the time of enrolment .CD4 results were available for 1095 (98.3%) patients, with 19 (1.7%) patients tested in the absence of a CD4 result due to having a clinical stage 3–4 illness. Median CD4 count was 107 (IQR: 52–161) . Of thos3 or with clinical stage 3–4 illness without a CD4 result tested CrAg positive. Of all patients with antigenemia, 22 (50%) were receiving ART at the time of screening. No measured factors were significantly associated with the odds of cryptococcal antigenemia in bivariable analysis. However, in adjusted analysis, patients who had previously received ART for any amount of time  and patients who had completed any formal education  had significantly lower odds of cryptococcal antigenemia  (95% C.I: 2.9–5.3) . The preigenemia .3 CD4 cell count threshold for their national cryptococcal screening guidelines [A number of African countries, including Nigeria, have adopted a 200 cells/mmidelines , 12. To The overall prevalence of cryptococcal antigenemia in this study (3.9%) fits within the range (1.7%–15.8%) of previously observed CrAg prevalence reported from countries in sub-Saharan Africa . It is cet al study found a significantly higher prevalence (4.4%) in the South-East compared to the South-West (1.4%) and the combined North-West and North-Central (0.5%) geopolitical zones. Other single-center studies have demonstrated CrAg prevalence of 1.6% (irrespective of CD4 count) and 12% (at CD4<200 cells/μL) at tertiary hospitals in Kano (North-West) and Benin City (South-South), respectively [et al. Other recent studies have also indicated a high prevalence of antigenemia in Sokoto [Cryptococcus spp. Although the environmental niches are not comprehensively defined, Cryptococcus spp is known to be associated with certain types of soil, flora, and fauna [Cryptococcus spp. isolated from environmental samples was associated with distinct ecological niches across the country [Cryptococcus spp. varies by lineage and species [The Ezeanolue ectively , 16. Then Sokoto . The obsnd fauna . A recen country . Previou species . The obs3 for CrAg is warranted and may lead to detection of a substantial number of patients with antigenemia who would be missed if screening were confined to lower CD4 thresholds.We observed that almost 60% of patients with antigenemia had a CD4 count≤100 cells/μL. However, in adjusted analysis we found that the odds of cryptococcal antigenemia in patients with CD4 of 101–200 cells/μL was not significantly lower compared to patients with CD4≤100 cells/μL . This is in contrast to previous studies in Nigeria which have found the risk of cryptococcal antigenemia is significantly higher in PLHIV with CD4 counts <100 cells/ μL , 15. OurThe odds of antigenemia in this study was not significantly associated with age or gender, which is consistent with previously published results from Nigeria , 17. HowHalf of the patients with antigenemia in this analysis were receiving ART at the time of their positive CrAg screening result, but with unknown ART initiation dates. This means that some of these patients could have been on ART for a short period of time if their routine baseline CD4 testing was delayed until follow-up visits post-ART initiation. However, the results of our multivariable analysis show that being on ART at the time of positive CrAg test was significantly protective against cryptococcal antigenemia. Therefore, it is likely that our estimate of the protective effect of ART against cryptococcal antigenemia is a conservative one and an even more protective effect of ART would have been observed in patients on ART for longer periods of time.In any case, this result highlights the importance of early HIV diagnosis and prompt ART initiation, coupled with CrAg screening of those with advanced HIV and initiation of pre-emptive antifungal therapy to reduce the incidence and mortality associated with CM in adult PLHIV with cryptococcal antigenemia. Early identification of PLHIV and initiation of ART before a patient’s immune system becomes seriously compromised is still considered the most effective way to reduce the number of patients at risk for serious OIs such as CM . Late HIThe study was limited by lack of data on patient symptoms, viral suppression status, length of time on ART in enrolled patients, and patient outcomes. Nevertheless, our results illustrate that a considerable proportion of people with advanced HIV in Nigeria are at high risk of CM in the absence of comprehensive CrAg screening and pre-emptive fluconazole treatment as part of routine HIV care.As a result of the data generated from this study progress is being made in implementing routine CrAg screening and pre-emptive treatment in Nigeria. At the time of writing, the Clinton Health Access Initiative (CHAI) and Unitaid, a global health funding agency, have partnered with National AIDS and STDs Control Programme (NASCP) to support implementation of the WHO recommended package of care for AHD , includiTo conclude, this nationally-representative survey showed a high overall burden of cryptococcal antigenemia in Nigeria, with variable prevalence across geopolitical regions. The data generated provided valuable evidence for implementing routine CrAg screening of AHD patients in Nigeria which has commenced in selected centres.S1 File(DOCX)Click here for additional data file.S1 Data(XLSX)Click here for additional data file.


As they age, people living with HIV (PLWH) must face new challenges, such as accelerated ageing and higher rates of comorbidities. This study described the characteristics of HIV acquisition among treatment‐naïve PLWH aged ≥50 years and <50 years in Beijing from 2010 to 2020, exploring associated risk factors for comorbidities.t‐test, Mann−Whitney U test and chi‐square test. Temporal trend data were analysed via joinpoint regression. A multivariate logistic regression model was conducted to analyse the associated factors with PLWH having one or more comorbidities.In this cross‐sectional study, differences in HIV‐related and non‐HIV‐related characteristics were compared using the The proportion of PLWH aged ≥50 years has significantly increased since 2013, with a corresponding increase in homosexual transmission in this age group over the past decade. The proportion of individuals with CD4 counts <200 cells/μl significantly decreased from 2010 to 2013 among PLWH aged ≥50 years and from 2010 to 2014 among those aged <50 years. Delayed initiation of antiretroviral therapy (ART) improved for both age groups over the course of the decade, especially from 2014 to 2020. Compared to PLWH aged <50 years, those aged ≥50 years had a higher proportion of CD4 counts <200 cells/μl, higher levels of plasma HIV RNA load and a higher prevalence of non‐HIV‐related risk factors. Multivariate analysis revealed that PLWH aged ≥50, male, not single, transmission through heterosexual contact or drug injection, WHO Stage IV, coinfection with hepatitis B virus/hepatitis C virus and CD4 counts <200 cells/μl at the initiation of ART were associated with higher risk of the presence of an HIV comorbidity.Due to the persistent burden of HIV‐related characteristics or symptoms and the increasing prevalence of coexisting comorbidities among treatment‐naïve PLWH aged ≥50 years, physicians should provide the highest‐quality screening, prevention, treatment and management of coexisting comorbidities, adopting a multidisciplinary approach. HoweverAlthough ART has significantly decreased HIV‐associated morbidity and mortality , AIDS‐reOlder PLWH face other challenges as well, such as accelerated ageing and higher comorbidity rates . A previThis study compared HIV‐related characteristics and comorbidities between ART‐naïve PLWH aged ≥50 years and <50 years to explore the associated factors with one or more comorbidities based on 11‐year surveillance data from Beijing.22.1This was a cross‐sectional study, conducted using data collected from a surveillance system that tracks clinical information on PLWH receiving ART and long‐term follow‐up care at the STD/AIDS Prevention and Treatment Institute of the Beijing Centre for Diseases Prevention and Control (CDC) in China. Clinical data were reported by clinicians in four designated HIV treatment hospitals in Beijing: Peking Union Medical College Hospital, Beijing You'an Hospital, Beijing Ditan Hospital and 302 Military Hospital of China. Our analysis included all treatment‐naive PLWH who initiated therapy at one of these hospitals between 1 January 2010 and 31 December 2020 . The datPLWH aged 18–80 years who initiated ART in Beijing, China, were included in this study. Two age groups were identified: PLWH aged 18–49 years and those aged ≥50 years. Confidentiality was protected for individual information processing. The study protocol was approved by the Research Ethics Committee of the Beijing CDC. The data were based on clinical records that had already been de‐identified, so informed consent was unnecessary.2.22, following the Working Group on Obesity in China  3.90%, 9.19%; p = 0.001). The demographic characteristics of the participants, stratified by age, are shown in Table p = 0.077), with a statistically significant increase over 2010–2016  and a fluctuation from 2016 to 2020. In both age groups, more were Beijing residents than were not. A much higher proportion of PLWH were married or cohabitating in the older group. As with younger PLWH, older PLWH were primarily infected through homosexual contact, followed by heterosexual contact, PWID and other (including unknown). Figure p = 0.008). However, the increase was only statistically significant in the older group . Figure p = 0.280), with a significantly decreasing trend observed from 2010 to 2015  and fluctuations observed from 2015 to 2020.In all, 23,622 PLWH who initiated ART between 2010 and 2020 were included in this study, of whom 2261 (9.57%) were aged ≥50 years, and 21,361 (90.43%) were aged <50 years. Most (72.27%) older PLWH were aged 50–59 years, 20.21% were aged 60–69 years and 7.52% were aged 70–80 years. As shown in Figure The HIV‐related and non‐HIV‐related characteristics of the participants by age are shown in Table p = 0.002), with inflection points in 2013 for the older and 2014 for the younger groups. Both groups experienced a sharp decrease in the initial trend , followed by a stable period. Temporal trends in the rate of delayed ART initiation among PLWH by age group are shown in Figure p = 0.463), and the initiation delay improved for both groups over the decade, especially from 2014 to 2020 . Nevertheless, a difference remained between the two groups, and the proportion of delayed ART initiation was 10% lower in the older group. All the aforementioned trends among treatment‐naïve PLWH in Beijing, China from 2010 to 2020, as determined by joinpoint analysis, are presented in Table Temporal trends by age group in the proportions of CD4 counts <200 cells/μl in treatment‐naïve PLWH are shown in Figure As the timeframe of this study includes year of 2020, when the COVID‐19 epidemic existed, which might  influence the diagnosis and treatment of HIV acquisition due to lockdowns and reduced access to clinical care, a sensitivity analysis was conducted that excluded data from 2020, presenting in Table A significantly higher prevalence of comorbidities was seen in the older group Figure . FurtherNo significant differences were seen in ART selection between older and younger PLWH. Between 2010 and 2020, efavirenz, lamivudine and zidovudine EFV+3TC+AZT) were the most commonly used ART regimens, accounting for approximately 50%. This shifted to EFV+3TC+tenofovir (TDF) from 2013 to 2020; the proportions administered fluctuated but were over 50% at all times  per month in 2017 . HIV casIn our study, although the rate of MSM was lower in the older group than the younger group, it remained the most common route of HIV in this group and was much higher than that found in a cross‐sectional study in Taiwan (49.0%)  and a coLate initiation of ART was defined as having CD4 counts <200 cells/μl or having a clinical AIDS diagnosis at ART initiation . The proNevertheless, older PLWH had a significantly higher proportion of CD4 counts <200 cells/μl, and experienced a slower decrease than the younger group. In addition, the proportion of CD4 counts <200 cells/μl in older PLWH is substantially higher than that reported in a report covering 31 European countries, where the corresponding proportion was 27.4% . AlthougThis study found that older PLWH were more than twice as likely to have one or more comorbidities than younger PLWH at the initiation of ART, similar to older PLWH with access to ART in many Western countries . It is aHIV acquisition and the associated immune activation are independent risk factors for many comorbidities . Our mulThe intersection of ageing‐related and HIV‐related social services and support systems should be enhanced. We strongly recommend that clinicians pay greater attention to comorbidities in older PLWH at the initiation of ART to better prevent and manage further comorbidities. Furthermore, it is necessary for health systems to reconsider care strategies and meet the growing needs of older PLWH. For example, improved screening algorithms are needed to detect metabolic disease in older PLWH. At present, there are no validated CVD risk assessment tools specifically designed for PLWH. The most prominent ones developed hitherto for the general population include the US‐based pooled cohort equations, the Framingham risk functions and the Europe‐based systematic coronary risk evaluation . HoweverOur study had several strengths. First, the data were routinely collected through a standard hospital‐based data‐collection platform, ensuring their validity and reliability. In addition, all subjects were ART‐naïve PLWH; thus, we excluded any adverse effects caused by ART regimens to focus on the effects of ageing and HIV status. However, our study also had notable limitations. First, only already available clinical or demographic parameters were analysed, and some variables had a missing rate of more than 10%, causing us to create a separated “missing” group in the regression model. Second, some comorbidities were not systematically examined, including hypertension, osteoporosis and malignancy, as the information examined was mainly from laboratory data, accumulated during clinical care. However, laboratory data are more reliable than measurements. Finally, the healthy lifestyle factors and socio‐economic status were not included. Future studies should pay closer attention to the more detailed characteristics of PLWH.5Our study highlights a significant increase in the proportion of PLWH aged ≥50 years and the important role of MSM in Beijing's HIV epidemic among older PLWH. In addition, widespread testing and earlier diagnosis should be implemented to address the late initiation of ART among older PLWH. Furthermore, the significant proportion of older PLWH in Beijing with multimorbidities indicates that HIV physicians should provide high‐quality care for screening, preventing and treating age‐related diseases, ideally through a multidisciplinary approach. Finally, under universal health coverage, older PLWH have lifelong access to comprehensive services, prioritizing ending HIV transmission through a strong monitoring system, integrated care and specialist access. This approach provides holistic care, ensuring accessibility and sustainability for older PLWH.DW, MZ, PW, JZ, YM, JL and FC disclose no competing interests.The authors’ responsibilities were as follows: DW wrote the manuscript. MZ contributed to conceptualization, writing, review, and editing. PW, JZ and YM contributed to the statistical analysis, discussion and reviewed/edited the manuscript. MZ, JL and FC were involved in the study design and data collection, contributed to the discussion, and reviewed and critically revised the manuscript.This work was supported by the National Key R&D Program of China during the 14th Five‐Year Plan Period [Project No. 2021ZD0114102], the National Natural Science Foundation of China [Project No. 71874100], Beijing Municipal Science & Technology Commission [Project No. D171100006717002], Incubation Fund of Vanke School of Public Health at Tsinghua University [Project No. 2021PY002] and Sanming Project of Medicine in Shenzhen [No. SZSM202111001].Table S1: Missing rates of each variable and management of missing data.Table S2: Trends in the proportion of older, male, homosexual, heterosexual, CD4 counts <200 cells/µL, and delayed ART initiation among treatment‐naïve PLWH in Beijing, China from 2010 to 2020, as determined by Joinpoint analysis.Table S3: Trends in the proportion of older, male, homosexual, heterosexual, CD4 counts <200 cells/µL, and delayed ART initiation among treatment‐naïve PLWH in Beijing, China from 2010 to 2019, as determined by Joinpoint analysis.Figure S1A: Temporal trend in the proportion of treatment‐naïve PLWH aged ≥50 years in Beijing, China, 2010–2019.Figure S1B: Temporal trend in the proportion of male treatment‐naïve PLWH by age group in Beijing, China, 2010–2019.Figure S1C: Temporal trend in the proportion of transmission through homosexual contact by age group in Beijing, China, 2010–2019.Figure S1D: Temporal trend in the proportion of transmission through heterosexual contact by age group in Beijing, China, 2010–2019.Figure S1E: Temporal trend in the proportions of treatment‐naïve PLWH with CD4 counts less than 200 cells/µL by age group in Beijing, China, 2010–2019.Figure S1F: Temporal trend in the proportion of delayed ART initiation among treatment‐naïve PLWH by age group in Beijing, China, 2010–2019.Click here for additional data file.


P = .019). From the ROC curve, the sensitivity was same at 95.5% for both methods, but the specificity of the urine-tenofovir point-of-care test was greater (96.6% vs 95.5%) than pharmacy refill record (P = .837). Urine-tenofovir point-of-care test provided equivalent adherence data to pharmacy refill data.Pharmacy refill records (PRR), are an accessible strategy for estimating adherence in low- and middle-income countries (LMICs). However, the low-cost urine-tenofovir point-of-care test opens up the possibility of an objective metric of adherence that is scalable to LMICs. This study compared adherence to tenofovir-based regimens using urine-tenofovir point-of-care (POC) test with pharmacy refill records in a Nigerian population of HIV-positive persons. This was a cross-sectional study among 94 HIV-positive adults, which was conducted from June to August 2021, in a large outpatient clinic in Lagos, Nigeria. Adherence to pharmacy appointments was automatically calculated using a computerized pharmacy appointment system (FileMaker Pro™). Urine drops on the urine-tenofovir POC test strip developed 2 lines for a negative test (tenofovir absent) and one line for a positive test. Fisher’s exact test was used to examine the association between pharmacy refill record and urine-tenofovir point-of-care test. Logistic regression was performed to predict viral suppression  using both methods of adherence determination. A Receiver Operating Characteristic (ROC) curve of the association between specificity and sensitivity was generated to evaluate the predictive value of adherence determined using pharmacy-refill record and urine-tenofovir point-of-care test in forecasting viral suppression. The statistical significance level was set at 0.05. Fisher’s exact test showed no statistically significant difference in adherence using urine-tenofovir point-of-care test or pharmacy refill record. The logistic regression model showed that an increase in pharmacy-refill record of ≥ 95% was associated with viral suppression ( Sixty-five percent of these persons living with HIV (PLHIV), were from Sub-Saharan Africa. Nigeria, a West African Country with a population of 313.4 million people reported an HIV prevalence of 1.4% in 2018. Nigeria has the third largest population of PLHIV,,4 and has also been referred to as “the largest HIV epidemic in Western and Central Africa.”There were an estimated 39 million people globally living with the Human Immunodeficiency Virus (HIV) at the end of 2022. In order words, 95% of the population of these countries knew their HIV status, 95% of those who knew their HIV status were on life-saving antiretroviral therapy, and 95% of PLHIV who were on antiretroviral therapy, had suppressed HIV viral load results. The level of the USAID 95-95-95 targets in Nigeria in 2022 were 86:89:93 among adults aged 15-45 years old. Nigeria has adopted policies which “lead to the path that ends AIDS.” Some of these policies include adoption of the World Health Organisation recommendation of rapid initiation of antiretroviral therapy (ART) within 7 days of HIV diagnosis . The treat-all policy (regardless of CD4 count) is implemented in over 95% of all HIV treatment sites for adults and adolescents in the country. Other policies such as multi month dispensing, 6-monthly viral load monitoring (for stable patients) or 3-monthly for patients who have unsuppressed viral load results, are outlined in the National HIV Treatment Guidelines.The world is making good progress towards the targets that were set to end the HIV epidemic by 2030. Five Southern African countries were reported to have achieved the 95-95-95 targets in 2022. Adherence is a patient’s ability to follow a treatment plan, take medications at prescribed times and frequencies, and follow restrictions regarding food and other medications. There are few antiretroviral drugs available for combination antiretroviral therapy options in low- and middle-income countries (LMIC). Ensuring proper adherence to available antiretroviral drugs is very important to avoiding the development of resistance to the few accessible antiretroviral drugs.The Nigerian National Treatment Guidelines recommend intensified adherence counseling for patients with unsuppressed viral load. Unlike most other currently available objective tests , which involve expensive and time intensive mass-spectrometry-based methods, antibody-based urine-tenofovir immunoassay which can be performed at the point-of-care (POC), is easy to conduct, and results are available in real-time (3–5 minutes). A point-of-care test allows for a rapid assessment of adherence levels in a clinic, as well as providing immediate feedback to an individual patient, which can help initiate intensive adherence counseling targeted to the patient. Point-of-care monitoring and feedback could improve adherence to ART and help increase viral suppression rates.Adherence assessment is critical to the success of ART and pre-exposure prophylaxis (PrEP). Commonly used measures of adherence such as “self-report,” or “pharmacy-pick-up”/ “pharmacy refill records,” are acclaimed not to be as reliable as objective adherence tests measuring antiretroviral (ARV) concentrations in biological samples. Paired urine and plasma tenofovir concentrations have been shown to be highly correlated and measuring tenofovir levels in urine assesses adherence. Beyond the high predictive utility of an adequate urine-tenofovir level to assess adherence to PrEP, urine-tenofovir concentrations can evaluate time since dosing. Since tenofovir is the most widely used nucleotide reverse transcriptase inhibitor in HIV treatment and prevention, the University of California, San Francisco Hair Analytical Laboratory helped to develop a highly selective antibody against tenofovir which was converted into an enzyme-linked immunosorbent assay and validated via liquid chromatography/tandem mass spectrometry. A lateral flow assay, which permits POC testing, was then developed, which examines recent adherence over the last 4 to 7 days based on a cutoff of 1500 nanograms (ng)/milliliter (mL) of tenofovir. Absence of tenofovir detected by our assay predicted future PrEP seroconversion in large demonstration projects (iPrEx OLE study and Partners PrEP).,14 Moreover, urine collection has been demonstrated to be highly acceptable to research participants and patients.,15,16Concentrations of tenofovir in urine have been successfully used to monitor adherence to PrEP.; and pregnant women, for whom adherence is very important to prevent mother-to-child transmission of HIV.The urine-tenofovir POC test will be very useful for special populations such as adolescents and young adults who are reported to have problems with adherence to ARTSince self-reported adherence and pharmacy-refill record are easy to assess in LMIC, these metrics are used most often to estimate population or individual level adherence. However, the low-cost urine tenofovir test opens up the possibility of an objective metric of adherence that is scalable to LMICs.The purpose of this study was therefore to compare adherence to tenofovir-based antiretroviral regimens by the urine-tenofovir point-of-care test and pharmacy-refill record in a Nigerian population of people living with HIV, and to compare the HIV viral load suppression predictive ability of each measure of adherence.The Outpatient HIV Clinic in Lagos, Nigeria, is situated in the Nigerian Institute of Medical Research which is charged with conducting research relevant to the country. The Institute was among the 25 centers selected in 2002 to implement the Federal Government of Nigeria’s antiretroviral drug access programme. The Institute was selected principally to conduct clinical research in the large antiretroviral therapy (ART) access programme. Cumulatively over 24,000 HIV positive individuals have been enrolled into the HIV programme since its inception. A diverse population of persons living with HIV (PLHIV) access care at the Nigerian Institute of Medical Research clinic. The clinic population include infants exposed to HIV, children and adolescents, pregnant women, and other adults. This cross-sectional study to evaluate the relationship between urine-tenofovir test results and pharmacy refill records was conducted between June to August 2021.This was a cross sectional study.Ethical approval for the study was obtained from the Institutional Ethics Review Board of Nigerian Institute of Medical Research (IRB-16-360 of 21-06-2022). All study data was de-identified, confidentiality of participants and their data was maintained all through the study. Informed consent was obtained from study participants, refusal to participate in the studies, did not affect the quality of care a patient received at the clinic.HIV-positive adults (≥18 years old) on first-line or second-line tenofovir-based ART regimen.Patients on non-tenofovir-based ART regimens. This is because the urine-tenofovir test can only detect tenofovir metabolites and would not react to metabolites of other antiretroviral drugs.,19 Assumptions made in the sample size calculation were, 5% precision, 5% type 1 error, and population size < 10,000. was The calculated sample size was ninety-one (91), and 100 persons were assessed for study participation eligibility. Four of those assessed were ineligible because they were not on tenofovir-based ART regimens while 2 persons declined providing consent. Ninety-four study participants who were PLWH on tenofovir disoproxyl fumerate-based regimens (on first- or second-line ART) were therefore recruited consecutively from the clinic and consented for participation.Sample size calculation for the study was based on proportion of 27% of non-adherence reported for pharmacy refill records from 2 African studies.The urine tenofovir immunoassay was donated by Hair Analytical Laboratory, San Francisco, and the following steps conducted for each participant:Each participant was presented with a cup and asked to provide a urine sample (about 5–10 mL).They were asked to screw the lid on to the urine cup after collection and bring it back out to the researcher.The researcher (using gloves) used the dropper provided with the urine test to drip 3 to 4 drops of urine from the urine cup into the divot of the urine test strip  which uses the total number of days that the patient was late/absent for drug-refill visits to calculate adherence to ART. Optimal and suboptimal adherence was defined as a cumulative adherence to drug-refill visits of ≥ 95% and < 95% respectively. The adherence measure with the greatest total area was interpreted as having the best prediction of viral load suppression.Statistical tests: International Business Machine (IBM) Statistical Package for Social Sciences (SPSS) version 26.0, Armonk, NY: IBM Corporation USA was used for statistical analysis. Statistical significance was set at 5% (0.05) level of probability. Fisher’s exact test was used to examine the association between pharmacy pick-up data (≥95% and < 95%) and the tenofovir urine assay (yes/no). A logistic regression was performed to predict viral suppression with adherence measured using the urine tenofovir POC test and pharmacy refill records. A receiver operating characteristic (ROC) curve of the association between specificity and sensitivity was generated to evaluate the predictive value of pharmacy refill records and the urine POC test, in forecasting viral suppression. The ROC curve was constructed by plotting the false positive rate (1 minus specificity) against the true positive rate (sensitivity). Detectable viral load was defined as greater than 1000 copies/mL.A total of 94 participants were recruited for the study Table  majorityThe result of the Fisher’s exact test, which is shown in Table 2 (2) = 10.627, P = .005  of the variance in viral suppression and correctly classified 94.7% of cases. It also showed that an increase in pharmacy refill rate of ≥ 95% was associated with viral suppression (P = .019). The contribution of urine POC to the model was however not statistically significant (P = .487).The model explained 15.5% (Nagelkerke P = .837).Figure ,22 Our findings are however at variance with some other previous studies which reported that pharmacy refill record was not a reliable method of adherence determination. Of note, this finding is valid only for closed-pharmacy systems where patients access medications from only one source, and the Nigerian National ARV programme is implemented as a closed-pharmacy system where patients can only pick-up ARVs from the pharmacy at the treatment center where they are registered.Our study showed that there was no difference between adherence measured using either pharmacy pick-up record or urine-tenofovir point-of-care test. It also showed that an increase in pharmacy refill rate of ≥ 95% was associated with viral suppression. Our data on pharmacy pick-up which is a good surrogate of adherence corroborates earlier reports of the high specificity of pharmacy pick-up records in identifying individuals who are not taking enough medication to attain treatment goals.–28 A cutoff of 80% adherence has been demonstrated to successfully define viral suppression at both < 1000 copies/mL and 200 copies/mL. The level of adherence that is required to achieve HIV viral suppression is now no longer clear because with newer antiretroviral treatments, lower levels of adherence may still achieve successful virologic suppression.,30 This work however adopted the most stringent adherence cutoff of 95% as defined by Paterson et al, and viral suppression was defined as < 1000 copies/mL as specified by the WHO 2016 Consolidated Guidelines for HIV and the Nigerian National HIV Treatment Guidelines.In terms of the cutoff we used for the pharmacy pick-up record categorization, studies vary in the definition of the optimal level of adherence, using ≥ 85%, ≥ 90%, or ≥ 95% of pills taken as the threshold level necessary to achieve viral load suppression.Urine-tenofovir POC test provided equivalent adherence data to pharmacy refill data. The performance of the urine tenofovir test opens up the possibility of an objective metric of adherence that is scalable to LMICs. Unlike most other currently available objective tests  which cost about $140 to $200 per sample, urine-tenofovir POC is cheaper at $10 per test.The main study limitation was its cross-sectional nature and future studies will examine this relationship over time. On the other hand, there was no bias introduced from the participants knowing their pharmacy refill data was being monitored by this one-time evaluation.Another limitation of this study is the small sample size which may not allow for extrapolation of results. This result however provides preliminary data valid to “closed-pharmacy” settings, where patients receive ARV from only one source.This study showed that the urine-tenofovir point-of-care test provided equivalent adherence data to pharmacy pick-up data in the closed pharmacy system. The result portends well for the utility of the inexpensive urine-tenofovir point-of-care test in low- and middle-income countries to objectively assess adherence.The authors gratefully acknowledge the Director-General, management staff, clinicians, pharmacists and data staff at Nigerian Institute of Medical Research. Mr. Samson Folami, a pharmacist on research internship, who assisted in conducting the urine-tenofovir POC test is also acknowledged.Conceptualization: Ebiere Clara HERBERTSONFormal analysis: Ebiere Clara HERBERTSONFunding acquisition: Ebiere Clara HERBERTSON, Monica GandhiInvestigation: Ebiere Clara HERBERTSONMethodology: Ebiere Clara HERBERTSON, Matthew A. SpinelliWriting—original draft: Ebiere Clara HERBERTSONSupervision: Rebecca Soremekun, Olubusola Olugbake, Cecile Decille Lahiri, Monica GandhiValidation: Cecile Decille Lahiri, Monica GandhiWriting—review & editing: Cecile Decille Lahiri, Monica GandhiVisualization: Monica Gandhi