ART) regimens has been extensively evaluated in the context of clinical trials, using HIV viral load (VL) measurements at pre‐specified timepoints after ART onset. However, data from real‐life studies using combined longitudinal measurements of cumulative viraemia are scarce. This study aimed to address the independent effect of different ART regimens on HIV cumulative viraemia over the first 12 months after treatment initiation, using programmatic data from the Ministry of Health of Brazil.The relative efficacy of different antiretroviral ; tenofovir, lamivudine and efavirenz (regimen 2); tenofovir, lamivudine and ritonavir‐boosted atazanavir (regimen 3)).Retrospective cohort study analysing cumulative viraemia under the most frequently used ART prescription between January 2014 and August 2017. Univariate analysis indicated that cumulative viraemia was significantly lower in patients receiving regimen 1 as compared with those receiving regimens 2 or 3 (p<0.0001 for both pairwise comparisons). In a multivariable analysis adjusted for age, sex, baseline T CD4+ counts and baseline HIV VL, ART regimen persisted with statistically significant effect on 12‐month cumulative viraemia. The model predicted a 45‐unit increase in log10 copy‐days/mL cumulative viraemia for regimen 2 as compared with regimen 1, and a 70‐unit increase in log10 copy‐days/mL cumulative viraemia for regimen 3 as compared with regimen 1 . In models restricted to youths (13 to 24 years old) and female patients, ART regimen had similar effects. ART regimen with dolutegravir in association with a tenofovir‐lamivudine backbone was superior to regimens containing efavirenz or boosted atazanavir in reducing HIV VL, as shown by cumulative viraemia over the first 12 months after treatment initiation. The superiority persisted even after adjusting the analysis for potential confounders.We included 112,243 patients >12 years old who received their first HIV transmission, and a potential reduction in resistance mutations in the initial 12 months under ART.Our findings could bring direct benefits to patients as suggested by lower viral replication during treatment, lower risk of  However, HIV VL may sometimes fluctuate throughout ART. Factors such as variations in HIV VL assays The use of cumulative viraemia measurement as an alternative to single‐timepoint VL has been previously suggested. It has the advantages of incorporating longitudinal measurements of VL, and more broadly depicting the extent of exposure to replicating HIV after the start of ART Since 2017, dolutegravir has been recommended in association with lamivudine and tenofovir as a preferred regimen for people > 12 years old living with HIV in Brazil. Clinical studies suggest that dolutegravir‐containing regimens are equivalent or superior to alternative ART regimens in both naïve and ART‐experienced patients 2In this retrospective cohort study, we used programmatic data from the Ministry of Health of Brazil, which comprises close to 84% of all people living with HIV referred for ART in the country. We obtained electronic records from two information systems, which gather data on VL and T CD4+ counts performed within the national public health care system, and on every ART prescription.We identified all patients >12 years old receiving a first ART prescription between January 2014 and August 2017 and persisting with the same ART regimen after ≥12 months. We then selected the patients who had at least two available HIV VL measurements collected at different timepoints. We extracted data on demographics, VL and T CD4+ counts from electronic databases, and included the most recent (baseline) T CD4+ measurement available up to 12 months before treatment initiation.HIV VL and T CD4+ counts were measured using Abbot Real‐time HIV‐1 with a lower sensitivity of 40 copies/mL and BD MultiTEST CD3/CD8/CD45/CD4 respectively.The ART regimens that were most frequently employed, and therefore used in our analyses, were: tenofovir, lamivudine and dolutegravir (regimen 1); tenofovir, lamivudine and efavirenz (regimen 2); and tenofovir, lamivudine and ritonavir‐boosted atazanavir (regimen 3).10‐VL measurement available to determine an individual's cumulative viraemia as previously described 10 copy‐days/mL.We obtained VL measurements for individuals in each regimen group at baseline and at every available timepoint up to 12 months after ART introduction. As expected in a real‐life dataset, not all participants had VL measurements consistently performed. Therefore, we used every logp<0.05 were considered statistically significant for all comparisons. All analyses were performed using SPSS (SPSS for Windows 15) and Stata Version 15.1 .We explored the effect of each ART regimen on cumulative viraemia in univariate analyses using unpaired T‐tests and in multivariable linear regression models with robust variance estimation adjusted for age, sex, baseline T CD4+ counts and baseline VL. We also included analyses restricted to youths (aged 13 to 24 years old) and women to investigate the effect of the different ART regimens on the cumulative viraemia in these subgroups. Two‐tailed The Scientific Committee approved access to unidentified data from the programmatic register at the Department of Surveillance, Prevention and Control of STIs, HIV/AIDS, and Viral Hepatitis, Ministry of Health of Brazil, with an exemption of informed consent.33, and mean HIV VL was 4.20 log10/mL (Table p<0.0001), and the proportion of black/mixed race was higher in females .We included 112,243 patients >12 years old who received their first ART prescription between January 2014 and August 2017 in Brazil. Most were male (72%), of White/Asian (49%) and Black/Mixed (51%) race/ethnicity, and with an overall mean age of 35 years. Before treatment initiation, overall mean T CD4+ count was 457 cells/mm10 copy‐days/mL) as compared with those receiving regimens 2 (mean 728.03 log10 copy‐days/mL) or 3 .Results from multivariable analysis adjusted for age, sex, baseline T CD4+ counts and baseline HIV VL are presented in Table 10 copy‐days/ml cumulative viraemia when compared with regimen 1 . Regimen 3 was associated with a 45‐unit increase in log10 copy‐days/mL cumulative viraemia when compared with regimen 1 . Interestingly, age, sex and baseline T CD4+ counts were not significantly associated with cumulative viraemia in this subgroup . Regimen 3 was associated with a 65‐unit increase in log10 copy‐days/mL cumulative viraemia when compared with regimen 1 . Similar to our primary analysis, older age was associated with higher cumulative viraemia in this subgroup .Finally, in a model restricted to the ≥24‐year‐old strata, the results were very similar to the model including all participants. We did not find statistically significant interactions between age strata and regimen groups in multiplicative scale  was associated with significantly lower cumulative viraemia as compared with ART regimens containing efavirenz or boosted atazanavir (+lamivudine‐tenofovir). The favourable effect of the ART regimen containing dolutegravir was observed in both univariate and adjusted analyses, and in analyses restricted to patients aged 13 to 24 years old and to female patients.Our findings are consistent with previous studies Studies focusing on the efficacy of dolutegravir‐containing regimens to treat teenagers are scarce and generally had small samples Because our study derives from real‐life programmatic records, we were constrained by what information was available, and had a considerable proportion of missing data. For example, race/ethnicity information was missing for 25,264 (23%) patients; the final multivariable model adjusted for age, sex, baseline VL and baseline T CD4+ counts included 97,386 (87%) of the patients initially included in the study. Even so, the remaining dataset was robust, and we have no evidence that the missing data mechanisms were related to the observed variables. Another potential limitation in our study is the existence of unadjusted confounders. Demographics and clinical characteristics might have influenced the choice of ART regimen and, therefore, have impacted cumulative viraemia – a confounding effect also known as indication bias. We adjusted our multivariable analyses for the main demographic and clinical characteristics that could have influenced the choice of ART regimen. We further opted to exclude regimens using raltegravir, since those would be preferred options for patients with tuberculosis coinfection and pregnant women, conditions possibly associated with higher cumulative viraemia. Additionally, the study period encompasses a recent change in national ART guidelines in Brazil, with the inclusion of dolutegravir as a first‐line option to treat HIV infection in 2017. Hence, it is plausible to infer that the choice of ART regimen reflected current recommendations for most patients and would be less influenced by indication bias.As opposed to studies in controlled conditions, such as clinical trials and conventional cohort studies, our findings are likely more generalizable, since they included real‐life data, without strict inclusion/exclusion criteria or controlled follow‐up settings.Our results support recent guideline recommendations by the Ministry of Health of Brazil, which implemented an ART regimen containing dolutegravir as a preferred first‐line ART choice. It also provides encouraging data for the implementation of ART strategies in public health settings in other countries.4An ART regimen using dolutegravir in association with a tenofovir‐lamivudine backbone was superior to regimens containing efavirenz or boosted atazanavir in reducing HIV VL, as depicted by cumulative viraemia over the first 12 months of treatment, even after adjustments for potential confounders. The results were consistent in youth and female patient subgroups. Our findings have potential implications for clinical practice and could bring direct benefits to patients, as suggested by lower viral replication during treatment, lower risk of HIV transmission, and possible reduction in resistance mutations in the initial 12 months of ART All authors declare no competing interests.ARPP, REGGP, ASB and VIAS conceptualized study design and data extraction strategy. ARPP, REGGP and VIAS performed data analysis. ARPP, REGGP, FR, NMCV, FBP, MVM, GFP, ASB and VIAS contributed to interpretation of results. ARPP, REGGP, FR, FBP, ASB and VIAS contributed in manuscript writing. All authors revised and approved the final version of the manuscript.


Surveillance of HIV drug resistance (HIVDR) is crucial to ensuring the continued success of antiretroviral therapy (ART) programs. With the concern of reduced genotyping sensitivity of HIV on dried blood spots (DBS), DBS for HIVDR surveillance have been limited to ART-naïve populations. To investigate if DBS under certain conditions may also be a feasible sample type for HIVDR testing in ART patients, we piloted nationwide surveys for HIVDR among ART patients using DBS in two African countries with rapid scale-up of ART.EDTA-venous blood was collected to prepare DBS from adult and pediatric ART patients receiving treatment during the previous 12–36 months. DBS were stored at ambient temperature for two weeks and then at -80°C until shipment at ambient temperature to the WHO-designated Specialized HIVDR Laboratory at CDC in Atlanta. Viral load (VL) was determined using NucliSENS EasyQ® HIV-1 v2.0 kits; HIVDR genotyping was performed using the ATCC HIV-1 Drug Resistance Genotyping kits.DBS were collected from 1,368 and 1,202 ART patients; 244 and 255 these specimens had VL ≥1,000 copies/mL in Kenya and Tanzania, respectively. The overall genotyping rate of those DBS with VL ≥1,000 copies/mL was 93.0% (95% CI: 89.1%-95.6%) in Kenya and 91.8% (87.7%-94.6%) in Tanzania. The turnaround times for the HIVDR surveys from the time of collecting DBS to completing laboratory testing were 6.5 months and 9.3 months for the Kenya and Tanzania surveys, respectively.The study demonstrates a favorable outcome of using DBS for nationwide surveillance of HIVDR in ART patients. Our results confirm that DBS collected and stored at ambient temperature for two weeks, and shipped with routine courier services are a reliable sample type for large-scale surveillance of acquired HIVDR. The accessibility of HIV antiretroviral therapy (ART) for HIV-infected persons has substantially increased worldwide in recent years. According to the World Health Organization (WHO) statistics, about 20.9 million people were receiving ART globally as of June 2017. About 19.2 million are in low- and middle-income countries representing a 46-fold increase from since 2003 , while ast-line or 2nd-line regimens so to switch to efficacious 2nd line or 3rd line regimens [It is well known that HIV can develop ADR mutations when inadequate blood drug concentrations occur due to treatment interruptions, poor adherence, or the use of suboptimal drug regimens . While rregimens .From 2004 to 2012, prospective surveys of ADR were implemented in at least 13 countries using the WHO-recommended ADR survey methodology . HoweverTo address these limitations, WHO in collaboration with the Centers for Disease Control and Prevention (CDC) and the United States President's Emergency Plan for AIDS Relief (PEPFAR) developed a simpler cross-sectional survey to assess ADR . The newAlthough dried blood spots (DBS) have been routinely used for early infant diagnosis of HIV in resource-limited countries , due to To inform updated methodologies for cross-sectional ADR surveillance, and to test the feasibility of using DBS for large-scale HIV VL testing and DR genotyping, we conducted two pilot ADR surveys in Kenya and Tanzania using nationally representative samples in a cross-sectional survey design. According to the 2013 UNAIDS Report on the Global AIDS Epidemic at the time when the surveys were conducted, Kenya and Tanzania had estimated 3.1 million people living with HIV in 2012 . DespiteHere we report the performance of DBS sample type-based strategies in the two pilot nationwide surveys of HIVDR. Our results confirm that DBS collected under certain condition are a feasible sample type for ADR survey. Results on virological outcome and DR patterns among patients in the surveys had been presented elsewhere –38.Ethical Review Committees of the Kenya Medical Research Institute (KEMRI), the Tanzania National Institute for Medical Research (NIMR) and Institute of Human Virology of University of Maryland School of Medicine approved the protocols. The anonymous testing at CDC was determined as non-human subjects research by the Office of the Associate Director for Science at the Center for Global Health, CDC, Atlanta, GA, USA.Following the WHO protocol for cross-sectional surveillance of acquired HIV drug resistance , fifteenTwo adult cohorts and one pediatric cohort were included in the survey from each country according to the WHO protocol. The inclusion criteria for each of the cohorts were as follows: (1) HIV-infected adults (age 15 and up) with documented ART start dates who had been on ART for at least 12 months and no more than 15 months; (2) HIV-infected adults (age 15 and up) with documented ART start dates who had been on ART for at least 24 months and no more than 36 months; (3) HIV-infected children (age 1 to 14 years) with documented ART start dates who had been on ART for at least 12 months and no more than 36 months. Patients presenting to the selected clinics for their regular clinic appointments and meeting inclusion criteria were asked to participate in the study. After obtaining informed written consent, they were consecutively enrolled into the study until the planned sample size for each site was reached. At enrollment, demographic, clinical and ART data were also abstracted from the medical records from each of the consented patients.Blood from each patient was collected in a 3-mL vacuum tube containing ethylene diamine tetra-acetic acid (EDTA) anticoagulant and used for preparation of two DBS cards at the ART clinics. DBS were made following a standardized protocol for ATCC kits by dropping of 100 μl of whole blood to each of the five pre-printed circles in the Whatman 903 card, dried overnight and then packaged with desiccants and a humidity indicator card. At the clinics, the dried and packaged DBS cards were kept in a dry and safe location at ambient temperature with no direct exposure to sunlight. The DBS cards were picked up biweekly from the ART sites by routine courier services and delivered to the storage facility in Nairobi or Dar es Salaam where they were stored at -80°C until shipment. Upon the completion of DBS collection, DBS were shipped at ambient temperature to the drug resistance genotyping laboratory at the International Laboratory Branch, U.S. CDC in Atlanta, Georgia for processing. One DBS spot was cut out per specimen and placed in a tube containing 2 mL of NucliSENS lysis buffer  for 30 minutes at room temperature with gentle rotation. Nucleic acid was then extracted using the NucliSENS® easyMAG® (Biomerieux) automated extraction system according to the manufacturer’s instructions. Nucleic acid was eluted in 25 μL of NucliSENS Extraction Buffer 3 and used for downstream testing. HIV-1 VL was measured by the NucliSENS EasyQ® automated system using NucliSENS EasyQ® HIV-1 v2.0 RUO test kits (Biomerieux) following the manufacturer’s instructions. For the specimens giving invalid result on the first test, a repeat test was performed, if an invalid result was produced again, no further attempt was made. With the initial input of 100 μl of whole blood, the assay has a limit of detection of 802 copies/mL for DBS and a linear range of detection of 500–21,000,000 copies/mL .pol gene was performed for the specimens from patients with virological failure  using the ATCC® HIV-1 Drug Resistance Genotyping Kit . The ATCC kit was developed based on a broadly sensitive in-house genotyping assay developed by CDC [pol gene was generated by RT-PCR and nested PCR using the kit Module 1: RT-PCR & Nested PCR (ATCC® GK-0098™). The purified PCR fragment was then sequenced using the kit Module 2: Cycle Sequencing (ATCC® GK-0200™), and the sequencing reactions were analyzed on the ABI Prism™ 3730 Genetic Analyzer (Applied Biosystems). The customized ReCALL (version 2.25) software program was used to edit the raw sequences and generate consensus sequences [Genotyping of the protease and reverse transcriptase regions of the HIV-1 d by CDC . In brieequences . REGA HIequences  was usedequences  with theequences .The prevalence (or proportion) estimates and their respective 95% confidence intervals (CIs) were calculated and adjusted for sample design through complex sample analysis. The complex sample analysis plan was defined based on the clusters of sampling protocol, strata (clinic type and clinic size) and the determined weights. The rates and proportions between groups were compared using the chi-square test, and the comparison of the groups of ordered classified data was performed by the Ridit analysis. Statistical calculations were performed using SPSS  software . All tests were 2-tailed and a P<0.05 was considered statistically significant.The sequences generated in the study have been submitted to GenBank with the accession numbers of MH317297—MH317524 for the Kenya samples and MH317525—MH317758 for the Tanzania samples.A total of 1,368  HIV-1 infected subjects receiving ART at 15 clinical sites in Kenya were enrolled in this study. A total of 1,202  HIV-1 infected subjects receiving ART at 15 clinical sites in Tanzania were enrolled in this study. For pediatric populations, the median age of the participants from both countries was seven years.The dried and packaged DBS cards were stored at ambient temperature for an average of 7 days (range from one to 14 days) and 11 days (range from two to 42 days) before they were transported and stored in the -80°C freezers at the central storage facility in Kenya and Tanzania, respectively. Overall, 10.9%  of the DBS cards were stored at ambient temperature for over two weeks, with median length of 19 days . All the DBS specimens from Kenya were stored at ambient temperature within two weeks.Viral load measurements were performed for all 2,570 DBS specimens collected from Kenya  and Tanzania  using NucliSENS EasyQ® HIV-1 v2.0 RUO test kits. At the first test run, 93.7%  of the DBS yielded valid VL results while 6.3% (161) were invalid due to inhibition of amplification of the internal control. Upon repeated test, all but one specimen from Kenya had valid VL measurements. Of the 1,367 specimens from Kenya with VL results, 244 had VL ≥1,000 copies/mL while among the 1,202 specimens with VL data available in Tanzania, 255 specimens had VL ≥1,000 copies/mL.With all the DBS with VL ≥1,000 copies/mL genotyping was performed using ATCC HIV genotyping kits. For DBS collected from Kenya, 93.0%  of the specimens were genotyped while 91.8%  of the DBS specimens collected from Tanzania were successfully genotyped .P < 0.001, Ridit analysis). In Kenya and Tanzania, 80.0% and 85.1% of the DBS specimens with VL 1,000–4,999 copies/mL were genotyped; 97.0% and 87.9% with VL 5,000–9,999 copies/mL were genotyped; 98.6% and 98.3% with VL ≥10,000 copies/mL were successfully genotyped, respectively (P = 0.59). Of the 298 specimens from pediatric patients with VL ≥1,000 copies/mL, 277 were genotyped (93.0%); and among the 201 specimens from adult patients with VL ≥1,000 copies/mL, 184 (91.5%) were genotyped (P = 0.56 for any significant difference).To analyze the influence of VL levels on DR genotyping rates, we combined the VL data from both countries and stratified them into 1,000–4,999, 5,000–9,999 and ≥10,000 copies/mL categories. As expected, an overall positive relationship between VL levels and DR genotyping rates were observed .To further analyze the impact of DBS quality on genotyping rates, we analyzed the storage length on genotyping rates. Among the 499 specimens collected from virologic failure patients, 75 specimens were stored at ambient temperature at the clinics for over two weeks, 67 (89.3%) of them were successfully genotyped while among the 424 specimens collected from virologic failure patients that were stored at ambient temperature at the clinics sites for less than or equal to two weeks, 394 (92.9%) of them were successfully genotyped. Although a small difference was noted there was no significant difference in genotyping rate between the two groups of specimens  and ReCALL software is cost-effective and time-saving methodology. It is practical to reduce the field sampling to a maximum of six months in a nationwide survey, as recommended by the WHO protocol for surveillance of HIV drug resistance in patients receiving ART [Simplicity of DBS-based sample collection and reduced cost of in-house or commercially available HIVDR genotyping assays make timely and large-scale/nationwide surveillance of ADR feasible. Results from our pilot study indicate that cross-sectional surveillance of ADR using DBS in combination with ATCC kits, currently manufactured by ThermoFisher Scientific (The HIV-1 Genotyping kits, ving ART . Laborat


WHO) has recommended that all people living with HIV (PLHIV) initiate antiretroviral treatment (ART), irrespective of CD4+ count or clinical stage. National adoption of universal treatment has accelerated since WHO's 2015 “Treat All” recommendation; however, little is known about the translation of this guidance into practice. This study aimed to assess the status of Treat All implementation across regions, countries, and levels of the health care delivery system.Since 2015, the World Health Organization  adult ART, regardless of clinical criteria, and these sites had been implementing Treat All for a median period of seven months at the time of the survey. The majority of sites (77%) reported typically initiating patients on ART within 14 days of confirming diagnosis, with 60% to 62% of sites implementing Treat All in East, Southern and West Africa reporting same‐day ART initiation for most patients.Almost all sites (93%) reported that they had begun implementing Treat All, and there were no statistically significant differences in site‐level Treat All introduction by health facility type, urban/rural location, sector (public/private) or country income level. The median time between national policy adoption and site‐level introduction was one month. In countries where Treat All was not yet adopted in national guidelines, 69% of sites reported initiating all patients on DEA sites, including rural, primary‐level health facilities in low‐resource settings. While further assessments of site‐level capacity to provide high‐quality HIV care under Treat All and to support sustained viral suppression after ART initiation are needed, the widespread introduction of Treat All at the service delivery level is a critical step towards global targets for ending the HIV epidemic as a public health threat.By mid‐ to late‐2017, the Treat All strategy was the standard of care at almost all Ie We also aimed to describe site‐level practices related to pre‐ART counselling, the timing of ART initiation and viral load monitoring capacity at sites where Treat All is the standard of care.22.12.1.1IeDEA is an international research consortium of HIV care and treatment sites in 46 countries across seven world regions: the Asia‐Pacific; the Caribbean, Central and South America; Central Africa; East Africa; Southern Africa; West Africa; and North America Between June and December 2017, a cross‐sectional 115‐item survey was administered in English or French to 255 active HIV care and treatment clinics that contribute longitudinal patient‐level data to IeDEA. In Southern Africa, where many IeDEA sites contribute data as part of a programmatic cohort that follows uniform practices across all clinics, one site from each cohort was surveyed; accordingly, four cohort‐representative sites were surveyed in Lesotho, Mozambique, Zambia and Zimbabwe, representing 8, 17, 105 and 35 clinics respectively, within each country's active observational cohorts.The survey was distributed in paper form and as an online questionnaire. REDCap electronic data capture tools hosted at Vanderbilt University Medical Center 2.1.2all patients on ART regardless of CD4+ cell count or symptoms.” Sites reporting that they only “Start some patients on ART regardless of CD4+ cell count or symptoms” – for example, patients with a pregnancy or coinfection with tuberculosis or hepatitis B – were not considered to be implementing Treat All.The survey explored the current criteria used for initiating ART and the month and year those guidelines were introduced at the service delivery site. Adult treatment sites were considered as having implemented the Treat All policy if they reported that they currently “Start Other survey items included questions related to facility attributes, including location , level , and sector (public vs. private). The survey also explored routine site‐level practices related to pre‐ART counselling, ART initiation and viral load monitoring. Sites that reported that they could routinely request or perform viral load (quantitative HIV RNA) testing were considered to have the capacity for viral load monitoring among patients initiating ART.2.1.3To determine dates of national adoption of Treat All, we conducted a systematic search of health ministry websites for national HIV treatment guidelines, policies, notices, and press releases related to Treat All. When policy documents were unavailable or specified only the year of Treat All adoption, the date of policy adoption was assessed based on other sources, including the International Association of Providers of AIDS Care (IAPAC) Global HIV Policy Watch As national HIV treatment guideline changes were ongoing in 2017, we considered the national guideline to be that which was in place at the time each site completed the survey. Sites were considered to be subject to a national Treat All policy if they completed the survey after universal HIV treatment had been officially adopted in published national guidelines. Sites were considered to be operating within a pre‐Treat All policy context if they completed the survey before the date of national Treat All adoption.We collected information on each country's income group classification in 2017 from World Bank databases 2.2Analyses included descriptive statistics . Frequencies of site‐level implementation of Treat All were stratified by site characteristics, country characteristics, and region, with Fisher's exact tests used to assess independence. The Wilcoxon test was used to compare medians. All statistical analyses were performed using SAS 9.4 , and ArcGIS Desktop 10.6  was used for descriptive mapping.Sites that did not report the month of site‐level Treat All introduction were included in frequency calculations of the timing of Treat All introduction relative to (i.e. before/after) national guideline adoption if the year of site‐level introduction differed from the year of national guideline adoption. Sites were excluded if the year of site‐level introduction was the same as that of national adoption because there was no way to verify whether these sites began implementation before or after the national guideline adoption.The interval between national guideline adoption and site‐level introduction was assessed as the time in months between the publication of updated national treatment guidelines that reflected Treat All and the month that each site reported beginning to provide ART to all HIV patients, regardless of CD4+ cell count or clinical disease staging. In countries where Treat All was not incorporated in national guidelines, we assessed the time, in months, between site‐level introduction of Treat All and the date the survey was completed as the duration of implementation. Sites that were unable to report both month and year of Treat All introduction were excluded from these analyses.3Responses to the IeDEA Site Assessment survey were received from 234/255 IeDEA sites, including 201/221 sites (91%) in 41 countries that provide HIV care to adult patients. Thirty‐four sites providing services to paediatric patients only were excluded from the analysis because the timing of Treat All guidance for paediatric patients differed from that for adult patients.3.1Overall, 93% of adult HIV treatment sites 187/201) reported that they currently initiate all patients on ART, irrespective of CD4+ cell count or WHO clinical stage (see Table 87/201 rep < 0.0001).In countries where universal treatment of PLHIV had been adopted in national treatment guidelines (26/41 countries), site‐level implementation of Treat All was almost universal , and there were no significant differences in site‐level implementation by country income designation or PEPFAR‐support status, or by facility type, location or sector. Site‐level implementation of Treat All was significantly lower in countries where universal HIV treatment had not yet been incorporated into national guidelines (15/41 countries) at the time of the survey , compared to countries where Treat All was adopted in national treatment guidelines   and at sites in urban areas , compared with rural sites . All Treat All‐implementing sites in the West Africa region (100%) and almost two‐thirds of sites in the Asia‐Pacific region reported that site‐level introduction of Treat All preceded national guideline adoption, as did half of the surveyed sites in the Caribbean, Central and South America and about one‐third of sites in the East Africa and North America regions. In contrast, no sites in Southern Africa and few sites in Central Africa reported implementing Treat All prior to national guideline adoption.Almost all sites  reporting implementation of Treat All specified the year of site‐level introduction, and 81% (152/187) reported both month and year of site‐level introduction. Just over one‐third (35%) of sites reported that they began initiating all patients on ART regardless of immune status or clinical disease stage prior to the adoption of Treat All in national guidelines (Table 3.3p < 0.001) and at public sector sites  compared with private sector facilities . The time to site‐level introduction of Treat All was also longer in low‐ and lower‐middle‐income countries , compared with high‐ and upper‐middle‐income countries  and in PEPFAR‐supported countries  compared with non‐PEPFAR‐supported countries ; however, these differences were not statistically significant, given wide variation in the timing of Treat All in high‐ and upper‐middle‐income countries. Similarly, the time to site‐level introduction of Treat All was longer at health centres , compared with district, regional/provincial and teaching hospitals  .In countries where Treat All had been adopted nationally, 138/175 (79%) sites reported both month and year of Treat All introduction. Among these sites, the median time lag between national guideline adoption and site‐level introduction was 1 month (IQR: −1 to 4 months) Table . IntervaIn countries where national Treat All policies had not yet been adopted, 14/26 sites that were treating all patients irrespective of CD4+ counts or other symptoms reported that they had been initiating all patients on ART for a median period of seven months at the time of the survey (IQR: −13 to −6 months).3.4p < 0.001), as were sites in urban areas compared to rural areas . Sites in high‐income countries and countries not supported by PEPFAR or the Global Fund were also significantly more likely to report that patients typically have no pre‐ART counselling sessions . Among the 14 sites that had not yet introduced Treat All, half (7/14) reported that they typically conduct one to two counselling sessions before initiating patients on ART, with six sites reporting that patients typically have three or more counselling sessions prior to initiating treatment.Approximately two‐thirds (66%) of sites implementing Treat All reported that they typically conduct one to two adherence counselling sessions prior to initiating patients on ART, while 24% (45/187) reported providing three or more such sessions Table , and 10%Among 187 sites implementing Treat All, 77% reported initiating patients on ART within 14 days of establishing treatment eligibility Table . Same‐dap < 0.0001); and in hospitals  compared with health centres (74/90 (82%) vs. 55/97 (57%); p < 0.001).More than two‐thirds of sites implementing Treat All (129/187) reported that viral load testing was available as part of routine care of patients at the site. Viral load testing capacity was nearly universal among sites in high‐income  and upper‐middle‐income countries . However, only 39% (21/54) of sites in low‐income countries and 52% (23/44) of sites in lower‐middle‐income countries reported that viral load testing was available as part of routine patient care. Capacity for routine viral load monitoring was also significantly more common among urban sites compared with rural sites (110/136 (81%) vs. 19/51 (37%); 4Surveying 201 adult HIV treatment sites that participate in the global IeDEA collaboration across 41 countries, this study found that the vast majority of sites had begun initiating all patients on ART by mid‐2017, regardless of immune status or clinical disease stage. Site‐level implementation of Treat All is almost universal in countries that have incorporated WHO's 2015 recommendation into national guidelines. Previous research has highlighted various logistical barriers and health system constraints, such as guideline dissemination, training of health personnel, drug stockouts and gaps in laboratory capabilities, which contributed to delays in implementing prior, CD4 count–based treatment guidelines In countries that officially adopted the Treat All policy prior to WHO's 2015 guidance, there was greater between‐site variation in the timing of site‐level introduction of Treat All, with implementation lags ranging from one to five years after national policy adoption. In these predominately high‐income countries, variation in site‐level introduction may reflect heterogeneous health policy environments, decentralized health systems, and a higher proportion of private‐sector sites operating autonomously. Earlier site‐level adoption of Treat All in these countries may reflect the feasibility of expanding HIV treatment, given lower HIV prevalence, higher‐resourced health systems, and stronger logistics systems in these settings The majority of surveyed sites in low‐ and lower‐middle‐income countries reported typically starting patients on ART within 14 days of eligibility ascertainment, which is promising, given evidence that rapid ART initiation leads to improved clinical outcomes Our study provides important early data assessing the timing of Treat All introduction at the service delivery level, as well as the interval between national guideline adoption and site‐level introduction. With a sample of 201 sites serving adult HIV patients across 41 countries, the IeDEA site assessment reflects the status of Treat All rollout among a large and diverse sample of HIV care and treatment sites across different regions, countries and types of facilities. While almost all sites reported universal HIV treatment as the standard of care, we found considerable variation in site‐level practices related to rapid ART initiation, with private sector sites and sites in high‐resource settings more likely to report longer times to treatment initiation. Consistent with other research Several study limitations should be noted. The survey data were self‐reported. Accordingly, in some instances, recall bias and social desirability bias may have led to inaccurate responses and/or responses more closely aligned with national treatment guidelines and norms than true practice. HIV care and treatment sites participating in IeDEA are primarily public‐sector health facilities, and they comprise a heterogeneous mix of academic and community‐based hospitals and health centres 5Data from this survey indicate that by mid‐ to late‐2017, the Treat All strategy was being implemented across most IeDEA sites in 41 countries, including rural, primary‐level health facilities in low‐resource settings. Further research is needed to assess patient outcomes and the quality and effectiveness of HIV‐related care under Treat All and to identify bottlenecks that contribute to ongoing delays in ART initiation and other suboptimal patient outcomes. However, the accelerating roll‐out of Treat All at HIV care and treatment sites across IeDEA is promising for the achievement of UNAIDS’ 95‐95‐95 targets to end the AIDS epidemic.KNA serves on the scientific advisory board for Trio Health. All authors declare that they have no competing interests.EB, SND, FM, DN and CWW developed the survey questionnaire. SND and FM designed the survey in REDCap, and FM coordinated overall data collection. DN conceptualized the project, and EB performed the data analysis and wrote the initial draft of the manuscript. FM, SND, OT, CWW, GS, JR, AF, MC, AP, BSM, FZ, KNA, CM, ADK, MY and DN contributed to the interpretation of findings and manuscript revisions, and all authors read and approved the final manuscript.Table S1. Date of national adoption of Treat All, median year, and time‐to‐implementation at IeDEA sites operating under Treat All at the time of the survey.Click here for additional data file.


One of the major factors contributing to HIV-1 drug resistance is suboptimal adherence to combination antiretroviral therapy (cART). Currently, recommended cART for HIV-1 treatment is a three-drug combination, whereas the pre-exposure prophylaxis (PrEP) regimens consist of one or two antivirals. Treatment regimens require adherence to a once or twice (in a subset of patients) daily dose. Long-acting formulations such as injections administered monthly could improve adherence and convenience, and thereby have potential to enhance the chances of expected outcomes, although long-lasting drug concentrations can also contribute to clinical issues like adverse events and development of drug resistance. Globally, two long-acting antivirals have been approved, and fifteen are in clinical trials. More than half of investigational long-acting antivirals target HIV-1 reverse transcriptase (HIV-1 RT) and/or integrase (HIV-1 IN). Here, we discuss the status and potential of long-acting inhibitors, including rilpivirine (RPV), dapivirine (DPV), and 4-ethynyl-2-fluoro-2-deoxyadenosine , which target RT, and cabotegravir (CAB), which targets IN. The outcomes of various clinical trials appear quite satisfactory, and the future of long-acting HIV-1 regimens appears bright. Revolutionary advances in combination antiretroviral therapy (cART) have rendered HIV from a fatal to chronic disease. If managed efficiently cART significantly improves the life expectancy of a patient . The cARTo date, one LA antiviral  has been approved by the United States Food and Drug Administration. Ibalizumab inhibits HIV infection at post attachment steps by binding to domain 2 of the CD4 receptor and blocking binding of HIV to the cell. Ibalizumab, together with optimized background therapy, is recommended for treatment-experienced patients with multidrug-resistant viruses who are failing current therapy [Currently, three RTIs are in clinical trials and another three are in preclinical development . HIV-1 REFdA is an extremely potent NRTI . The EFdEFdA has a high genetic barrier to resistance in culture, which has been attributed to the strong and generally conserved interactions between EFdA and the HIV-1 RT polymerase active site ,24. In vWith respect to the potential of EFdA/MK-8591 as an LA antiviral, a single injection in rats of an extended release parenteral formulation of MK-8591 (in bioerodible poly(lactic acid) (PLA) and poly(caprolactone) (PCL) and nonerodible ethylene co-vinyl acetate (EVA)) was shown to result in levels of the inhibitor adequate for efficient antiviral effect for more than 180 days ,27. EFdA2) ranging between 0.35 and 0.40 mg/day from multipurpose intravaginal rings (IVRs) has also been reported. These rings also contained acyclovir (ACV) and etonogestrel (ENG) in combination with ethinyl estradiol (EE) [6 cells) was present up to 35 days. In animal studies, the concentration of TFV-diphosphate was at least 10-fold greater than that associated with effective PrEP in humans taking standard daily doses of oral TDF [Tenofovir alafenamide fumarate (TAF)  is chemiiol (EE) . In PBMCoral TDF . GS-9131  is a pho99 in a tissue explant infection model [Dapivirine (DPV), a diaryl pyrimidine derivative, is a second-generation NNRTI . It is con model . Anotheron model . The reson model . A folloon model  showed ton model , social on model ,54, pharon model , pregnanon model , and rinon model  have beeRilpivirine (RPV)  alone or90) of RPV LA (12.5 ng/mL) in more than 92% of participants [Encouraging pharmacokinetic properties of RPV LA formulation (in surfactant poloxamer 338) were reported in preclinical and phase I clinical trials ,62,63,64icipants . The priIn the phase IIb LATTE trial, a combination of 25 mg of RPV and selected doses of CAB were used once-daily oral as maintenance therapy for 72 weeks, after an induction period of 24 weeks by CAB with two NRTIs or efavirenz (EFV) plus two NRTIs . The res50 = 1.2 nM), displays antiviral activity against a broad range of NNRTI resistance viruses, and does not have cross-resistance to other NNRTIs [Elsulfavirine (VM-1500) is an NNRTI and prodrug of active compound VM-1500A  Figure . It recer NNRTIs ,70. Elsur NNRTIs . In a prr NNRTIs . Four INSTIs , elvitegravir (EVG), dolutegravir (DTG), and bictegravir (BIC)) have been approved for HIV treatment. One of these, RAL and another INSTI cabotegravir (CAB) (yet to be approved) , are at n = 110) received 800 mg CAB LA intramuscularly (n = 82) or placebo (n = 28) every 12 weeks after an initial four weeks receiving 30 mg of CAB in mannitol, polysorbate 20, polyethylene glycol 3350, and water once daily. Cohort 2 (n = 90) received 600 mg CAB LA intramuscularly (n = 69) or placebo (n = 20) every eight weeks after receiving 30 mg of CAB for four weeks, once daily. The results of this study revealed that (i) CAB LA was well-tolerated, and (ii) CAB LA 600 mg every eight weeks met pharmacokinetic targets for study participants [CAB is an investigational second-generation INSTI, which is currently in advanced clinical trials for both treatment and prevention. CAB has a higher resistance barrier than first-generation INSTIs (RAL and EVG), but lower than the other two second-generation INSTIs (DTG and BIC) . A phaseicipants . In the phase IIb LATTE2 clinical trial, 256 HIV-infected treatment-naive patients initially received oral cabotegravir 30 mg plus abacavir (ABC) (600 mg) and lamivudine (3TC) 300 mg once daily for 20 weeks. After the 20-week period, the patients with viral suppression (plasma HIV-1 RNA <50 copies/mL) were randomized in the ratio of 2:2:1 to receive intramuscular CAB LA (400 mg) plus RPV (600 mg) at four-week or eight-week intervals (CAB LA 600 mg plus RPV 900 mg) or the continuation of CAB plus ABC/3TC. The study concluded that injectable combination of CAB LA and RPV every four or eight weeks was as effective as daily CAB/ABC/3TC oral therapy. At Week 96, 84–94% of patients had HIV RNA suppressed to <50 copies/mL. The injectable two-drug combination (CAB LA and RPV) was tolerable and safe . CurrentRAL is a first-generation INSTI. It has been recommended by the European AIDS Clinical Society, the United States Department of Health and Human Services, and the International Antiviral Society, USA panel ,3, as paSubtype-specific polymorphisms and pre-existing resistance mutations can influence the efficacy of antiretrovirals ,79,80,81pol, which were also maintained in gag, int/vif, and env [A detailed phylogenetic analyses showed two distinct genetic clusters in  and env . These tThe resistance profile of CAB is still emerging. However, some reports have documented CAB resistance mutations. In a study conducted with SIVmac251-infected rhesus macaques, mutations I31L, Q91R, E92Q/G/M, T97A/I, G106S, G118R, H156G/R, and V172L and a duplication of five residues at position 232 have been implicated in CAB resistance ,87. ExceThe emergence of NRTI resistance mutations in different subtypes can potentially reduce the long-acting formulation of certain NRTIs. For example, the K65R mutation is associated with both TAF and TDF resistance. Reports have shown that the K65R mutation is selected faster in HIV-1C than in HIV-1B and HIV-1A ,82. GlobAlthough the preclinical and clinical data presented so far are promising, some clinical issues remain to be addressed. These issues include side effects, drug–drug interactions, and pregnancy, and the pharmacokinetics with long-lasting drug concentrations is not only a prerequisite for the promising clinical benefits, but can also lead to the development of drug resistance. The dosing interval must be selected based on the trough of the compound at the end of the injection interval to ensure that it remains above the concentration required to inhibit HIV-1 efficiently in order to avoid selective pressure for the development of drug resistance. Furthermore, even if the injection interval can be defined so that suboptimal drug concentrations are avoided, there is a potential for emergence of viral resistance as drug concentrations decline during protracted periods of sub-therapeutic exposure after ART discontinuation. Thus, even if LA agents could increase adherence in many patients, an advanced risk for resistance development still persists if patients are non-adherent to the schedule of optimized dosing intervals.In conclusion, here, we presented the status of potential LA antivirals that target HIV-1 RT and HIV-1 IN. So far, the results from clinical trials appear encouraging, but more data are required before LA antivirals can be commonplace. Nonetheless, the future of the LA formulations appears bright. Once the LA combinations are approved, improved adherence to and convenience of cART are expected to be achieved.


Background: Lopinavir/ritonavir (LPV/r) is a major antiretroviral treatment in China, but little is known about the performance of first-line LPV/r-based regimen in treatment-naïve patients with human immunodeficiency virus type 1 (HIV-1) infection. This study aims to assess the efficacy and adverse effect events of LPV/r plus lamivudine and tenofovir or zidovudine as an initial antiretroviral treatment in HIV-1-infected individuals for whom cannot take efavirenz (EFV) or is allergic to EFV.Methods: We performed a retrospective study of patients registering with the China’s National Free Antiretroviral Treatment Program from July 2012 to January 2017, followed at a tertiary care hospital in Beijing, China. The primary outcome was the proportion of subjects with HIV-1 RNA ≤40 copies/ml at 6 and 24 months of treatment. We assessed the immunological response and adverse events.Results: In total, 4,862 patients were enrolled in the study and 237 were eligible for analysis in each study arm. During the first six months, virological suppression was better with the LPV/r-based regimen than with the EFV-based regimen (93.80 vs 87.80% for P < 0.05). Viral suppression rates continued to increase until 12 months, remain steady thereafter until 24 months, for both groups. The multilevel analysis revealed that patients in the LPV/r group were more likely to display improvements in CD4 T-cell count over time than those in the EFV group (P < 0.001). Grade 3 or 4 laboratory adverse events were observed in 14 patients (5.91%) from the LPV/r group and three patients (1.20%) in EFV group.Conclusion: Our findings demonstrate that LPV/r-containing regimens are effective and well-tolerated in Chinese treatment-naïve patients with HIV-1 infection. Left untreated, human immunodeficiency virus (HIV) infection leads to a severe, life-threatening immunodeficiency syndrome. Worldwide, 36.9 million people were estimated to be living with HIV at the end of 2017 . The incAntiretroviral therapy (ART) reduces the risk of disease progression and prevents HIV-1 transmission. Most ART guidelines worldwide recommend its use for all patients with HIV-1 infection, regardless of their CD4 T-cell counts. The China’s National Free Antiretroviral Treatment Program (NFATP) was set up in 2003 and has significantly expanded access to ART in China. Morbidity and mortality in HIV-infected patients have decreased markedly in the last few years , but the+ T-cell counts, drug resistance is a concern or testing is not available, the patient is female and wishes to have childbearing demand, the patient has a history of mental illness and cannot take EFV or the patient is allergic to EFV.According to the NFATP guidelines, the first-line regimen the treatment of HIV infection should consist of a combination of two nucleoside reverse transcriptase inhibitors (NRTIs) and one non-nucleoside reverse transcriptase inhibitor (NNRTI): lamivudine (3TC), zidovudine (AZT) or tenofovir disproxil fumarate (TDF), and efavirenz (EFV) or nevirapine (NVP) or rilpivirine (RPV) . The proEFV and LPV/r are no longer recommended as first-line treatments in most developed countries, because of their adverse effects , but thePrevious studies have suggested that LPV/r performs well in treatment-naïve HIV-1-infected individuals , but litWe performed a follow-up study of patients who registered with the NFATP from July 2012 to January 2017 and were followed at the Center for Infectious Diseases of Beijing Youan Hospital, Capital Medical University in Beijing, China. This center is one of the most important HIV/AIDS health care centers participating in the NFATP in China, where more than 8,000 HIV-infected patients on ART are followed regularly.+ T-cell count or plasma HIV viral load at baseline missing); 6) patients who switched regimens. In total, 319 patients were using LPV/r as a first-line regimen and 2,832 patients were using EFV as a first-line regimen. We performed case-control matching to identify the best-matched pairs (1:1). Finally, 237 patients were included in each of the treatment arms in this study (The inclusion criteria were: 1) HIV-1 infection confirmed by western blotting; 2) patient >18 years of age. The exclusion criteria were: 1) pregnancy; 2) use of dual therapy; 3) history of ART before LPV/r therapy; 4) treatment for <3 months; 5) missing baseline data  LPV/r-based regimen: LPV/r plus TDF/AZT plus 3TC; or 2) EFV-based regimen: EFV plus TDF/AZT plus 3TC. General data (demographic characteristics and symptoms) were collected at baseline. Leukocyte count, hemoglobin level, platelet count, alanine aminotransferase (ALT), total bilirubin, lipid, and glucose levels were determined at baseline and at each visit.+ T-cell count and plasma HIV RNA levels were determined at baseline and every six months thereafter. Routine blood CD4+ T-cell counts (cells/µl) were measured by four-color flow cytometry with human monoclonal anti-CD4-APC, anti-CD3-FITC, anti-CD8-PE, and anti-CD45-PerCP antibodies  on peripheral whole-blood samples from each patient according to the manufacturer’s instructions. The cells were analyzed on a BD FACS Canto™ II flow cytometry system . HIV-1 viral load was determined with an automated real-time PCR-based m2000 system  in accordance with the manufacturer’s instructions with a limit of detection of 40 copies/ml.CD4+ T-cell count from baseline at 6, 12, 18, and 24 months. Adverse events were assessed by determining: 1) the number of patients who discontinued or switched the ART regimen due to adverse events 2). the number of patients with laboratory abnormalities at least grade 3 due to drugs related. The severity of drug toxicity was evaluated according to the AIDS Clinical Trial Group toxicity grading scale.The primary outcome was the proportion of subjects with HIV-1 RNA ≤40 copies/ml at 6, 12, 18 and 24 months. The main secondary endpoint was percentage change in CD4P < 0.05 was used to characterize the statistical significance. Categorical variables as age, sex, CD4+ T-cell count, HIV viral load, ART regimens, and laboratory values are presented as numbers and percentages and were analyzed in chi-squared tests. We used linear multilevel models to calculate differences in the change in CD4+ T-cell count from baseline to 24 months. Data were managed and analyzed with SAS version 9.14 . Differences were considered statistically significant if P < 0.05 in two-tailed tests.Variables that did not follow a normal distribution are presented as the median and interquartile range (IQR) and were analyzed in Wilcoxon rank sum tests. + T-cell count, viral load, and serum lipid concentrations, but LDL-c concentration was higher in the group of patients on the LPV/r-based regimen  . Virological suppression rates continued to increase until 12 months, remaining stable thereafter until 24 months in both groups  (Mean CD4None of the patients discontinued treatment due to adverse events. Adverse laboratory events of grade 3 or 4 were noted in 14 patients (5.91%) in the LPV/r group and three patients (1.20%) in the EFV group  in Africa and Asia showed that >80% of the patients had suppressed plasma HIV RNA levels from week 12 onward (< 400 copies/ml) when treated with the LPV/r monotherapy . The gre testing .+ T-cell count had increased by 209.3 and 287.8 cells/µl relative to baseline at 12 and 24 months, respectively. Baseline CD4+ T-cell counts are associated with immune response after ART. Patients with a CD4+ T-cell count <200 cells/µl at the start of treatment had poorer immunologic outcomes than patients with >200 cells/µl, consistent with the findings of previous studies  . ReducinHowever, some limitations of this study deserve mention. The sample size was small and all the patients came from a single center, limiting the extent to which the results can be generalized in whole China. No control group receiving a NNRTI was included. In addition, for reasons that were not always recorded on the patients’ medical charts, only 159 patients were still in follow-up at 24 months, corresponding to an attrition rate of 33%. In addition, the higher loss of follow-up in the group of LPV/r may be related to the bi-daily administration, and/or to the digestive tract side effects. The data were limited to those available from the medical charts, and it was not possible to test additional biomarkers or factors associated with treatment failure. Additional studies are required to address these issues.In conclusion, LPV/r-based ART was found to be beneficial and well-tolerated as a first-line ART in a resource-limited setting such as China. We observed high rates of virological suppression, immunological responses, and tolerability in treatment-naïve patients. Long-term (24 months) treatments with TDF+3TC+LPV/r or AZT+3TC+LPV/r were similarly beneficial. The use of LPV/r-based ART for treatment-naïve patients could be beneficial for patients for whom drug resistance testing is not available.All datasets generated for this study are included in the article/supplementary material.The studies involving human participants were reviewed and approved by the Beijing Youan Hospital Research Ethics Committee, Beijing Youan Hospital, Capital Medical University. The patients/participants provided their written informed consent to participate in this study.BS, YW, LD, and LS conceived the study, designed the experiments, and analyzed the data. TJ, HZ, ZL, AL, YS, and WH performed the experiments, carried out the data collection and data analysis. RZ, TZ, HW, SH, and LS contributed to reagents and materials. BS, YW, and LD wrote the article and revised the manuscript. All authors read and approved the final manuscript.th Five-Year Grand Program on Key Infectious Disease Control , the National Natural Science Foundation of China , the Beijing Municipal of Science and Technology Major Project (D161100000416003 to HW), Beijing Municipal Administration of Hospitals’ Youth Program (QML20161702), and the Beijing Key Laboratory for HIV/AIDS Research (BZ0089). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.This work was supported by the National 13The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


In ART programs in sub-Saharan Africa, a growing proportion of HIV-infected persons initiating first-line antiretroviral therapy (ART) have a history of prior antiretroviral drug use (PAU). We assessed the effect of PAU on the risk of pre-treatment drug resistance (PDR) and virological failure (VF) in a multicountry cohort of HIV-infected adults initiated on a standard non-nucleoside reverse transcriptase inhibitor (NNRTI)-based first-line ART. Multivariate logistic regression was used to assess the associations between PAU, PDR and VF . Causal mediation analysis was used to assess the proportion of the effect of PAU on VF that could be eliminated by intervening on PDR. Of 2737 participants, 122 (4.5%) had a history of PAU. Participants with PAU had a 7.2-fold (95% CI 4.4–11.7) risk of carrying PDR and a 3.1-fold (95% CI 1.6–6.1) increased risk of VF, compared to antiretroviral-naïve participants. Controlling for PDR would eliminate nearly half the effect of PAU on the risk of VF. Patients with a history of PAU are at increased risk of ART failure, which is to a large extent attributable to PDR. These findings support the recent WHO recommendations for use of differentiated, non-NNRTI-based empiric first-line therapy in patients with PAU. Although reliable data are limited, ART programs in sub-Saharan Africa have reported that between 10 and 25% of first-line ART initiators have previously used antiretroviral drugs, either because they re-started ART after disengaging from care, or they used short-course antiretrovirals through prevention of mother-to-child transmission (PMTCT) programs, or pre- or post-exposure prophylaxis2.In low and middle-income countries (LMICs), antiretroviral treatment (ART) regimens to treat HIV-1 infections are standardized under the WHO-defined public health approach3, which impairs response to standard non-nucleoside reverse transcriptase inhibitor (NNRTI)-based first-line ART6. However, for patients with PAU, few studies to date have evaluated the response to standard first-line ART or optimal management7. The vast majority of LMICs provide standard first-line therapy regardless of antiretroviral history or PDR testing8.People with previous antiretroviral drug use (denoted PAU) are at an increased risk of having drug-resistant HIV before starting ART This study aimed to investigate the effects of PAU on PDR and virological failure (VF) in a multi-country cohort in sub-Saharan Africa, and the extent of which this effect could be eliminated by intervening on PDR.5, conducted between 2007 and 2014. All participants were followed up according to local standard-of-care guidelines. The present study included all participants who initiated first-line ART containing an NNRTI plus two NRTIs. Retrospective viral load (VL) testing was performed before ART initiation and annually after ART initiation. Participants provided written informed consent at study enrolment. The study was approved by the appropriate research ethics committees at all collaborating sites and the Amsterdam UMC, University of Amsterdam, Institutional Review Board. The study was performed in accordance with relevant guidelines and regulations.The Pan-African Studies to Evaluate Resistance Monitoring (PASER-M) study was a prospective multi-country cohort including 13 sites in 6 countries , as profiled elsewhere5. Sanger sequencing of the pol gene was performed if VL ≥ 1000 cps/ml using in-house assays. PDR was defined as the presence of ≥1 major drug resistance mutation (DRM) included in the International Antiviral Society–USA mutation list of December 2017 that are associated with any NRTI or the NNRTIs nevirapine or efavirenz9, plus the revertant mutations at codon 215 (A/C/D/E/N/S/V)10.VL and PDR were retrospectively measured at either of two reference laboratories in Uganda and South AfricaMultivariate logistic regression with robust standard errors to account for clustering of observations within sites was used to assess the association between PAU and PDR and VF at month 12, defined as VL ≥ 400 cps/mL or a switch to second-line ART due to treatment failure up to 12 months. PAU was defined both as a dichotomous and a categorical variable according to type as follows: none, ART (standard triple ARV combinations), single-dose nevirapine (sdNVP) for PMTCT, or other ARV combinations . Models were adjusted for potential confounders, which were selected stepwise from the following list of independent variables: age, sex, country, calendar year of treatment initiation, type of NNRTI and NRTI, PDR, pretreatment VL and CD4 cell count, and the 12 months average of 30-day self-reported adherence. Subsequently, we investigated PDR as a potential effect modifier of the association between PAU and VF by including an interaction term in the model, and stratifying the model according to the presence/absence of PDR.11. We calculated: 1) the proportion mediated, a measure that determines how much of the effect of the exposure (PAU) on the outcome (VF) is due to the effect of the exposure (PAU) on the intermediate (PDR). Proportion mediated is calculated as the ratio of natural indirect effect  to the total effect (TE), where TE = NIE + NDE ; 2) the proportion eliminated, a measure that determines the effect of the exposure (PAU) on the outcome (VF), that could be eliminated by intervening on the intermediate (PDR). Conceptually, this is the scenario where each patient receives a fully active ART regimen, either empirically or guided by PDR testing; therefore, by intervening on PDR we could eliminate a part of the effect of PAU on VF. Proportion eliminated is calculated as TE-CDE(m =0 )/TE, where CDE (controlled direct effects) is the effect of PAU on VF while fixing the intermediate PDR (m) to level 0. The causal mediation analysis was done using the paramed syntax in Stata with log-linear regression, assuming interaction12.We also investigated PDR as a potential intermediate on the causal pathway of the association between PAU and VF using causal mediation analysis Fig. 11. We ca1; (2) We assessed the effect of PAU on acquired drug resistance (ADR) at 12 months for patients with VF ≥ 1000 cps/mL; (3) We further elucidated the effects of PDR on VF by restricting its definition to the presence of NNRTI-resistance (NNRTI-PDR); (4) We assessed the longer-term effect of PAU on VF (up to 24 months follow-up).We performed the following sensitivity analyses to confirm the robustness of the associations: (1) We used a higher VL threshold of ≥ 1000 cps/mL to define VF (WHO definition)Of the 2737 participants initiating ART, 122 (4.5%) had a documented history of PAU and 2615 (95.5%) were antiretroviral-naive; 23 (0.8%) participants were excluded because information on PAU was missing Table . Compare2557/2714 (94.2%) participants had a PDR test performed, of whom 144 (5.6%) had PDR, with 115/2442 (4.7%) in antiretroviral-naïve participants and 29/115 (25.2%) among those with PAU (p < 0.001) .200/2031 (9.8%) participants who had a VL test result at 12 months experienced VF while 9 other patients had been switched to second-line treatment before 12 months. Of these 20/86 (23.3%) patients had PAU and 190/1953 (9.7%) were antiretroviral-naive (p ≤ 0.001). In the adjusted analysis, the odds of VF was 3.1-fold  higher in participants with PAU, compared to those who were antiretroviral-naive; and varied with the type of PAU: aOR 3.1  after sdNVP, 3.9  after ART, and 1.4  after other ARV combinations . Genotypic results were available for 130/182 participants with a viral load >1000 cps/mL at 12 month, 95 (73%) of which had one or more major drug-resistance mutations. Compared with antiretroviral-naive participants, people with PAU had an increased risk of ADR   In the regression model with interaction term, there was no evidence that PDR was an effect modifier of the association between PAU and VF (p for interaction = 0.485) Table . SimilarTable proportion mediated (33%) and an increase in the proportion eliminated (51%%)  and an increase in the proportion eliminated (63%) .192/1838 (10%) participants who had a VL test result at 24 months experienced VF while 53 other patients had been switched to second-line treatment before 24 months. Of these 25/73 (34.2%) patients had PAU and 243/1818 (13.4%) were antiretroviral-naive (p ≤ 0.001). In the adjusted analysis, the odds of VF was 4.3-fold  higher in participants with PAU, compared to those antiretroviral-naive; and varied with the type of PAU: aOR 2.9  after sdNVP, 6.7  after ART, and 3.0  after other ARV combinations Table .Causal mediation analysis showed that the proportion of the effect of PAU on VF mediated through PDR was 24% and the proportion of the effect of PAU on VF that could be eliminated by intervening on PDR was 29%.This prospective study among HIV-infected adults in sub-Saharan Africa starting first-line NNRTI-based ART found that persons who had a history of PAU, i.e. ART or sdNVP for PMTCT, were seven times more likely to have PDR, and three times more likely to experience VF within the first year of NNRTI-based ART, compared to those who were antiretroviral-naïve at ART initiation.13, with higher impact among patients with PAU15.A causal mediation analysis provided two important additional insights. First, the pathway through the intermediate PDR was estimated to explain about 38% of the operation of the effect of PAU on VF. Conceptually, this means that the higher VF rates found in patients with PAU could partially be attributed to the presence of PDR, predominantly associated with the drug class of NNRTIs. We speculate that the residual effect of PAU could partially be attributed to unmeasured NNRTI-resistant minority variants, since the limited sensitivity of Sanger-based sequencing to detect minority virus populations may have resulted in an underestimation of the total effect of PDR. NNRTI-resistant minority variants have previously been shown to be associated with VFSecond, if we could eliminate the effect of the intermediate PDR on VF, the effect of PAU on VF is estimated to be reduced by half or more. Conceptually, this means that the use of an alternative fully-active first-line regimen in patients with PAU could half the number of failures that are attributable to PAU. This could be achieved by adopting either of two strategies in patients with PAU: the use of individualized PDR testing to guide the choice of first-line treatment, or a change of standard first-line regimen that is non-NNRTI-based (e.g. dolutegravir). The latter option has the advantage of addressing the potential residual impact of PAU on VF due to unmeasured minority resistant variants in absence of more sensitive resistance tests.2. A cross-sectional study in Nigeria found that patients with PAU were four times more likely to experience VF when initiated on NNRTI-based therapy7.Previous studies on this topic are limited. Across seven WHO-led national surveys in LMICs, PDR was found to be considerably higher among persons with PAU (22%) than among antiretroviral-naive people (8%)8. Our findings also provide further support to lifelong ART in childbearing women (PMTCT option B+) to avoid the risks associated with cycles of ART stopping and re-starting.Our findings emphasize the importance of thorough assessment of previous antiretroviral history before ART initiation, and the use of non-NNRTI-based empiric first-line therapy (e.g. based on the integrase-inhibitor dolutegravir) in line with the latest WHO guidelines (July 2017)Our findings suggest that potential interventions to eliminate the effect of PDR  could significantly reduce the risk of VF attributable to PAU. This impact is particularly substantive in reducing early VF during the first year of ART (48% risk reduction up to 12 months). However, in the longer term the impact may be more modest (29% risk reduction up to 24 months). These findings suggest that in the longer term the influence of PDR may be waning and that other factors explain the continuous impact of PAU on the risk of VF. We hypothesize that unaddressed factors associated with the initial default from care (hence the presence of PAU) may be undermining succesful adherence to long-term treatment, underscoring the need for enhanced adherence interventions for patients with PAU.Strengths of the study were its prospective design, large sample, and the availibility of combined data on PAU, PDR and virological outcomes. The setting of routine ART programs enhanced the generalizibility of the results to other LMICs.16. This could have resulted in overall underestimation in the effect of PAU on VF. These limitations highlight the importance of enhancing electronic patient information systems that can link patient data across ART delivery sites.Study limitations were the lack of detailed PAU histories, precluding an in-depth analysis of attributes such as adherence, dosage, timing and duration, and the use of patient self-report and medical records to document PAU histories, with potential for recall and desirability biasIn conclusion, patients with a history of PAU in African ART programs are at increased risk of ART failure, which is to a large extent attributable to the presence of PDR. To help meet the third of the UNAIDS global targets , the choice of first-line ART regimens should be guided by a thorough assessment of antiretroviral history. Patients with PAU should receive differentiated, non-NNRTI-based empiric first-line therapy as recommended by the latest WHO guidelines.Lusaka Trust Hospital , Coptic Hospital (M Labib), KARA Clinic and Laboratory (J Menke), Lusaka, Zambia; Muelmed Hospital, Pretoria, South Africa ; Themba Lethu Clinic, Clinical HIV Research Unit,  and Department of Molecular Medicine and Haematology , University of the Witwatersrand, Johannesburg, South Africa; Acts Clinic, White River, South Africa (M Hardman); Newlands Clinic, Harare, Zimbabwe ; Coast Province General Hospital, International Centre for Reproductive Health Kenya, Mombasa, Kenya ; Mater Misericordiae Hospital, Nairobi, Kenya (M Dolan); Joint Clinical Research Centre, Fort Portal, Mbale and Kampala, Uganda ; Lagos University Teaching Hospital, Lagos, Nigeria ; Department of Virology, University Medical Center, Utrecht, The Netherlands (R Schuurman); Amsterdam Institute for Global Health and Development, Kampala, Uganda ; Department of Global Health, Amsterdam UMC of the University of Amsterdam, Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands .Supplementary tables


This study aimed to understand the influence of local media, religion and cultural beliefs on the therapeutic compliance of patients living with HIV.This study was conducted in two rural hospitals in the Central Kongo province of the Democratic Republic of Congo. Semi-directional interviews were conducted with patients on antiretroviral therapy using a phenomenological qualitative method.Our results indicated that patients living with HIV in the rural region of the Democratic Republic of Congo are in a constant state of tension between the messages for compliance to antiretroviral treatment advocated by caregivers, and those broadcasted by audiovisual media, religious leaders and local beliefs. This dissonance constitutes a real barrier to therapeutic compliance.Collaborative strategies between healthcare providers, patients, as well as religious, media and traditional organizations are urgently needed. In Deceer HAART .Our study was based on the well-known Festinger's theory on cognitive dissonance. This theory suggests that each individual has an inner desire to maintain all one's attitudes and beliefs in harmony . HoweverStudy sites: this study was conducted in May and June 2016 in two rural hospitals in the central Kongo province (Nsona-nkulu of Mbanza-ngungu and Saint-Luc of Kisantu) in the Democratic Republic of Congo. We selected these hospitals for two main reasons. First, they are among the most important structures in rural areas treating such a large number of HIV-patients. Second, the authorities of these two sites expressed strong support for the conduct of the study.Study design and patients' recruitment: we used a qualitative approach based on a phenomenological method in order to characterize patients' experiences and their own interpretations during the antiretroviral treatment process [ process . Adult vData collection: semi-directional individual interviews were conducted in three languages, two local  and one official (French). Open-ended questions were asked to patients using the language of their choice, allowing them to freely and easily talk about their disease and HIV-related issues [d issues . All intSample selection: as this research focused on interviews accumulating multiple cases and based on oral histories with recorded and fully transcribed interviews, a contrast-saturation sample was preferred [referred . This sareferred . Indeed,Transcript: the recorded information was faithfully and completely transcribed shortly after the interview on paper and on a computerized document in the language of expression of the patient by the researcher himself. After all the interviews, a summary sheet of each interview - mentioning the time, duration and place of the interview and the major lines of the context was filled in.Translation of interviews: interviews recorded in local languages  were translated into French by two professionals holding master degrees in these languages. Firstly, each expert carried out the translation independently. Secondly, a comparison of the translated texts was conducted after in order to detect the diverging points.Data analysis: based on the transcriptions of each interview, a content analysis was performed using the Hsieh method [h method . This aph method . This meEthical aspects: the study was approved by the National Committee of Health Ethics (NCHE) of the Democratic Republic of Congo (decision N ° 017/CNES/BNPMMF/2016 of 08 January 2016). The authorities of each site selected for the study were informed before the actual start of the study and enabled to introduce us to head nurses and doctors in charge of the care of HIV-patients. An informed consent form written in French and translated into local languages  was filled by the investigator for each patient. Thus, before beginning the interview, the interviewer read carefully the informed consent form in the language of choice of the patient. A copy of the consent form, was provided to interviewees, in case they have questions later. Providing an informed consent was a selection criterion for the enrolment in the study. Each interview was recorded using dictaphones and notes were also taken. Any patient for whom informed consent was originally sought was free to interrupt the interview and withdraw the consent at any time of the study. The confidentiality of data registration and notes was strictly respected. Written patient data were systematically stored in a locked cabinet. Computer files were protected using passwords. The recordings used during the analyses were destroyed afterwards.A total of 50 interviews were conducted among patients aged between 19 and 79 years old, including 18 men and 32 women. The largest number of interviews (26) were conducted at the Nsona-Nkulu site (26 vs 24), including 43 conducted using the local languages . Interviews lasted on average less than 34 (±10) minutes.Disagreement in the media: all patients confirmed to have received useful guidance and advices from healthcare providers, helping them to follow their HIV antiretroviral treatment. However, several participants revealed that anti-HAART propaganda was made through various messages broadcasted on local radio stations. These messages included claims for curative treatments for HIV, encouraging patients to stop HAART. "…at the very beginning of antiretroviral treatment, the nurses explanations helped me a lot and I was taking my medication appropriately. But…Last month I stopped taking my antiretrovirals for 5 days, especially because people are promoting certain products coming from India through local radios they do not like mixing with modern treatment, I had to interrupt the antiretrovirals temporarily and I took them back when I found that all they said was false." This conflicting information left patients in a state of permanent psychic tension, with doubts on whether or not taking antiretroviral treatment. "But above all we are confused. Should we go to those people who talk about the complete cure of AIDS through some local radios or should we continue with antiretroviral therapy …"Dissonance in the messages of religious leaders: religions and religious leaders have an important role in the facilitation of the therapeutic compliance but may also be a barrier. Patients stressed that spiritual leaders of mother churches  often recommend patients to take into account caregivers' trustworthy advices. "… I was already discouraged, but my pastor convinced me to continue this treatment. When I saw him, he told me that he could pray for me, but his prayer would be effective if I continued with the treatment. Since then, I resumed treatment and I am better …" In contrast, other patients emphasized the negative role of charismatic churches called revivals, disorienting them by promising miracle cures related to their ability to castigate the evil spell. "In our church, the deacons initially told us that this disease was caused by sorcerers. They began by chasing away evil spirits for 4 months with towels, we were given holy water to drink instead of antiretrovirals "; "We went into exorcising by stopping the treatment for three months. Afterwards, I realized that on the contrary my health was getting worse … And since I restarted the treatment, my weight increased, I resumed certain activities …" Patients stressed that they were trying to listen to contradictory messages; on the one hand messages supporting antiretroviral therapy from the leaders of the traditional churches, and on the other hand messages from the revival churches advocating miraculous healing. In short, traditional churches urge the patients to start treatment as early as possible while in contrast revival churches recommend to delay the start of antiretroviral therapy because they associate mysticism to the disease, using exorcism to care it. "… ohhhh the priest of the parish prayed for me, he advised me to go back to hospital in order to continue the treatment after the prayer. My sister did not trust the priest and took me to their pastor. The latter rather said that my illness was from a mystical cause whose healing is only spiritual … I spent a long time without treatment, … I was confused "At the revival church, they told me not to start antiretroviral therapy because it was first necessary to get out the evil spirits that are in me … That's why I started my treatment very late… when I met the spiritual chief of our Kimbanguist church, he blessed me and asked me to go back to hospital and start my treatment as soon as possible. This supported me, and I decided to resume the treatment." All these contradictory messages from the spiritual leaders of mother and revival churches raise questions on the right path to follow among patients who seem really disoriented by the strategies adopted by revival. Generally, this is only after their health condition deteriorates that patients resume treatment. Thus, it would seem that health deterioration was the main factor that forced patients to start antiretroviral therapy. "I sometimes interrupted it, especially when religious care required it. But when I saw that my health was collapsing, I decided to break this path. And since I took my antiretroviral treatment, it´s fine now ".Dissonance in traditional beliefs: some patients also mentioned that in chronic diseases, cultural beliefs, traditions and customs still have a strong hold in spite of the social evolution. These cultural beliefs may raise doubts on the effectiveness of the antiretroviral treatment. "… In our country, we resort to modern medicine especially for acute disease. However, the path of traditions is not yet neglected. Since my childhood, this is the way that our parents used to cure us of any incurable disease … no, I doubt that antiretroviral treatment will really work…" Moreover, in most cases, patients are in conditions of vulnerability and feel victims or accused. That is why, very often, family members may take the lead in the management of their disease. "I cannot decide…My brother forced me to take traditional treatments. I was frustrated, stressed out…" Several patients also reported seeing the "modern" medical doctor during the antiretroviral treatment process but also at the same time traditional healers due to the insistence of their family. Patients listed the different strategies used by traditional healers to "cure" their disease among which intake of herbal teas or resort to tatoos " Many people advised us to go to hospital, to see a doctor or a nurse, at the same time we were advised to resort to tattoos, to consume several herbal teas we are wondering on whom to rely". Other patients indicated that the use of fetishism during antiretroviral therapy may be relevant. In most cases, these fetishists require VIH patients to drop antiretroviral therapy during the incantation period. However, patients generally resume treatment once their health has deteriorated. "I gave up on antiretroviral treatment because I had to adhere to the instructions of the fetishist doctors. Imagine that one of them made me drink the blood of a hardly slaughtered fowl. Another fetishist doctor made me sleep under the bed for 4 nights. While I spent time with the fetishist doctors, my health changed in a very negative way. I decided to go back to the antiretroviral treatment, otherwise it would be very bad for my health ". In Africa in general, HIV is often considered as a bad luck thrower disease. This design prevents people living with HIV from initiating antiretroviral therapy as soon as possible. Moreover, for patients on antiretroviral therapy, this cultural belief arouses the appearance of a cognitive dissonance Our study enabled us to better understand the influence of media, religions and cultural beliefs on compliance to antiretroviral therapy in 50 patients from rural regions of RDC. The phenomenological based approach also permitted us to thoroughly investigate patients' personal experiences . We adapDissonance in broadcast messages: our findings indicate two opposite media views r regarding antiretroviral therapy: one supporting antiretroviral therapy and the other broadcasting anti HAART messages. This indicates a dangerous lack of control as regards broadcast messages. And yet "any communication act should be part of the cognitive environment of the population and should be understood on the basis of the experience of its realization [lization . Our finlization . For inslization . In addilization . Thus, "lization . Inconsilization . An effeDissonance in the messages from religious leaders: traditional African religion plays an important role in individual's day life, as an essential element of the "indigenous knowledge systems". However, this "knowledge" also appears to be an important source of dissonance among patients with VIH. Our results are in line with other studies carried out in rural regions showing that spirituality plays an important role in the self-regulation of the disease and its treatment [reatment . Our resreatment . In our reatment  traditioreatment . This trreatment . We showDissonance on traditional beliefs: beliefs in tradition are the third major reason which creates psychic tension among patients with. Such beliefs on antiretroviral therapy (ARV) are crucial for the compliance with treatment but are still too poorly documented in sub-Saharan African countries [et al. [ountries . Kemppai [et al.  demonstr [et al. . We also [et al. . TraditiOur results suggested that the speeches from religious leaders or from media generate a major cognitive dissonance among patients with HIV. Patients find themselves torn between different beliefs, leading to a state constant tension, and causing non-compliance with treatment. Effective strategies to improve the collaboration between the different stakeholders  are urgently needed. Considering all cultural and traditional aspects is also of high relevance in the fight against HIV. In addition, educational interventions and campaigns involving various stakeholders such as caregivers , opinion leaders  as well as local associations raising awareness of the importance of antiretroviral therapy should be implemented among rural populations. Other studies of this kind are needed in similar contexts.Africa remains the continent most affected by HIV infection;The general prevalence of HIV in the Democratic Republic is low, but with the hidden epidemic in rural areas;Chronic diseases in the Democratic Republic of Congo are influenced by culture.Some local media are making antiretroviral propaganda in the context of this study, which propaganda has never been denounced. Cognitive conflicts caused by discreet media in patients on antiretroviral therapy create dissonance that strengthen antiretroviral treatment non-compliance;Sensitization of opinion leaders to the control of the messages broadcasting by medias in connection with the patient's health;The mobilization and involvement of cultural leaders  as a strategy to improve adherence to antiretroviral treatment would be a good therapeutic education strategy in this context.The authors declare no competing interests.