Human immunodeficiency virus (HIV)–positive cases have been reported among people who injected drugs in Liangshan Prefecture in southwest of China since 1995 and Liangshan has become one of the most seriously affected epidemic areas in China. In 2004, several patients with HIV/acquired immunodeficiency syndrome (AIDS) initiated antiretroviral treatment (ART) at the Central Hospital of Liangshan Prefecture. From 2005 to 2013, the number of patients receiving ART dramatically increased.We conducted a retrospective cohort study to analyze the long-term survival time and associated factors among patients with HIV/AIDS who received ART in Liangshan Prefecture for the first time. Data were collected from the Chinese AIDS Antiretroviral Therapy DATAFax Information System. A life table and the Kaplan–Meier and Cox proportion hazard regression were used to calculate the survival time and its associated factors, respectively.3 , 50–199/mm3 , and 200–349/mm3  were at a higher risk of death than those with a CD4 cell count ≥350/mm3.Among 8310 ART-naïve patients with HIV/AIDS who initiated ART, 436 patients died of AIDS-related diseases, and their median time of receiving ART was 15.0 ± 12.3 months, whereas 28.7% of them died within the first 6 months after treatment. The cumulative survival rates of those receiving ART in 1, 2, 3, 4, and 5 years were 97.1%, 93.4%, 90.6%, 88.8%, and 86.0%, respectively. Multivariate Cox regression analysis showed that male patients on ART were at a higher risk of death from AIDS-related diseases  than female patients. Patients infected with HIV through injection drug use (IDU) were at a higher risk of death  than those infected through heterosexual transmission. Patients with a baseline CD4 cell count <50/mmART prolonged survival time of patients with HIV/AIDS and improved their survival probability. Patients with HIV/AIDS should be consistently followed up and the CD4 T-cell count regularly monitored, and timely and early antiretroviral therapy initiated in order to achieve a better survival rate. Gradual progression of HIV to AIDS has resulted in an increase of the AIDS-related deaths. In December 2003, the government of China announced the “Four Frees and One Care” policy to ensure the accessibility of antiretroviral treatment (ART) to poor urban and all rural PLHIV. Since 2003, China has scaled up free ART for patients with HIV/AIDS, resulting in an increased ART coverage and decreased HIV-related mortality. By the end of 2011, a total of 150,692 patients with HIV/AIDS were treated through China's National Free Antiretroviral Treatment Program, and 122,613 of them are still on treatment. The national “12th Five-Year” Action Plan for Containment and Prevention of HIV/AIDS set goals for reducing new HIV infections by 25% and reducing mortality from AIDS-related causes by 30% (2010 baseline). In order to reach these goals, the State Council of China issued the “State Council on Further Strengthening the Work on Response to HIV/AIDS” in February 2011, requiring expanded antiretroviral therapy (ART) coverage to improve treatment accessibility.China health authorities estimated that the number of people living with human immunodeficiency virus (PLHIV)/acquired immunodeficiency syndrome (AIDS) would account for 0.033% of China's total population by the end of 2013. due to patient sociodemographic diversity, lack of medical resources, and treatment delivery gaps.Free ART has been provided in China since 2003. However, the scale-up of ART service in China encountered many challenges in terms of coverage and quality, particularly at the county level in western China,6 improves patients’ quality of life, and restores patients’ participation in social and family functions. Thus, Liangshan Prefecture began to provide free antiretroviral treatment for PLHIV in accordance with standard treatment procedures in 2005. As only limited studies have been published on HIV/AIDS-related mortality and its predictors among the patients on ART in Liangshan, we conducted this retrospective cohort study to shed light on survival time and its associated factors among patients with HIV/AIDS who were ART naïve prior to ART initiation from 2005 to 2013.As one of the most serious AIDS epidemic areas in China, HIV positives were reported among the injection drug users in Liangshan Prefecture of China in 1995. HIV spread in Liangshan through needle sharing among people who injected drugs during the earlier period of the epidemic. Since then, Liangshan has become one of the heavily HIV-affected epidemic regions in China, with increasing HIV-related morbidity and mortality. ART reduces morbidity from HIV infection, decreases death from HIV/AIDS-related diseases,22.12 in area, has jurisdiction over 17 counties and cities, which are Xichang, Zhaojue, Butuo, Puge, Jinyang, Meigu, Yianyuan, Ganluo, Huili, Huidong, Dechang, Xide, Leibo, Mianning, Yuexi, Muli, and Ningnan. Heath care including facilities, equipment, and personnel had been underdeveloped. The China government and international society has exerted great efforts on ART and health intervention services to Liangshan since 2004. ART was started among a very few patients with HIV/AIDS in 1 central hospital of Liangshan in 2004, and most of those patients were scattered in the remote rural areas and could not reach the treatment services on a timely basis. The lack of awareness and knowledge of HIV infection, restricted resources, and high treatment costs were also barriers to reach ART services. The first group of 4 ART-designated hospitals was set up in 2008 at county level. By 2013, a total of 18 designated hospitals were available to provide ART services at the county level in Liangshan. All ART-designated hospitals have provided free ART and physical check for patients with HIV/AIDS since September 1, 2010.Liangshan Yi autonomous prefecture was and still is a remote, impoverished, and mountainous area, located in Southwest China. Liangshan had a population of 4.97 million people at the end of 2013, of which 50.7% (2.52 million) were of Yi ethnic minority making it the largest Yi population in China. Liangshan, 60,400 km2.2 Physical and clinical examinations were provided on ART enrollment. Hospital staff recorded information from each follow-up visit (every 6 months), including date of death, cause of death, and dropout or transfer to another medical facility.A retrospective cohort study design was used to enroll patients with HIV/AIDS receiving ART in the 18 designated hospitals for patients with AIDS in Liangshan between January 2005 and December 2013. Among the 8602 cases enrolled from 2005 to 2013, a total of 8310 cases were included in the study. All 8310 patients were at least 18 years of age, ART naïve prior to ART, and based on the treatment criteria of the “National AIDS Free Antiviral Treatment Manual.”2.3Demographic data, time of HIV diagnosis, date of ART initiation, death, and medical characteristics were downloaded from the Chinese AIDS Antiretroviral Therapy DATAFax Information System, which is attached to the National Information Management System on HIV/AIDS Prevention and Control, and eligibility of patients was checked. We grouped the patients into 5 categories including constitutional (fever or lymphadenopathy), pulmonary , gastrointestinal , skin or mucosal , and neurological . If there were difficulties in classification in diagnosis of opportunistic infections in some designated hospitals, signs and symptoms collected at the first physical examination served as surrogates.The ART initiation date was counted as the first follow-up visit of the research, and the follow-up deadline was December 31, 2013. If a patient died from HIV/AIDS-related causes, the date of death was recorded as the date of the outcome. If a patient died from an illegal drug overdose, suicide, traffic accident, other diseases, or other causes of death, or was lost to follow-up, the case was censored at the date of the last record. If the patient survived through the deadline, December 31, 2013, then that was his/her date of censorship. The assumed date of lost to follow-up was defined as the last follow-up visit date adding 3 months, which is half of the interval of follow-up, that is, 6 months. Date of death was verified based on patients’ hospital record, or national residence registration system if death occurred outside hospitals, or was reported by the decedent's relatives.2.4Ethnical approval (no.: X140617339) for this study was obtained from the Institutional Review Board of the National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention. Permission to access ART registers and database was given by the Liangshan Prefecture Health Bureau and each of the 18 designated hospitals that provided ART services for patients with HIV/AIDS in Liangshan. No personally identifiable information was seen or used during data analysis.2.5P value <0.1 were included into Cox proportional hazard models. Cox proportional hazard models were used to estimate the hazard ratio of death between levels of confounders. Unadjusted and adjusted hazard ratios (AHRs) with their 95% confidence interval (CI) were reported. All the tests were 2-tailed, and the type 1 error rate was set at 5%.The database was set up via EpiData 3.0 for windows  and transferred and analyzed via SPSS version 17.0 . Categorical data were summarized by frequencies. Continuous variables were summarized using medians and respective standard deviations (SDs). Median survival time of patients receiving ART services was calculated by Kaplan–Meier estimator/methods as a point where 50% of the patients were still alive. Survival time after ART initiation was calculated by different categories of predictors, and differences in survival time between these predictors were examined by using the log-rank test of Kaplan–Meier. Univariate factors with a 33.1Among 8310 patients receiving ART services, the median age at ART initiation was 34.6 ± 9.1 years, with an age range from 18 to 89 years of age. Age at initiation did not significantly differ between males and females . The patient's demographic and medical characteristics by enrollment year to initial ART services are shown in Table About two-thirds of patients, 65.5% (5443/8310), were infected through IDU, 31.3% (2602/8310) through heterosexual transmission, 0.5% (54/8310) through homosexual transmission, 0.2% (20/8310) through blood transfusion or paid plasma donation, and 2.4% (200/8310) of the transmissions were unknown. The median time from diagnosis of HIV infection to ART initiation was 24.7 ± 21.7 months. The longest was 157 months. A total of 36.6% (3037/8310) of patients initiated ART at <12 months after HIV/AIDS diagnosis, 37.0% (3071/8310) enrolled between 13 and 36 months after diagnosis, and 26.4% (2197/8310) initiated at >37 months after diagnosis.3. Among those (6884) having a CD4 cell count, 2.5% (170) of the patients were <50 cells/mm3, 19.6% (1349) 50 to 199 cells/mm3, 48.8% (3361) 200 to 349 cells/mm3, and 29.1% (2004) >350 cells/mm3 at the start of ART.A total of 3.8% (319/8310) of patients suffered from pulmonary tuberculosis (TB) before receiving ART services, 89.3% (285/319) of whom received anti-TB therapy. A total of 21.0% (1748/8310) of patients suffered from AIDS-related diseases or symptoms 3 months before starting ART. In terms of WHO clinical staging, 42.4% (3527/8310) of patients started treatment in stage I, 20.0% (1659/8310) in stage II, 34.1% (2836/8310) in stage III, and 3.1% (255/8310) in stage IV. The overall median CD4 cell count for 6884 patients who received CD4 testing when enrolling in ART services was 321.2 ± 200.3 cells/mmP < 0.001). The proportion of patients suffering from AIDS-related diseases or symptoms 3 months before receiving ART services decreased from 61.6% (53/86) in the first period to 20.4% (1370/6714) in the third period (P < 0.001), and patients with a baseline CD4 cell count <350 cells/mm3 decreased from 87.2% (75/86) in the first period to 52.2% (3506/6714) in the third period (P < 0.001). A majority of patients (51.2%) who initiated ART in the first period were in advanced WHO clinical stages 3 and 4, but only 38.9% (2620/6714) of patients in the third period were in advanced WHO clinical stages 3 and 4, and the difference was significant (see Table The number of patients initiating ART significantly increased by year from 8 cases in 2005 to 2765 cases in 2013. The proportions of patients between 30 and 45 years of age decreased from 72.1% (62/86) in the first period, 2005 to 2007, to 57.5% (3860/6714) in the third period, 2011 to 2013  of patients were still receiving ART services, 13.3% (1101/8310) had dropped out of ART services, 2.5% (207/8310) were lost to follow-up, 5.3% (436/8310) had died of AIDS-related diseases, and 3.0% (246/8310) had died of other causes. The overall survival rate of the patients was found to be 96.6/100 person-years. Among the patients who died of AIDS-related diseases during the follow-up period, their average treatment time was 15.0 ± 12.3 months. A total of 28.7% (125/436) died in their first 6 months of ART initiation, 16.3% (71/436) died between 6 and 12 months of ART initiation, and 55.1% (240/436) died after 12 months of starting ART.3. Among the patients who died between 6 and 12 months after ART initiation, 42.3% (30/71) were WHO clinical stage III or IV, and 45.5% (30/66) of CD4 cell counts were <200 cells/mm3. Among the patients who died after 12 months from starting ART, 32.1% (77/240) were in WHO clinical stage III or IV, and 36.5% (81/222) of CD4 cell counts were <200 cells/mm3.Among the patients who died in the first 6 months from ART initiation, 51.2% (64/125) were in WHO clinical stages III and IV, and baseline CD4 cell counts for 59.6% (65/109) were <200 cells/mmCumulative proportions of survival of the study population are shown by 12-month intervals in Table 3 survived longer  than patients whose baseline CD4 cell count was <50 cells/mm3 , and patients who had not suffered from pulmonary TB had longer survival times  than those who had suffered from pulmonary TB   than female patients in Liangshan Prefecture Table . MarriedPulmonary TB and AIDS-related diseases or symptoms 3 months before receiving ART services were found to be significant predictors of mortality. Patients with pulmonary TB and AIDS-related diseases or symptoms had a higher death hazard rate compared to those who did not suffer from these diseases .3, the death hazard rate was about 10 times higher  among patients starting ART with a CD4 cell count <50 cells/mm3, 3 times higher  among those with a CD4 cell count between 50 and 199 cells/mm3, and 2 times higher  among those with a CD4 cell count between 200 and 349 cells/mm3.Compared to those starting treatment with >350 cells/mmWHO classification clinical stage at ART enrollment was a predictor of mortality among the patients receiving treatment. The patients at WHO stage 4 when starting ART had twice the death rate of patients at WHO stage 1.4–12 ART has been associated with prolonging survival time of patients with HIV/AIDS. However, survival time of patients with HIV/AIDS receiving ART services varied in different countries and regions, which depended on adherence of therapy, baseline CD4 cell count, demographic characteristics of the patients, and coinfection of diseases. We found that the first year's cumulative proportion of surviving patients with HIV/AIDS in Liangshan was similar to the cumulative mortality rate from a triple-drug ART initiation study in British Columbia, Canada, in 2000, but lower than that of studies of high-income countries. Results of other years were similar to the survival analysis study of 3013 cases from Dehong Prefecture of Yunnan Province, China, in which 2-, 3-, 4-, and 5-year survival rates were 94%, 93%, 92%, and 92%, respectively, but higher than those of patients treated in Botswana's national ART program.This study analyzed survival outcomes and explored the associated factors of survival time among patients with HIV/AIDS receiving ART in Liangshan for the first time. The median survival time after ART initiation among the patients during the study period was 94 months. This result was higher than those of the studies in Tanzania, Botswana, Uganda, and South Africa. Among patients who died from AIDS-related diseases, the majority of deaths occurred within the first 12 months after initiating ART, which was similar to the results of a study in southern India, and lower than the study in Botswana in which approximately 86% of all deaths occurred within the first year. Most of the patients who died in the first year after starting ART were in advanced clinical stages of the disease or WHO clinical stage III or IV, and their CD4 cell count was <200 cells/mm3. The first 12 months of therapy is critical in reducing the chance of dying from AIDS-related diseases. Thus, earlier CD4 cell count testing, follow-up of patients, and clinical observation should be strengthened and especially focused on patients with a lower CD4 count and advanced WHO clinical stages.,19Compared with other years, mortality and morbidity of the first year after ART initiation were higher, especially within the first 6 months.3) was higher than the figures of the MASA Program implemented in Botswana from 2002 to 2010, and that of a 5-year retrospective cohort study during 2004 to 2009 in Tanzania, but similar to the baseline CD4 cell count of newly identified HIV cases in China in 2012. The proportion of the patients starting ART with a CD4 cell count <200 cells/mm3 (22.1%) and the proportion of patients with advanced WHO clinical stage 3 or 4 (37.3%) were significantly lower than sub-Saharan Africa countries, such as Tanzania and South Africa.,18 With the criteria of initiating ART on a CD4 count lifting from <200 to <350 cells/mm3 and the policy of scaling up free ART services promotion in rural areas of Liangshan during the period of the study, more patients were found, enrolled to ART services, and followed up. The basic median CD4 cell count of the patients starting ART increased, and the proportion of the CD4 count <200 cells/mm3 and the patients with advanced WHO clinical stage at ART initiation decreased over the years.The overall basic median CD4 cell count . We also found that patients who started ART with WHO clinical stage 4 suffered from pulmonary TB or AIDS-related diseases, and patients who had symptoms 3 months before receiving ART services had a higher death hazard rate compared to those with WHO clinical stage 1 and were disease or symptom free. Patients stating ART with an advanced disease stage as defined by WHO stage 4 had an increasing risk of immune reconstruction syndrome and death. TB and wasting syndrome appeared to be the most common causes of early mortality. We should prevent and manage opportunistic infections such as TB, and offer better pre-ART care to reduce early death of patients with HIV/AIDS receiving ART, especially among patients with CD4 cell counts <200 cells/mm3. However, a prospective, randomized, placebo-controlled trial in Africa on early initiation of ART for HIV-positive patients with TB concluded that ART can be delayed until after completion of 6 months of TB treatment for patients with TB who have a CD4 cell count of >220 cells/mm3.Some HIV cohort studies demonstrated that starting ART at a higher CD4 cell count would reduce morbidity and avert the high mortality rates among patients with advanced HIV disease. This might underestimate the impacts of AIDS-related diseases on the mortality of the patients when starting ART. Finally, overall time from HIV diagnosis to receiving ART partly depended on the result and time of CD4 cell count testing. So some patients with lower CD4 cell counts later initiated ART, and survival time of these patients was underestimated.There are a few limitations in this study. First, because the ART information system  was not established in Liangshan until 2005, the previous information regarding ART services was not involved in the cohort study. Although the number of these patients was small, their outcomes of ART might slightly impact the overall survival time. Second, the exact dates for the patients lost to follow-up were not collected, and we assumed the median time between the last 2 follow-up dates as the proxy of the date of lost to follow-up. The survival time for patients incurred a recall bias when survival analysis was carried out. Third, AIDS-related diseases were recorded by the lay medical staff based in villages and towns where the patients first enrolled, and their knowledge of diagnosis was limited. Most common signs and symptoms were categorized simply as follows: fever, pulmonary , gastrointestinal , skin or mucosal , and central nervous system .Therefore, in order to reduce deaths caused by AIDS, PLHIV in Liangshan, especially those who were infected through IDU, should be timely followed up, be provided health education on adherence of treatment, and be given physical examinations, and the CD4 cell count should be monitored. ART should be timely delivered and well adhered to based on the results of follow-up, CD4 cell count testing, and physical checks.The authors thanks Zhijun Li, Senior Medical Officer of Global AIDS Program China Office, US Centers for Disease Control and Prevention, Beijing, China, for assisting with statistic method in the study analysis and Dr Yifei Hu, associate professor of School of Public Health, Capital Medical University, for her technical advice for manuscript revision and editorial assistance. They also thank Dr Edward C. Mignot, Shandong University, for linguistic advice.


We have previously shown that a high dose of the cyclooxygenase-2 inhibitor celecoxib can reduce HIV-associated immune activation and improve IgG responses to T cell-dependent vaccines. In this follow-up study, we included 56 HIV-infected adults, 28 antiretroviral therapy (ART)-naïve and 28 on ART with undetectable plasma viremia but CD4 counts below 500 cells/μL. Patients in each of the two study groups were randomized to receive 90 mg qd of the cyclooxygenase-2 inhibitor etoricoxib for six months, two weeks or to a control arm, respectively. T cell activation status, HIV Gag-specific T cell responses and plasma inflammatory markers, tryptophan metabolism and thrombin generation were analyzed at baseline and after four months. In addition, patients received tetanus toxoid, conjugated pneumococcal and seasonal influenza vaccines, to which IgG responses were determined after four weeks. In ART-naïve patients, etoricoxib reduced the density of the activation marker CD38 in multiple CD8+ T cell subsets, improved Gag-specific T cell responses, and reduced in vitro plasma thrombin generation, while no effects were seen on plasma markers of inflammation or tryptophan metabolism. No significant immunological effects of etoricoxib were observed in ART-treated patients. Patients receiving long-term etoricoxib treatment had poorer tetanus toxoid and conjugated pneumococcal vaccine responses than those receiving short-course etoricoxib. Cyclooxygenase-2 inhibitors may attenuate harmful immune activation in HIV-infected patients without access to ART.Pathologically elevated immune activation and inflammation contribute to HIV disease progression and immunodeficiency, potentially mediated by elevated levels of prostaglandin E Chronic, untreated HIV infection is characterized by a state of pathological immune activation and inflammation, which contributes to disease progression and immunodeficiency . Express+ T cell function is essential for viral control [+ T cell function to eliminate the majority of latently infected cells and prevent viral rebound from any remaining reservoirs [In the absence of ART, HIV-specific CD8 control , 14, but control  and not  control , 17. In  control . Most cuservoirs , 20.2 (PGE2) [2 inhibits T cell activation via a cyclic AMP-/protein kinase A-dependent mechanism [A major driver of HIV immunopathogenesis is the translocation of microbial products from the gut lumen to the submucosa and circulation, due to a defective gut barrier . This ch2 (PGE2) –25. We hechanism –28. Anotechanism , 30.We have previously shown that treatment with high-dose COX-2 inhibitors (COX-2i) for 12 weeks can reduce the expression of T cell activation markers in both untreated  and treaThe CONSORT checklist and study protocol are available as supplementary information; see Adult, HIV-infected patients were included from the outpatient clinic at the Department of Infectious Diseases, Oslo University Hospital, from January 2011 through May 2014, in one of two study groups. One group consisted of ART-naïve patients, with CD4 counts above 350 cells/μL and plasma HIV RNA above 2000 copies/mL, a confirmed diagnosis of HIV infection less than 8 years pre-inclusion and no current indication for ART according to European guidelines at the time . The othExclusion criteria for all study participants were concomitant use of non-steroidal anti-inflammatory drugs, corticosteroids or interferon-alpha, total cholesterol >7 mM, elevated serum creatinine, creatinine clearance <30ml/min, hypertension, heart failure, diabetes, ischemic heart disease, peripheral arteriosclerosis and/or cerebrovascular disease, cardiovascular events or stroke in parents, siblings or offspring of <55 years of age, pregnancy or insufficient birth-control, breast-feeding, deranged liver function, inflammatory bowel disease, active peptic ulcer, or gastrointestinal haemorrhage.ART-naïve and ART-treated patients were separately randomized to one of three arms in a 2:1:1 fashion and in blocks of 20, by drawing allocation numbers from a pre-generated random sequence to which the investigators were blinded beforehand. Arm 1 received oral etoricoxib 90 mg once daily for six months, arm 2 received oral etoricoxib 90 mg once daily for two weeks whereas arm 3 received no drug. The study was open label. Patients were examined and blood samples were drawn at screening, inclusion (week 0), study week 5 in arms 2/3, study week 9 in arm 1, four months and six months.Final analysis of immunological endpoints was performed at four months as opposed to the protocol-ascribed six months. This was due to illness of key study personnel, leading to delayed sampling at six months of a significant proportion of patients, after cessation of study drug. Thus, endpoint data related to COX-2i effects beyond four months of follow-up were incomplete. Notably, no patients discontinued the study due to adverse events or commencement of ART after four months of follow-up  and the Norwegian Regional Committee for Medical and Health Research Ethics South East (application #2010/1593). The study was registered at Clinicaltrials.gov (Identifier: NCT01269515). The study was independently monitored for safety by Link Medical.+ T cells after four months of etoricoxib treatment and changes in IgG levels to the three study vaccines four weeks post-vaccination. Secondary endpoints were changes in HIV Gag-induced CD8+ T cell responses and plasma markers of inflammation, tryptophan metabolism and coagulation after four months.Primary endpoints were changes in CD38 density on CD8Adverse events were registered at all study visits, and graded as non-serious/serious and likely related to etoricoxib or not. Routine clinical biochemistry parameters were analyzed at all sampling time points, and values outside reference ranges were evaluated by a clinical investigator.+ and CD8+ T cell counts and plasma HIV RNA was determined at all sampling time points by routine clinical assays.CD4+ T cell subsets, thawed peripheral blood mononuclear cells (PBMC) were surface-stained with αCD3 V450, αCD8 APC-H7, αCD38 PE, αPD-1 FITC, αCD45RA APC, αCD27 PerCP Cy-5.5 and αCCR7 PE-Cy7 , then analyzed. To quantify regulatory T cells thawed PBMC were first incubated with Fixable Viability Stain 450 (BD), then surface-stained with αCD3 PerCP Cy-5.5, αCD4 APC-H7, αCD25 FITC, αCD45RA APC  and αCD127 PE-Cy7 . Subsequently, cells were fixed and permeabilized using the FoxP3 Buffer set (BD), followed by intracellular staining with αFoxP3 PE (BD).To characterize CD8+ subsets was determined by the Quantibrite method [+ T cells had >95% 1:1 PE:mAb ratio. By comparing PE MFI with that of Quantibrite beads (BD) with four known densities of PE, the number of CD38 molecules per CD8 cell was calculated.The density of activation marker CD38 on CD8e method . The αCD+ T cell effector responses, thawed PBMC were rested overnight and tested for viability by Muse Count and Viability Assay  before stimulation with an overlapping, 15-mer HIV Gag peptide pool  at a final concentration of 2 μg/mL/peptide. Costimulatory antibodies αCD28 and αCD49d , brefeldin A , monensin , and αCD107a PE were added at the start of the stimulation. Unstimulated and positive controls  were included for all samples. Cells were incubated for 5.5 hours at 37°C, incubated with Fixable Viability Stain 450, fixed and permeabilized using BD Cytofix/Cytoperm, and stained with αCD3 PerCP, αCD8 APC-H7, αIL-2 APC, αIFN-γ PE-Cy7, αMIP-1β FITC and αTNF-α BV605 .To quantify HIV-specific CD8Cells were analyzed on a BD FACS Canto II flow cytometer, data was acquired using FACS Diva 6.1 (BD) and analyzed using FlowJo X . Gating of non-discrete populations was done using fluorescence minus-one (FMO) controls, where appropriate. Examples of all gates are included in CD8 effector responses were background-subtracted using the unstimulated control, with responses <0.01% adjusted to 0. Polyfunctional subsets were defined by Boolean gating, while a total Gag-specific response was calculated by summing all 4 cytokine responses and the CD107a response per sample. Polyfunctional response data were graphed and analyzed in SPICE .Soluble (s)CD25, sCD163, sCD14, interleukin (IL) 6 (high sensitivity), interferon-inducible protein (IP) 10 and C-reactive protein (CRP) were measured in cryopreserved EDTA plasma by ELISA .Thrombin formation in cryopreserved citrate plasma was assayed using the CAT assay  accordinFree protein S, free Tissue Factor Plasminogen Inhibitor (TFPI) and D-dimer were analyzed in cryopreserved citrate plasma using commercial ELISA kits .Plasma concentrations of tryptophan and its metabolite kynurenine in cryopreserved EDTA plasma were analyzed by liquid chromatography—tandem mass spectrometry by Bevital AS  .To investigate the effect of long-term vs. short-course etoricoxib treatment on vaccine IgG responses, study participants received the following three T cell-dependent vaccines at study week 5 (arm 1) and study week 1 (arms 2/3): seasonal influenza virus type A/B vaccine , tetanus toxoid vaccine  and 13-valent pneumococcal conjugate vaccine . Participants who had received one of the study vaccines within the preceding 2 years were not re-vaccinated and were excluded from analysis of responses to the vaccine in question. Vaccine-specific IgG levels were measured in cryopreserved sera at baseline and 4 weeks after vaccination .IgG antibodies to tetanus toxoid were quantified by ELISA. Sera were tested at two-fold dilutions, and antibody levels were determined according to the International Standard for Tetanus Immunoglobulin . IgG antibody levels above 0.1 IU/mL were considered protective. All sera from a given patient were run on the same plate.Total IgG antibodies to a mix of 23 pneumococcal polysaccharides , were measured by ELISA after Cell Wall Polysaccharide (CWPS) adsorption of sera . The IgG antibody levels to PPV23 were given as arbitrary units (U/mL), according to an in-house standard. All sera from a given patient were run on the same plate.Serum antibody titers to influenza virus A/H1N1pdm09 were detected by influenza hemagglutination inhibition (HI) assay. This antigen was included in all the seasonal influenza vaccines given in this study. Sera were tested in serial two-fold dilutions starting at 1:10 with turkey red blood cells as indicator cells . The HI 1/2 approx. 22 hours), the arms receiving two weeks of etoricoxib and no study drug were combined in analysis of immunological effects at four months. In analysis of vaccine responses at four weeks post-vaccination, the three treatment arms were analyzed separately, to evaluate the effect of short-term etoricoxib treatment as a vaccine adjuvant, compared to continuous etoricoxib therapy. COX-2i-related changes in immunological variables in all treatment arms are given in All statistical methods used were non-parametric. Differences in proportions were evaluated with chi-square tests. The effects of etoricoxib treatment were evaluated by comparing changes in variables (Δ) at four months of etoricoxib treatment between treatment arms within the ART-naïve and ART-treated groups separately. To increase statistical power, and as the wash-out period of etoricoxib effects on immunological parameters was considered to be in the order of days , rendering all baseline clinical data baseline similar between the intervention arms, including CD4 counts and CD4/CD8 ratios .Comprehensive analysis of etoricoxib effects showed minimal differences between patients receiving long-term etoricoxib (arm 1) and controls (arm 2+3) within both the ART-naïve and ART-treated study groups. However, despite randomization, there were significant baseline differences in CD4 counts (p = 0.04) and CD4/CD8 ratio (p = 0.03) between treatment arms in the ART-naïve study group and similar evidence for a more advanced disease phenotype in ART-treated patients . While tWe nevertheless observed no effect of four months of etoricoxib treatment on CD4 counts or CD4/CD8 ratio, in ART-naïve or ART-treated patients. There was no effect of etoricoxib on HIV viremia in ART-naïve patients, or on viral load blips in ART-treated patients (data not shown).+ T cells, both as frequency of positive cells and as CD38 density  than the ART-treated group . In contrast, etoricoxib did not significantly affect the expression of activation, exhaustion or differentiation markers on CD8+ T cells in ART-treated patients  and activated (CD4+CD25hiCD45RA-FoxP3+) Tregs were lower in the ART-naïve group than the ART-treated group at baseline , but there was no effect of etoricoxib on the frequency of Tregs in either study group (data not shown).Frequencies of both total .In terms of HIV-specific immunity, the baseline total CD8+CD107a+MIP1β +IFN-γ+ T cell subset (p = 0.04) and possibly increased the CD8+CD107a+MIP1β + subset , but not of CD14, IL-6 and CRP, than the ART-treated group . There wAt baseline, the ART-naïve group had higher plasma levels of tryptophan catabolite kynurenine and a higher kynurenine/tryptophan (K/T) ratio than the ART-treated group  and Peak than ART-treated patients  in both ART-naïve and ART-treated patients. ART-naïve patients receiving four months of etoricoxib had less of an antibody increase at week 4 post-vaccination than the arm receiving two weeks of etoricoxib  and 14 ART-treated patients (50%) had previously recorded vaccination with a 23-valent pneumococcal polysaccharide vaccine, but no patients had previously received the 13-valent conjugated pneumococcal vaccine. However, there was no significant difference in IgG levels at baseline or 4 weeks after administration of a 13-valent conjugated pneumococcal vaccine between previously vaccinated and unvaccinated patients (data not shown). Once again, ART-naïve patients receiving four months of etoricoxib had a smaller increase in IgG levels four weeks after vaccination than the corresponding two week etoricoxib arm  had protective influenza H1N1 IgG titers (>40), due to previous exposure to swine flu or vaccination with the same antigen. Of patients without pre-existing protective IgG levels, 11 ART-naïve and 7 ART-treated patients had protective IgG levels 4 weeks after vaccination , and no significant effect of etoricoxib treatment on influenza vaccine IgG levels was observed in either study group (data not shown).+ T cells, enhanced HIV Gag-induced CD8+ T cell effector responses and reduced thrombin generation in plasma. However, in this patient group, no effects of etoricoxib on plasma markers of inflammation or tryptophan metabolism were observed. In this first study of a COX-2 inhibitor in ART-treated patients with suboptimal CD4 reconstitution, no significant effects of etoricoxib were observed.The objective of this study was to explore the immunological effects of conventional doses of a COX-2 inhibitor, etoricoxib, in both untreated HIV-infected patients and in patients on ART with viral suppression but suboptimal CD4 reconstitution. In ART-naïve patients who received long-term etoricoxib, we observed a reduced density of activation marker CD38 on CD8+ T cells and used this marker as a primary endpoint [+ T cells in ART-naïve, HIV-infected patients after 12 weeks of high-dose celecoxib [Several markers of immune activation are predictive of clinical endpoints in HIV infection. In this and previous investigations of COX-2i, we quantified the density of CD38 molecules on CD8endpoint . Althougendpoint . We haveelecoxib , but thiIn the current study, etoricoxib did not, however, reduce immune activation markers in aviremic patients on ART. In a previous study of rofecoxib and celecoxib in ART-treated patients, there was evidence of reduced CD38 expression on CD8 T cells only in the few patients with residual plasma viremia and higher baseline CD38 expression . Thus, C2 exposure of T cells, and did observe small increases in the relative frequency of prevalent polyfunctional Gag-induced CD8 subsets in ART-naïve patients who received etoricoxib. CD8 responses directed towards Gag epitopes have been repeatedly associated with viral control in untreated HIV infection [in vitro observations can only be ascertained in larger studies with longer observation periods.While T cell activation is a prerequisite for an effective adaptive immune response, the generalized hyperactivation seen in HIV infection is accompanied by compromised function, at least of HIV-specific T cell clones –17. We hnfection –42 and pnfection . Thus, tHIV-associated inflammation is also reflected by elevated levels of plasma markers such as pro-inflammatory cytokine IL-6 and monocyte activation marker sCD14, which both predicted mortality in the SMART trial of intermittent vs. continuous ART , 45. ComTreatment with etoricoxib, however, did not affect the plasma levels of these inflammatory markers, in ART-naïve or ART-treated patients. As CD14 is shed from monocytes on exposure to bacterial lipopolysaccharide (LPS), sCD14 is often used as a surrogate marker of microbial translocation from the gut . The facAnother aspect of HIV-related immune dysregulation is the induction of the tryptophan-catabolizing enzyme IDO in innate immune cells by interferon-γ and Toll-like receptor stimulation. IDO upregulation has been implicated in the suppression of T cell responses as well as skewing the Th17/Treg balance towards increased frequencies of Tregs, which may contribute to gut barrier dysfunction and thus drive systemic inflammation in HIV infection . IDO actHIV infection is associated with a state of hypercoagulability , 55, andin vitro thrombin generation, particularly in hypercoagulable states, has not been firmly established [COX-2i and most other non-steroidal anti-inflammatory drugs are associated with a small increase in the risk of cardiovascular events, particularly in patients with established cardiovascular disease . Howeverablished .in vitro studies suggest that COX-2i have the potential to directly inhibit antibody production in B cells [+ T cell responses we observed in ART-naïve etoricoxib-treated patients, is that COX-2i facilitate a Th1-polarization of the T cell response, reducing B cell help by T follicular helper cells. This could imply a potential enhancement of vaccine-specific CD8+ T cell responses with COX-2i treatment. Thus, our data suggest that COX-2i may modulate humoral and cellular vaccine responses differently in HIV-infected patients, which warrants further investigation in future studies.A final hypothesis was that in the setting of HIV-associated immune hyperactivation, COX-2i may improve T cell help in stimulating B cells to produce vaccine antibodies. In keeping with this, we have previously observed improved IgG recall responses after tetanus toxoid vaccination in ART-naïve, HIV-infected patients receiving high-dose celecoxib . However B cells –64, whicThis exploratory trial included a limited number of patients in several arms and the endpoint analysis unfortunately had to be performed after four as opposed to the per-protocol six months. Both these factors limit the study’s power to determine moderate effects of etoricoxib. The baseline differences in CD4 count and CD4/CD8 ratio between the treatment arms were unfortunate, and could potentially have been avoided by incorporating stratification on baseline CD4 count into the randomization procedure . While t2 from activated innate immune cells plays a central role in COX-2-related immunomodulation, the study would have been strengthened by a characterisation of circulating monocytes and dendritic cells, particularly with regard to activation status, COX-2 expression and functional measures such as in vitro eicosanoid secretion in response to TLR agonists. Quantifying circulating levels of PGE2 and metabolites may also be relevant in future studies, although interpretation may be difficult due to short plasma half-lives [Considering our hypothesis that PGElf-lives  and whet+ T cells, as well as a possible antithrombotic effect. We did not, however, observe comparable effects in patients with suboptimal immune reconstitution despite viral suppression on ART. While ART is now recommended for all HIV-infected patients, and global ART coverage is steadily improving, COX-2i or non-selective COX inhibitors could play a role in limiting immunological pathology in selected patients not accessing ART. However, the large clinical trials needed to establish any clinically relevant benefit of COX-2i treatment in this setting may not be feasible.In conclusion, our results suggest that a conventional dose of a COX-2 inhibitor is safe in HIV-infected patients both on and off ART, and has potentially beneficial effects in untreated patients, on both generalized hyperactivation and HIV-specific function of CD8S1 Fig(TIF)Click here for additional data file.S1 File(DOC)Click here for additional data file.S2 File(PDF)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 Table(XLSX)Click here for additional data file.


Persistence with an antiretroviral therapy (ART) regimen for HIV can be defined as the length of time a patient remains on therapy before stopping or switching. We aimed to describe ART persistence in treatment naïve patients starting therapy in the United Kingdom, and to describe differential persistence by treatment regimen.We performed a retrospective cohort study at eight UK centres of ART-naïve adults commencing ART between 2012 and 2015. Aggregate data were extracted from local treatment databases. Time to discontinuation was compared for different third agents and NRTI backbones using incidence rates.1949 patients contributed data to the analysis. Rate of third agent change was 28 per 100 person-years of follow up [95% CI 26–31] and NRTI backbone change of 15 per 100 person-years of follow up [95% CI 14–17]). Rilpivirine, as co-formulated rilpivirine/tenofovir/emtricitabine had a significantly lower discontinuation rate than all other third agents and, excluding single tablet regimens, co-formulated tenofovir/emtricitabine had a significantly lower discontinuation rate than co-formulated abacavir/lamivudine. The reasons for discontinuation were not well recorded.Treatment discontinuation is not an uncommon event. Rilpivirine had a significantly lower discontinuation rate than other third agents and tenofovir/emtricitabine a lower rate than co-formulated abacavir/lamivudine. The extent to which a patient takes medication in accordance with the expectations of the prescribing clinician can be quantified by a variety of methods. Early antiretroviral therapy (ART) for HIV necessitated extremely high levels of adherence,Persistence, however, refers to the length of time that a patient remains on therapy and can be defined as the duration of time from initiation to discontinuation.Eight UK specialist HIV treatment centres contributed data to this cohort; four in London, two in Manchester, one each in Liverpool and Brighton. Aggregate data were extracted from local treatment databases and/or clinical records. Inclusion criteria were: all treatment naïve people living with HIV commencing antiretroviral therapy between January 2012 and June 2015. Considered regimens were those within the British HIV association (BHIVA) guidelines at the time of the study and included in regional treatment guidelines: co-formulated tenofovir/emtricitabine (TDF/FTC) or abacavir/lamivudine (ABC/3TC) with ritonavir boosted darunavir (DRV/r), ritonavir-boosted atazanavir (ATV/r), efavirenz (EFV) or raltegravir (RAL), and co-formulated EFV/TDF/FTC or co-formulated rilpivirine (RPV)/TDF/FTC. All data were extracted in aggregate anonymised form and identifiable individual level data were not used. Patients were followed from date of ART start to the first date of treatment discontinuation, administrative censoring (June 2015) or last available viral load, and treatment discontinuation was defined to include stopping or switching therapy. Time to discontinuation was compared between ART regimens using incidence rates, with 95% confidence intervals calculated assuming a Poisson distribution when fewer than 20 evens, and with a Normal approximation otherwise. Statistical tests of difference in incidence rates, where carried out, used Poisson regression. As this study used only anonymised, aggregate data, ethical approval was not required.3. There was missing pre-treatment viral load data for 75 patients; for the remainder 729/1874 [39%] had a viral load of greater than 100,000 copies/ml. The breakdown of the included regimens is shown in A total of 2851 patients were initially identified; at two centres data were recorded by drug and not by regimen so for 902 patients taking EFV, TDF and FTC it was not possible to determine if they were taking STR or MTR. These patients were excluded from the analysis, leaving 1949 individuals. The median age was 37 (IQR 30–45) 1682/1949 [86%] were men, 1368/1949 [70%] men who have sex with men (MSM) and 1371/1949 [70%] of white ethnicity. Pre-treatment CD4 count data were missing for 138 patients; for the remainder, the median CD4 count was 343 (IQR 219–492) and 281/1811 [16%] patients had a CD4 count of less than 200 cells/mmDuring 2215 patient-years of follow-up – a mean follow up of 1.1 years per patient – 339 individuals changed the NRTI backbone, including as part of STR change (15 per 100 person-years [95% CI 14–17]) . CompariThe reasons for discontinuations are shown in We describe the comparative persistence of antiretroviral therapy by initial regimen in nearly 2000 real-world people living with HIV in the UK in the UK. Patients enrolled in clinical studies may not be entirely reflective of the populations from which they are drawn; the large number of patients from multiple centres in our analysis provides a robust view of current day-to-day clinician and patient choices when initiating and discontinuing antiretroviral therapy.It is possible to draw several conclusions from these data. Firstly, for patients in the UK, discontinuation of initial treatment is not an uncommon event. The discontinuation rate of third agent and NRTI backbone of 28 (95% CI 26–31) and 15 (95% CI 14–17) per hundred person-years respectively are comparable to those seen in other high-income settings: in an Italian cohort of 4052 patients starting ART between 2008 and 2014, discontinuation rates at 1,2 and 3 years were 26%,40% and 49%, respectively.Secondly, in common with other studies, we found that where the reasons for discontinuation of therapy were recorded, they were overwhelmingly due to toxicity or simplification rather than virologic failure. However, the large proportion of records with missing data warrant caution in drawing any firm conclusions in this regard.Thirdly, we observed significant differences in persistence with therapy across ART components. The rates of discontinuation of RPV as co-formulated RPV/TDF/FTC were considerably lower than all other considered regimens. Though the missing data on reasons for discontinuations make it difficult to draw firm conclusions, the fact that overall discontinuations in our cohort are driven by toxicity and simplification makes it likely that the very low rates seen in patients taking co-formulated RPV/TDF/FTC are driven by the favourable side effect profile and possibly the convenience of a STR. When examining MTR NRTI backbone we found a less striking, though still statistically significant, difference in rates of discontinuation of TDF/FTC and ABC/3TC, with lower rates of discontinuation of TDF/FTC. Rates of discontinuation of EFV/TDF/FTC were similar to MTR EFV.Our study has a number of limitations. Most importantly, the data are retrospective and observational; decisions on choice of initial regimen and whether to discontinue are complex and result from a combination of clinician, patient, virus and drug characteristics. The persistence of co-formulated RPV/TDF/FTC may be due to the characteristics of the patients that clinicians in the UK are choosing to start on this regimen as well as the qualities of the regimen itself. In addition, decisions to switch therapy are based both upon the tolerability of the regimen and the availability of alternatives; the availability of newer STR containing elvitegravir or dolutegravir  could reduce the persistence of the regimens we have examined in the future. In addition, our data are aggregated; without individual-level data we are unable to perform a survival analysis to characterise the timing of treatment discontinuation, or to identify factors predictive of treatment discontinuation. This raises the possibility of selection bias of patients with more characteristics predictive of remaining on therapy towards RPV/TDF/FTC. We did not collect data on resistance patterns or HLA-B*5701 status, factors which will heavily influence initial ART regimen and the choice to discontinue.In addition, mean follow up times were short, at around a year. The aggregate nature of the data means that the length of follow up of individual patients is not available, and so it is not possible to say how many patients were followed up for less than a year; however the fact that around a third of patients were recruited in the year prior to administrative censoring means that a significant minority of patients had follow up times of less than a year. This raises the possibility that, for some ART regimens, the discontinuation rate may be higher in the first year of therapy but a lower rate (for those remaining on therapy) for subsequent years on treatment; the lack of longer term follow up in these data do not allow this question to be addressed but caution should be exercised in extrapolating our results to long-term durability of treatment.Despite these limitations, this study provides an insight into real life decisions with regard to initiation and discontinuation of ART in the UK, and the differential persistence of ART regimens in current use. These data may prove useful in guiding initial ART choice. Ultimately, a robust understanding of persistence and the determinants of persistence across available ART regimens will provide clinicians and patients with the tools needed to guide individualised ART, and maximise the chances of good outcomes for people living with HIV.The authors report no conflicts of interest.


We conclude that this mDRV/C co-formulation behaves like mDRV/r in seminal plasma in terms of viral load control and semen quality.Many patients previously using darunavir/ritonavir (DRV/r) (800/100mg) have switched to darunavir/cobicistat (DRV/C) (800/150 mg) either as part of triple therapy (ART) or as monotherapy with DRV (mDRV). The latter approach continues to be used in some countries for patients receiving long-term treatment. However, to date, the behaviour of DRV/C in the seminal compartment has not been analysed. This study explores how the combination behaves in monotherapy, with respect to the control of viral load and seminal quality. To this end, we studied 20 patients who were treated with mDRV/C after previous treatment with mDRV/r for at least 24 weeks. A viral load control in seminal plasma similar to that published in the literature was observed after 24 weeks of treatment with mDRV/C . Similarly, semen quality was confirmed (70% normozoospermic) in patients treated with this formulation, as has previously been reported for ART and mDRV/r. The DRV levels measured in seminal plasma were above EC Sexual transmission is the main route of infection by human immunodeficiency virus type 1 (HIV-1). However, the risk of transmission via this route in patients who are positive for HIV-1, who are receiving antiretroviral treatment with ART and who achieve undetectable plasma viral load, provided there is correct adherence to the ART and the patient currently has no other sexually transmitted disease, is close to zero  ,3.The semen quality of patients who are positive for HIV-1 and receiving treatment with ART is known to be impaired ,5. A simThe noninferiority of monotherapy with protease inhibitors enhanced with ritonavir to ART treatment has not been established, according to various meta-analyses ,8 and syFewer studies have been conducted of mDRV/C (800/150 mg) ,22. The Very few studies have examined the question of the seminal reservoir in patients receiving monotherapy with protease inhibitors combined with ritonavir ,26 and oThe purpose of the present study is to evaluate semen quality, viral load and DRV levels in seminal plasma among patients who initiated treatment with mDRV/r, who have received at least six months’ treatment with mDRV/C and who present undetectable plasma viral load.Twenty HIV-1 patients aged over 18 years were drawn from those attending the outpatient infections clinic at Virgen de las Nieves University Hospital . These patients had received mDRV/C for 24 weeks and had previously been treated with mDRV/r for at least 24 weeks. All 20 patients had undetectable plasmatic viral load (<20 copies/mL) for a minimum of six months before starting mDRV/C. The following exclusion criteria were applied: the presence of sexually transmitted infection; any active disease at or during follow-up, including acute or chronic hepatitis B; history of virological failure to regimens based on protease inhibitors; history of illness that could provoke a decrease in semen quality, except for HIV infection itself; concomitant use of drugs with potential interaction with the prescribed drugs; low adherence to the prescribed therapy.From these 20 patients, eight were selected, four with positive viral load in semen and four with negative viral load, to determine the concentration of DRV in seminal plasma . All theThe results for viral load and semen quality of these 20 patients, after treatment with mDRV/C for 24 weeks, were compared with those obtained in a previous study performed in 21 patients who after receiving at least 24 weeks of ART, were given mDRV/r for 48 weeks . Of the The patients received the normal medical visits, every four months. Adherence to the medication was monitored by pharmacy report and by asking the patient during the medical visit.Age, androgenic history, reproductive history, CD4+, CD4+ nadir, HIV viral load in seminal fluid and plasma. The following semen quality parameters were analysed: viscosity, appearance, liquefaction, volume, pH, sperm concentration, percentages of progressive and total motility and of live sperm.All the samples were collected by masturbation, after 3–4 days of sexual abstinence, in the andrology laboratory of the Human Reproduction Unit at the Virgen de las Nieves University Hospital. On delivery of the sample to the laboratory, the following data were recorded: period of sexual abstinence, whether any loss of the ejaculate had occurred, medication taken by the participant, recent febrile processes, body mass index and recent extreme sports activity. All the samples were analysed within one hour of collection, by a single highly-trained observer, with more than ten years’ professional experience, who regularly participated in internal and external controls. In this way, between-observer variation was avoided and the accuracy of the study was ensured.The ejaculates were analysed according to WHO recommendations  and the The viral load in seminal fluid was determined after centrifugation at 3000g for 15 min. The technique used to quantify HIV-1 RNA in the final processed sample was that of real-time PCR, an adaptation of the HIV-1 COBAS Ampliprep/Taqman assay version 2.0 (Roche).trough and seminal plasma concentrations were quantified using a modified and validated liquid chromatography with a tandem mass spectrometry method [DRV, Cy method . The parA descriptive analysis was performed to obtain measures of central tendency and dispersion for the numerical variables, and absolute and relative frequencies for the categorical ones. The Shapiro-Wilks test of normality was applied. Differences between the groups were determined by a bivariate analysis, using the non-parametric Mann-Whitney test for the numerical variables and Pearson’s chi-square test or Fisher’s exact test for the categorical ones. The level of significance considered for all analyses was p<0.05. The statistical analysis was performed using IBM SPSS Statistics 19 software.+ T cell count was 882 cell/μL (SD:316.8) and the mean nadir CD4+ T cell count was 277 cell/μL (SD:191.5).The mean age was 47.5 years (SD: 6.8), the mean CD4HIV-PCR in the seminal fluid was analysed for all 20 patients; four (20%) were positive (>20 copies/mL), with a range of 21–1070 copies/mL.The data on semen quality for patients on monotherapy are summarised in Tables Of the patients included in both studies (n = 5) three had no positive viral load in seminal plasma with no monotherapy regimen, one had viral load in both regimens and one had positive viral load with mDRV/C and negative viral load with mDRV/r (data not shown).Comparison of viral load positivity of the seminal plasma among patients with mDRV/C (20%) with respect to those with mDRV/r (3%) revealed no significant differences (p = 0.0656). Neither were any differences observed regarding the average number of copies .Semen quality was normal in 16/28 (57.1%) of patients in ART, in 13/21 (61.9%) of those in mDRV/r and in 14/20 (70%) of those in mDRV/C. No significant differences were observed in comparisons of ART with mDRV/r (p = 0.7372), ART with mDRV/C (p = 0.3643) or mDRV/r with mDRV/C (p = 0.5848).The median concentration of DRV in seminal fluid was 489.4 ng/mL (range: 204.4–1889.2 ng/mL), with 680.5 ng/mL in the four patients with positive viral load and 405.9 ng/mL in the four with negative viral load (p = 0.149) .To our knowledge, this study is the first to analyse semen quality and viral load in HIV+ men treated with mDRV/C. To date, all seminal plasma studies of monotherapy in HIV+ patients have been performed using ritonavir, at low doses, as a pharmacokinetic enhancer. The mDRV/C treatment combination was adopted because of the potency of the DRV/C  combinatIn our study, 20% of the patients treated with mDRV/C had a negative plasma viral load and a positive seminal viral load, a similar proportion to that observed in other studies of patients treated with ART ,30–32 orFurthermore, the viral load of RNA-HIV found in the seminal plasma of patients treated with mDRV/C presented values similar to those observed by other authors with 270–1345 copies/Ml , with 31The levels of DRV observed in seminal fluid are similar to those found by other authors in patients with similar treatments ,36. The 50 [90 [The levels of DRV in the seminal plasma of the eight patients in our study were above EC50  and EC9050 [90 , indepen50 [90 . Other a50 [90 .The standardisation of seminal quality studies is of crucial importance if valid conclusions are to be obtained. Our group participated in the development of the SEMQUA recommendations for the design and evaluation of seminal quality studies  and the Regarding seminal quality, no significant improvement was observed with mDRV/C with respect to mDRV/r or ART, with normozoospermic patients accounting for 70%, 62% and 57%, respectively, of the total. However, the observed pattern of improving seminal quality in patients who received mDRV/r and mDRV/C may be due to the fact that the nucleoside analogues received by patients in antiretroviral treatment are associated with greater mitochondrial toxicity ,43.The main limitation of this study is the limited number of cases examined, regarding both viral load and seminal quality, and the number of determinations of DRV concentration in seminal plasma. Accordingly, our findings are subject to confirmation by subsequent studies with a larger number of participants. A second limitation is the centrifugation step performed to separate the seminal plasma samples. Unrecognized cell contamination of the seminal plasma samples could confound our results and might result in inhibition of PCR and false HIV-RNA measurements, despite the centrifugation step. We believe this scenario is unlikely, however, as we observed no inhibition of PCR in the 20 samples analysed. Furthermore, the proportion of HIV-1 infected men with sustained suppressed HIV-1 RNA in blood plasma who have detectable levels of HIV-1 RNA in seminal plasma, as commented above, was similar to that observed by other authors using a different centrifugation protocol ,30–33.Despite its limitations, the present study provides suggestive evidence that in HIV-1 patients treated with mDRV/C, viral load and seminal quality results are similar to those obtained in the previous study in this respect , both in


The survival rate of human immunodeficiency virus (HIV)-infected patients receiving treatment in Ethiopia is poorly understood. This study aimed to determine the survival rate and predictors of mortality among HIV-infected adults on antiretroviral therapy (ART) at Jinka Hospital, South Omo, Ethiopia.A 6-year retrospective cohort study was conducted using 350 patient records drawn from 1,899 patients on ART at Jinka Hospital from September 2010 to August 2015. The data were analyzed using Kaplan-Meier statistics and Cox regression models.Of the 350 study participants, 315 (90.0%) were censored and 35 (10.0%) died. Twenty-two (62.9%) of the deaths occurred during the first year of treatment. The total follow-up encompassed 1,995 person-years, with an incidence rate of 1.75 deaths per 100 person-years. The mean survival time of patients on highly active antiretroviral therapy (HAART) was 30.84±19.57 months. The overall survival of patients on HAART was 64.00%  at 72 months of follow-up. The significant predictors of mortality included non-disclosure of HIV status , a history of tuberculosis , and ambulatory  or bedridden  functional status, World Health Organization (WHO) clinical stage IV illness , and substance abusers .Patients with a history of tuberculosis treatment, ambulatory or bedridden functional status, or advanced WHO clinical stage disease, as well substance abusers, should be carefully monitored, particularly in the first few months after initiating antiretroviral therapy. Patients should also be encouraged to disclose their status to their relatives. Human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) have created enormous challenges worldwide. Since 2000, around 38.1 million people have become infected with HIV and 25.3 million people have died of AIDS-related illnesses [Despite significant global achievements in all aspects of controlling this pandemic, HIV/AIDS remains a major public health concern in sub-Saharan Africa, which is where 25.8 million (70%) of the 36.9 million people estimated to be infected by HIV in 2014 live [Introduced in 1996, highly active antiretroviral therapy (HAART) was a breakthrough in the developed world, leading to the reduction of mortality and improvements in the quality of life of people living with HIV and AIDS. The introduction of antiretroviral drugs also significantly lowered the rate of HIV transmission from mother to child ,4. Thus,As of June 2015, 15.8 million people living with HIV had access to ART, up from 13.6 million in June 2014 [The HIV/AIDS epidemic has remained one of the important public health challenges in Ethiopia since it was first recognized in 1984. Currently, Ethiopia has a low rate of HIV endemicity, with a national prevalence of 1.1% . CurrentThe government of Ethiopia launched its ART initiative in 2003 based on a subsidized fee-based approach. Subsequently, the service was rapidly scaled up with a number of global and national initiatives . With thCurrently, 339,043 adults are receiving ART in the country, corresponding to an ART coverage rate of 65%. The ART regimens in Ethiopia include stavudine (D4T), lamivudine (3TC), nevirapine (NVP), zidovudine (AZT), 3TC-NVP, D4T-3TC-efavirenz (EFV), and AZT-3TC-EFV .The eligibility criteria for initiating ART have been frequently revised. Until the end of 2012, the eligibility criterion for initiating ART was a CD4 count of less than 200 cells/μL of blood or WHO stage IV disease. Since 2013, all patients with CD4 counts less than 350 cells/μL of blood, or WHO stage III or IV disease are eligible for ART initiation. Through the end of 2014, the WHO recommended starting ART in patients with a higher CD4 count (up to 500 cells/μL of blood), in order to help countries improve access to ART and to increase its utilization [Despite the scale-up of ART, retention of patients and early mortality remain major challenges for such programs in sub-Saharan Africa . SeveralHowever, the factors contributing to the survival and mortality of HIV-infected patients on ART have not been explored in the area of the current study: South Omo, southern Ethiopia. This area is unique because it is mainly inhabited by pastoralist and agro-pastoralist populations, including more than 16 ethnic groups with lifestyles and cultures different from those of the rest of the country. As a result of its diverse ethnic groups and cultures, South Omo is a tourist destination in Ethiopia. Hence, this study was designed to investigate the outcomes of ART, focusing on survival and predictors of mortality among HIV-infected adults on ART in Jinka Zonal Hospital, South Omo, Ethiopia.A facility-based retrospective cohort study design was conducted in Jinka Hospital, Jinka, from November to March 2016. Adult patients who started HAART from September 2010 to August 2015 in this hospital were recruited for the study. Jinka, the administrative capital of the South Omo Zone in the Southern Peoples, Nations, and Nationalities Region, is located 750 km to the south of Addis Ababa, the capital of Ethiopia. The hospital provides general outpatient and inpatient care, surgical and obstetric emergency services, and acts as the only zonal referral hospital for all health services for the pastoralist and agro-pastoralist population residing in South Omo. Jinka Zonal Hospital started providing ART services to HIV/AIDS patients in October 2005. As of August 2015, a total of 3,199 HIV/AIDS patients have utilized ART services at this hospital, of whom 1,899 are currently on ART.The records of all HIV-positive adults who were on ART at Jinka Zonal Hospital and who enrolled in treatment from September 1, 2010 to August 30, 2015 were the source population. The records of selected HIV-positive adults who had started ART at the hospital within this period were included in the study.Ethical clearance was obtained from the institutional review board of the Aklilu Lemma Institute of Pathobiology, Addis Ababa University, and Jinka Hospital officials received a support letter from the university. Retrospective data were collected anonymously and confidentially.The sample size was estimated using the power and sample size calculation software developed by Dupont & Plummer . To obtaSimple random sampling was done using commands in Excel ; all 1,899 records of patients receiving ART in Jinka Hospital were listed in a single Excel spreadsheet, and a random selection of 350 records was made.The data were collected using a standard checklist on an Excel spreadsheet, incorporating information extracted from electronic and paper-based ART registration and follow-up forms used in the ART clinic. Using the data extraction sheet, information about study participants, such as socio-demographic characteristics, residence, weight, disclosure status, duration on ART (in months), functional status, types of opportunistic infections, baseline WHO clinical staging, baseline and follow up CD4 cell counts, ART regimen type, ART eligibility criteria, substance use, regimen changes and reasons for those changes, and survey endpoints were retrieved from the clinical records of the HIV/AIDS patients by trained ART data clerks. Incomplete clinical records were omitted and were replaced with the record of the next patient on the list. The data collection form was checked for completeness and consistency with each patient’s clinical records by a supervisor, a public health officer by profession, on a daily basis.The primary outcome variable was time to event in months. HAART-initiated patients were followed until the date of death, loss to follow-up, transferring out, or the end of the study. Individuals who were on HAART, lost to follow-up, or had transferred out at the end of the study period were censored; that is, they were considered to be alive for the time period that they had been under follow-up. The survival time was calculated in months using the time between the dates of treatment initiation and the date of the event (death) or date of censoring. The predictor variables were age, sex, educational level, marital status, occupation, residence, functional status, WHO clinical stage, drug regimen, CD4 count, substance use, and opportunistic infections.After the Excel data were reshaped and adjusted, the data were transported to SPSS version 20.0 . Descriptive statistics such as median, interquartile range (IQR), and mean and standard deviation (SD) were used to summarize the characteristics of the cohort. The Kaplan-Meier log-rank model was used to estimate the survival time of ART patients based on the independent variables. Bivariate and multivariate Cox proportional hazards regression models were used to identify the predictors of mortality. Variables found to be statistically significant in the bivariate analysis (p<0.05) were included in the multivariable Cox proportional hazards regression model to identify independent predictors of mortality and to estimate the adjusted hazard ratios (aHRs). Both crude hazard ratios and aHRs with 95% confidence intervals (CIs) were reported. Variables that were statistically significant (p<0.05) were considered predictors of mortality among the study participants.The study included 350 ART patients who were followed up for a total of 72 months, with a median of 28.5 months. The majority of patients (59.1%) were female; 206 (58.9%) were married; 204 (58.3%) were illiterate, whereas 108 (30.9%) had completed primary school; 247 (70.6%) were Orthodox Christians; 247 (70.6%) were urban dwellers; 114 (32.6%) and 78 (22.3%) were daily laborers and farmers, respectively; 245 had four or fewer family members in their household; 318 (90.8%) had an unimpaired functional status; 330 (94.3%) had disclosed their HIV status; 313 (89.4%) had at least one opportunistic infection; and 183 (52.3%) were in WHO clinical stage III. The median age, CD4 count, and weight of the patients at base line were 30 years , 254 cells/μL , and 52 kg , respectively. Of the 350 study participants, 315 (90.0%) were censored, including 277 (79.1%) on ART, 21 (6.0%) who were lost to follow-up, and 17 (4.8%) who transferred. The remaining 35 (10.0%) died. Twenty-two (62.9%) of the deaths occurred during the first year of treatment, while eight (22.9%) deaths occurred in the second year of follow-up.The socio-demographic and clinical characteristics of the study participants are given in The total extent of follow-up was 1,995 person-years, with an incidence rate of 1.75 deaths per 100 person-years. The mean survival time of patients on HAART was 30.84 months . The overall survival of patients on HAART was 64.00%  at 72 months of follow-up .The log-rank test was conducted to check for the existence of any significant differences in survival among various levels of the categorical variables considered in the study. Accordingly, the Kaplan-Meier analysis indicated significant evidence of differences in survival times in the categories of past tuberculosis treatment, functional status, WHO clinical staging, baseline CD4 count, initial regimen types, substance abuse, disclosure status, and opportunistic infections .The Kaplan-Meier survival function  indicateThe lowest survival probabilities were observed for patients with a bed ridden functional status (13.25%), a history of tuberculosis treatment (50.86%), no disclosure of HIV status (52.41%), a baseline CD4 count <350 cells/μL (52.83%), and WHO stage IV disease (43.7%) .To identify independent predictors of mortality and survival, multivariate regression was performed for all predictors found to be significantly associated with survival in the bivariate analysis. According to the Cox survival regression model, all predictors associated in the bivariate analysis were found to be strong predictors of mortality in the multivariate analysis, except for baseline CD4 cell count , Table 4The ART retention rate (79.0% after 72 months of follow-up) was significantly associated with occupation and WHO clinical stage, with housewives  and daily laborers  more likely to continue ART than other occupation types .The retention rate of 79.0% after 72 months of follow-up in this study is comparable with studies performed throughout most of sub-Saharan Africa, where retention ranges have been reported to range from 57 to 72% ,26. NearIn this study, the overall survival probability of HIV/AIDS patients on ART was found to be 64.00%  at 72 months of follow up, which is slightly higher than was reported in studies performed in Debre-Markos, Addis Ababa, and Cameroon, where the mean survival probabilities were 57%  , 41.00% In this 6-year retrospective cohort study, 35 patients died of a total of 350 participants over six years of follow-up, resulting in a total death prevalence of 10.0% and an incidence rate of 1.75 per 100 person-years. Twenty-two (62.9%) of the deaths occurred during the first year of follow-up. The total number of deaths that occurred in this study is much lower than was reported in a study conducted in Debre-Markos Hospital, Ethiopia, where 40.7% of patients died . MoreoveHowever, our results are similar to the mortality rate of 11.1% exhibited in the Somali region of Ethiopia , and witThe multivariate Cox regression analysis showed that non-disclosure of HIV status, previous tuberculosis treatment, ambulatory and bedridden functional status, and advanced WHO clinical stage were independent risk factors for early mortality. In our study, HIV status disclosure was found to be a predictor of prolonged survival in HIV patients on ART, in agreement with another study conducted in Addis Ababa, Ethiopia, where disclosure was found to have a protective effect for early mortality  . AlthougAs in the present study, bedridden functional status  and advanced WHO stage  were reported to be independent predictors of mortality in the Somali region of Ethiopia , and in The current study found a much lower mortality incidence rate than early studies carried out in Ethiopia that reported mortality rates of 15.4 and 16.7 per 100 person-years in ART taking patients ,34. ThisIn conclusion, the probability of survival and the retention rate of patients on ART in this study was 64.0% and 79.0%, respectively, at 72 months of follow up, which is moderate and comparable with most results found in sub-Saharan countries. The independent predictors of mortality were non-disclosure of HIV status, previous tuberculosis treatment, ambulatory and bedridden functional status, and advanced WHO clinical stage. Hence, patients should be encouraged to disclose their status to their families or others, and those with an ambulatory or bedridden functional status and/or advanced WHO clinical stage disease should be monitored closely by their clinicians. Although hospital ART services are functioning well, further studies should investigate the causes of early mortality.