Objective. To define the long-term (2–4 years) clinical and virological outcome of an antiretroviral treatment (ART) programme in rural South Africa. Methods. We performed a retrospective observational cohort study, including 735 patients who initiated ART. Biannual monitoring, including HIV-RNA testing, was performed. Primary endpoint was patient retention; virological suppression (HIV-RNA < 50 copies/mL) and failure (HIV-RNA > 1000 copies/mL) were secondary endpoints. Moreover, possible predictors of treatment failure were analyzed. Results. 63% of patients (466/735) have a fully suppressed HIV-RNA, a median of three years after treatment initiation. Early mortality was high: 14% died within 3 months after treatment start. 16% of patients experienced virological failure, but only 4% was switched to second-line ART. Male gender and a low performance score were associated with treatment failure; immunological failure was a poor predictor of virological failure. Conclusions. An “all or nothing” phenomenon was observed in this rural South African ART programme: high early attrition, but good virological control in those remaining in care. Continued efforts are needed to enrol patients earlier. Furthermore, the observed viro-immunological dissociation emphasises the need to make HIV-RNA testing more widely available. Sub-Saharan Africa houses most of the 33 million people who are human immunodeficiency virus- (HIV-) infected globally. The scale-up of antiretroviral treatment (ART) roll-out that has taken place in this region over the last decade is impressive. Consequently, an increasing number of treatment-outcome data from African ART programmes has been published. In spite of frequently observed high early mortality rates, ART provides clear benefits for most HIV-infected patients. Typically, improvements in clinical, immunological, and virological outcome measurements are seen within months after starting treatment. However, long-term data (more than one year of followup) are less readily available , 2. MoreNdlovu Medical Centre (NMC) is located in rural South Africa. Since the start of its ART programme, prospective virological monitoring has been done for all patients. Previously, we reported favourable short-term (one-year followup) results of patients receiving ART at NMC . The obj3 were used as criteria for treatment eligibility. Treatment consisted of efavirenz or nevirapine plus stavudine or zidovudine and lamivudine. In case of virological failure, second-line ART was available. To this end, a boosted protease inhibitor  was added to the nucleoside reverse transcriptase inhibitor (NRTI) backbone. Ndlovu MC is located in a poor, rural area of Limpopo, a province in the northeast of the Republic of South Africa. Details on NMC and its ART programme have been described elsewhere . For the2) are calculated at each visit. CD4+ T-cell counts  and plasma HIV-RNA levels  are measured before treatment initiation and regularly thereafter . Patients are seen by HIV-counsellors during each clinic visit in order to provide information and to stimulate treatment adherence.Data were retrospectively collected from the medical charts. Body mass indices  a 50% decline from the on-treatment peak CD4+ T-cell count value [Immunological failure was defined according to the WHO guidelines as either (1) a CD4+ T-cell count after six months of therapy below 100 cells/mmnt value .Patient retention-rate was the primary endpoint. Secondary outcomes were virological suppression and treatment failure. The negative and positive predictive values  of immunological failure, to determine virological failure, were calculated. Moreover, to define predictors of treatment failure, we compared the distribution of several determinants NRTIs used; employment status and years since treatment initiation) between patients with treatment success and those experiencing treatment failure. To this end, all patients who started ART were included in analyses. The same determinants were used to define predictors of virological failure. In order to minimize the influence of early mortality, only patients with more than three-month followup were included in these analyses. t-test or the paired t-test as appropriate. Proportions were compared with the χ2 test, and data that were not normally distributed were analyzed via the Mann-Whitney U or Wilcoxon test. Kaplan-Meier survival analysis was used to estimate the time from initiation of antiretroviral therapy to virological suppression and the time from initial suppression to subsequent virological failure. Odds ratios and 95% confidence intervals (95% CI) were calculated using logistic regression analysis. The Cox proportional-hazards model was used to identify independent predictors of the endpoints. To this end, determinants that were associated with the outcome in univariate analysis  were included in multivariate analysis. A P-value ≤ .05 was considered statistically significant. Data were processed and statistical analyses were done using SPSS version 15.Continuous data were compared with the Student's 3, IQR 20–140) and BMI  demonstrate that many patients were at an advanced stage of disease when initiating treatment. Most individuals initially received a stavudine-containing ART regimen ; in 26% (151/579) of those patients, stavudine was subsequently switched to zidovudine, as they showed signs of neuropathy or lipodystrophy. Efavirenz was the most commonly prescribed NNRTI (58%. 426/735).The first 735 adults who started ART at NMC were included in analysis. Median duration between treatment initiation and data collection was 35 months (range 24–59). Women predominated . Unemployment rate was high at 70%; 24% of patients had less than six years school attendance. The median baseline CD4+ T-cell count . Most  of these patients were still in care and on treatment at the NMC, but 10% (47/476) patients were transferred out to other clinics. The remaining 35% (259/735) of patients had either died or were lost to followup. Mortality was the main cause for attrition . Attrition typically occurred soon after treatment initiation; within three months, one out of five persons was not in care anymore n = 152, . 562/735 patients (76%) achieved virological suppression on first line ART. Suppression was established at a median of 12 weeks after treatment initiation. Not achieving virological suppression was mainly due to early attrition . Longitudinal virological monitoring showed continued virological control on first-line ART in most patients . This proportion increased to 80% (466/583) if only those with more than 3-month followup were included. Virological failure was observed in 117/735 patients (16%: 20% {117/583} of those with >3 months followup). Median duration between initial response and subsequent failure was 18 months. Only 4% (31/735) of all patients who started first-line ART were switched to second-line ART. Most of them achieved virological suppression after switching . Virological outcome data are summarized in Ongoing viral replication was limited in patients receiving first-line ART. During complete followup, less than 10% of patients who remained in care had an HIV-RNA > 1000 copies/mL and the vast majority of patients (71–82%) showed complete, virological suppression . On the basis of immunological parameters, virological failure would have been missed in 66/117 patients (56%) and 44/95 patients (46%) would mistakenly have been classified as experiencing virological failure. Immunological failure therefore showed a PPV and NPV for virological failure of 54% and 87%, respectively. Overall, treatment failure  occurred in 337 patients (46%) during followup. Of all baseline factors that were associated with treatment failure in univariate analysis , only a low performance (Karnofsky) score  and male gender  remained independently associated with the outcome after multivariate analysis .P = .03) and age (P = .07) were associated with virological failure in univariate analysis. Neither remained independently associated with this outcome after multivariate analysis.In patients with more than three-month followup, baseline CD4+ T-cell count  virological monitoring was performed. Still, a substantial number of patients continued their first-line ART after showing the first evidence of virological failure. The delay between virological failure and treatment switch is probably due to care-givers focusing on extra adherence counselling, prior to switching to the only available second-line regimen. On the basis of virological failure alone, 16% of patients in our cohort had an indication for a treatment switch. A recent review reported nearly twice as many patients in low and middle income countries needing a second-line regimen , but otThere are some limitations to our study. Diagnostics for underlying illnesses and documentation of adverse events were limited. Causes of attrition were therefore generally unknown. Moreover, due to the retrospective nature of our study, bias due to unmeasured determinants cannot be ruled out. In conclusion, in this rural South African ART programme with access to virological monitoring, early attrition was the main cause for treatment failure. Virological failure was limited in those remaining in care. Continued efforts are needed to enrol patients earlier into care. Furthermore, the observed viro-immunological dissociation emphasises the need to make HIV-RNA testing more widely available.


Background. Adherence to antiviral therapy is important for HIV-infected people living in low- and middle-income countries, because of poor access to alternative regimens. Methods. We conducted a cross-sectional survey of adherence in Cambodian patients enrolled in the ESTHER program and treated with WHO first-line regimen for at least 6 months. The survey was based on a self-report questionnaire, drug assay, MCV measurement, visual analog scale, and viral load HIV RNA. Results. Two hundred fifty-nine patients treated for a median of 16 months participated in the survey. At inclusion in the program, 158 patients (61%) were ARV-naïve. The virological success rate was 71% overall and 81% in previously ARV-naive patients. Considered individually, the measures suggested perfect adherence in 71% to 93% of patients. In multivariate analysis adjusted for sex and therapeutic status before HAART initiation, only the biological markers were associated with virological efficacy. Self-funded treatment before entry to the program was highly predictive of virological failure. Conclusion. Adherence was excellent in these Cambodian patients. Biological markers were predictive of virological efficacy. MCV might thus serve as a simple alternative for assessing adherence and predicting virological efficacy among patients receiving AZT- or d4T-based regimens. Since highly active antiretroviral therapy (HAART) became widely available in industrialized countries, mortality and morbidity among patients living with HIV/AIDS have been substantially reduced . RecentlIt is particularly important to assess adherence during HAART programs, mainly owing to the limited availability of alternative regimens . Indeed,Adherence is difficult to evaluate, however. Self-report questionnaires have been widely used, for their low cost and simplicity, in both industrialized and developing countries , 22. VisWe therefore conducted a cross-sectional survey of HIV-infected patients receiving NNRTI-based regimens through the ESTHER program in Phnom Penh (Cambodia) in order to identify simpler tools for the identification of nonadherent patients and for the prediction of virological failure. μL) both to ARV-naïve patients and to patients having previously paid for ARV themselves. In keeping with national guidelines, first-line therapy consisted of two nucleoside reverse transcriptase inhibitors (NRTIs) plus one NNRTI. The HAART combination was (AZT or d4T)/3TC/efavirenz (EFV) initially, but was then switched to (AZT or D4T)/3TC/nevirapine (NVP) after July 2004, owing to EFV supply problems. Patients were seen in the hospital every month after enrolment, for a physical examination and to record clinical and therapeutic information. On HAART initiation, the patients also entered a therapeutic education program run by nurses. The patients were seen monthly for three months, or more if the educational objectives were not reached . The adherence study was restricted to patients who had been on HAART for at least six months, to increase the odds that they had met their educational objectives. In February 2003, the Cambodian Ministry of Health and the French ESTHER initiative implemented a free treatment program for patients living with HIV/AIDS at Calmette hospital, Phnom Penh. HAART was prescribed according to WHO recommendations  “did you miss any HAART doses during the last four days?,” (ii) “Were you late for any of your intakes by more than two hours during the last four days?,” and (iii) “did you miss any HAART doses last week-end?.” Because of the low educational level of many patients, one-third of the questionnaires were administered by nurses.A visual analog scale similar to that developed for pain evaluation was also used. The patients were asked to position a cursor between “never” (score 1) and “always” (score 10) in response to the question: “In general, would you say you take your treatment…?.” Any answer different from 10 was considered to represent nonadherence.EFV and NVP plasma concentrations were measured by using high-performance liquid chromatography (HLPC). Patients were asked to come to the clinic in the morning without having taken their daily dose of NVP, and 12 hours after their last dose of EFV. Patients with EFV and NVP concentrations below 1000 ng/mL and 3000 ng/mL, respectively, were considered nonadherent.As all the patients took AZT or D4T, those with an MCV of ≤100 fL were considered nonadherent.A blood sample was collected to determine the CD4 cell count  and HIV RNA viral load (ANRS second-generation (G2) real-time RT-PCR) .All patients who had at least one adherence assessment were included in the analysis. Among the 341 patients meeting the inclusion criteria (including more than 6 months of HAART), 13 patients (3.8%) had died, 14 (4.1%) had been lost to follow-up, 9 (2.6%) had been directed to others centers, 12 were on an LPV/r-containing regimen, 8 were on a triple NRTI combination, and 25 could not be evaluated. A total of 259 patients were finally included in the analysis.P values <.05 were considered significant.The association between each measure of adherence and virological failure (defined as >400 HIV RNA copies/mL) was tested for significance by using the Chi-square test. A logistic regression model was used to evaluate the contribution of the different measures of adherence to predict virological failure. All statistical analyses were performed using Stata 8 software ; all tests were two-sided and μL ; 158 patients (61%) were ARV-naïve and 101 (39%) had already taken ARV before entry to the program . At the time of the evaluation, HAART consisted of AZT/3TC/NVP in 183 (71%) patients, AZT/3TC/EFV in 46 patients (18%), d4T/3TC/NVP in 17 patients (6%), and d4T/3TC/EFV in 14 patients (5%). The median CD4 cell count increments at 6 and 12 months were, respectively, 54/μL  and 92/μL (31–144). At the study visit, the median treatment duration was 16.1 months . Viral load was below 400 HIV RNA copies/mL in 71.5% (n = 185) of the patients overall, and in 81% (n = 128) of the 158 ARV-naïve patients.Among the 259 patients evaluated, 151 (58%) were male. Median age was 35 years (interquartile range (IQR), 31–41). At inclusion in the program, the median CD4 cell count was 93/As shown in The association between virological failure and the different measures of adherence was first investigated in all the patients , and theAfter adjustment for sex and therapeutic status at entry to the ESTHER program, logistic regression showed that the results of the self-report questionnaire did not correlate with virological failure. Only the biological measures were associated with virological failure . ExposurResistance to NNRTI-based regimens emerges rapidly when adherence is poor. In our study, adherence was considered “perfect” in more than 90% of patients, whatever the method used to estimate it, and 81% of previously ARV-naïve patients were virological responders. Similar good results have been obtained in Cambodia by an MSF team , 33, as Several factors could explain this good adherence. First, treatment was free of charge for all the patients, thanks to the financial stability of the program. Second, good drug procurement and distribution practices avoided drug supply disruption. Both points have been shown to be a significant cause of drug resistance and ARV failure in Uganda . Third, In low- to middle-income countries, where access to viral load assays is limited, HAART efficacy is monitored by using clinical and immunological criteria that have relatively low positive predictive value for virological failure , 36. In We also evaluated MCV and plasma drug assay, as more objective measurements of adherence , 26. We The absence of macrocytosis was associated with virological failure, as all the patients were on AZT- or d4T-based regimens. The association was strong in previously ARV-naïve patients and persisted in multivariate analysis. In Cambodia, as well as in many other low- to middle-income countries, AZT and d4T are the most widely used NRTIs, in keeping with WHO recommendations. MCV was determined during standard automated blood analyses, which are widely available in many district hospitals in Cambodia. This parameter might thus be used in combination with clinical and immunological criteria to monitor HAART exposure and efficacy. Forty percent of our patients had taken dual NRTI therapy or a fixed dose combination of D4T/3TC/NVP before entry to the ESTHER program, and the efficacy of the study regimens was lower in these patients than in previously ARV-naïve patients. Self-funded treatment in the private sector was significantly associated with subsequent virological failure, even after adjustment for other factors . This waResistance to NNRTIs and NRTIs is the most important issue in low- to middle-income countries, where access to protease inhibitors is limited. WHO-approved first-line HAART must be maintained as long as possible, and the identification of patients at risk of resistance must be a priority. Unfortunately, access to viral load assay and genotypic resistance tests is currently limited. As self-report questionnaires may lack accuracy and as drug monitoring is difficult to implement, MCV could be an interesting alternative marker of adherence. Viral load assay could be added if MCV results suggest poor adherence.


Tuberculosis is a leading cause of death worldwide, yet the determinants of death are not well understood. We sought to determine risk factors for mortality during treatment of drug-susceptible pulmonary tuberculosis under program settings.Retrospective chart review of patients with drug-susceptible tuberculosis reported to the San Francisco Tuberculosis Control Program from 1990-2001.Of 565 patients meeting eligibility criteria, 37 (6.6%) died during the study period. Of 37 deaths, 12 (32.4%) had tuberculosis listed as a contributing factor. In multivariate analysis controlling for follow-up time, four characteristics were independently associated with mortality: HIV co-infection , older age at tuberculosis diagnosis ; initial sputum smear positive for acid fast bacilli ; and experiencing an interruption in tuberculosis therapy . The association between treatment interruption and risk of death was due to non-adherence during the intensive phase of treatment . The median duration of treatment interruption did not differ significantly in either intensive or continuation phases between those who died and survived . No deaths were directly attributed to adverse drug reactions.In addition to advanced age, HIV and characteristics of advanced tuberculosis, experiencing an interruption in anti-tuberculosis therapy, primarily due to non-adherence, was also independently associated with increased risk of death. Improving adherence early during treatment for tuberculosis may both improve tuberculosis outcomes as well as decrease mortality. Tuberculosis is a leading cause of death worldwide. According to the World Health Organization (WHO) over 1.7 million people with tuberculosis died in 2008 , it is pThe current study of factors associated with mortality in drug-susceptible, pulmonary tuberculosis took advantage of a pre-existing dataset investigating risk factors for relapse . For the+ T lymphocyte counts were provided by the San Francisco AIDS Registry. HIV status was unknown in 99 (17.5%) patients. As part of the parent study, rigorous evaluation of the medical records confirmed that these patients had no identifiable risk factors for HIV [The study was approved by the Committee on Human Research of the University of California, San Francisco. A retrospective cohort study design was used to evaluate outcomes including mortality while on treatment for tuberculosis. A standard data collection form was used to record information extracted from all patient records, including HIV serostatus, history of opportunistic infections, tuberculosis, co-morbid conditions, chest radiograph results, bacteriology results, treatment regimen, use of directly observed therapy (DOT) and interruptions of treatment due to non-adherence or adverse reactions to tuberculosis medications. DOT was categorized as "full" (throughout treatment) or "partial" (during intensive phase of treatment only). San Francisco Tuberculosis Control Program requires treatment be initiated under DOT for patients with any of the following characteristics: sputum smear positive for acid fast bacilli, suspected or confirmed drug resistant disease, HIV co-infection, slow sputum conversion, homeless/shelter resident, history of intravenous or non-intravenous drug use, psychological disorder, alcohol abuse, history of prior tuberculosis, and when the treating clinician deems patient too infirm to self manage or suspects high likelihood of non-adherence. Viral load and CD4 for HIV . All patPatients were considered cured if they completed all prescribed doses, converted their cultures to negative and had resolution of symptoms. Treatment failure was defined by positive cultures after 4 months of treatment . Death wAll statistical analyses were performed using SAS Version 9.1 software . Cox proportional-hazards regression analysis was used to assess risk factors for mortality. The chi squared test, Student's t-test, and Wilcoxon rank-sum test were used to test associations unrelated to mortality. Factors associated with mortality in univariate analysis (p < 0.10) were selected for a multivariate Cox proportional-hazards regression model. CD4 cell count was missing in 29 of 204 cases with HIV co-infection; for multivariate analyses involving CD4 count, missing values were imputed using a multiple imputation strategy . All meaOf 565 patients meeting eligibility criteria, 37 (6.6%) died while on treatment for tuberculosis. Sociodemographic and clinical characteristics are shown in Table An episode of interruption in therapy from any cause was identified in 205 of 565 study participants. Of the 205, 186 cases had an interruption in therapy that met the study definition for inadequate therapy. Overall, 27% of patients experienced an episode of inadequate therapy during the intensive phase of treatment, and 23% in the continuation phase. Experiencing an episode of inadequate therapy, in particular during the intensive phase, was significantly more common in the patients who died as compared with those who survived (p = 0.001). Analyzed separately by the two causes defined for inadequate therapy, non-adherence versus adverse reactions, the association remained significant for non-adherence during the intensive phase , but not for adverse reactions. While the relative hazard was high for the association between adverse reactions during the intensive phase and mortality, the relationship did not reach statistical significance . Overall, the median duration of treatment interruption for patients who died was not different from those who survived . Examining the median duration of days a patient received inadequate treatment in more detail, by phases of treatment  had tuberculosis listed in the death certificate, autopsy or chart either as the direct cause of or contributing to cause of death, with nine of these also having AIDS listed as a contributing factor. Of the remaining 25 deaths for which tuberculosis was not listed in the death certificate or autopsy, 13 (35.1%) were attributed to complications of AIDS. None of the deaths were directly attributed to adverse drug reactions or hepatotoxicity. In multivariate analysis, four characteristics were independently predictive of mortality: HIV co-infection ; older age at diagnosis ; initial sputum smear positive for acid fast bacilli ; and episode of inadequate tuberculosis therapy during the intensive phase of treatment   are shown in Figure In this study, four characteristics were independently associated with increased risk of mortality during treatment for drug susceptible tuberculosis. These characteristics were older age at diagnosis, HIV co-infection, sputum smear positivity for acid fast bacilli at baseline and experiencing an interruption in tuberculosis therapy during the intensive phase of treatment. Whereas prior studies have reported older age, comorbid conditions including HIV and advanced tuberculosis as non-modifiable determinants of death in tuberculosis ,13-15, oWe sought to clarify other aspects related to interruptions, including the timing, duration and cause of interruptions. The timing of inadequate therapy for tuberculosis proved to be important. Interruptions during the intensive phase were associated with mortality, whereas interruptions during the continuation phase were not. This finding suggests that interruptions occurring early, when drugs have bactericidal activity against replicating organisms, have greater implications for risk of death than interruptions during the continuation phase when therapy is focused on clearing persistent bacilli to prevent relapse . In regaOur study has several limitations. Given its retrospective nature, we were unable to distinguish between the reason for and effect of treatment interruption as it related to the association with death. While we reviewed all available charts, computer records, death certificates, and autopsy information to determine cause of death, a minority of cases had post mortem analyses (7/37). Consequently, factors associated with death were not necessarily causal. Second, our findings are not relevant for HAART treated/exposed populations, as the majority of the HIV-infected individuals in this study were HAART naive. Of the 37 deaths, only one HIV-infected individual was on HAART, precluding our ability to evaluate the role of HAART in preventing death. This is an important limitation given the well recognized benefits of HAART on survival. However, we believe our findings are still relevant as the majority of HIV-related tuberculosis in the world continues to be managed without early initiation of HAART. Finally, we cannot extrapolate these findings to foreign-born individuals who self-reported Asian race as they were excluded from the parent study. A recent evaluation of deaths among 7,999 culture positive pulmonary tuberculosis cases in Shanghai, China, identified advanced age, sputum smear positivity, comorbid conditions and gender as factors associated with death . HoweverIn summary, in addition to the nonmodifiable characteristics of advanced age at diagnosis, HIV co-infection and sputum smear positivity at baseline, experiencing an interruption in treatment during the intensive phase of treatment was associated with an increased risk of death. Our analyses suggest that non-adherence, more so than adverse drug reactions, may be driving this association. Continued investment in programs such as DOT that can promote adherence early during treatment for tuberculosis may both improve tuberculosis outcomes as well as decrease mortality.The authors declare that they have no competing interests.PN participated in design of the study, conducted chart reviews for data abstraction, and drafted the manuscript. IR, BCDJ, AU participated in chart review, data abstraction and interpretation of data. LGH and DHO participated in the design of the study and performed the statistical analyses. LMK and PCH participated in data interpretation and manuscript revisions. CLD conceived of the study, and participated in its design and coordination. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/11/1/prepub


Background. We aimed to assess cardiac conduction safety of coadministration of the CYP3A4 inhibitor lopinavir/ritonavir (LPV/r) and the CYP3A4 substrate artemether-lumefantrine (AL) in HIV-positive Ugandans. Methods. Open-label safety study of HIV-positive adults administered single-dose AL (80/400 mg) alone or with LPV/r (400/100 mg). Cardiac function was monitored using continuous electrocardiograph (ECG). Results. Thirty-two patients were enrolled; 16 taking LPV/r -based ART and 16 ART naïve. All took single dose AL. No serious adverse events were observed. ECG parameters in milliseconds remained within normal limits. QTc measurements did not change significantly over 72 hours although were higher in LPV/r arm at 24  and 72 hours  after AL intake. Conclusion. Coadministration of single dose of AL with LPV/r was safe; however, safety of six-dose AL regimen with LPV/r should be investigated. Malaria and HIV infection are leading causes of morbidity and mortality and remain major health problems in endemic regions. Malaria causes about 300–500 million clinical cases annually, 90% of which occur in sub-Saharan Africa . The Joi Studies have demonstrated increased risk for malaria in HV infected patients especially those with lower CD4 cell counts –4. More falciparum; with the advantage of rapid clearance of parasites by artemether and the slower elimination of residual parasites by lumefantrine  to correct for the influence of heart rate. A senior cardiologist evaluated the PR, QRS, and QT intervals visually on the ECG.Medical history, physical examination, vital signs, routine clinical laboratory tests, ECGs and urine screens for pregnancy were performed at screening. On the study day, medical history, physical examination, vital signs, and a blood smear for malaria parasites were performed. Adverse events were recorded continuously throughout the trial, and the onset, duration, severity, and relationship to the trial drugs if any were noted. Standard 12-lead ECGs were recorded at screening, immediately prior to dosing  were screened between January and June 2009; 12 (17%) were excluded because they had other concurrent illnesses that required treatment, 28 (39%) were excluded because they had abnormal ECG tracings and 32 (44%) were enrolled, 16 in each arm. Patients in the two study arms were comparable on majority of baseline characteristics ; howeverP = .06 and 421 versus 404, P = .03, resp.) but the mean PR-interval was significantly higher in the ART naïve arm  (P = .17). The QTc interval measurements for participants in both study arms remained within normal ranges over the 72 hours period  remained well within normal limits in both study arms . The meaP = .02) . Mean  of AL in HIV-infected patients taking LPV/r based ART and HIV positive ART naïve patients. Since LPV/r is a potent CYP3A4 inhibitor, only a single dose of AL was given in order to avoid any unknown potential adverse effects of the latter. We found that HIV-positive patients taking LPV/r had a higher QTc interval prior to administration of AL compared to HIV-positive ART naïve patients, nevertheless, the difference was not statistically significant. It is possible that this could have been a result of the effects of LPV/r on the heart; however, we cannot establish a causal relationship since we did not have QTc measurements for these patients prior to initiation of LPV/r. This however, raises concern especially in view of the recent FDA alert over the effects of LPV/r on the heart. Indeed the label for LPV/r includes warnings and precautions regarding QT/QTc interval and PR interval prolongation . Although the QTc interval for the LPV/r arm was significantly higher than that for the ART naïve arm at 72 hours, the difference could not be attributed to LPV/r coadministration with AL because baseline QTc interval was higher in the LPV/r arm and both study arms had an increment in QTc interval values from baseline which remained well within normal limits . It is p This is one of the very few studies that have assessed the cardiac safety of coadministration of AL and LPV/r in HIV positive patients. Previous studies have evaluated safety of AL in healthy volunteers and patients with malaria. Bindschedler and others found that the QTc interval remained unchanged after a single dose of AL in healthy males . The difOur data suggests no evidence of cardiac conduction abnormalities after concomitant treatment with LPV/r and a single dose AL. There is need to assess the safety of the full six-dose regimen of AL in HIV positive patients receiving LPV/r based ART.


This study aims to investigate the time pattern of inconsistence condom use (ICU) during the first year of antiretroviral therapy (ART) and its relationship with treatment adherence in naïve HIV-infected adult patients.Data collection was nested within a longitudinal trial on HIV treatment. ICU was defined as reporting to have “never”, “sometimes” or “nearly always” used condoms with one’s main or casual partner(s) - either HIV-negative or of unknown HIV status in the three previous months. Adherence was defined as taking 100% of their ART prescribed doses in the 4 days before the visit and “not having interrupted treatment”, even once, for more than two consecutive days during the 4 previous weeks. Mixed logistic regression was used to study the relationship between adherence and ICU.Among the 459 patients enrolled, 212 (46%) during 334 visits reported to have had sexual intercourse at least once with their partner(s) – either HIV-negative or of unknown HIV status- during the first 12 months of ART. The proportion of ICU was 76%, 50% and 59% at month 0 (M0), month 6 (M6) and month 12 (M12), while 60% and 66% of patients were ART-adherent at M6 and M12, respectively. After adjustment for the frequency of sexual activity, type of sexual partner(s), perceived social class and desire for a child, patients adherent to ART were less likely to report ICU when compared with baseline .Adherence to ART is associated with a lower risk of ICU but this result needs to be interpreted carefully. As adherence behaviors are not only determined by problems with the healthcare systems but also by social barriers encountered by patients in their daily life, counseling should not only be ART adherence-centered but also patient-centered, including sexual risk minimization and psychosocial support. Since the introduction of the WHO “3 by 5” initiative per se) we preferred to target individuals who had behaviors leading to a higher risk of HIV transmission– i.e., individuals with partners who were seronegative or whose serostatus was unknown.This analysis, based on longitudinal data of HIV-infected adults enrolled in the Stratall ANRS 12110/ESTHER trial in Cameroon, was designed to study the time pattern of unsafe sexual behaviors during the first 12 months of ART and its relationship with treatment adherence. However, as the study is focused on predictors of positive prevention  in Cameroon, designed to compare the effectiveness of clinical monitoring (n = 238 patients) versus clinical plus laboratory monitoring  Socio-economic, psychosocial and behavioural data were collected after the clinical visit at baseline , and at months 6 and 12, using face-to-face questionnaires administered by community health workers trained by the research team. During face-to-face interviews, patients were asked a series of questions including information about sexual activity and adherence to treatment. Patients also received counseling on ART-adherence and prevention of HIV transmission when initiating ART and at each follow-up visit. Condoms were provided for free in the hospitals’ pharmacies.Clinical data collected for the purpose of the trial, including HIV clinical stages and CD4 cell count (assessed by Facscount equipment), were also used in this analysis.Institut de Recherche pour le Développement (France) and all study participants provided written informed consent.The study protocol was approved by the National Ethics Committee of Cameroon and the institutional Ethics Committee of the Use of condoms during the previous three months was assessed separately for the main partner and for casual partners using a four-level scale: never, sometimes, nearly always or always As information about HIV-status  was only available for the main partner, all casual partners were considered to have unknown HIV status.Variables retained for the analyses were classified into the following five categories:socio-demographic and economic characteristics: gender, age, educational level, professional status, marital status, place of religion in one’s life and perceived social class. They were assessed using a ten-point visual scale, with higher scores denoting a better perceived social situation  clinical characteristics: WHO clinical stage and CD4 cell count.sexual behavior and reproductive life during the previous three months: number of sexual partners including casual partners, frequency of sexual intercourse, type of sexual partner(s) , condom use, having children and the desire for a/another child.caregiver-patients relationships: feeling comfortable with doctors , trust in doctors and trust in other healthcare staff using a three-point Likert scale  and healthcare staff’s readiness to listen, assessed using a six-point visual scale ranging from 1 to 6 with higher values denoting a higher perceived degree of readiness to listen.psychosocial variables: adherence to ART, satisfaction about information provided by care staff, binge drinking, experience of discrimination and depressive symptoms.Adherence to ART was assessed using a validated scale To assess patient satisfaction about information provided by healthcare staff, two variables were used: 1) readiness to listen of healthcare staff and 2) perceived quality of information provided by healthcare staff assessed using a four-point Likert scale .Finally, patients who reported high healthcare staff’s readiness to listen and reported to have received clear or quite clear information were considered as “satisfied about information provided by care staff”.Binge drinking was defined as the consumption of three large bottles  and/or six glasses or more of alcoholic beverages on any one occasion P-value <0.20 in the univariate analyses were eligible to enter the initial multivariate model. The final multivariate model was obtained by using a backward stepwise procedure based on the log-likelihood ratio to eliminate non-significant (P>0.05) variables from the initial model.We first estimated the global proportion of ICU during the first 12 months of ART and the frequency of ICU at each visit. The proportion of ICU over a given period was calculated as the number of visits at which the study population reported ICU over the number of visits performed. Mixed-effect logistic regression models - which enable the correlations between repeated measures to be taken into account - were used to estimate the relationship between adherence and sexual risk behaviors. As the proportion of patients reporting ICU during the first 12 months of ART was not significantly different between the two treatment approaches  when performing a chi-square test , both groups were pooled in analysis. All explanatory variables with a Statistical analyses were performed using SPSS v15.0  and Intercooled Stata 10  software packages.−3 (test de Mann-Whitney)); they were more frequently married, reported more often the desire to have a/another child, and had a higher median CD4 cell count. No significant differences were however detected concerning gender and WHO clinical stage.All 459 PLWHA who initiated ART in the Stratall ANRS 12110/ESTHER trial agreed to participate in the socio-behavioral study. During the first 12 months of ART, data on sexual behaviors were available for 435 patients (95%). Among them, 308 (71%) were women, median  age was 36 years (30–45), 101 (23%) reported being married and 213 (49%) patients had an educational level higher than secondary school. Patients who had no data on sexual behaviors (n = 24) were not significantly different compared with those for whom data were available in terms of gender, age and CD4 cell count at ART initiation (data available on request). Among patients having data on sexual behaviors, 241 (55%) reported sexual activity at least once during all follow-up visits while 194 (45%) reported sexual abstinence during the first 12 months of ART. Those patients who reported sexual activity were younger than their sexually abstinent counterparts  declared that they had sex only with HIV positive partner(s). We therefore conducted our analysis on the remaining 212 (88%) patients  who reported at least once to have had sexual intercourse during the first 12 months of treatment with their main or casual partner(s) - either HIV-negative or of unknown HIV status. Among these 212 patients, 153 (72%) - accounting for 212 visits (62%) - reported inconsistent condom use.3 was 200 [82–393] and the median [IQR] score of depressive symptoms was 22 The median age [IQR] of patients was 35 [29–43] and more than a third (69%) were women. A quarter (25%) were married and approximately half (51%) reported having a professional activity. Regarding HIV-related characteristics, a quarter (26%) of patients were at WHO clinical stage IV, the overall median [IQR] CD4 cell count per mmOf the total 344 visits corresponding to 212 HIV-patients who reported at least once that they had sex during the first 12 months of treatment with main or casual partner(s) - either HIV-negative or of unknown HIV status (study population), 113 (32%), 112 (33%) and 119 (35%) were visits at enrollment (M0), M6 and M12 respectively. During follow-up, ICU was reported in 212 visits (corresponding to 153 patients), broken down as follows: 86/113 visits (i.e. 76% of visits) at M0, 56/112 (50%) at M6 and 70/119 (59%) at M12 respectively. Adherence to ART was reported at 67/112 visits (i.e. 60% of visits) at M6 and at 79/119 (66%) at M12. The proportion of ICU at visits where adherence to ART was reported was 45% (30/67) at M6 and 57% (45/79) at M12 versus 58% (26/45) at M6 and 63% (25/40) at M12 at visits where non-adherence was reported. To test whether the relationship between non-adherence and ICU could change over time, we tested the interaction between time and adherence over the period M6–M12. It was not significant, confirming that this relationship did not indeed change over time.In univariate analysis , severalAfter adjustment in multivariate analysis for the frequency of sexual acts, type of sexual partner  only or having both a main and casual partners), perceived social class and desire for a child, adherence to ART was independently associated with a lower risk of ICU compared with baseline  . In ordeIn this population of Cameroonian HIV-infected adults followed up in nine rural district hospitals, we documented a reduction in ICU during the first year of follow-up after ART initiation. This is consistent with the results of meta-analyses conducted both in high and low-resource settings In terms of PLWHA sexual behaviors, the impact of ART initiation has been studied in several longitudinal studies in Sub-Saharan Africa settings. A decline in the proportion of sexual risk behaviors 6 months after ART initiation has been highlighted in Uganda and South Africa Furthermore, the study’s findings show that participants who desired to have children were more likely to report inconsistent condom use As previously found in other studies, the frequency of sexual intercourse per week Despite these interesting results, some study limitations need to be recognized. Sexual behaviors and adherence assessment are based on self-reports which are known to be affected by social desirability bias In conclusion, this study highlights that adherence to ART is associated with a lower risk of ICU but this result needs to be interpreted carefully. As adherence behaviors are not only determined by problems with the healthcare systems but also by social barriers encountered by patients in their daily life, counseling should not only be ART adherence-centered but patient-centered, including sexual risk minimization and psychosocial support.


CYP2B6, ABCB1/MDR1, ABCG2, and ABCC4) in which variation has been suggested to affect the pharmacokinetics of drugs commonly employed to treat HIV/AIDS. We show that genotyping for ABCB1 variations (rs1045642 and rs2032582) may help predict HIV treatment response. We found variations in this gene have a significant association with outcome as measured by CD4+ T cell counts in a discovery subset  = 1.58; 95% CI 1.02–2.45), these results were confirmed in a validation subset of the cohort . Exploratory analysis suggests that this effect may be specific to NVP (nevirapine) or 3TC (lamivudine) response. This publication represents the first genetic analysis in a continuing effort to study and assist the patients in a very large, unique, and historically significant HIV-AIDS cohort. Genotyping of AIDS patients for ABCB1 variation may help predict outcome and potentially could help guide treatment strategies.HIV/AIDS has the highest mortality among infectious diseases in China. In ongoing efforts to alleviate this crisis, the national government has placed great emphasis on efforts in Henan province where HIV-infected former plasma donors in the 1990s contributed to AIDS becoming a public health crisis. Concomitant with a national initiative focusing the use of phamacogenetics for the better prediction of treatment response, we studied genetic variants with known pharmacokinetic phenotypes in a set of 298 HAART-treated  patients infected with HIV from the Henan cohort. We measured the association of response to treatment, assessed as changes in CD4+ T cell counts after antiretroviral therapy, of five polymorphisms in four genes ( National efforts in China to stem the HIV epidemic have focused on Henan province as a key target area. In this province in the 1990’s, HIV-infected former plasma donors were a factor in the rise of the AIDS crisis in China Complete elimination of HIV is difficult to achieve with current clinical practices. In part due to resting infected T cells, HIV latency, and other factors, this residual infection contributes to therapy failure and resistant strains While there is consensus that monotherapy with available drugs is not effective to control HIV infection, the choice of drugs for combination therapy depends on several factors. The panel of drugs used to treat AIDS in China has been standardized and follows the national guidelines for the public antiretroviral therapy program. The antiretroviral NRTIs provided free of cost by the national government are: AZT, 3TC, d4T, ddI, ABC, and TDF; the NNRTIs are: EFV, NVP; and the PIs are: ATV, IDV, and LPV/r. Inclusion of AZT, NVP, 3TC or d4T, because of the ability of these drugs to bypass the blood-brain barrier, is common CYP2B6, ABCB1/MDR1, ABCG2, and ABCC4) that have been shown to affect the pharmacokinetics of several standard HAART drugs and response to treatment. Polymorphisms in several genes, especially those coding proteins in drugs absorption, distribution, metabolism and excretion ABCB1 polymorphisms may predict virologic failure in response to EFV CYP2B6 can predict pharmacokinetic aspects of EFV response ABCC4 gene (559G>T and 1460G>A) are associated with higher intracellular accumulation of AZT in vitroABCG2 C421A allele is associated with the disposition of 3TC Standard antiretroviral therapy doesn’t take the genetic variation of patients into account, contributing to varying treatment response among patients. In this study we explored the association of HAART response with five polymorphisms in four genes  of Henan Province for more than six months. These patients were enrolled in a follow up investigation by the Henan CDC initiated in 2004; the participants’ viral load levels are monitored once per year and CD4+ T cell counts are monitored twice a year and the study is ongoing. This initial study is a pilot program with the goal of greatly extending the population that is being assessed genetically. The total cohort size in Henan Province is over 23,000. To prevent the transmission and decrease the mortality of HIV/AIDS in China, the government has established a comprehensive system, including HIV counseling and test, antiretroviral therapy, treatment monitor and a database of patients’ information of age, sex, treatment regimens, viral load and CD4 T cell counts each year. Based on this system, we plan for these initial results to be validated in the large Henan province cohort.. Progression to AIDS in adults was diagnosed as any patient in WHO clinical stage 4 or for whom the CD4 count is less than 200 cells/mm3 or a CD4 percentage less than 15%. WHO clinical stage 4 is defined as suffering from severe associated diseases such as HIV wasting syndrome, pneumocystis pneumonia, recurrent severe bacterial pneumonia, chronic herpes simplex infection  etc Random sampling was used to select a total of 298 HIV-infected Chinese patients living in four areas with high prevalence of HIV infection  of Henan province for more than six months. These patients were enrolled in a follow up investigation by the CDC of Henan province from 2004 to 2011 and the participants’ viral load were regularly monitored once per year and CD4+ T cell counts were monitored twice a year. The median study period of the patients is 7.5 years, and the study is ongoing. The full criteria employed to determine inclusion into the study were: 1) the HIV serum positive status of the subject was confirmed by detection of HIV antibody, antigen and HIV nucleic acid according to the published “National Guidelines for Detection of HIV/AIDS” or the patient was diagnosed as to having progressed to AIDS; 2) the patient received HAART; 3) the treatment regimens had been recorded; 4) the patient viral load and CD4+ T cell count was assayed regularly and these records are available from the CDC of Henan provinceWhole blood samples from participants were obtained by the local CDC. After erythrocyte lysis, white blood cells were separated and stored immediately at −80°C. Genomic DNA was isolated using the Wizard Genomic DNA Purification Kit  following manufacturer’s instructions. The DNA was quantified with UV-vis spectrophotometer (NanoDropND-1000) and then diluted to working concentrations of 25 ng/µL.CYP2B6 516G>T (rs3745274), ABCB1 3435T>A/C/G (rs1045642), ABCB1 2677T>G/A (rs2032582), ABCG2 421C>A (rs2231142), ABCC4 559G>T (rs11568658) were selected based on a literature review Five SNPs: P-value, odds ratios (ORs) and 95% confidence intervals (95% CIs) for the ability of these genotypes to predict therapeutic response when a binary outcome measurement was used, and linear regression for the measurements using continuous values. CD4+ T cell counts were assessed twice per year from 2004 until 2011. In consultation with local physicians as to how CD4+ T cell counts is used to evaluate response to the aggressive early treatment strategy employed with these patients, the following scale was used: 0: CD4+ T cell counts were less than 250/mm3 at the final measurement; 1: counts consistently greater than 250/mm3 from the initial to final measurement; 2: counts improved from less than 250/mm3 in the initial measurement to greater than 250/mm3 in the final measurements. This was further simplified to a binary assessment of “no change” (0 or 1) and “improved” (2). These scales were determined prior to analysis. Genotype associations were assessed as additive, recessive, and dominant models. As there were two SNPs for ABCB1, these were also assessed using a simple additive model.Logistic regression models were used to estimate P-value was less than 0.05. All P-values were 2-sided. Prior to study the cohort was randomly partitioned into a discovery  and validation  subsets, the validation subset was not used in the initial discovery analyses. The splitting of the cohort into discovery and validation cohorts was not employed when exploring association with specific treatments. Because the patient counts per genotype in the different treatment regimens was low for some subgroups a Fisher exact test was used to assess the distribution of patients in these analyses. The statistical analyses were performed using SPSS software .To determine independence of the alleles of other factors, namely age, sex and progression to AIDS, multivariate logistic regression modeling was employed. All results were considered significant if the The selection criteria of the patients are described in the materials and methods and the selection flowchart is shown in The five selected SNPs were genotyped by a high-throughput PCR-sequencing approach . Each geABCB1 alleles in a recessive model  when assessed individually showed strong ORs but non-significance. The combined SNPs’ association was confirmed in the validation subset using the recessive model, and also was significant as an additive model. The two ABCB1 SNPs were also significant when assessed individually in the validation set of patients. Outcome assessed on the three-level scale did not show a significant association with ABCB1 in the discovery subset, but was significant in the validation set. ABCB1 was also significant when assessed in the presence of age, sex, and whether the patient manifested AIDS . Further studies are needed to validate these predictive associations.A wide variety of treatment regimens has been employed with this cohort, using a number of different HAART combinations . There ier drugs . To ensuexcluded . The ass outcome . While nABCB1. This finding was upheld in a small validation subset of the cohort. Additionally, an exploratory analysis was performed to identify potential associations with treatment. Though the treatment regimens for this cohort were very diverse, we found preliminary evidence suggesting that the ABCB1 variations may be mediating response to treatment with either NVP or 3TC, or both.In this study we discuss the findings of an initial genetic study of a historically important HIV cohort. This group of patients is unique both as a target of a very large national health initiative and for its uniform demographics, which should aid efforts to discover clinically applicable genetic associations. We found that improvement in CD4+ T cell counts over the course of treatment was significantly associated in a discovery subset with variation in ABCB1 variants are significantly different between the European and Han HapMap populations , and these variations may confound attempts at translating clinical results achieved in European populations to similar practice in China.This is not the first association that has been made between ABCB1 and treatment, though identification of variation within this gene is currently not a standard clinical tool. ABCB1, also known as multidrug resistance protein 1 (MDR1), is a member of the MDR/TAP subfamily ABCB1 polymorphisms with changes in expression, pharmacokinetics measurements, and drug response ABCB1ABCB1 variants studied herein with outcome response to several drug therapies . No significant association with plasma concentration was seen for either genotype. However a comparison of the TT genotypes vs. the combined CC/CT genotypes for the 3435 T>C variant was significant for the subgroups receiving EFV. Interestingly, this association was stronger in an analysis that controlled for race Many studies have assessed the potential associations of The difficulty in translating the well understood biochemical function of ABCB1 in transporting several drugs across cell membranes to consistent clinical findings could be due to an intrinsically small effect size. It is also possible that other factors make these studies difficult. HAART can employ several different drugs, in fact the use of several drugs is essential to help prevent the rise of resistant viral strains. However this makes strong associations studies difficult; the use of several drugs decreases the number of patients available to assess a single therapy combination. Additionally, it’s very likely drug-drug interactions are a significant confounding factor. This could be mediated through other enzymes, primarily the cytochrome P450 enzymes, or through ABCB1 itself. It has been shown in vitro that ABCB1 is induced in response to administration of NVP Table S1SNPs description and primers design.(DOCX)Click here for additional data file.Table S2Association analyses between SNPs and lack of drug in regimen.(DOCX)Click here for additional data file.


Temporary cART during primary HIV-infection (PHI) did not select for drug resistance mutations after treatment interruption and did not affect the subsequent virological response to long-term cART. Our data demonstrate that fear of drug resistance development is not a valid argument to refrain from temporary early treatment during PHI. In the Primo-SHM trial, a multicenter randomized trial comparing no treatment with 24- or 60-weeks of combination antiretroviral therapy (cART) during primary HIV-infection (PHI), we recently demonstrated that temporary early cART lowered the viral setpoint and deferred the need for reinitiation of cART during chronic HIV-infection The aim of this study was to assess the effect of temporary cART during PHI on the subsequent virologic response to long-term cART, in patients who previously participated in the Primo-SHM trial. To this end, we compared the viral decay and the time to viral (re)suppression between the early treated patients who reinitiated cART and the patients in whom treatment was deferred until conventional criteria to start long-term cART had been reached.3, severe constitutional symptoms, the occurrence of an AIDS defining event, or if the patient preferred on (re)initiating cART. Follow-up visits after (re)start of cART were scheduled according to standard treatment guidelines, i.e. after four weeks of treatment and every three months thereafter. This study was approved by the Medical Ethics Committee of the Academic Medical Hospital in Amsterdam, the Netherlands, and written informed consent was obtained from all participants.Between May 2003 and March 2010 168 patients with laboratory evidence of PHI were randomized in the Primo-SHM trial to receive no treatment  or 24 or 60 weeks of early cART  10 c/ml. Data of the 24- and 60-weeks early treated patients were combined in all analyses because the viral decay was not significantly different between the two groups (data not shown).In the current study, we included the 94 out of 168 participants (56%) who had started or restarted long-term cART by September 2011 and who had at least one pVL measurement after (re)initiation of cART. (Re)Start regimens were at the discretion of the treating physician. Resistance testing was performed at diagnosis of PHI. To investigate possible acquired resistance during or after stopping of early cART, we performed additional resistance testing of the reverse transcriptase gene retrospectively in the first stored plasma sample obtained within one year after TI with a pVL above 3.0 logSociodemographic characteristics and laboratory data at (re)start of long-term cART were compared between the naive and early treated patients using chi-square, Fisher's exact and Kruskal-Wallis tests where appropriate. Viral decay after start/restart of cART in naive/early treated patients was analysed using linear mixed models incorporating repeated measurements, which showed a tri-phasic pattern with distinct slopes from week zero to four, week four to eight and from week eight onwards. For this analysis patients were censored once they reached a pVL <50 c/ml. A similar analysis was done for the early treated group, comparing viral decay during early initial cART with the decay after subsequent restart of cART. Time to viral (re)suppression, defined as a pVL <50 c/ml, was compared between the two groups using Kaplan-Meier plots and multivariable Cox regression analysis. The proportion of patients having an undetectable viral load (<50 c/mL) and the mean (SD) CD4+ T cell count in the two groups were plotted and compared at 24-week intervals for 144 weeks after the (re-)start of cART. All analyses ignored modifications of treatment regimens, but censored patients at the moment of interruption of cART for more than two weeks. Data were analyzed using SAS version 9.2 .10 c/ml (P = 0.24) and 446 (SD 164) versus 481 (236) cells/mm3 (P = 0.46), respectively. Additionally, the naïve patients had less transmitted drug resistance mutations as compared to the early treated patients at the moment of PHI-diagnosis (0 versus 8 (14%); P = 0.048). 5/8 early treated patients carried a M41L mutation, 2 patients a M46I mutation of whom one also had a T215S mutation and one carried a K103N mutation. In 52/63 early treated patients all antiretroviral drugs had been stopped simultaneously at TI: at that moment 31/63 (49%) were receiving dual-class NNRTI-based therapy, 15/63 (24%) dual-class boosted PI-based therapy, and 6/63 (10%) triple-class therapy. In the remaining 11/63 patients (17%) a staggered TI method was used, in which the NNRTI was stopped prior to the NRTI-backbone. Six early treated patients (6%) did not have a pVL <50 c/ml at TI (range 58–1882 copies/ml). The median time between TI and restart of long-term cART was 1.9 (IQR 0.9–3.1) years.Of the 36 naive and 132 early treated participants in the Primo-SHM trial, 31 (86%) and 63 (48%) had (re)initiated long-term cART by September 2011, respectively, and were included in this study. At the time of diagnosis of PHI (so before any treatment was started) the pVL and CD4 count data of the naïve and early treated patients were 5.14 (SD 0.90) versus 5.34 (0.73) log3, respectively, and were not significantly different between the naive and early treated patients. The naive patients had a higher mean pVL at (re)start (5.0 (SD 0.7) versus 4.7 (0.7) log10 c/ml; P = 0.07). Naive patients initiated long-term cART more often with an NNRTI-containing regimen than early treated patients (24 (77%) versus 37 (59%); P = 0.10). Four naive (13%) and 23 early treated patients (37%) (re)started long-term cART with a boosted PI (P = 0.03), and three (10%) versus three (5%) patients, respectively, (re)initiated with triple-class therapy (P = 0.40).89/94 (re)starting participants (95%) were men. Mean age and CD4 count at (re)start of long-term cART were 44 (SD 9) years and 290 (110) cells/mmDrug resistance testing was performed after TI in 56/63 (89%) early treated participants. None of these patients had developed a novel (acquired) drug resistance mutation. Of the remaining seven patients, one harboured a 103N mutation, which was already present at diagnosis of PHI , and for six patients no stored samples were available or the first available stored sample was older than one year. The median interval between TI and the timepoint of resistance testing was 5.0 (IQR 4.0–8.0) weeks. In 3/56 patients the time point of resistance testing was >12 weeks after TI. Other patient characteristics  were comparable between the two groups. One early treated patient was lost-to-follow-up after restart of long-term cART and he was censored at this visit. Patient characteristics are summarized in P = 0.87). The mean interval between pVL measurements was not significantly different for the two groups (53 (SD 23) vs. 50 (20) days, respectively, P = 0.54). Viral decay after treatment (re)initiation was similar between the naive and early treated patients: during the first four weeks the pVL decreased with 0.62 and 0.58 log10 copies/ml/week respectively (P = 0.32), from week four to eight with 0.087 and 0.13 log10 copies/ml/week (P = 0.37), and from eight weeks onward with 0.043 and 0.027 log10 copies/ml/week (P = 0.23) (P = 0.72). All naive and early treated patients achieved viral (re)suppression. The mean number of pVL measurements after (re)start of cART, upto and including the first undetectable pVL, was 2.3 (SD 1.2) in the naive and 2.3 (1.5) in the early treated patients, respectively ( = 0.23) . AdjustiP = 0.70). As expected, a higher vireamia at (re)start of long-term cART was predictive for a longer time to viral suppression (HR 0.37 per 1 log10 copies/ml increase (95% CI 0.25–0.56); P<0.001). Other parameters, including reinitiating with an NNRTI-based regimen or with triple-class therapy, were not associated with time to viral (re)suppression (data not shown).In the Cox analysis early treatment during PHI as compared to no treatment was not associated with time to viral resuppression (HR 0.81 (95% CI 0.27–2.39); P = 0.043), respectively. This difference in time to first undetectable viral load measurement appeared to be primarily driven by the higher viral load at the time of start of early cART compared to the viral load at the restart of cART in the phase of long-term cART. Therefore, we additionally constructed mixed linear regression models comparing viral decay during the early treatment episode and subsequent restart of long-term cART , from week four to eight with 0.13 and 0.14 log10 copies/ml/week (P = 0.70), and from eight weeks onward with 0.048 and 0.021 log10 copies/ml/week (P = 0.003).In the early treated group, the median time to viral (re)suppression (Kaplan-Meier estimate) was longer in the early treatment phase compared to the phase of long-term cART: 21.7 (IQR 12.0–24.7) and 16.6 (8.7–21.0) weeks  of the early treated patients. We therefore cannot exclude with certainty that there might have been selection of drug resistance after TI in these patients. This is in particular relevant for patients who interrupted an NNRTI-based regimen, because of the long half-life of NNRTIs. However, in all seven patients, irrespective of the regimen, the pVL was resuppressed upon restart, which virtually excludes clinically important mutations. The early treated patients reinitiated long-term cART more often with a boosted PI than naive patients. Many early treated patients preferred not to restart an NNRTI because of side-effects they had experienced previously during the early cART period, and therefore favoured a PI-containing regimen.Our study is supported by another study in which 37 PHI-patients were treated with temporary early cART and no drug resistance was observed after TI In conclusion, temporary cART during PHI was not associated with a reduced virologic response after subsequent reinitiation of long-term cART. Concerns for developing drug resistance mutations after TI have not been substantiated. Therefore, fear of drug resistance development is not a valid argument to refrain from early treatment during PHI: even if patients interrupt early treatment, they still have a good and durable response after subsequent reinitiation of cART. A question is whether early cART should be interrupted at all, butin our experience some patients prefer to interrupt treatment after a period of early treatment. In brief, this study contributes to the increasing data supporting (temporary) early cART during PHI.


HIV RNA viral load (VL) has been shown to increase during opportunistic illnesses (OIs), suggesting active HIV replication in response to infection among patients not taking antiretroviral therapy (ART). We assessed the effects of OIs on HIV RNA VL and CD4+ T cell counts among patients on ART with initially suppressed VL.Between 2003 and 2007, we enrolled and followed 1094 HIV-1-infected adults who initiated ART and had quarterly blood draws for VL and CD4+ T cell count. In VL/CD4+ T cell measurement intervals following undetectable VL, we compared the elevation in VL to detectable levels and CD4+ T cell count changes between intervals when participants had episodes of OIs and intervals when they did not have OIs.p value=<0.001), 1.4 cells/µL per three months lower per one year increase in age  and 4 cells/µL per three months lower per 10 cells/µL increase in the starting CD4+ T cell count value .VL was more likely to be detectable if participants had OIs in the prior three months compared to when they did not (OR=4.0 (95% CI=1.9–8.6)). The CD4+ T cell counts declined 24.1 cells/µL per three months in intervals where the participants had OIs compared to an increase of 21.3 cells/µL per three months in intervals where they did not have OIs (adjusted difference in the rate of CD4+ T cell count change of 61.7 cells/µL per three months (95% CI=13.7–109.7), P value=0.012). The rate of CD4+ T cell count increase was 25.6 cells/µL per three months (95% CI=11.6–39.6) higher for females compared to males (Episodes of opportunistic infections among patients taking ART with undetectable VL were associated with elevation of HIV RNA VL to detectable levels and decline in CD4+ T cell counts.Clinical Trial Number: NCT00119093. Clinical observations in HIV-positive patients show increased plasma HIV viral load (VL) during opportunistic illnesses (OIs), suggesting active HIV replication in response to OIs. Malaria ,2, tuberWe analyzed data from the Home-Based AIDS Care Project (HBAC), a three-year randomized trial designed to compare three different monitoring strategies for HIV-positive patients receiving ART. Details of this trial have been presented elsewhere .Between May 2003 and April 2007, we enrolled and followed HIV-1-infected clients of the The AIDS Support Organization (TASO), who were initiated on ART at the Tororo Branch of TASO. Enrolment was offered to clients with a CD4+T cell count<250 cells/µL or severe HIV disease (defined as WHO Stage 3 or 4 or a history of recurrent herpes zoster), an AST or ALT<5 times upper limit of normal, a calculated creatinine clearance≥25 mL/min, and a Karnofsky Score>40%. The Cockroft–Gault formula was used to estimate creatinine clearance. The first-line ART regimen was stavudine, lamivudine and nevirapine (or efavirenz for those taking concurrent rifampicin), and all participants received cotrimoxazole prophylaxis. Pre-packaged ART, cotrimoxazole and other medicines were replaced using a weekly storage container, and pill counts conducted at the study clinic by a pharmacist.All participants provided written informed consent in their preferred language and were free to withdraw their participation in the study at anytime without losing access to free ART from TASO. The study was approved by Uganda National Council of Science and Technology, the Institutional Review Boards of the Uganda Virus Research Institute, and the Centers for Disease Control and Prevention (CDC). Funding was provided by the U.S. Department of Health and Human Services/CDC through the Emergency Plan for AIDS Relief.Trained lay field officers visited clients’ homes weekly to deliver medications and collect data regarding drug adherence, potential symptoms of drug toxicity or death of a household member in the preceding seven days . ParticiCD4+ T cell counts and HIV RNA VL were measured at three-monthly intervals. Field workers completed weekly client monitoring forms that included information on client symptoms, problems with taking medication or other information which might impact participant health. All diagnoses of OIs were presented at the weekly medical case conference and reviewed by the medical team as a whole. For diagnosis of an OI, we considered all WHO Stage 3 or 4 illnesses and we also included malaria. While not technically an opportunistic illness, which usually refers to WHO Stage 3 or 4 illnesses, malaria is one of the most common causes of illness and death among HIV-positive individuals in endemic areas of sub-Saharan Africa. As well malaria infections have been shown to affect HIV VL in HIV-positive individuals not on ART .Pneumocystis jirovecii pneumonia was diagnosed clinically using chest radiography, clinical presentation and a response to cotrimoxazole treatment. All illnesses were diagnosed by physicians at the study clinic in Tororo and reviewed at the weekly medical case conferences.Cryptococcal disease was diagnosed by compatible symptoms and serum cryptococcal antigen testing . Pulmonary tuberculosis (TB) was defined as two sputum smears positive for acid-fast bacilli using microscopy or negative sputum smears with a chest radiograph compatible with TB and a lack of response to a two-week trial of antibiotic therapy. Extra-pulmonary TB was diagnosed by clinical presentation and infrequently by lymph node biopsy and pathological confirmation. Diagnoses of Kaposi's sarcoma and cervical cancer were based on biopsy results. We measured HIV VLs using Cobas Amplicor HIV-1 Monitor version 1.5  and enumerated CD4+ T cell count using TriTEST reagents following an in-house dual platform protocol and MultiSET and Attractors software using an FACScan or FACSCalibur flow cytometer .We estimated adherence using pill count data stored in a computerized pharmacy database as: (number of pills delivered minus number of pills returned) divided by number of pills delivered.Data were entered using Epi Info  and analyzed using SAS .To assess the effect of OIs on HIV RNA VL and CD4+ T cell count among participants with suppressed HIV RNA VL, we compared the elevation in HIV RNA VL to detectable levels and CD4+T cell count changes between measurement intervals when participants had episodes of OIs and intervals when they did not have OIs. We based our analysis on quarterly measurement intervals that started with undetectable HIV RNA VL (<50 copies/mL). We conducted analysis with two outcome measures, i.e., detectable HIV RNA VL (>50 copies/mL) in measurements that followed a previous quarterly measurement with undetectable HIV RNA VL, and rate of CD4+ T cell count change within measurement intervals. For the analysis of the effect of OIs on detectable HIV RNA VL, we used a logistic regression model using a log-link function. For the analysis of rate of change in CD4+T cell count, we used a linear regression model. In both models, generalized estimating equation method with an exchangeable correlation structure was used to take into account the dependence of observations due to repeated measures for the same individuals. Covariates that were considered in the models were gender, duration on ART at the start of the interval, age, BMI, ART adherence and first-line ART regimen.For participants who had an OI following undetectable HIV RNA VL, we plotted the subsequent changes in CD4+T cell count over time, starting from the time of the undetectable HIV RNA VL preceding the OI. For comparison, we also plotted a similar graph for those who never had OIs, starting from the time of their first undetectable HIV RNA VL.Of the 1094 antiretroviral-naive clients who were started on ART, 47 had no follow up HIV RNA VL or CD4+ T cell count measurements after initiating ART and were excluded from the analysis. Of the remaining 1047 participants, 73% were female, the median age was 38 years, the median CD4+T cell count at enrolment was 131 cells/µL (IQR=72–196) and median HIV RNA VL at enrolment was 207,787 copies/mL  .The median interval between lab measurements was 91 days, and the 1047 people included in the analysis had a total of 11,477 visits in the four years of follow up where laboratory measurements were done. For 79% of these, the HIV RNA VL in the preceding measurement was undetectable. A total of 176 OIs were diagnosed in 137 individuals during follow up. The five most common diagnoses were malaria (23%), cryptococcal meningitis (21%), TB (19%), Kaposi's sarcoma 12%) and candidiasis (8%). The median time from ART initiation to OI diagnosis was six months, and the median CD4+ T cell count at the time of diagnosis was 109.5 cells/µL. Of the 176 OIs that occurred during follow up, 90 (48%) occurred after the participants had initially achieved an undetectable HIV RNA VL. In 77 (86%) of these 90 OI diagnoses, the immediately preceding measured HIV RNA VL was undetectable (<50 copies/mL), in 5 (6%) it was between 50 and 10000 copies/ mL and in 8 (9%) it was>1000 copies/mL, the definition of virologic failure according to the Ugandan Ministry of Health national antiretroviral treatment guidelines [% and canA total of 9036 quarterly measurements followed a previous measurement for which the HIV RNA VL was undetectable. Of these 9036 measurements, OIs occurred in 56 (0.6%) and VL become detectable in 371 (4%).p=0.001), after adjusting for the non-independence of repeated observations within an individual, gender, duration on ART, age, BMI at baseline, first-line ART regimen, ART adherence preceding the interval and previous three month CD4+ T cell count (p=<0.001)).The HIV RNA VL was more likely to be detectable if participants had OIs since the previous quarterly measurement, 14% (8/56), compared to when they had none, 4% (363/8980). This difference was statistically significant (OR=3.8 (95% CI=1.73–8.39); ll count . In a siFor individuals that had increases in HIV RNA VL to detectable levels, the median VL achieved was higher among those who had had an OI or malaria  compared to those who had not had an OI .p=0.013), comparing intervals when participants had OIs to intervals when they did not have OIs. Other factors that were significantly associated with the rate of CD4+ T cell count change were previous three-month CD4+T cell count, duration on ART and gender. After controlling for OIs, age, CD4+ T cell count at the start of the interval and BMI, the rate of CD4+ T cell count increase was on average 25.7 cells/µL per three months (95% CI=11.6–39.7) higher for females compared to males (p=<0.001). The rate of increase was negatively associated with older age  and CD4+T cell count values at the start of the interval .p=0.198).An analysis for effects of OIs on changes in CD4+T cell count percent showed CD4+ T cell count percent to decrease at a rate of 0.04 percentage points per three months in intervals when participants had OIs, compared to an increase of 0.8 percentage points per three months in intervals when they had no episodes of OIs. However, the adjusted difference was not statistically significant . In addition, participants had a mean decline of 24.1 CD4+ T cells/µL per three months in intervals during which they had episodes of OIs compared to a mean increase of 21.3 CD4+ T cells/µL per three months in intervals during which they had no episodes of OIs. We also observed that participants who had episodes of OIs tended to have declines in CD4+ T cell count in the long run .Though our results on elevation of VL were based on a small number of OIs and elevated VLs, our findings are similar to what has been observed among HIV-positive people not taking antiretroviral therapy –7. WhileThe observed effects of OIs on VL underscore the importance of OI prevention interventions even among people taking ART. Prior to the availability of ART, data on the benefits of cotrimoxazole prophylaxis regardless of CD4+T cell count influenced Uganda Ministry of Health and WHO policy ,16,17. SIn addition to being a predictor of disease progression, HIV-1 RNA concentration in the blood is also a strong determinant of both sexual and mother-to-child transmission of HIV ,14. TherIt is possible that we may have underestimated the association of OIs with subsequent VL elevation and CD4+ T cell count decline because the study population were visited weekly at their home and most new infections were likely to be promptly treated. It is possible that some VLs became detectable after OIs but resolved prior to the next quarterly blood draw due to prompt treatment of OIs. Many patients taking ART in programmatic settings in sub-Saharan Africa do not have access to prompt medical attention, and the effect could be greater than what we have observed in the context of prompt treatment of OIs.In conclusion, our findings show that episodes of OIs among HIV-infected adults with suppressed VL while taking ART were associated with elevations in VL and reduced improvement in CD4+ T cell counts. Prevention of OIs is therefore important even among patients on ART who have attained suppressed VLs.


HIV-1 infection generates numerous abnormalities in the B cell population. The majority of these defects are reverted by antiretroviral therapy. Our aim was to evaluate the effects of re-exposure to HIV antigens on the frequency and functionality of antibody secreting cells (ASC) in patients undergoing structured treatment interruptions (STI). As re-exposure to viral antigens may also boost the production of  antibodies, we also assessed the neutralizing activities during STI cycles.Retrospective study of 10 patients undergoing 3 cycles of STI with 2 weeks on and 4 weeks off HAART. ASC frequencies were determined by flow cytometry in samples obtained at the beginning and the end of STI. Neutralization capacity, total IgG concentration and anti-gp120-IgG titres were evaluated.Median viral loads were higher at the end of STI compared to time of treatment stop: 20[20-1200] vs 615[20-452000] respectively for the first STI, 20[20-654] vs 3655[20-45900] (p<0.05) for the second and 35[20-82] vs 290[20-17400] (p<0.05) for the third STI. The frequency of ASC followed the same trend: 0.35%[0.17-1.15] at the beginning of first STI vs 0.27[0.20-4.95] at treatment restart, 0.35[0.10-1.40] vs 0.82[0.30-3.25] for the second and 0.30[0.10-0.70] vs 0.40[0.15-1.85] for the third STI. Eight out of 10 patients maintained stable total IgG levels during the study. HIV-neutralizing activity was observed in two patients concomitantly with high anti-gp120 titters. In one patient the neutralizing activity remained constant while the second patient showed elevated neutralizing Ab after first STI and once treatment was reinitiated after the 2nd STI.Our data suggest that STI and its associated transient increases in viral load drive the frequencies of ASC in an antigen-specific manner. In some subjects, this re-exposure to autologous virus boosts the presence of neutralizing antibodies, albeit in a somewhat delayed manner.


Antiretroviral therapy (ART) decreases mortality risk in HIV-infected tuberculosis patients, but the effect of the duration of anti-tuberculosis therapy and timing of anti-tuberculosis therapy initiation in relation to ART initiation on mortality, is unclear.We conducted a retrospective observational multi-center cohort study among HIV-infected persons concomitantly treated with Rifamycin-based anti-tuberculosis therapy and ART in Latin America. The study population included persons for whom 6 months of anti-tuberculosis therapy is recommended.3, 171 (68%) received >180 days of anti-tuberculosis therapy, 168 (66%) initiated anti-tuberculosis therapy before ART, and 43 (17%) died. In a multivariate Cox proportional hazards model that adjusted for CD4+ lymphocytes and HIV-1 RNA, tuberculosis diagnosed after ART initiation was associated with an increased risk of death compared to tuberculosis diagnosis before ART initiation . In a separate model among patients surviving >6 months after tuberculosis diagnosis, after adjusting for CD4+ lymphocytes, HIV-1 RNA, and timing of ART initiation relative to tuberculosis diagnosis, receipt of >6 months of anti-tuberculosis therapy was associated with a decreased risk of death .Of 253 patients who met inclusion criteria, median CD4+ lymphocyte count at ART initiation was 64 cells/mmThe increased risk of death among persons diagnosed with tuberculosis after ART initiation highlights the importance of screening for tuberculosis before ART initiation. The decreased risk of death among persons receiving > 6 months of anti-tuberculosis therapy suggests that current anti-tuberculosis treatment duration guidelines should be re-evaluated. According to 2010 World Health Organization estimates, 1.7 million people in Latin America and the Caribbean are living with HIV/AIDS. Among HIV-infected persons, tuberculosis is one of the leading opportunistic infections and causes of death. Of the estimated 8.7 million incident tuberculosis cases globally in 2011, up to 13% occurred in HIV-infected persons, leading to 430,000 deaths among HIV- infected tuberculosis patients [3 at the time of tuberculosis diagnosis, starting of ART within 2-4 weeks of initiating anti-tuberculosis therapy significantly improves survival [Antiretroviral therapy (ART) significantly improves survival among HIV-infected tuberculosis patients ,3,4. Amosurvival ,6,7. Howsurvival ,9. It issurvival ,11. The survival ,13,14—thsurvival ,16,17,18survival ,20,16.We therefore assessed the mortality rate among HIV-infected tuberculosis patients who concomitantly received ART—initiated either before or after tuberculosis diagnosis. We also assessed the relationship between duration of anti-tuberculosis therapy and the risk of death, to inform the optimal duration of anti-tuberculosis treatment.www.iedea.org) [We conducted a retrospective observational cohort study within the Caribbean, Central and South America Network for HIV Research (CCASAnet) of the International Epidemiologic Databases to Evaluate AIDS  . The corThe cohort included HIV-infected adults (> 18 years old) who initiated ART between 1997 and 2007 and were followed for up to one year or more after ART initiation. Patients were included if they received ART at any time while concomitantly receiving rifamycin-based  anti- tuberculosis therapy. ART could have been started before or after anti-tuberculosis therapy initiation. To assess the effect of duration of anti-tuberculosis therapy on mortality, we limited the study to persons for whom 6 months of therapy was recommended . Persons with central nervous system, bone, joint, or pericardial tuberculosis were excluded because recommendations indicate at least 9-12 months of therapy [ART was defined as regimens that included three or more antiretroviral drugs. For this study, the sentinel episode of tuberculosis was the participant’s first tuberculosis episode during which they concomitantly received ART. Tuberculosis diagnoses were established by each study site, based on smear, culture, clinical and radiographic criteria, as well as response to anti-tuberculosis therapy. The date of tuberculosis diagnosis was defined as the date of anti-tuberculosis therapy initiation. Tuberculosis recurrence was defined as development of a new tuberculosis case after completing treatment of the sentinel episode. All tuberculosis cases were validated by review of the participant’s medical records and primary source documentation by local site investigators; independent quality control and TB case validation were performed at each study site . Baseline CD4+ lymphocyte and HIV-1 RNA measurements were defined as at the time of ART initiation; measurements prior to tuberculosis diagnosis were also utilized. Baseline CD4+ lymphocyte count was defined as the measurement closest to ART initiation but not more than 6 months prior to, or 7 days after, the date of ART start. Baseline HIV-1 RNA was defined as the pre-ART measurement closest to, but not more than 6 months prior to ART initiation. The same window periods were used for measurements prior to tuberculosis diagnosis. Episodes of immune reconstitution inflammatory syndrome (IRIS) were captured, as defined by local site investigators.Groups were defined according to timing of ART initiation in relation to anti-tuberculosis therapy initiation. Continuous variables were compared with the Wilcoxon rank-sum test. Categorical variables were compared with the Pearson chi-square test. For the evaluation of risk factors for death after tuberculosis diagnosis, univariate and multivariate Cox proportional hazards models stratified by site were constructed. Variables in the multivariate models were determined a priori based on their clinical relevance regarding survival. Missing CD4+ lymphocyte and HIV-1 RNA values were imputed via multiple imputation for multivariable models. For the evaluation of anti-tuberculosis treatment duration and mortality, the analysis was performed among a) all persons with known anti-tuberculosis therapy duration regardless of duration, b) limited to persons with known therapy duration who survived at least 6 months from initiation of treatment for the sentinel TB episode, and c) limited to persons with known therapy duration who survived at least seven months to compare persons who received 5-7 months vs. > 7 months of therapy. Deaths occurring before or after one year of follow-up from time of tuberculosis diagnosis were included. P-values < 0.05 were considered statistically significant.Of the 3,539 HIV- infected persons who initiated ART during the study period, 533 (15%) received a diagnosis of tuberculosis. We excluded 219 patients who did not receive concomitant anti-tuberculosis therapy and ART, 20 patients who did not receive rifamycin-based anti-tuberculosis therapy, 40 patients who required extended TB treatment , and 1 patient with 0 days of follow-up. The final TB dataset included 253 patients who met all inclusion criteria. The clinical and demographic characteristics of the study population are in Characteristics of the 253 tuberculosis cases are listed in 3; P=0.02) and before tuberculosis diagnosis . They also tended to more likely be female and from Peru. There was no statistically significant difference in age, smear-negative disease, HIV risk factor, or HIV-1 RNA at ART initiation or before tuberculosis diagnosis.There were no statistically significant differences in age, sex, HIV risk factor, CD4+ lymphocyte count at ART initiation or before tuberculosis diagnosis, HIV-1 RNA at ART initiation or before tuberculosis diagnosis, or death between those who did vs. did not develop recurrent tuberculosis (data not shown). Compared to persons with tuberculosis who survived, those who died had lower median CD4+ lymphocyte count at ART initiation .In univariate Cox proportional hazards models of time from tuberculosis diagnosis to death among all tuberculosis patients, being diagnosed with tuberculosis after ART initiation tended to be associated with an increased risk of death compared to persons diagnosed with tuberculosis before ART initiation . The finAmong tuberculosis patients who survived at least 6 months from the time of tuberculosis diagnosis, receipt of > 6 months of anti-tuberculosis therapy was associated with a significantly decreased risk of death after adjusting for CD4+ lymphocyte count and HIV-1 RNA at the time of tuberculosis diagnosis, as well as timing of ART initiation in relation to anti-tuberculosis therapy initiation .Among the 153 patients who started ART after tuberculosis diagnosis whose tuberculosis treatment duration was known, 41 started within 60 days, 30 started within 61-90 days, 27 started within 91-120 days, 55 started >120 days after tuberculosis diagnosis. Patients who initiated ART >60 or >90 days after TB diagnosis had delayed progression from tuberculosis to death after adjusting for CD4+ lymphocyte count . ResultsThere were several important findings of this study, related to the duration and timing of tuberculosis treatment in HIV-infected persons. First, patients who received more than six months of tuberculosis treatment had a significantly decreased risk of death compared to persons receiving less than six months. We are unaware of other studies that have assessed the effect of anti-tuberculosis therapy duration on mortality among HIV-infected tuberculosis patients who concomitantly received antiretroviral therapy. However, there have been several studies and a meta-analysis suggesting that more than six months of anti-tuberculosis therapy is associated with lower rates of tuberculosis treatment failure and relapse ,19,20,16Although our study suggests that more than six months of anti-tuberculosis therapy is associated with improved survival, our analysis has limitations. To minimize bias, we performed analyses including only persons who survived at least 6 months after tuberculosis diagnosis, However, in clinical practice, not all persons assigned to at least 6 months of treatment would survive six months. Among persons who survived at least 6 months, the clinical and demographic characteristics of those treated for < 6 months vs. > 6 months were generally similar. However, those treated for < 6 months were also more likely to receive twice-weekly therapy in the continuation phase than those who received > 6 months; this could have contributed to the worse outcome in the former group. Furthermore, in an additional analysis comparing 5-7 months of anti-tuberculosis therapy with more than seven months of therapy among patients who survived at least 7 months, the association between prolonged therapy and improved survival weakened. In addition, longer treatment duration also has potential adverse effects given the drug-drug interactions with antiretroviral therapy and overlapping drug toxicity. These facts highlight the need for a large, prospective, randomized trial of two treatment durations among patients on ART. Study outcomes would include mortality and tuberculosis failure/relapse.Another important finding of our study was the higher risk of death among persons diagnosed with tuberculosis after ART initiation compared to those diagnosed before ART initiation. This has also been observed in HIV-infected tuberculosis patients in Haiti , but was3; the risk of disease progression and death tended to be increased among persons with higher CD4 counts [3. Since initiation of ART was an inclusion requirement for our study, tuberculosis patients who delayed ART such that they died before initiation were not included, and those classified as starting ART >60 or >90 days after anti-tuberculosis therapy were guaranteed to live >60 or >90 days, respectively, possibly biasing our results. Additional operational studies are warranted.ART started >60 or >90 days after anti-tuberculosis treatment initiation was associated with a decreased risk of death. In three recent randomized controlled trials, initiation of ART within 30 days of anti-tuberculosis therapy was associated with a decreased risk of AIDS and death, but only among persons with baseline CD4+ lymphocytes < 50 cells/mm4 counts . The medThere were several additional limitations of our study. First, it was retrospective and observational. There may have been potential unmeasured confounding factors such as tuberculosis drug resistance, which affected the results. Second, the proportion of patients with culture-confirmed tuberculosis was low. Although this could potentially affect the generalizability of these findings to other settings, all patients met clinical criteria for tuberculosis and were diagnosed according to the standard of care in their respective countries. However, the low proportion of patients with culture-confirmed tuberculosis contributed to the lack of information on drug resistance. Resistance rates likely vary by study site. Third, while we captured data on IRIS, there was likely under-ascertainment of this endpoint given the retrospective study design. Fourth, the tuberculosis treatment duration may have included interruptions, which would have extended the overall duration. Finally, while directly-observed therapy (DOT) is recommended in all study sites, we did not have information on the number of patients who received DOT.With the above limitations noted, we conclude that the decreased risk of death among persons receiving more than six months of anti-tuberculosis therapy suggests that current anti-tuberculosis treatment duration guidelines should be re-evaluated. A prospective, randomized trial is needed to determine the optimal anti-tuberculosis treatment duration among HIV-infected persons receiving ART. The increased risk of death among persons diagnosed with tuberculosis after ART initiation highlights the importance of screening for tuberculosis before ART initiation.