A positive association (p < 0.001) was observed between alpha-tocopherol and cholesterol concentrations, a finding due, in part, to the relationship between liposoluble vitamins and lipid profile. This study demonstrated differences in alpha-tocopherol concentrations between patients using different HAART regimens, especially regimens involving the use of new drugs. Long-term prospective cohort studies are needed to monitor vitamin E status in HIV/AIDS patients since the beginning of treatment.HIV/AIDS patients are probably more predisposed to vitamin E deficiency, considering that they are more exposed to oxidative stress. Additionally, there are an extensive number of drugs in the highly active antiretroviral therapy (HAART) regimens that may interfere with vitamin E concentrations. The objective of this study was to compare serum concentrations of alpha-tocopherol in 182 HIV/AIDS patients receiving different HAART regimens. The patients were divided into three groups according to regimen: nucleoside analog reverse-transcriptase inhibitors (NRTIs) + non-nucleoside analog reverse-transcriptase inhibitors (NNRTIs); NRTIs + protease inhibitors + ritonavir; NRTIs + other classes. Alpha-tocopherol was assessed by high-performance liquid chromatography. Multiple linear regression analysis was used to evaluate the effects of HAART regimen, time of use, and compliance with the regimen on alpha-tocopherol concentrations. Alpha-tocopherol concentrations were on average 4.12 μmol/L lower for the NRTIs + other classes regimen when compared to the NRTIs + NNRTIs regimen ( Acquired immunodeficiency syndrome (AIDS) is characterized by progressive depletion and dysfunction of CD4 T cells, associated with the development of opportunistic infections and neoplasms. Several mechanisms are involved in this process, including chronic immune activation that disrupts T cell homeostasis and induces oxidative stress, with depletion of plasma antioxidant concentrations ,2. ThereAntioxidants are known to play a vital role in the immune system, reducing oxidative stress induced by the excessive production of reactive oxygen species . Apparen3. Since 2013, treatment is recommended for all HIV-infected patients with CD4 T lymphocyte count ≤500 cells/mm3 [The introduction of highly active antiretroviral therapy (HAART) has significantly increased the life expectancy of patients infected with HIV. In fact, the primary goals for initiating therapy are to reduce HIV-associated morbidity, to restore and preserve immunological function, to suppress plasma viral load, and to prevent HIV transmission . Treatmeet al. [With the emergence of HAART and all its benefits, researchers and clinicians believed that oxidative stress could be decreased in HIV-infected patients. However, the effect of HAART on oxidative stress is controversial. A previous study has shown that HAART permits better control of viral load, consequently increasing the concentrations of antioxidants to normal levels . Howeveret al.  raised tAmong antioxidants, vitamin E has been extensively studied over the past decades, mainly because of its ability to serve as a chain-breaking antioxidant, to prevent the propagation of lipid peroxidation, and to reduce free radical damage . Vitaminet al. [According to Fawzi  and Montet al. , the rapet al. . Additioet al.  that mayTo our knowledge, no study has compared vitamin E status among patients on different antiretroviral therapies. Therefore, the objective of the present study was to compare serum vitamin E concentrations in patients with HIV/AIDS receiving different HAART regimens.The clinical protocol of this study (COEP No. 1915/09 and 0113/09) was in accordance with the ethical guidelines of the National Health Council. All subjects gave informed consent to participate in the study.3, who had received stable HAART for at least 6 months [A cross-sectional study was conducted on 182 HIV-infected men and women ranging in age from 20 to 59 years and with CD4 T lymphocyte counts ≥200 cells/mm6 months . The patA questionnaire was applied for collection of demographic, socioeconomic, life style, clinical, biochemical and immunological data, as well as data regarding HAART. The results of the most recent laboratory tests of the patients (up to 6 months prior to the interview) were considered for analysis.Body weight and height were measured in duplicate. The nutritional status of the patients was assessed based on body mass index (BMI) and was classified according to WHO criteria .The different HAART regimens used by the patients were divided into three groups and included at least three drugs: 2 nucleoside analog reverse-transcriptase inhibitors (NRTIs) and 1 non-nucleoside analog reverse-transcriptase inhibitor (NNRTI); 2 NRTIs and 1 protease inhibitor (PI) plus ritonavir; 2 NRTIs and other classes including fusion inhibitors, integrase inhibitors, entry inhibitors, and PIs plus these drugs. The other classes of antiretroviral drugs specified above were grouped together because of the small number of patients using these recent drug classes.et al. [Compliance with HAART was defined based on the criteria of Nemes et al.  as the i®, Excelsa Baby I  and stored in properly identified amber Eppendorf® tubes  at −80 °C until the time of analysis.Peripheral blood samples were collected after a 12-h fast in a dimly lit room to prevent degradation of vitamin E. The samples were centrifuged immediately at 3000 rpm for 15 min . Next, 50 μL of the mixture was injected into an HPLC system  equipped with a Rheodyne manual sample injector . The chromatograms were integrated using the Shimadzu Class VP software , and calibration curves were constructed for the calculation of alpha-tocopherol concentrations. Separation was performed on a 5-μm HyperClone ODS C18 analytical column . The cut-off points used for alpha-tocopherol were <11.6 μmol/L (deficient levels), 11.6 to 16.2 μmol/L (low levels), and >16.2 μmol/L (acceptable levels) [Considering that alpha-tocopherol is the most biologically active form of vitamin E , alpha-tet al. . After tTotal cholesterol and fractions and triglycerides were analyzed by the cholesterol oxidase-phenol ampyrone (CHOD-PAP) and glycerol phosphate oxidase-phenol ampyrone (GPO-PAP) colorimetric enzymatic methods, respectively. For samples showing triglycerides <400 mg/dL (4.52 mmol/L), serum low-density lipoprotein (LDL)-cholesterol concentration was estimated using the formula of Friedewald .Subpopulations of CD4 T lymphocytes were analyzed qualitatively by flow cytometry . Viral load was evaluated quantitatively by the branched DNA 3.0 method .Data were double entered using the EpiData 3.1 program  and analyzed with the Stata 10 program . Absolute and relative frequencies and measures of central tendency (mean and median) and dispersion  were used for description of the sample.Multiple regression analysis was performed to determine the effect of the explanatory variables  on the response variable . Gender, age, education, per capita income, smoking status, physical activity, BMI, clinical comorbidities, HIV infection (years), total cholesterol and fractions, triglycerides, and CD4 T lymphocyte count were used as control variables.p value. A level of significance of 0.05 was adopted in the final model.Vitamin E is a liposoluble compound, which depends on lipoproteins for its transport in human plasma. Therefore, among other variables, total cholesterol was included as a control variable in the multiple regression analysis. The explanatory variables were entered into the multiple regression models irrespective of their The present study was approved by the Ethics Committees of the Public Health School (COEP No. 079/09) and School of Medicine (CAPPesq No. 0113/09), University of São Paulo. All subjects gave informed consent to participate in the study.The baseline characteristics of the study population are shown in Most of the patients were males (62.1%). The mean age was 43.8 (±6.6) years and the patients had 10.9 (±3.7) years of schooling and a per capita income of R$ 890.00 (991.1). One third of the patients were smokers and a similar proportion reported no physical activity. According to BMI, more than 50% of the subjects were eutrophic, 36% were overweight, 5.5% were obese, and approximately 4% were underweight. Clinical comorbidities associated with metabolic alterations were observed in 54.9% of the patients and mainly included dyslipidemia, hepatitis, lipodystrophy, arterial hypertension, diabetes mellitus, and insulin resistance (data not shown). Infection with HIV was due to unprotected sexual relations in 74.2% of the interviewed subjects and the mean duration of HIV infection was 11.5 (±4.1) years. The mean time of use of the last HAART regimen was 4.0 (±2.7) years. Most patients used the combination of NRTIs + NNRTIs (47.3%) and NRTIs + PIs plus ritonavir (46.2%). With respect to compliance with the HAART regimen, 81.9% of the subjects reported to have consumed the antiretroviral drugs during 3 days before the interview.Mean alpha-tocopherol concentration was 21.9 (±6.9) μmol/L. Deficient, low and acceptable concentrations of this vitamin were observed in 6.6%, 12.1% and 81.3% of the patients, respectively.Mean total cholesterol and high-density lipoprotein (HDL)-cholesterol levels were within the normal range recommended for adults  and HDL-cholesterol: ≥40 mg/dL (1.0 mmol/L)). Mean LDL-cholesterol and triglyceride concentrations were above the levels recommended by the US Department of Health and Human Services (LDL-cholesterol: <100 mg/dL (2.6 mmol/L) and triglycerides: <150 mg/dL (1.7 mmol/L)) . Elevate3) was 649 (±279.9) and the median value was 592 (range: 200–1746). The laboratory test results of one patient were excluded because no recent tests could be obtained.Viral load was undetectable in 85.1% of the sample. Mean CD4 T lymphocyte count (cells/mmp = 0.037) (p < 0.001) was observed between serum alpha-tocopherol concentrations and cholesterol, with an average increase in this vitamin of 0.082 μmol/L per 1 mg/dL (0.026 mmol/L) increase in cholesterol. The HAART regimen, duration of the last HAART regimen, HAART compliance and total cholesterol explained 19% of the variation in alpha-tocopherol concentrations.In the final multiple linear regression model, serum alpha-tocopherol concentrations differed significantly between two of the HAART regimens used (= 0.037) . Alpha-tThe HAART era has led to a decline in mortality and in comorbidities related to HIV infection. However, concern with the quality of life and survival of HIV-infected individuals continues in view of the frequent occurrence of metabolic disorders  that migp = 0.03) in mean alpha-tocopherol concentrations in patients receiving the combination of NRTIs + other classes when compared to those using NRTIs + NNRTIs. These lower concentrations of alpha-tocopherol in the group using NRTIs combined with the other classes of antiretroviral drugs (most of them new drugs) may be related to indications of salvage therapy, intolerance or poor treatment compliance, previous use of inadequate regimens, and primary resistance (subjects carrying a resistant virus) [The results of this study showed a decrease of 4.12 μmol/L (t virus) ,21. Regrt virus) .in vitro study, Munteanu et al. [et al. [et al. [In the pre-HAART era, more than 60% of HIV-positive patients commonly had vitamin and/or mineral deficiency, a fact suggesting that the infection itself leads to nutritional deficiencies . Howeveru et al.  suggeste [et al.  reported [et al.  found hiet al. [et al. [et al. [et al. [Deficient (<11.6 μmol/L) and low (11.6 to 16.2 μmol/L) concentrations of alpha-tocopherol were observed in 18.7% of the population studied. Mean concentrations of alpha-tocopherol were 21.62 (±6.33), 22.60 (±6.92) and 19.11 (±10.21) μmol/L in the different intervention groups . One of the difficulties in comparing the results of studies evaluating alpha-tocopherol concentrations in HIV-infected patients is the arbitrary use of different cut-off values. Pontes Monteiro et al.  observed [et al.  demonstr [et al.  and Falc [et al.  reported [et al.  impairs et al. [An additional problem is that serum concentrations of micronutrients may not reflect the true nutritional status of subjects infected with HIV. According to Tang et al. , interpret al. .Dyslipidemia, a metabolic disorder commonly observed in patients with HIV/AIDS, is characterized by increases in total cholesterol, LDL-cholesterol and triglycerides, and a reduction in HDL-cholesterol. Hypertriglyceridemia, for example, is frequently observed in HIV-infected patients . Risk coFinally, this study has some limitations: (1) the cross-sectional design which does not permit to establish cause-effect relationships; and (2) the lack of measurement of acute phase proteins, although acute infection was an exclusion criteria for selection of the patients.HIV/AIDS patients in Brazil will probably benefit from vitamin E supplementation, especially those receiving HAART regimens consisting of NRTIs and other classes . Long-term prospective cohort studies are needed to monitor vitamin E status in HIV/AIDS patients since the beginning of treatment to confirm our results.


Objective: Best long-term practice in primary HIV-1 infection (PHI) remains unknown for the individual. A risk-based scoring system associated with surrogate markers of HIV-1 disease progression could be helpful to stratify patients with PHI at highest risk for HIV-1 disease progression.Methods: We prospectively enrolled 290 individuals with well-documented PHI in the Zurich Primary HIV-1 Infection Study, an open-label, non-randomized, observational, single-center study. Patients could choose to undergo early antiretroviral treatment (eART) and stop it after one year of undetectable viremia, to go on with treatment indefinitely, or to defer treatment. For each patient we calculated an a priori defined “Acute Retroviral Syndrome Severity Score” (ARSSS), consisting of clinical and basic laboratory variables, ranging from zero to ten points. We used linear regression models to assess the association between ARSSS and log baseline viral load (VL), baseline CD4+ cell count, and log viral setpoint (sVL) (i.e. VL measured ≥90 days after infection or treatment interruption).+ cell count at baseline was negatively correlated with ARSSS , whereas HIV-RNA levels at baseline showed a strong positive correlation with ARSSS . In the regression models, a 1-point increase in the score corresponded to a 0.10 log increase in baseline VL and a CD4+cell count decline of 12/µl, respectively. In patients with PHI and not undergoing eART, higher ARSSS were significantly associated with higher sVL . In contrast, in patients undergoing eART with subsequent structured treatment interruption, no correlation was found between sVL and ARSSS .Mean ARSSS was 2.89. CD4The ARSSS is a simple clinical score that correlates with the best-validated surrogate markers of HIV-1 disease progression. In regions where ART is not universally available and eART is not standard this score may help identifying patients who will profit the most from early antiretroviral therapy. Since 2010, HIV treatment guidelines recommend early antiretroviral therapy (eART) in case of symptomatic primary HIV-infection (PHI) http://clinicaltrials.gov, ID 5 NCT00537966) + cell count, HIV-1 Immunoblot, p24 antigen and genotypic resistance testing). Patients were actively screened for acute hepatitis B and C, syphilis, gonorrhea, chlamydia trachomatis and herpes simplex. If the patient was referred from an external physician, data from the first external visit were recorded.Between January 2002 and September 2012 we prospectively enrolled 290 individuals with a documented PHI in the longitudinal Zurich Primary HIV Infection Study (ZPHIS), which is an open-label, non-randomized, observational, single-center study  was determined as previously described Acute/recent PHI was confirmed in all patients as previously published + cell count, including patients with PHI + cell count dropped to below 350 copies/ml + cell counts were collected every 2-4 weeks during the first three months and then on every regular visit four times annually.Since the beginning of the study in 2002, eART was offered to all patients in a research setting, even though general treatment guidelines did not yet recommend eART for PHI patients Based on an extensive literature search we defined 17 symptoms and signs which we considered ARS symptoms and signs  [21]–; for 14 days 2.2 ; for 28 days 2.0 ; for 60 days 4.7 ; and for 84 days 4.2 . After ZPHI enrollment, 171 of all 290 patients (59%) started an eART within one day. However, patients with an ARSSS above the median score were significantly more likely to start an eART within one day than individuals with an ARSSS below the median value (p = 0.04). Within 7 days, 222 of the 290 (77%) enrolled study subjects had started eART. No correlation was found between the ARSSS and time to virus suppression.To test the hypothesis that individuals with a high ARSSS were treated faster, we investigated whether there was a correlation between an ARSSS above the median value and the time to treatment (i.e. time period between the first positive test and the start of treatment). Indeed, these individuals were treated significantly faster than individuals with an ARSSS below the median value . The impact of having an ARSS above the median value remained significant when we considered whether patients received treatment within a given time-window . After adjusting for CD4Genome-wide genotyping was performed for 250 patients. After SNP quality control and exclusion of population outliers, 652,904 SNPs were available for association testing, from 196 patients of European ancestry. After correction for multiple testing, no association between ARSSS and human SNPs or HLA class I types was found. In particular, the SNPs tagging HLA-B*5701 (rs2395029) and HLA-C expression levels (rs9264942), which are the strongest genetic predictors of HIV-1 control + cell count, the baseline viral load, and the setpoint viral load in untreated patients with a primary HIV-1 infection.The most relevant finding of this study is that the newly developed ARSSS, a risk stratification score based on simple and easily obtainable clinical and laboratory parameters, is predictive of the two major, well studied, and clinically relevant surrogate markers associated with HIV-1 disease progression. In particular, a significant correlation was found between the ARSSS and the baseline CD4+ cell count and viral load + cell count and viral load is less studied and validated due to inherent difficulties in diagnosing and recruiting patients with PHI in large numbers and to the considerable variation of immunological and virological parameters during PHI + cell count <350 cell/µl within six months of seroconversion was associated with a significant increased risk for AIDS and death in patients with PHI in the preART era Although a vast number of potential surrogate markers for HIV-1 disease progression have been studied + cell count and viral load.The potential usefulness of a clinical score to determine the course and prognosis of HIV-1 diseases at the time point of seroconversion was previously demonstrated by other groups a priori defined score is arbitrary and a predictive model is needed. However, there is evidence that useful algorithms can be developed without prior statistical evaluation of individual parameters and formulas. An educated guess based on experience of investigators and knowledge of the literature for selection of variables seem often superior, because they are not affected by accidents of sampling Apgar test which is still used in clinical practice One could argue that the composition of our + cell count, baseline VL and sVL that was observed in untreated patients. However, this absence of a signal could also be due to the limited power (only 40 patients with structured treatment interruption).An interesting finding which supports the clinical value of the ARSSS in selecting patients for early treatment is that in contrast to the sVL in treatment-naïve patients, no correlation was found with sVL of patients having undergone eART with subsequent treatment interruption. It has been clearly shown in several studies that eART during PHI leads to a transient reduction of the viral setpoint by approximately a factor of 10 when compared to deferred therapy An additional value of the ARSSS lays in the fact that this score captures patients at highest risk for HIV transmission. Several studies have demonstrated that the risk of HIV transmission increases with higher viral load Recently, it has been demonstrated that viral genetic traits can explain up to 50% of viral setpoint variation in HIV-1 infected individuals + cell count and VL might have been determined earlier during PHI when CD4+ cell depletion and VL reached high levels. To circumvent this potential bias, we corrected VL and CD4+ cell counts according to the EDI and the significant correlation still remained. (iii) Reporting of clinical symptoms is inherently imprecise, but this problem is reduced by combining several predictors in the ARSSS. (iv) We chose an a priori approach to build our score based on variables selected according to knowledge on the literature and our own experience and did not use a statistical model evaluating individual parameters before building the final score. Potentially, important variables could be missed. It cannot be ruled out that the later strategy would also perform well or even better. However, the selection of variables based on a statistical approach is more prone to selection bias inherent to the data, which is not the case in an a priori approach because selection of the parameters is independent on the dataset that is analyzed using the score. Using both approaches and selecting the better performing score would not be appropriate because they could influence each other. In aggregate, the fact that our a priori built score is predictive of key surrogate markers for HIV-1 progression supports the validity of our approach.Our study has strengths and limitations: Strengths: (i) Patients were seen in one center by a stable study-team and laboratory values were measured in a central laboratory; thus, variability of parameters analyzed could be minimized. The study protocol has been unchanged since 2002. (ii) The study population was homogeneous . (iii) AIn conclusion, the ARSSS predicts the key surrogate markers for HIV-1 disease progression at a very early stage and thus could be used to identify patients with PHI at highest risk of clinical disease progression and may also serve as a research tool. It should be verified in an independent prospective cohort of PHI patients.


Plasma trough concentrations of lopinavir (LPV) given as LPV/r 800/200 mg once daily (OD) are reduced in comparison with 400/100 mg twice daily (BID). While OD dosage of LPV/r is sufficient to achieve viral suppression in plasma, data about drug penetration and viral suppression in central nervous system (CNS) is needed, mainly if LPVr is used as maintenance monotherapy strategy in selected patients. The objective of this study was to evaluate CSF HIV-1 RNA and CSF LPV concentrations in patients receiving LPV/r monotherapy OD (LPVrMOD).This is a cross-sectional sub-study within a prospective, open-label pilot simplification study to evaluate the efficacy and safety of LPV/rMOD in virologically suppressed patients previously receiving a BID LPV/r monotherapy regimen (LPV/rMBID), the “Kmon study” (NCT01581853). To assess LPV concentrations and HIV-1 RNA in CSF, a lumbar puncture (LP) was performed in a subgroup of patients after at least one month of LPVrMOD treatment. Plasma-paired samples of all patients were also obtained. HIV-1 RNA was determined by real-time PCR (limit of detection 40 copies/mL). Liquid chromatography-tandem mass spectrometry  was used to determine CSF and blood plasma LPV concentrations.Nine patients were included. Median (range) age was 48 (34–56) years, median CD4 cell count 672  cells/mL, median nadir CD4 count 125 (35–537) cells/mL and 40% of subjects were HCV-positive. Before starting LPV/rMOD median time on a LPV/r-containing regimen and on LPV/rMBID were 9 (4–11) years and 15 (7–24) months respectively, median time with undetectable HIV viral load was 5 (3–12) years and 2 patients had a previous documented blip. LP was performed a median of 24 (8–36) weeks after starting LPV/rMOD and 24 (11–28) hours after the last LPV/rMOD dose CSF and plasma HIV RNA was 40 copies/mL in all patients. Median LPV CSF concentration was 9.78 (1.93–78.3) ng/mL, median LPV plasma concentration 1,103  ng/mL and median LPV CSF/plasma ratio 0.3% (0.1–1.2).No CSF viral escape was detected and LPV concentrations were above the IC50 for wtHIV-1 (1.9 ng/mL). However, as concentrations were close to IC50 in some patients, a careful clinical follow up of patients receiving this regimen would be advisable. Larger longitudinal studies will be helpful for a better understanding of the CNS antiviral activity of LPVr monotherapy.


Limited data are available on the durability and effectiveness of maraviroc in routine clinical practice. We assessed the durability of maraviroc-containing regimens during a 30-month period, as well as their immunovirological and clinical efficacy, according to viral tropism in treatment-experienced individuals with viral load (VL) >50 copies/ml in the French Hospital Database on HIV.3 measured twice at least one month apart, and clinical failure as hospitalization for a non-AIDS event, an AIDS event, or death. Multivariable Cox regression models adjusted for potential confounders were used to assess the influence of viral tropism on durability, the immunovirological responses, and clinical outcome.Virological success was defined as VL<50 copies/ml, immunological success as a confirmed increase of at least 100 CD4 cells/mm356 individuals started maraviroc with VL>50 copies/ml of whom 223 harbored R5 viruses, 44 non-R5 viruses and 89 viruses of unknown tropism. Individuals with non-R5 viruses were more likely than individuals with R5 viruses to discontinue maraviroc . At 30 months, the estimated rates of virological and immunological success were respectively 89% and 51% in individuals with R5 viruses and 48% and 23% in individuals with non-R5 viruses. In multivariable analysis, non-R5 viruses were associated with a lower likelihood of both virological success (hazard ratio (HR): 0.42; 95% confidence interval (CI), 0.25–0.70) and immunological success . No difference in clinical outcome was found between individuals with R5 and non-R5 viruses. The effectiveness of maraviroc-containing regimens in individuals with unknown viral tropism was not significantly different from that in individuals with R5 viruses. A limitation of the study is the absence of genotypic susceptibility score.In this observational study, maraviroc-containing regimens yielded high rates of viral suppression and immunological responses in individuals with R5 viruses in whom prior regimens had failed. The primary aims of antiretroviral therapy (ART) for HIV infection are to reduce morbidity and prolong life by reducing viral load and restoring the CD4+ T cell count with minimal toxicity/adverse events. Combination antiretroviral therapy (cART) suppresses viral load and delays disease progression, but efficacy can be undermined by the occurrence of drug resistance . New druAs maraviroc efficacy is dependent on R5 receptor usage for cell entry, it is necessary to determine the tropism of the individual’s virus. In France, genotypic tropism assays based on the V3 region of the HIV envelope protein are reimbursed by social security.CCR5 antagonists are also being developed as immunomodulatory and antiinflammatory agents. Clinical studies –12 have The purpose of this study was to describe the routine use of maraviroc in treatment- experienced HIV-infected individuals with treatment failure, and to assess its effectiveness in terms of durability, virological and immunological responses, and clinical outcome according to viral tropism.The French Hospital Database on HIV (FHDH) is a hospital-based multicentre open cohort in which inclusions have been ongoing since 1989 . It inclst, 2008 and June 30th, 2011, at least one year before the last recorded FHDH visit in the center, with an available CD4 cell count within 6 months before maraviroc initiation and at least one CD4 cell count and one VL measurement after maraviroc initiation. HIV-1 coreceptor tropism test execution (yes/no), assay type (phenotypic/genotypic) and result were collected from the medical records. The phenotypic assay was Trofile™ (Monogram Biosciences). The genotypic assay was mainly geno2pheno with a false-positive rate (FPR) cut-off of 10%, which was shown in a study of the ANRS AC11 network of virology laboratories to have good predictive value as compared with the Trofile phenotypic test [This study was restricted to antiretroviral-experienced HIV-1-infected individuals, at least 18 years of age who started maraviroc-based therapy with a viral load (VL) of >50 copies/ml between January 1pic test . The genThe baseline for all analyses was the date of maraviroc treatment initiation. Tropism was classified in 3 categories: R5; non-R5 if X4 or dual; and unknown tropism if not tested or if the results were unavailable. Baseline characteristics were analysed according to viral tropism.3 measured twice at least one month apart); and clinical outcome ; immunological response , baseline CD4 T cell count , baseline VL , use of prophylaxis for opportunistic infections, number of previous antiretroviral drugs, duration of prior antiretroviral exposure, and co-prescribed NRTIs, boosted PI, RAL, and ETV at baseline. All these variables were retained for multivariable analysis. Sensitivity analyses were performed by splitting the results for individuals with “unknown tropism” into two categories: “unavailable” (no knowledge of whether or not a test was performed) and “not tested”. SAS software  was used for all statistical analyses.We calculated Kaplan-Meier estimates for the rates of maraviroc discontinuation, virological response, immunological response and clinical outcome at 30 months. For virological and immunological responses, maraviroc discontinuation could be considered as a competing event . Therefore, a competing-risk approach was adopted when evaluating biological outcomes. In this approach, if maraviroc was discontinued, follow-up was right-censored at the date of the individual's last visit during the 30-month follow-up period. This approach ensures that no endpoint is recorded during the period between maraviroc discontinuation and the end of the 30-month follow-up period, thus avoiding a situation in which the majority of individuals switch from maraviroc and achieve a viral load reduction on an alternative treatment. For the clinical endpoint, we used an intention-to-continue-treatment approach, ignoring treatment change in order to adopt a conservative approach as for the analyses of biological outcomes. Univariable and multivariable Cox regression models were used to assess the influence of viral tropism  on the durability of maraviroc-containing regimens, and on virological response, immunological response and clinical outcome. The following potential confounding factors were analyzed: the type of treatment change (addition of MVC / switch to MVC with no other change / switch to MVC + other new drug(s)), gender, age, sub-Saharan origin, AIDS status, HCV co-infection, the nadir CD4 T cell count (<100/mmThe flow chart of the study is shown in 3), lower nadir CD4 cell counts (median 17 versus 102/mm3) and more frequent AIDS status (63.6% versus 45.3%) than individuals with R5 viruses. Individuals with non-R5 viruses were more likely to be co-prescribed at least three antiretrovirals (84.1% versus 52.5%). The maraviroc-based regimens included at least one NRTI in 68.0% of cases, one PI in 64.6% (darunavir in 40.2%), etravirine in 31.2%, raltegravir in 52.0% and T20 in 8.4%. Median follow-up was 21.4 months (IQR: 14.9–30.4).The individuals’ baseline characteristics are shown in Among the 356 individuals who started maraviroc therapy, 109 individuals discontinued treatment. The estimated rate of maraviroc discontinuation at month 30 was 41%. The flow chart in The estimated rates of maraviroc discontinuation before month 30 were 34% among individuals with R5 viruses and 75% among those with non-R5 viruses . IndividViral load fell below 50 copies/ml in 268 individuals. The estimated rate of virological success at month 30 was 81% overall, with a clear difference between individuals harboring R5 and non-R5 viruses ) Figs  and 4. T3 in 145 individuals. The estimated rate of immunological success at month 30 was 48% overall, with a clear difference between individuals harboring R5 and non-R5 viruses ) ) Figs  and 4. T7)) Figs . The medDuring the 30-month follow-up period, 90 individuals experienced clinical failure consisting of at least one hospitalization for a non-AIDS event n = 44), an AIDS event (n = 41) or death (n = 5). The non-AIDS events necessitating hospitalization were: infections (n = 18), malignancies (n = 4), chronic viral hepatitis (n = 3), gastrointestinal bleeding (n = 2), substance abuse, psychiatric disease, myocardial infarction or other ischemic heart disease, respiratory disease, gastrointestinal disorders (1 case each), other causes (n = 9), and unclassifiable causes (n = 3). The following AIDS events occurred: esophageal candidiasis (n = 7), encephalopathy (n = 7), cytomegalovirus disease (n = 6), Kaposi’s sarcoma (n = 4), Burkitt’s lymphona (= 4), cerebral toxoplasmosis (n = 3), extrapulmonary cryptococcosis, herpes simplex, progressive multifocal leukoencephalopathy (n = 2 each), cervical cancer, Pneumocystis jirovecii pneumonia, recurrent pneumonia, and extrapulmonary mycobacterial infection (n = 1 each). The estimated rate of clinical failure at month 30 was 30% overall, with no difference between individuals with R5 viruses and those with non-R5 viruses ) Figs  and 4.4, an AIDIn this observational study of antiretroviral treatment-experienced individuals with VL >50 copies/ml, we evaluated the effectiveness of maraviroc-based regimens in routine clinical practice. Maraviroc was used mainly in individuals with R5 viruses. Maraviroc discontinuation was more frequent among individuals with non-R5 viruses than among those with R5 viruses. Maraviroc is sometimes prescribed within salvage regimens for individuals with non-R5 viruses and is quickly withdrawn if immune recovery is not achieved. At maraviroc initiation, individuals with non-R5 viruses had more advanced HIV infection including lower CD4 T cell counts, and most of them were prescribed four-drug regimens. The rate of maraviroc discontinuation among individuals with R5 viruses (13% at 12 months) was lower in this observational study than in the Motivate trials (37% at week 48) , possiblAs expected, individuals with R5 viral tropism had better virological and immunological responses than individuals with non-R5 tropism. No influence of R5 status on virological and immunological responses was found in an Italian study , but it Here, among individuals harboring R5 viruses, the rate of VL suppression was 41% at 3 months and 89% at 30 months. In a recent French study of routine clinical practice, VL was <50 copies/ml at 3 months in 54% of 104 treatment-experienced patients starting maraviroc-based therapy . This ra3 in individuals harboring R5 viruses. This is similar to the increase observed at week 96 in the Motivate trials, where the median change was +113 cells/mm3 in individuals receiving maraviroc twice a day [3 after 6 months. In an Italian study of maraviroc, raltegravir and etravirine combination therapy [3 at week 96), possibly because VL at maraviroc initiation was higher (4.2 log10 copies/ml) than in our study (3.3 log10 copies/ml) and in a German study (2.9 log10 copies/ml) [At month 30, the median increase in the CD4 T cell count from baseline was +98 cells/mmce a day . The medce a day , with a pies/ml) . Indeed,pies/ml) .Regarding clinical outcome, we found no significant difference in the combined rate of hospitalization for non-AIDS events, AIDS events and death between individuals harboring R5 viruses and those with non-R5 viruses. This is surprising because the immunovirological success rate was higher in individuals harboring R5 viruses. It might be explained by rapid maraviroc discontinuation and a switch to more appropriate regimens in individuals with non-R5 viruses. Also, follow-up may have been too short or the statistical power too low to show a significant difference in clinical outcome.The main strength of our study is its large size and routine clinical setting, providing additional evaluation of the use of maraviroc in combination with other recent drugs in treatment-experienced patients. In this observational setting, we were unable to adjust the results for the genotypic susceptibility score, or adherence. However, as we adjusted for new drug and type of treatment change, we feel our results are nevertheless robust. Another limitation is that viral tropism was unknown in 25% of cases. However, responses were similar in individuals with unrecorded tropism test performance and those known to harbor R5 viruses suggesting that most of the 15% of individuals with unknown tropism test status had in fact been shown to harbor R5 viruses, without this information being noted in the medical records. Of course, the viral tropism should always be known to allow the maraviroc prescription and the result reported in the medical records.In conclusion, this study shows that, among HIV-infected individuals in treatment failure, maraviroc-containing regimens are generally used in those with R5 viruses, in whom they are effective in terms of durability, viral suppression, immunological recovery, and clinical responses.S1 File(TIF)Click here for additional data file.S1 Text(PDF)Click here for additional data file.


We explored the impact of transient cART started during the primary HIV-infection (PHI) on the long-term immunologic and virologic response on cART resumption, by comparison with treatment initiation during the chronic phase of HIV infection (CHI).We analyzed data on 1450 patients enrolled during PHI in the ANRS PRIMO cohort between 1996 and 2013. “Treatment resumption” was defined as at least 3 months of resumed treatment following interruption of at least 1 month of treatment initiated during PHI. “Treatment initiation during CHI” was defined as cART initiated ≥6 months after PHI. The virologic response to resumed treatment and to treatment initiated during CHI was analyzed with survival models. The CD4 cell count dynamics was modeled with piecewise linear mixed models.3 and CD4% were significantly greater in patients who started treatment during CHI.136 patients who resumed cART for a median (IQR) of 32 (18–51) months were compared with 377 patients who started cART during CHI for a median of 45 (22–57) months. Most patients (97%) achieved HIV-RNA <50 cp/mL after similar times in the two groups. The CD4 cell count rose similarly in the two groups during the first 12 months. However, after 12 months, patients who started cART during CHI had a better immunological response than those who resumed cART (p = 0.01); therefore, at 36 months, the gains in √CD4 cells/mmThese results suggest that interruption of cART started during PHI has a significant, albeit modest negative impact on CD4 cell recovery on cART resumption. Treatment initiation for patients with primary infection changed from “Treatment initiation during primary HIV infection (PHI) has both advantages and disadvantages: it limits the loss of CD4 cells, suppresses viremia, limits the size of the latent reservoir, attenuates immune activation -7, and rA small fraction of HIV-1-infected patients - so-called ‘post treatment controllers’ (PTC) - maintain viral suppression after stopping cART. This status is mostly established when treatment was initiated early during PHI -15. PTC Enrollments in the ongoing ANRS PRIMO cohort started in 1996, providing an opportunity to analyze diverse cART modalities, including the timing of treatment initiation . Here weThe ANRS PRIMO cohort consists of 1450 HIV-infected patients enrolled during PHI between June 1996 and December 2013 in 94 French hospitals. Primary infection is confirmed by an incomplete Western blot, or detectable p24 antigenemia, or detectable plasma viral load with a negative or weakly reactive enzyme-linked immunosorbent assay (ELISA), or an interval of less than 6 months (3 months since 2002) between a negative and positive ELISA. Clinical and biological data are collected at months 1, 3 and 6 and every 6 months thereafter, as previously described . The HIVAll patients are antiretroviral-naïve at enrollment and give their written informed consent. The cohort was approved by the Paris-Cochin Ethics Committee. No specific recommendations for treatment initiation were given in the PRIMO cohort, apart from regularly revised, French recommendations.The date of HIV infection was estimated as the date of symptom onset minus 15 days, the date of an incomplete western blot minus 1 month, or the midpoint between a negative and a positive ELISA.Transient cART during PHI was defined as treatment that started within 3 months after the estimated date of HIV infection, lasted at least 3 months, was interrupted for at least 1 month, and was then resumed. cART initiation during CHI was defined as initiation at least 6 months after HIV infection, for at least 3 months. cART was defined as a regimen comprising at least two nucleoside reverse transcriptase inhibitors combined with either a protease inhibitor (boosted or not) or an integrase inhibitor or a non nucleoside reverse transcriptase inhibitor (NNRTI). The CD4 cell counts and HIV loads at cART initiation/resumption are those obtained between one month before and 7 days after cART initiation.The response to treatment was compared between patients who started cART during CHI and those who resumed cART after transient treatment started during PHI. Time zero was the date of treatment initiation in the CHI group and the date of treatment resumption in the group with transient cART during PHI.Baseline characteristics were compared with the Chi2 test and the Wilcoxon rank-sum test for dichotomous and continuous variables, respectively. When necessary, continuous covariates were categorized according to the median of observed values, or using published cut-off values.10 copies/mL was included in the model as a continuous variable after verifying the linearity assumption.Kaplan-Meier survival curves were used to analyze the time to virologic response, defined as a decrease in plasma HIV RNA to below 50 copies per milliliter, and were compared using the logrank test. Univariate and multivariate analyses were performed with Cox proportional hazards models. The proportionality assumptions were assessed by checking the log cumulative survival plots. Censoring was imposed when the patient was lost to follow-up or interrupted cART for more than 15 days. Baseline HIV load in logThe CD4 cell count kinetics were analyzed on a square-root scale in order to obtain a normal distribution. CD4 cell gains were modeled using piecewise linear mixed-effects models in order to take into account the correlation between measurements in a given subject. The models included both fixed and random effects for the intercept and slope. The best model (Akaike’s criterion) was obtained with slope changes at M3 and M12. We modeled the CD4 cell dynamics for the first 60 months after cART initiation, during which the median number of available CD4 cell measurements was 9 per subject (IQR 6–14). Slopes of CD4 cell counts were compared between the two groups (cART initiation during CHI versus resumption after transient treatment started during PHI). Models were adjusted for age (≥40 versus <40 years), the calendar period , HIV-RNA levels (≥5 log versus <5), active smoking at cART initiation/resumption, HIV transmission group , geographic origin, time since HIV infection, the HIV subtype (B versus non B), and genotypic resistance at baseline.3 and HIV load ≥ 5 log) from their counterparts with favourable characteristics (CD4 ≥ 500 cells/mm3 and HIV load <5 log).In order to take into account the potential severity of the underlying HIV disease at baseline, the CD4 cell count at HIV primary infection diagnosis was introduced in the model. Stratified analyses were also performed, separating patients who started cART during PHI and had unfavourable baseline characteristics  and those with a non boosted PI or NNRTI. We also distinguished, among patients who started ART during PHI, those treated for at least 24 months and those treated for less than 24 months before cART interruption. Finally, we explored the impact of the duration of cART interruption (>12 months versus ≤ 12 months).Percentage CD4 cell counts were also modeled. The best model (Akaike’s criterion) for CD4% increase was obtained with one slope change at M3. The multivariate model comprised the same variables as in the CD4 cell count model.The mean CD4 count and percentage evolution were depicted by plotting the mixed model predictions.P values <0.05 were considered to denote statistically significant differences. Analyses were performed with STATA software .i) for the immune response we restricted the analyses to the subset of sustained virologic responders, i.e. patients who achieved and maintained VL <50 copies/mL throughout treatment; ii) immunologic and viral analyses were repeated after excluding the 14 patients who participated in standardized treatment interruption studies .Among the 1450 patients enrolled in the ANRS PRIMO cohort, 377 started cART during CHI, while 136 patients started a second course of ART after transient treatment started during PHI. The two populations differed in terms of their baseline characteristics, as expected. Patients who initiated transient cART during PHI had lower CD4 cell counts and higher viral loads at cohort entry than those who started ART during CHI (Table 3 (246–442) and 332/mm3 (248–426), p = 0.90, and the respective median viral loads were 4.7 log10 (4.2-5.3) and 4.9 log10 copies/mL (4.4-5.3) (p = 0.7).Table The median time since PHI was 46 months (26–72) at cART resumption and 23 months (12–42) at cART initiation during CHI. Patients who resumed cART were older than those who initiated cART during CHI while they were the same age at PHI diagnosis. They received boosted PIs and integrase inhibitors less frequently , probably owing to differences in the calendar periods . Resumed treatment lasted significantly longer than treatment initiated during CHI: median (IQR) 47 months (23–66) versus 32 months (18–51) (p = 0.0002).10copies/mL) and the CD4 cell count at cART initiation, the period of cART initiation , the HIV transmission group, place of birth, education, time since HIV infection, the HIV subtype (B versus non B) and baseline genotypic resistance. Adjustment for the type of cART regimen instead of the calendar period led to similar conclusions. As expected, higher viremia at cART initiation was predictive of slower viral suppression (HR = 0.8 for a one-log increase in HIV RNA load (95% CI 0.7-0.9), p = 0.001). Baseline genotypic resistance was associated in multivariate analysis with slower viral suppression (HR 0.7 (95% CI 0.5-0.9), p = 0.02). No other parameter included in the multivariate analysis was associated with the time to viral suppression.At 12 months of cART, VL was < 50 copies/mL in 130 (97%) patients who resumed cART and in 369 (97%) patients who started cART during CHI. The median (IQR) time taken to reach <50 copies/mL was respectively 5.0 months (3.2-7.6) and 5.0 months (3.0-7.4), logrank test, p = 0.6. , we still found a better long-term immunological response in patients who started cART during CHI than in those who resumed cART.CD4% was modelled with 2 slopes (0–3 months and >3 months)  as a proxy for the severity of their underlying HIV disease.This study is the first to suggest that interruption of treatment started during PHI may have a detrimental impact on the long-term immune response on treatment resumption. Randomised therapeutic trials conducted during PHI usually focus on the degree of viral rebound and CD4 cell loss after cART interruption, and not on long-term trends in CD4 cell numbers after treatment resumption. The remarkably lengthy follow-up of our cohort offers a possibility to explore this issue. We also studied the CD4 cell percentage dynamics, which is rarely reported despite being informative of immune reconstitution and complementary to the CD4 cell count .3 will gain about 200 cells/mm3 during the first year of cART [The CD4 cell dynamics observed here are concordant with published data on treatment initiation during chronic HIV infection -26. The  of cART . Reconst of cART ,28. In t of cART .It is widely agreed that interruption of long-term cART started during CHI is harmful. In the CASCADE collaboration and SMART trial, poorer immune reconstitution was observed after ART resumption than during first-line cART initiated during CHI ,29: two The difference in CD4 cell recovery observed here between patients who resumed cART after transient treatment started during PHI and those who started cART during CHI might have resulted indirectly from drug resistance following cART interruption, yet no difference in the viral response was observed. Moreover, in the sensitivity analysis restricted to sustained viral responders, the CD4 count slope was still shallower in the cART resumption group.The detrimental consequences of discontinuing cART started during CHI have been explained in terms of increases in markers of inflammation, coagulation and immune activation, coinciding with the viral rebound after cART interruption ,32. A si3, a value in line with the evolving thresholds at which French guidelines recommended treatment initiation during the 1996–2013 study period.One limitation of our work, as in any observational study, is that the patients who interrupted cART after transient treatment started during PHI might have had different prognostic status from those who started cART during CHI. However, complementary analyses that took into account potentially unfavourable characteristics at HIV infection, as well as the duration and type of first-line cART regimen and the duration of cART interruption, yielded the same conclusions. It might also be argued that the patients who started treatment during CHI could have differed from their “usual” counterparts as they had been followed in the cohort since PHI. However, the viral response to cART initiated during CHI was similar to that observed in randomised trials , and the3 in both groups. The difference between the groups was about 53 CD4 cells/mm3 after 36 months of cART for a patient starting at 300 cells/mm3. However, recent data suggest that complete immune reconstitution might be defined by higher levels than the commonly accepted count of 500 cells/mm3 [It may be argued that the difference in immune reconstitution is not clinically pertinent: indeed, after 36 months the mean CD4 cell count was above 500 cells/mmThe possibility of inducing long-term immuno-virologic control by initiating ART at an early stage of HIV infection is exciting, and further research is needed to identify future post-treatment controllers (PTC) and those achieving recently described functional cure .Our results show that cART interruption after transient cART started during PHI has a significant, albeit modest negative impact on CD4 count reconstitution after cART resumption, an encouraging finding in the context of therapeutic trials attempting to induce PTC status. Pending the results of these studies, our findings confirm that, once initiated, cART should not be interrupted, except in research settings and under close medical surveillance.


One out of ten newly diagnosed patients in Europe was infected with a virus carrying a drug resistant mutation. We analysed the patterns over time for transmitted drug resistance mutations (TDRM) using data from the European Spread program.Clinical, epidemiological and virological data from 4317 patients newly diagnosed with HIV-1 infection between 2002 and 2007 were analysed. Patients were enrolled using a pre-defined sampling strategy.The overall prevalence of TDRM in this period was 8.9% (95% CI: 8.1-9.8). Interestingly, significant changes over time in TDRM caused by the different drug classes were found. Whereas nucleoside resistance mutations remained constant at 5%, a significant decline in protease inhibitors resistance mutations was observed, from 3.9% in 2002 to 1.6% in 2007 (p = 0.001). In contrast, resistance to non-nucleoside reverse transcriptase inhibitors (NNRTIs) doubled from 2.0% in 2002 to 4.1% in 2007 (p = 0.004) with 58% of viral strains carrying a K103N mutation. Phylogenetic analysis showed that these temporal changes could not be explained by large clusters of TDRM.During the years 2002 to 2007 transmitted resistance to NNRTI has doubled to 4% in Europe. The frequent use of NNRTI in first-line regimens and the clinical impact of NNRTI mutations warrants continued monitoring. The use of combination antiretroviral therapy has strongly reduced morbidity and mortality among patients infected with HIV . This usThe objective of this study is to determine the trends in transmitted drug resistance in newly diagnosed HIV-1 infected patients over time in Europe. For this purpose, we analyzed the data collected by the pan-European SPREAD programme. This programme combines the efforts of virologists, clinicians and public health institutes to study the epidemiology of transmission of drug resistant HIV ,9. SPREAEthical requirements are fulfilled according to the procedure described in the EC contract. The procedure differs among the 32 countries in the network according to national legislation. Briefly, for each participating hospital or collection center, approval was obtained by the institutional medical ethical review committee. Additionally, a written informed consent was obtained for each patient. In countries where a mandatory surveillance system was already established, legally no informed consent was needed. All surveillance data were made anonymous and coded at national level.The SPREAD Program includes patients with newly diagnosed HIV-1 infection from September 2002 through December 2007 in 26 European countries  and Israel. Although Israel is not officially part of Europe, the WHO includes Israel in the WHO European region definition . PatientA blood sample was taken for genotypic resistance testing within six months after diagnosis. Population-based nucleotide sequencing of parts of the reverse transcriptase (RT) and protease (PR) genes of the virus was performed at local laboratories by means of commercially available kits or in-house methods ,9. All cSeroconversion was documented in a proportion of the newly diagnosed patients. For some of these patients (n = 882) seroconversion could be established because a last negative test was available within 3 years before diagnosis. In these patients, the date of infection was estimated as the midpoint between the date of the last negative and first positive test. In addition, for 506 patients primary HIV-1 infection was documented based on laboratory data . In these 506 patients, the date of the first positive (and subsequently confirmed) HIV test was used as the estimated date of infection. Patients were defined as recently infected when the duration of infection was <1 year [For the purpose of analysis, Western Europe was defined to include those countries with a long history of good access to antiretroviral drugs. These countries included: Austria, Belgium, Cyprus, Germany, Denmark, Spain, Finland, Greece, Ireland, Italy, Luxembourg, the Netherlands, Norway, Portugal, Sweden, France, the United Kingdom, Switzerland, and Iceland. In our study, Israel was also included in the Western Europe category.http://www.bioafrica.net/rega-genotype/html/) [The HIV-1 subtypes were determined by use of the Rega HIV-1 subtyping tool  .http://www.hiv.lanl.gov) as identified using the HIV BLAST tool  subtype reference from the Los Alamos Sequence Database.Phylogenetic analyses were performed to investigate clustering of sequences with TDRM. As controls we included 1) the genetically most closely related sequences in the entire SPREAD dataset (n = 46) as identified by neighbor-joining phylogenetic trees constructed using Mega5; 2) the most closely related sequences (according to the percent of matching bases) in the Los Alamos Sequence Database  software followed by manual editing and removal of TDRM-related codons . Maximum2 test, Fisher exact test, or logistic regression techniques. Continuous data were investigated by means of the Mann–Whitney U test, linear regression, or Poisson regression. Prevalence values were calculated with a 95% Wilson score confidence interval (CI) on the basis of a binomial distribution. Trends in the prevalence of TDRM were calculated by logistic regression. Several factors were investigated as potential risk factors for TDRM: route of infection, recent infection, subtype, sex, age, continent of origin, CDC stage, CD4 cell count (square root transformed), log viral load. All statistically significant (P < 0.1) univariate predictors of TDRM were considered as possible confounding factors in the multivariate time trend analysis.The data were analysed using the statistical software R (version 2.11.1). Categorical data were compared by use of the χThe SPREAD programme enrolled 4,470 newly diagnosed HIV-1 patients from September 2002 through December 2007. Included here are 4,317 patients for whom genotypic information was available. Data from patients included until 2005 (n = 2687) have been reported previously . The curTable The overall prevalence of TDRM in newly diagnosed patients during the period 2002–2007 was 8.9% (95% CI: 8.1-9.8), of whom 69% were infected with viruses carrying a single TDRM. Most mutations found were associated with nucleos(t)ide reverse transcriptase inhibitor (NRTI) resistance at 5.0% (95% CI: 4.4-5.7), but NNRTI resistance mutations at 2.9% (95% CI: 2.4-3.4) and protease inhibitor (PI) resistance mutations  were also observed. Dual- and multi-class resistance was seen in 0.8% and 0.4% of the patients, respectively. Most NRTI TDRM  were of the thymidine analogue mutations (TAMs) class that are associated with resistance to zidovudine and stavudine. The highest prevalence was found for the revertant mutations at position 215 (S/D/C/E/I/V at 2.7%), followed by M41L (1.7%), and L210W (0.6%). The most prevalent drug resistant mutations were K103N (1.7%), G190A (0.5%), Y181C (0.4%) for NNRTI and L90M (0.6%) for PI.P = 0.008), CD4 cell count (square root transformed) , MSM , subtype B  and recent infection . In a multivariate analyses, only the MSM  and subtype B  remained significant. The NRTI and NNRTI drug classes showed the same significant predictors for resistance in the univariate analyses as was shown for the overall TDRM, although the square root CD4 cell count was not being associated with resistance for the NRTI drug class. In the multivariate analyses only the MSM risk group  and subtype B  remained significant for the NRTI drug class. For the protease inhibitors class, the factors associated with TDRM were log HIV-RNA load, age per 10 years, square root CD4 cell count, and recent infection. None of these factors remained significant in the multivariate analyses.We analyzed which factors were associated with drug resistance for both the total TDRM group as well as for the subgroups by drug class  was stable over time   and generally involved TAM mutations.We investigated TDRM trends with data collected by the pan-European SPREAD programme. Several studies reported on the changes of TDRM over time in single countries in Europe -26. ReceComparable to Europe, in North America antiretroviral drugs have been available for a prolonged time. A recent published study in San Francisco reported an increase of prevalence of TDRM between 2003 and 2007 whereas the prevalence decreased not-significantly afterwards . In CanaIn the previous study published by the SPREAD programme, transmitted NNRTI resistance showed a statistically significant parabolic time trend over the time period of 2002 to 2005 (n = 2687) with a peak at the end of 2004 (p = 0.02) [We investigated several factors that could explain the increase of transmitted NNRTI resistance in Europe. Migration from Africa could have explained the increase as a single-dose of the NNRTI nevirapine has been used extensively for prevention of mother-to-child-transmission, which resulted in increased levels of NNRTI resistance . HoweverChanges in prescribing practices most likely explain the increased rates of transmitted NNRTI resistance mutations. NNRTIs have become more popular in first-line treatment as international guidelines have increasingly recommend the use of NNRTI for initial therapy ,18,33. aThe decreasing transmission of PI resistant mutations can also be explained by changes in prescribing practices over time. From 2004, the guidelines for treatment of adult HIV infection have recommended the use of NNRTIs over PIs due to better virological outcome, lower rates of toxic effects, and fewer interactions between drugs . In addiThe persistent high levels of TAMs and revertants over the years are not in line with prescribing practices. TAMs were originally selected by the thymidine analogues stavudine and zidovudine, which have been used extensively in the past but have over time become less common in first-line treatment ,46. The A limitation of our study is that we used population sequencing to identify drug resistance associated mutations. Although population sequencing is standard practice across Europe, this technique fails to identify drug-resistant minority variants that are present in <20% of the virus population infecting a patient . These mRepresentativeness of the data could also be a limitation in our study. We assessed the representativeness by comparing the distribution of the transmission groups in all countries included in SPREAD with the HIV surveillance data from the European Centre for Disease prevention and Control (ECDC) (data not shown). The proportional distribution of the different transmission groups was very comparable. However, compared to the data from ECDC, MSM were somewhat over-represented in some of the countries participating in SPREAD. This may suggest that the estimated prevalence in our study might be slightly overestimated.A strength of our study is the data collection that is performed within the SPREAD programme. The SPREAD programme is a large and sufficiently powered pan- European study that has been running since almost ten years. During this time the programme included patients newly diagnosed with HIV using a predefined strategy that is based on the transmission routes and geographical distribution of HIV in the participating countries.The SPREAD programme studies the prevalence of TDRM in newly diagnosed patients, of which most patients are chronically infected. Several studies showed that resistance levels in recently infected patients are higher compared to those in chronically infected patients ,49. The The results from this study have several implications for clinical practice and public health. The single TAMs and revertants found do generally not cause resistance to nucleos(t)ides currently popular in first-line regimens . Therefore, the high prevalence of resistance to single TAMs that was found in Europe probably will not have a great impact on the efficacy of first-line therapy. The low prevalence of PI mutations and their negligible effect on the efficacy of boosted PIs also implies that they will not have a major public health implication. Conversely, the increasing prevalence of transmitted NNRTI resistance is likely to negatively influence the therapy response to NNRTI-containing regimens. Since it is it unknown whether the increasing NNRTI resistance levels will increase even more or will level-off, surveillance of TDRM will remain important.In conclusion, during the last decade, rates of transmitted resistance to certain drug classes have changed considerably. PI resistance declined between 2002 and 2007. In contrast, a significant increase in transmitted NNRTI resistance was observed. This finding underscores the importance of baseline drug-resistance testing prior to the beginning of treatment, given the medical evidence that transmitted NNRTI reduces the efficacy of current first line NNRTI-based regimens .The authors declare that they have no competing interest.All authors  1) have made substantial contributions to conception and design, or acquisition of data and interpretation of data; 2) have been involved in revising it critically for important intellectual content; and 3) have given final approval of the version to be published. DF, DAMCVV, ABA, JA, OH, LBJ, CK, DS, J-CS, JV, AMJW and CABB made substantial contribution to analysis and interpretation of data. DF, DAMCVV and CABB have been involved in drafting the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/14/407/prepubTable S2. Predictors of TDRM to individual drug classes: univariable and multivariable models. Predictors of TDRM: univariable and multivariable models. Click here for file


Although hepatotoxicity related to antiretroviral treatment (ART) has become less frequent, hepatotoxic events, such as transaminase elevations (TE), are still a matter of concern. RPV/FTC/TDF (EPA) is a new single tablet regimen which is widely used in real life practice. Clinical trials showed an adequate profile of liver safety in the sub-population of HIV/HCV-coinfected patients receiving rilpivirine. However, the number of individuals included in these analyses is low . The aimThis is a retrospective analysis of HIV/HCV-coinfected subjects who started EPA at the infectious diseases units of 14 centres throughout Spain, included as cases. Subjects who started an ART different to EPA during the study period at the same hospitals were selected as controls. The primary outcome variables were grade 3 or 4 TE and grade 4 TBE.Of the 191 patients included, 31 (16.2%) subjects were naïve to ART. Eighty-seven individuals started EPA and the remaining ones were controls. The most common NRTI backbone among the controls was TDF/FTC [59 (56.7%) patients] followed by NRTI-sparing regimens [24 (23.1%) individuals] and ABC/3TC [17 (16.3%) subjects]. Among controls, 67 (64.4%) started a ritonavir-boosted protease inhibitor, mainly DRV/r [41 (39.4%) patients] followed by ATV/r [16 (15.4%) subjects]. EFV, ETV and RAL were started in 16 (15.4%), 12 (11.5%) and 13 (12.5%) subjects, respectively. The median (Q1–Q3) follow-up was 5.79 (3.65–8.61) months for the cases and 11.44 (5.8–12.88) months for the controls. TE was observed in two (2.3%) cases versus five (4.8%) controls (p=0.358), accounting for a density of incidence of 4.32/100 person-years versus 5.51/100 person-years . All TE were grade 3 and no patient discontinued ART due to TE. None of the cases developed TBE versus four (3.8%) controls, all of them receiving ATV/r.The frequency of grade 3–4 TE associated with EPA in HIV/HCV-coinfected patients under real life conditions is very low. In addition, TE in HIV/HCV-coinfected patients treated with EPA are usually mild and do not lead to treatment discontinuation. TBE was not seen in patients taking EPA. All these data confirm that EPA is safe in this particular subpopulation.


The Chinese national observational cohort study suggests that the treatment-as-prevention (TasP) approach can be an effective public health HIV-1 prevention strategy. However, results from that study may have been biased because the follow-up time of index patients prior to their initiation of antiretroviral therapy (ART) was excluded. In this study, we correct for such bias by using an extended time-dependent Cox regression model to conduct a cohort study analysis of serodiscordant couples in Guangxi of China, inclusive of all follow-up time.During the follow-up of this observational cohort study of HIV-1 sero-discordant couples, the positive index partners may have never be treated with ART, or enter untreated but subsequently began treatment, or may have been treated immediately upon entry into the public health system. The treatment effectiveness of ART in HIV-1 acquisition among HIV-negative partners is assessed by the extended Cox regression model with treatment status as a time-varying covariate.A total of 6548 sero-discordant couples were included in the cohort study analysis. Among them, 348 negative partners sero-converted. HIV seroincidence was significantly higher among the nontreated  compared with those receiving ART . An overall 35% reduction in risk of HIV transmission was associated with receiving ART , and the yearly risk reduction was also significant in the first 3 consecutive years of follow-up. Moreover, ART was found to be significantly inversely associated with multiple baseline characteristics of index partners.TasP may be feasible on a national or regional scale. In addition to other proven preventive strategies such as the use of condoms, ART adherence to maintain viral suppression would then be the key challenge for successful TasP implementation. In the aforementioned Chinese national observational cohort study, for example, TasP effectiveness was assessed by only comparing the follow-up time of index partners who never received any ART with the follow-up time of index partners after they had initiated ART; thus, the follow-up time of index patients from the baseline visit to their initiation of ART was not included for analysis. . Such an assessment might result in a bias towards couples who are inherently less likely to transmit. To address this issue of possible bias in real-world settings, we use an extended time-dependent Cox regression model to conduct a cohort study analysis of serodiscordant couples in Guangxi of China. In this model, whether the index partner receives ART or not will be treated as a time-dependent covariate in the extended Cox model. The aim of this study is thus to more accurately assess TasP effectiveness on the transmission of HIV among serodiscordant couples in a real-world setting, such as Guangxi, China.21 HIV infection through drug injection accounted for 69% of reported HIV cases in 2003, but the proportion of HIV infections through sexual intercourse increased to 66% in 2009 in Guangxi.23 Since the Chinese National Comprehensive AIDS (acquired immune deficiency syndrome) Response Policy and “Four Frees and One Care” program were launched in 2003,24 the Chinese Center for Disease Control and Prevention (China CDC) has established national HIV databases. These cohort study databases can be used to study the effectiveness of ART on the transmission of HIV in serodiscordant couples.The HIV epidemic among drug users was first detected in 1996 in Guangxi. By the end of 2004, Guangxi had accumulated the third highest number of HIV cases reported in China.3 (cutoff increased from 200 cells per μL in 2008); WHO stage III/IV diseases; or willingness to receive ART, regardless of the criteria 1 and 2. Serodiscordant couples were defined by two criteria: at baseline, 1 individual was HIV-positive (index patient), while their partner tested HIV-negative; and at the partner who tested HIV-negative at baseline had at least 1 additional follow-up HIV test result. In order to assess seroconversion rates overtime among HIV serodiscordant couples, we retrospectively analyzed national HIV epidemiology and treatment databases. Individuals in the treatment database were linked to their own records in the epidemiology database by the use of their unique treatment identification numbers or national identification numbers. Data linkage between the epidemiology and treatment databases was verified twice in a relational database. Additional details concerning these cohort study databases have been previously published elsewhere.25 By the end of 2013, 89,388 HIV-positive individuals were reported to the Guangxi HIV database. After exclusion of couples who did not meet the study criteria, 1890 couples were included in the treatment-naive cohort, and 4658 couples were included in the treated cohort , those who entered untreated but subsequently began treatment during follow-up (group 2), and those treated immediately upon entry into the public health system (group 3). Baseline characteristics of all index patients were extracted from the databases, such characteristics included sex, age, education status, marital status, occupation, and route of transmission. CD4 count at the baseline visit was extracted for those never treated in group 1 and before treatment in group 2, respectively. CD4 count at the visit before initializing treatment was extracted for those after treatment in group 2 and in group 3.P-value of 0.05 or less was regarded as statistically significant. The data were analyzed using Statistical Analysis System .The cohort study endpoint was time to incidental HIV seroconversion. Kaplan-Meier analysis was used to calculate the HIV-infection-free survival probabilities for the HIV-negative partners. In order to assess treatment effectiveness, we estimated the treatment hazard ratios  by using univariate and multivariate extended Cox regression models with the time-varying covariate of treatment status. In order to control for bias, the following factors were included in the adjusted models: duration of follow-up, sex, age, education, marital status, occupation, route of HIV infection, and baseline CD4 cell count of the index patient. A 2-sided The study was approved by the institutional review board of the Guangxi Center for Disease Control and Prevention.P < 0.05).A total of 6548 couples were included in the cohort study analysis. The numbers of participants were 6200 for nonseroconversion couples and 348 for seroconversion couples, respectively. The number of serodiscordant couples enrolled by year is illustrated in Figure By the end of 2013, a total of 348 HIV seroconversions were observed during the follow-up period. Table Due to some differences of baseline characteristics between the nontreatment and treatment groups in real-world setting, we estimated rates of HIV incidence stratified by the baseline variables for subgroup analysis, and adjusted the HRs to control for potential confounding Tables  and 3. TTreatment was found to be significantly inversely associated with several baseline characteristics of index partners: male sex , female sex , age above 25 years , less than high school education , being married , being a farmer , where the index partner had been infected by heterosexual intercourse , and baseline CD4 counts of 500 cells per μL or less . No significant differences between nontreatment and treatment groups were found for the following baseline characteristics of index partners: age between 18 and 24 years, education above high school, living with a partner, not being a farmer, infected by injection drug use or other means, and CD4 counts of 500 cells per μL and above Table 26 Another recent cohort study with the HIV-positive index patients, mainly former plasma donors in Henan province of China found ART was highly protective against seroconversion when the former plasma donor index patient was actively receiving ART treatment at the last follow-up .27 However, this study had a large imbalance between patients with treatment and no treatment, due to RR = 0.36  in univariate Cox regress analysis. The previous study results showed a 26% relative reduction in HIV in the treated cohort of Chinese national serodiscordant couples (2003–2011).14 Based on the results of HPTN 052, our study strongly supports the public health prevention strategy of TasP among serodiscordant couples under real-world conditions on a national or regional scale.13Our study found a 35% reduction in HIV transmission in couples where the index patients had received ART. A small cohort study in rural Yunnan province of China showed that serodiscordant partners of HIV-positive patients receiving ART had about one third of the risk of HIV transmission compared to those of HIV-positive patients not receiving ART.29 Other reason is that drug resistance to ART increased overtime.33 In order to guide public health decision making, future studies are urgently needed to clarify the duration of protection conferred by TasP.Our study results showed that treatment was significantly protective in the first 3 years of follow-up and was protective across most baseline socio-demographic characteristics, with a few exceptions. This finding updated our previous study that protection was only significant in the first year. Exactly how durable this protection is remains unclear. Some factors associated with duration of this protection should be considered in future studies: future cohort studies need statistical power to measure this long-term protection overtime, including sufficient numbers of seroconversions over the observational period. This reduction in risk could also be related to the natural history of HIV transmission among serodiscordant couples, as those susceptible to infection usually decreases overtime.34 A few international studies showed that early treatment led to virological and clinical benefits.36 However, 1 national cohort study in China has also shown that patients with higher CD4 cell counts at ART initiation were more likely to drop out of HIV care,37 and another prospective follow-up study in China found that patients with higher CD4 counts before treatment were at increased risk for poor virological response.38 Additional studies are needed to clarify the effects of early ART initiation on adherence and attrition at short-term versus long-term treatment timescales. Such studies could help to address the issues of initiating ART treatment at high CD4 cell counts.Another major finding of our study was that treatment reduced HIV transmission when the index partners’ CD4 cell counts were below 500 before treatment. TasP may be less beneficial to those whose index partners had relatively high CD4 cell counts before initializing ART. The impact of higher CD4 cell count on virologic failure warrants further investigation. The Chinese treatment guideline has changed and advocates initiating ART treatment at higher CD4 levels (above 350), if patients are willing to receive ART and will have good adherence.39 Such programs help reduce HIV and sexual transmitted diseases among high risk groups of injection drug uses and female sex workers in China.41 ART adherence, education, and interventions are a key challenge for successful implementing TasP strategies in real-world settings.Our study validated reduction in the risk of HIV transmission in couples wherein index patients received ART. Treatment was significantly protective for most baseline characteristics of index partners, such as for male, female, age above 25 years, education below high school, married, farmer, and infected by heterosexual intercourse. Successful implementation of a strategy for HIV TasP will depend on its ability to be implemented in real-world scenarios. It is an urgent need to provide comprehensive harm reduction measures to serodiscordant couples such as condoms, methadone maintenance therapy (MMT), needle exchanges, and STD management services.Our study has several limitations. First, although we controlled for numerous confounders in multivariate modeling, differences in baseline characteristics among the 3 groups suggest that selection bias may have led to overestimation of the ART's true impact. Second, the median duration of follow-up is relatively short, and the long-term durability of TasP needs to be clarified in future studies. Third, some variables in our study are self-reported, so some misreporting or underreporting may have happened. Our study further strengthens support for ART's preventive effect in the real-world, but ART adherence and risk behavior reduction while implementing TasP require further study.20