Short term efficacy of combination antiretroviral therapy (cART) in resource-constrained settings is comparable to that found in western studies. However, long term data are limited. India has the third largest HIV infected population in the world but the long-term outcome of first line therapy according to the national guidelines has not been evaluated yet. Therefore, we conducted a long-term longitudinal analysis of the efficacy of the national first-line therapy in India from an observational cohort of Indian patients in two different clinical settings.A total 323 patients who had been on ART for a median of 23 months and achieved virological suppression <100 copies/ml by their study baseline visit, were included and followed for two years. Blood samples were collected every six months for viral load and CD4 count. Drug resistance genotyping was performed when the viral load was >2000 copies/mL. Adherence and treatment interruptions (>48 h) were assessed via self-report. In the studied patients, the median duration of viral suppression was 44 months; 15.8% of patients showed viral rebound, and 2.8% viral failure. Viral rebound or failure was significantly negatively related to perfect adherence (100% adherence and no treatment interruption >48 hrs). Virological re-suppression in the subsequent visit was observed in three patients without any change in therapy despite the presence of key mutations.Our study reports for the first time, a good long-term response to the first line therapy for a median of nearly four years although a less than perfect adherence increases the risk for treatment failure and subsequent drug resistance development. The empirical findings in this study also indicate the overall success of the Indian ART program in two different settings which likely are representative of other clinics that operate under the national guidelines. The attainment and maintenance of sustained viral suppression is the ultimate goal of antiretroviral therapy (ART). The optimal response to therapy is the substantial decrease in viral load (VL) to below the technical specificities of the VL assays which results in the avoidance of emergence of drug resistance mutations The National AIDS Control Organisation (NACO) sponsored by the government of India, initiated the National AIDS Control Program (NACP) to provide free ART through established ART-centres in April 2004 India has the third largest HIV-1 epidemic in the world with a burden of nearly 2.5 million people, where HIV-1 subtype C is the predominating subtype Therefore, to understand the clinical impact of the Indian national ART guideline, the primary purpose of our study was to investigate long term virological outcome among Indian HIV-1 infected patients on first-line therapy, following initial viral suppression. In addition, we evaluated the factors associated with virological rebound, its consequences, and emergence of drug resistance mutations.The sample described in this paper was derived from a large observational clinical cohort of 533 patients from two tertiary care hospitals in the southern part of India, which adhere to the national therapeutic guidelines Blood samples were collected in EDTA tubes. CD4 count was measured using a single platform flow cytometric assay . Viral load was measured by an in-house real time polymerase chain reaction with TAQMAN assay at Molecular Diagnostics and Genetics, Reliance Life Sciences, Mumbai, India. Given the lower detection limit of the VL assay (<100 copies/mL), intermittent viral rebound was defined as a single episode of detectable viral load >100 copies/mL. Virological failure was defined as two successive viral load values >400 copies/mL. Patients with VL >2000 copies/mL were genotyped for drug resistance using in-house techniques www.hiv.lanl.gov).HIV-1 subtyping was determined using the maximum likelihood (ML) phylogenetic tree using the reference sequences downloaded from Los Alamos Database  which has been found to predict virological failure better than other self-report measures in this setting t-test or Mann–Whitney U-test, while categorical variables were analyzed via frequencies and cross-tabulations, with χ2 tests to assess the significance of the associations. All analyses were conducted in PASW Statistics version 18.Differences between groups on continuous variables were examined by independent sample The study was approved by the Committee for Human Research at University of California, San Francisco, USA and the Institutional Ethical Review Board of St John’s Medical College and Hospital, Bangalore, India. Written informed consent was obtained from all the study participants before enrolling into the study.3 (IQR: 243–525). During the study period 35.3% (114/323) patients maintained a good immunological profile (CD4 >350 cells/mm3) at all waves in which they were present. The median duration of viral suppression was 44 months (IQR 36–54) and 15.8% (51/323) of patients showed intermittent viral rebound without failure during the study period. Viral failure was observed in only 2.8% (9/323) of patients. Among the patients, 75.2% (243/323) was able to maintain ≥95% adherence throughout the study and 47.4% (153/323) were able to maintain perfect adherence (100% adherence by VAS and no treatment interruptions) during the same time (3 vs. 404 cells/mm3), but the difference was not statistically significant (p = 0.147) due to lack of statistical power, given the small number of patients (n = 9) with viral failure.The demographic and clinical characteristics of the 323 patients at baseline and during the two year follow-up period are presented in ame time . Patientame time . Mean CDHIV-1 subtyping using the Maximum likelihood (ML) phylogenetic tree with the best fitting general time reversible substitution model with inverse gamma distribution (GTR+G+I) with 500 bootstrapped data sets identified all the study sequences as HIV-1 subtype C , which iComparisons between participants with and without viral rebound/failure  showed t3) in their remaining study visits for 12 months, 18 months and 6 months, respectively.Drug resistance mutations were identified in 9 of the 16 patients with VL > 2000 at their first instance of viremia during the study period  . Among tAmong the six patients with virological failure who had high viremia during their first viral rebound, four had accumulated more NRTI drug resistance mutations (DRMs) in their follow up visit (data not shown).Our results indicate a good overall long-term response to first line therapy reflecting an overall success of the standardized Indian national program for individuals with HIV infection. By the end of the two-year study period, 81.4% of the patients remained virologically suppressed for a total median duration of nearly four years (based on time on ART at baseline + two-year study period) and this efficacy is likely to continue be longer as most of the patients reached the study endpoint with good immuno-virological conditions. As the study was conducted in two different settings, one public tertiary care hospital and one non-profit private tertiary care hospital, which follow the same therapeutic guidelines, recommended by the NACO, it is likely that the results are generalizable to other Indian clinics that follow the same protocols.Previous studies on short term efficacy of antiretroviral therapy from resource limited settings, within two years after initiation, have obtained comparable results to studies conducted in resource rich settings in Europe and America Non-adherence to therapy has been shown to be associated with intermittent viremia Previous studies have shown that sub-optimal adherence, treatment interruptions and improper dosing can lead to drug resistance In contrast, among the six virologically failing patients who had higher viremia during their first viral rebound, four accumulated new NRTI mutations by their subsequent follow-up visit, which is concordant with a previous finding from South Africa which observed increase in NRTI DRMs in 88% of subtype C infected patients between two visits (6 to 12 months apart) Given limited drug options, patients who have good immunological status with minimal drug resistance and low viremia may still get benefit from their first line regimen as observed by us and others A number of caveats need to be noted regarding the present study. First, the number of patients was relatively small. Second, the adherence measurements by self-report may overestimate the outcome. Third, the majority of the patients in this cohort showed good adherence throughout the study period, which may also have influenced the outcome. Therefore our findings may not generalize to other geographical settings in the country, where the adherence is considerably lower. Finally, we are not able to genotype the patients who had viral load below <2000 copies/mL. However a technical merit of our study is that it reflects the natural clinical practices in the setting where the national guidelines are followed.In conclusion, our study documents for the first time the evidence that among patients who reported perfect adherence to a standardized national first line regimen, the vast majority of the virologically supressed patients continued responding well to the therapy after nearly four years. Our results also strongly support virological monitoring in the setting. It serves not only to detect early virological failure, but can also be used to alert clinicians to the need for targeted adherence interventions for those patients whose viral rebound indicates sub-optimal adherence. The accumulation of new NRTI mutations also supports calls for virological monitoring to identify early failure to avoid the development of cross-resistance to other NRTI drugs. Such cross resistance may jeopardise the national second line options which include two NRTI drugs. Future research should therefore investigate the role of drug resistance and treatment outcome with HIV-1 subtype C viruses to identify the optimal time of switching failing patients to appropriate second line regimens.


Spirulina platensis, a cynobacterium used frequently as a dietary supplement had been found to exhibit many immune-stimulating and antiviral activities. It had been found to activate macrophages, NK cells, T cells, B cells, and to stimulate the production of Interferon gamma (IFN-γ) and other cytokines. Natural substances isolated from Spirulina platensis had been found to be potent inhibitors against several enveloped viruses by blocking viral absorption/penetration and some replication stages of progeny viruses after penetration into cells. We aimed to study whether this dietary supplement possesses any therapeutically feasible activity worthy of further larger controlled clinical evaluation.Sixty six patients with chronic hepatitis C virus infection and eligible for inclusion had been randomized to either Spirulina or Silymarin treated groups for a period of six months treatment.The two groups were followed up and blindly compared for early (after 3 months) and end of 6 months treatment virological response. The effects of both treatments on each of alanine aminotransferase (ALT), Chronic Liver Disease Questionnaire scores (CLDQ), Arizona Sexual Experience Scale scores (ASEX) and the occurrence of any attributable adverse events were also compared.10. Though the proportion of responders in Spirulina group was greater than in the Silymarin group, the difference was not statistically significant at the end of both 6 months (p = 0.12) and 3 months treatment (p = 0.22) by Exact test. Alanine aminotransferase as well as CLDQ and ASEX scores were found to be more significantly improved in Spirulina than in Silymarin treated group.Among the 30 patients who had been treated with Spirulina and completed the 6 months protocol, 4 patients (13.3%) had a complete end of treatment virological response and 2 patients (6.7%) had a partial end of treatment response defined as significant decrease of virus load of at least 2-logsOur results could suggest a therapeutically feasible potential for Spirulina platensis in chronic HCV patients, worthy to conduct a larger sized and longer study to confirm these safety and efficacy encouraging results.ACTRN12610000958088WHO Clinical Trial Registration ID: http://apps.who.int/trialsearch/trial.aspx?trialid=ACTRN12610000958088 Flaviviridae family of positive-strand RNA viruses, is a major cause of chronic liver disease. WHO estimated that about 170 million people, (3% of the world's population), are infected with HCV and 3-4 million persons are newly infected each year [Infection with hepatitis C virus (HCV), an enveloped virus that belongs to the Prevalence rates vary widely, ranging from 0.15% in Scandinavia to about 15% in Egypt . The oveAbout 80% of newly infected patients progress to develop chronic infection. Cirrhosis develops in about 10% to 20% of persons with chronic infection. Liver cancer develops in 1% to 5% of persons with chronic infection over a period of 20-30 years .Apart from its numerous contraindications and severe adverse effects, the current recommended treatment for chronic hepatitis C is not only too costly for most persons in developing countries to afford but also weakly effective .A meta-analysis showed that only about 17% of patients with chronic hepatitis C obtained a sustained virological response on interferon monotherapy, which was the only recommended treatment until the late 1990 [The current gold standard therapy is a combination of peg-interferon alfa and ribavirin ,9. PatieThough around 78%-82% of patients with genotype 2 or 3 infection respond to 24 wk of treatment, those with high viral load are difficult to treat (< 70% responders) .Generally, non-responders to prior standard bitherapy respond to retreatment in about 13% of the cases and relapsers in 58.5% of the cases .Therapy requires weekly subcutaneous injections, twice-daily oral dosing and frequent visits, with blood tests. Side effects occur in nearly all patients. As a result, 15%-20% of patients in clinical trials and > 25% in clinical practice discontinue therapy.Ribavirin does not appear to be effective when used alone. Furthermore, there is no clear evidence as to whether treatment reduces the risk of liver related morbidity or mortality .An alternative treatment which is less costly, safer and more efficacious is being the search of many research authorities al-over the world.Many herbal products had been studied and proved to offer some hepatoprotective activity and showed some benefits in the treatment of viral hepatitis, Glycyrrhizin, Silymarin, Curcumin, Schiszandra are examples -18.Spirulina is a blue-green alga (cyanobacterium) that has been consumed as food in many countries since ancient times. It is presently marketed as a food supplement  due to its high contents of proteins, γ-linolenic acid, vitamins and minerals . Many toSpirulina and many other Cyanobacteria had been found to exhibit many immune-stimulating and antiviral activities not only in-vitro but also in animals and human volunteers. It had been found to activate macrophages, NK cells, T cells, B cells, and to stimulate the production of antibodies and cytokines. It enhances Interferon gamma (IFN-γ) production in an interleukin12, 18 (IL-12/IL-18)-dependent fashion -29.Many natural substances derived from blue-green algae such as Sulfated homopolysaccharides and Sulfoglycolipids demonstrated monocyte/macrophage activation properties and found to substantially increase mRNA levels of key cytokines like interleukin-1beta (IL-1beta) and tumor necrosis factor-alpha  .Calcium spirulan (Ca-SP), a natural sulfated polysaccharide, isolated from Spirulina platensis had been found to be a potent inhibitor against several enveloped viruses. Ca-SP was shown to target not only viral absorption/penetration stages but also some replication stages of progeny viruses after penetration into cells ,32.Whereas Cyanovirin-N (CV-N)-35 and MAt low nanomolar concentrations, CV-N was demonstrated to bind to HCV envelope glycoproteins, to block the interaction between the envelope protein E2 and CD81, a cell surface molecule involved in HCV entry ,39.The availability of Spirulina as an over the counter safe dietary supplement with reasonable costs added to the abovementioned data supporting both antiviral and immune-stimulant activities urged us to conduct this pilot clinical trial to test safety and efficacy of this supplement in patients with chronic hepatitis C.The study was conducted in an outpatient setting according to a randomized, double-blind, comparative study design with mean follow-up of 6 months.To detect a 0.17 difference in proportion of responders between both comparison groups, with 80% power and two tailed 5% level of significance, the minimal sample size was calculated to be 30 for each group.Sixty six eligible patients with documented chronic hepatitis C, genotype 4 had been included in the study according to the following criteria:• Chronic hepatitis C infection genotype 4 with PCR positive test +/- elevated liver enzymes.• Males or females between 18 and 70 years old.• Interferon naive .• Relapsers , or non-responders to interferon or combined therapy are eligible if they stopped the antiviral drugs at least 3 months before recruitment.• Pregnant females.• Patients with other causes of hepatitis, concurrent HIV virus infection, or active Schistosomiasis.• Critically ill complicated patients with severe hepatic failure, malignancy or multi-organ failure.The study protocol was reviewed and approved by the local ethical committee according to the Declaration of Helsinki. All subjects gave written, informed consent before any study-related procedures were performed.rd generation ELISA plus/or minus elevated liver enzymes were assessed for eligibility, by being subjected to full history taking, clinical examination and the following tests:Eighty five consecutive patients presenting to the 2 outpatient clinics from October 2008 to March 2010 as known cases of chronic hepatitis C infection or just newly diagnosed from history, clinical examination, 3• Detection of HCV-RNA by PCR quantitative measurements by COBAS Amplicor 2.0, Roche Molecular Diagnostics, Pleasanton, CA, USA (lower limit of detection of 50 IU/mL).• Screening test for HBsAg, anti-HIV, Shistosoma antigens.• Upper abdominal and liver ultrasonography,• Liver and kidney functions tests, urine analysis, stools analysis, complete blood count.Patients fulfilling the inclusion/exclusion criteria were randomly divided into 2 arms:1. An experimental group who started treatment with Spirulina 500 mg dry powder extract capsules  in a dose of one capsule 3 times daily for a period of 6 months.2. A control group who took Silymarin 140 mg capsules (generic product prepared by the same company) in a dose of one capsule 3 times daily for the same period.Both drugs were packed in similar containers of 60 capsules of similar color and shape, packed and coded by Beovita Safe Company researchers blinded to the randomization process.Randomization was done using software generated block randomization technique and both patients and investigators were blinded for the allocated drug. The randomization list and the drug codes were locked in sealed envelopes till the end of follow up period, final assessment and statistical analysis.1. Complete virological response (defined as loss of detectable hepatitis C virus RNA at the end of 6 months treatment (c-ETR) and at the end of 3 months treatment ).10) at the end of 3 months (p-EVR) and 6 months (p-ETR).2. Partial virological response  at the end of treatment.4. Improvement of health related quality of life scoring using the Chronic Liver Disease Questionnaire (CLDQ) developed by Younossi ZM et al. ,41 The C5. The change in The Arizona Sexual Experiences Scale (ASEX) scores before and after 6 months of treatment was compared between groups. ASEX is a 5-item rating scale that quantifies sex drive, arousal, penile erection/vaginal lubrication, ability to reach orgasm, and satisfaction from orgasm. Possible total scores range from 5 to 30, with lower scores reflecting enhanced sexual function and higher scores reflecting impaired sexual function .6. Occurrence of adverse events and toxicity: All subjects were examined and interrogated at each follow up visit for the occurrence and nature of any adverse events. All such events were recorded in the patients' case report forms. Adverse events were assessed for causality as probably related, possibly related, unlikely to be related or not related to study medications.All patients in both groups had been followed up in monthly visits with physical examination, assessment of CLDQ and ASEX scorings, hematological studies, liver and kidney function tests and abdominal ultra-sonograms. Quantitative HCV-RNA by PCR test was done for each patient before treatment and after 3 and 6 months.t test. Comparisons of means of scale dependent variables between the independent treatment groups were done using one way ANOVA or Student t test for independent samples. Z test for proportions, or Fisher's Exact tests were used for analysis of proportions and categorical variables. Multivariate analysis of covariance (MANCOVA) using the treatment group as the fixed independent factor with the baseline Child-Pugh score and the pre-treatment virus load as covariates to adjust for any initial group differences on the dependent outcome variables (the difference between baseline and post-treatment CLDQ and ASEX scores and their interaction). Statistical significance is considered when two sided p < 0.05.Data were analyzed using the computer software package SPSS version 12, SPSS Inc. 233 South Wacker Drive, 11th Floor, Chicago, IL. Comparisons between means of paired scale variables before and after treatment were done using paired sample Sixty six eligible patients had been randomized to either Spirulina or Silymarin treatment groups. All patients had been followed up for a period of 6 months treatment. Four patients from Silymarin group and three patients from Spirulina group did not complete the protocol  (defined as no reduction of at least 2 logs10 from the baseline virus load) was reported in the remaining 80% of Spirulina treated group  had a complete end of treatment virological response. While 2 patients (6.7%) had partial end of treatment response defined as significant decrease of virus load of at least 2-logAll the 4 Spirulina treated patients who exhibited c-ETR were from those who had presented with low baseline viremia (virus load ≤ 100000 IU/mL). The lower the baseline viremia the higher was the response rate, as shown in a 3 × 3 table  had been reported in 17 out of the 30 Spirulina assigned patients and in 15 of the 29 Silymarin group. The mean (SD) of baseline serum ALT was 74.7 (35) and 78 (33.7) respectively. At the end of 6 months therapy there was a statistically significantly greater reduction in serum ALT in Spirulina treated group than in Silymarin group by one way ANOVA  with mean (SD) = - 23.7 (22.3) and -6.8 (23.2) respectively.Both health related quality of life scales as measured here by the Chronic Liver Disease Questionnaire (CLDQ) overall scores, and the sexual functions measured by Arizona Sexual Experience Scale (ASEX) total scores were statistically significantly improved in both treated group at the end of 6 months. See Table . The meaMultivariate analysis of covariance (MANCOVA) using the treatment group as the fixed independent factor while adding the baseline Child-Pugh score and the pre-treatment virus load as covariates showed that the treatment group  and the baseline Child-Pugh score  exhibited significant effects on the vector of the two outcome variables (the improvement in CLDQ and ASEX scores), while the baseline virus load did not (p = 0.15)It was also clear in the univariate analysis Table  that theNo serious adverse effects attributable to therapy were reported in both groups, apart from mild transient nausea, bloating, giddiness and headache in less than 6 patients in both groups..[To our knowledge, this study is the first human trial to address the effect of Spirulina platensis whole unfractionated dried extract on virus load, liver function, health related quality of life and sexual functions in patients with chronic HCV. There is only so far one article in Medline by Băicuş C, et al. who did We opted to use the whole herbal extract and not any one of the fractionated bioactive molecules presuming that the whole natural multi-components as previously discussed in introduction could offer not only antiviral activity but also other immune enhancing activities that might be summated together to produce therapeutic effects on this state of chronic viral infection that evades the immune system.Our results showed significantly greater effects of Spirulina than Silymarin on most studied parameters including the significantly greater reduction of serum ALT and the greater improvement in both disease specific health related quality of life and sexual functions scores. Though the virological response rates were not statistically significantly different between the 2 treatment groups, yet it reached the level of significance with the one sided Z test for proportions in those who presented with low or intermediate baseline viremia.We did not note considerable changes in both virus load and serum ALT early in the first month as it seems that the beneficial effects take some times to appear as we found that improvements in most parameters were even higher after 6 months treatment than after 3 months.We hypothesized that there must be a time needed to establish and solidify the immune mechanisms behind the activation, release and action of endogenous interferons and other interplaying cells and mediators. Even the parenterally administered high dose of interferon alpha took some months to manifest its maximal virological response, that is why we wait at least 3 months to predict the sustained virological response through the early complete or even partial virological response.It is the main limitation of our study that we did not follow up patients for one year treatment followed by 6 months off-treatment period as the case in the protocols for the study of interferon alpha based therapy. We designed this relatively short term pilot study to answer a simple research question; is there any therapeutically feasible potential for Spirulina in chronic HCV patients, worthy to conduct a larger study with longer follow up period.The motivation to conduct this study, "apart from the theoretically convincing background", was the unintended data coming from some of our patients who took Spirulina as nutritional supplement and reported to us marked improvement of the general well being and sexual activity. From this probing experience, as well as from the results of Danoff A, et al.  and SoykThis study was mainly focusing to help a considerable percentage of chronic HCV patients who are facing the situation of contraindication, intolerability or non-response to the current gold standard therapy. They usually become feeling hopeless and unsecure with deterioration in their overall wellbeing, functional status and quality of life. If further studies confirm our results with reproducibility, this could be an alternative treatment in such situations if at least it can improve quality of life, physical activity and performance. We did not focus on the luxury of sustained virological response at this exploratory stage, but it will be our objective in the coming planned study.The raised issues from the already discussed in-vitro and preclinical data about the potential immune stimulation and virus entry blocking also urged us to plan to test a new hypothesis; could the complementary therapy with Spirulina improve the response to the current gold standard antiviral therapy?. This will be tried to answer in our next study; through testing the effect of combining Spirulina with the current gold standard therapy, or the effect of offering a lead-in course for those who have high baseline virus load.From our results we can conclude that there is a therapeutically feasible potential for Spirulina platensis dried extract worthy to conduct a larger sized study with a longer follow up period to confirm these safety and efficacy encouraging results in the treatment of chronic hepatitis C infected patients.D-10965 Berlin, had supplied the drugs and partly the costs of the laboratory tests.Beovita-Safe Pharma, a Joint German Egyptian Company, Katzbachstr. 29, MY conceived of the study, formulated the research question, participated in its design, coordination and conduction. He took active part in all the process from patient screening to final assessment, statistical analysis and manuscript writing. AS shared MY in all the steps from screening of patients to manuscript writing and approval.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-230X/12/32/prepub


This study examines the proportion of patients in the TREAT Asia HIV Observational Database (TAHOD) receiving PCP prophylaxis, and its effect on PCP and mortality.Pneumocystis jiroveci pneumonia (PCP) prophylaxis is recommended for patients with CD4 counts of less than 200 cells/mm3. The effect of prophylaxis on PCP and survival were assessed using random-effect Poisson regression models.TAHOD patients with prospective follow up had data extracted for prophylaxis using co-trimoxazole, dapsone or pentamidine. The proportion of patients on prophylaxis was calculated for each calendar year since 2003 among patients with CD4 counts of less than 200 cells/mm3, 58% to 72% in any given year received PCP prophylaxis, predominantly co-trimoxazole. During follow up, 62 patients developed PCP (0.5 per 100 person-years) and 169 died from all causes (1.36/100 person-years). After stratifying by site and adjusting for age, CD4 count, CDC stage and antiretroviral treatment, those without prophylaxis had no higher risk of PCP, but had a significantly higher risk of death . PCP prophylaxis had greatest absolute benefit in patients with CD4 counts of less than 50 cells/mm3, lowering mortality rates from 33.5 to 6.3 per 100 person-years.There were a total of 4050 patients on prospective follow up, and 90% of them were receiving combination antiretroviral therapy. Of those with CD4 counts of less than 200 cells/mm3 received PCP prophylaxis. Patients without prophylaxis had significantly higher mortality, even in the era of combination ART. Although PCP may be under-diagnosed, these data suggest that prophylaxis is associated with important survival benefits.Approximately two-thirds of TAHOD patients with CD4 counts of less than 200 cells/mm Pneumocystis jiroveci pneumonia (PCP) remains a major cause of morbidity and mortality among HIV-infected persons presenting with advanced infection . Althoug3 for more than two decades, and current guidelines still support its use for that indication [PCP prophylaxis has been considered the standard of care for patients with CD4 counts of less than 200 cells/mm3 who have achieved virological suppression [3 in developed countries, it is not clear if early discontinuation can be safely practiced in developing countries. There is also relatively little data describing what proportion of patients fall into this subset and the clinical outcomes for not receiving PCP prophylaxis, especially in different geographic settings in the developing world.Some studies suggest that after initiation of cART, primary and secondary PCP prophylaxis can be discontinued for patients with CD4 counts of less than 200 cells/mmpression -7. WhileCo-trimoxazole has efficacy against a wide range of protozoal and bacterial infections, including toxoplasmosis, isosporosis, malaria, salmonellosis, nocardiosis, and pneumococcal disease. Therefore, in addition to its protective effect against PCP, mortality differences might be observed due to the activity of co-trimoxazole against these other important pathogens among immunocompromised patients, even if some of these are non-AIDS-defining illnesses. This beneficial impact is potentially greater in resource-limited settings where pneumococcal vaccination rates for HIV-infected persons are low, countries with a heavy disease burden of malaria, or countries with higher rates of diarrhoeal illness. Walker and colleagues showed that co-trimoxazole prophylaxis significantly reduced mortality and malaria among HIV-infected adults who were on cART in Africa .3 who did not receive PCP prophylaxis, and its effect on PCP and mortality. The purpose of this study was to describe PCP prophylaxis practice in the Asia-Pacific region, and to understand the potential impact of any gaps between guidelines and practice on clinically important outcomes.This study examines the proportion of HIV-infected patients who were receiving antiretroviral treatment and care in the TREAT Asia HIV Observational Database (TAHOD) with CD4 cell counts of less than 200 cells/mmEstablished in 2003, TAHOD is a collaborative observational cohort study involving 19 sites in the Asia-Pacific region (see Acknowledgements). Detailed methods have been published previously [The data collected in TAHOD include patient demographics, CD4 and CD8 count, HIV viral load level, prior and new AIDS-defining illness, date and cause of death, prior and current prescribed antiretroviral treatment (ART) and prophylaxis used (with dates of both start and stop). Data on treatment for opportunistic infection were not collected. Data on severe adverse events and routine laboratory testing were also collected, depending on the availability, from each participating sites. AIDS-defining illness, including PCP, was defined according to 1993 Centers for Disease Control and Prevention (CDC) revision of the AIDS case definition .Specifically, a definitive PCP diagnosis is by microscopy (histology), while a presumptive diagnosis is based on: (i) a history of dyspnea on exertion or non-productive cough of recent onset (within the past three months); AND (ii) chest x-ray evidence of diffuse bilateral interstitial infiltrates or evidence by gallium scan of diffuse bilateral pulmonary disease; AND (iii) response to empirical anti-PCP therapy. Data are submitted according to a common protocol. Upon recruitment, all available data prior to entry to TAHOD (considered as retrospective data) are extracted from patient case notes. Prospective data are updated six monthly at each clinic and transferred to the data management centre for aggregation and analyses.TAHOD patients were included in this analysis if they had prospective clinical visits after enrolment. Prophylaxis data using co-trimoxazole, dapsone or aerosolized pentamidine (AP) were extracted. Prophylaxis data were checked again in each TAHOD site during the study period to make sure the data were most reliable. Dosage on prophylaxis is not collected in TAHOD. Prescriptions of prophylaxis, as well as antiretroviral treatment, are according to the local clinical guidelines. TAHOD sites are encouraged to contact patients who were not seen in the clinics in the previous 12 months.The baseline date for this analysis was defined as the date the patient was enrolled in TAHOD, and all patients with at least one prospective follow-up period were included. At enrolment, 171 patients had been diagnosed with PCP, and these patients were subsequently excluded in analysis for PCP diagnosis. For analysis on all-cause mortality, all patients were included (including the 171 patients with PCP at enrolment).3 in each calendar year and by TAHOD sites. Incidence rates of PCP diagnosis and all-cause mortality were calculated after stratification by current use of PCP prophylaxis and current CD4 cell count.The proportion of patients on PCP prophylaxis was calculated for each calendar year from 2003, among active patients who were seen in the database, and among patients who had CD4 counts of less than 200 cells/mm3, which yielded similar predictions (data not shown).Random-effect Poisson regression with a forward stepwise approach was used to model incidence rate ratios (IRRs) for time to PCP diagnosis and time to all-cause mortality. CD4 cell count, current CDC disease stage, use of PCP prophylaxis and cART were included as time-updated variables. Patients remained untreated until initiating ART. Other variables considered to be included in the analysis were age and sex. The final multivariate model included all covariates that remained significant at the 0.10 level (two sided). All models were stratified for TAHOD sites. Ninety-five percent confidence intervals (CIs) were calculated using the exact Poisson distribution if there were less than 20 events and a normal approximation if there were 20 events or more. Sensitivity analyses were done excluding sites with extremely low proportion of prophylaxis in patients with CD4 counts of less than 200 cells/mmData management and statistical analyses were performed using SAS for Windows  and Stata .3 (IQR 168 to 442). The annual rate of loss to follow up (defined as not seen in clinic in the previous 12 months) was 6.8 per 100 person-years.The analysis included a total of 4050 patients who were enrolled in TAHOD and prospectively followed. The median age at enrolment was 36 years , with 64% of patients younger than 40 years. The majority were males (71%). At enrolment, 47% of patients were at CDC stage A, 10% at stage B, and 43% at stage C. There were 171 patients (4% of 4050) who were diagnosed with PCP at enrolment. The median CD4 count at enrolment (the latest within six months) was 301 cells/mm3 when patients started prophylaxis and the median time (IQR) on prophylaxis was 300 (105-560) days. Of all patients in TAHOD, 90% were on combination antiretroviral treatment, while 39% ever received prophylaxis. Among patients who ever received prophylaxis, 94% received antiretroviral treatment, and 21% of the person-years observed were on prophylaxis after initiation of cART. The prescription of prophylaxis varies across the TAHOD sites: median CD4 counts at start of prophylaxis ranged from 87 to 297 cells/mm3 and median time on prophylaxis ranged from 15 to 472 days.Overall, the median CD4 counts (IQR) was 163 (89-261) cells/mm3 and proportions of patients (with CD4 counts of less than 200 cells/mm3) who were on PCP prophylaxis by calendar year. In 2003, when TAHOD was established, close to 60% of patients were tested with CD4 counts of less than 200 cells/mm3. The proportion decreases steadily between 2003 and 2009, and by 2009, approximately 20% of active patients seen in that year were tested with CD4 counts of less than 200 cells/mm3. Among these patients, the proportion of patients on PCP prophylaxis remains stable, approximately 60%, ranging from 58% in 2007 to 72% in 2009. Across TAHOD sites, prescription of prophylaxis varies, ranging from less than 30% to close to 100% in patients who had CD4 counts of less than 200 cells/mm3, but results were consistent within sites. Co-trimoxazole was the predominant agent used for PCP prophylaxis , compared with dapsone (7%) and AP (2%).Figure 3. In both models, the risks of PCP diagnosis were similar whether or not a patient was receiving PCP prophylaxis . As shown in the upper half of Figure 3.A total of 62 PCP cases were diagnosed prospectively, a rate of 0.50 per 100 person-years (95% CI 0.39-0.64). Among these PCP cases, 44 were diagnosed as definitive PCP, 14 were presumptive, and four cases were unknown diagnosis type. Current CD4 count was the only predictor of the risk of PCP diagnosis. Table 3, with the greatest absolute benefit in patients with CD4 less than 50 cells/mm3. In this profoundly immunosuppressed group, PCP prophylaxis was associated with significantly lower mortality, from 33.5 per 100 person-years to 6.3 per 100 person-years.There were 169 patient deaths during prospective follow up, a rate of 1.36 per 100 person-years (95% CI 1.17-1.58). Table 3, and PCP prophylaxis was indicated for them. However, only two-thirds of these patients received PCP prophylaxis throughout the period. Patients without prophylaxis had a significantly higher mortality, with the effect being most pronounced in those with the lowest CD4 cell counts. However, PCP rates were not significantly higher among those not receiving PCP prophylaxis. It is possible the cohort size was insufficient to demonstrate a significant difference in this clinical endpoint. PCP could also have been under-diagnosed because a definitive diagnosis requires confirmatory laboratory evidence, typically on respiratory samples obtained via bronchoalveoloar lavage. PCP can also be misdiagnosed as pneumonia caused by other etiologies, including tuberculosis.In this cohort of 4050 HIV-infected patients, a substantial proportion of patients (from 58% in 2003 to 20% in 2009) had advanced immunosuppression with CD4 counts of less than 200 cells/mm3 by six, 12 and 36 months were 13%, 24% and 39%, respectively [Nevertheless, these data suggest that PCP prophylaxis, predominantly the use of co-trimoxazole, is associated with important survival benefits. In the pre-cART era, the risks of developing an initial episode of PCP in patients with CD4 counts of less than 200 cells/mmectively . The poo3 was estimated to prevent 343 cases of primary PCP per 1000 patients, costing US$5100 per quality-adjusted life-year gained compared with no prophylaxis [3, significantly higher than the PCP incidence of 0.45 per 100 person-years among those who continued prophylaxis until CD4 counts were more than 200 cells/mm3 (adjusted risk ratio 5.32) [Among patients receiving cART, giving prophylaxis until CD4 counts are more than 200 cells/mmphylaxis . A studyio 5.32) .3. Unlike the DART African cohort, TAHOD patients reside in the Asia-Pacific region, with almost all TAHOD sites located in urban centres, which are malaria-free for the most part. The mortality benefit of co-trimoxazole prophylaxis therefore cannot be readily explained by its effect on malaria. It is possible that co-trimoxazole reduces mortality by its protective efficacy against an array of other pathogens for which HIV-infected persons with the lowest CD4 cell counts are at higher risk, such as cerebral toxoplasmosis, salmonellosis or pneumococcal disease. A higher incidence rate of bacterial infections (14.48 per 100 person-years) was observed among the Taiwan patients on cART with CD4 counts of less than 200 cells/mm3 who were not on PCP prophylaxis compared with an incidence rate of 5.56 per 100 person-years for those taking prophylaxis [In our study, this mortality benefit was observed even among patients with CD4 counts over 200 cells/mmIt is possible that PCP prophylaxis prescribing behaviour might be a marker of better quality of care, or provider compliance with treatment guidelines. Another possible explanation for the mortality difference observed between those who received PCP prophylaxis compared with those who did not could be that patients who were unable to tolerate co-trimoxazole or dapsone prophylaxis due to rash or other toxicities and were less able to afford the more expensive third-line agent, aerosolized pentamidine, were more likely to go without PCP prophylaxis. Socio-economic factors might therefore act as potential confounders affecting the outcomes studied.Among other explanations for why almost one-third of patients with appropriate indications did not receive PCP prophylaxis was the issue of high pill burden, especially in those with the lowest CD4 cell counts. This was cited by some clinicians when queried about low rates of prophylaxis from their sites. It is possible therefore that the effect of concomitant opportunistic infections (for which high pill burdens are a marker) could account for the difference in mortality between those with and without PCP prophylaxis.3 who had achieved virological suppression. However, the studies are not directly comparable; the COHERE study, conducted in European cohorts, had as its primary endpoint incidence of primary PCP rather than mortality, and viral load measurements were generally accessible [Other studies have examined the risk of discontinuing PCP prophylaxis in patients with CD4 counts of less than 200 cell/mmcessible . In our Our finding that almost one-third of this cohort with the appropriate CD4 indication did not receive PCP prophylaxis was somewhat unexpected because the TAHOD sites comprise major urban academic centres for HIV care and often represent the leading national HIV treatment centres in their respective countries. Some clinicians cited anticipation that patients' CD4 cell counts would rise quickly with cART treatment, and wishing to avoid causing rash or other toxicity in patients taking multiple medications. The precise reasons for not prescribing prophylaxis in individual HIV-infected patients were hard to examine, and retrospective collection of this information would risk introducing recall bias. More specific study plans should be developed, aiming at prescription practice, compliance with and tolerability of prophylaxis against PCP and other opportunistic infections.Several limitations should be considered in interpreting the results in this study. TAHOD subjects were recruited from patients who were considered by site investigators to be good candidates for long-term follow-up. The patients in this cohort and their treatment, therefore, may not be truly representative of all HIV-infected patients in the Asia-Pacific region. In addition, data on prophylaxis adherence were not collected in TAHOD. Allowing for these limitations and extrapolating from this data, one might speculate that PCP prophylaxis rates for other HIV treatment centres could be even lower. There were a small proportion of patients with missing or unavailable CD4 count information, which would, to some extent, increase the uncertainty of our final models.Lastly, due to the observational nature of TAHOD, there are possible unmeasured confounders associated with prophylaxis. As a consequence, our findings could overestimate the benefit of prophylaxis, even after adjustments and stratification. We therefore recommend that the interpretation of our data be made cautiously.3, even with virological suppression. When developing protocols and guidelines for prophylaxis against opportunistic infections, it may be prudent to be aware of potential differences between different geographic regions and access to resources.Patients without prophylaxis had significantly higher mortality, even in the era of combination ART, suggesting that prophylaxis is associated with important survival benefits. Our data highlight an important gap between guidelines and actual practice that represents a missed opportunity for prevention. Implementing PCP prophylaxis according to accepted guidelines could have a substantial impact on mortality for HIV-infected populations in Asia, as well as Africa. These findings also suggest that we may wish to proceed with caution when calling for discontinuation of PCP prophylaxis for patients who have CD4 cell counts of less than 200 cells/mmThe authors declare that they have no competing interests.PLL undertook study conception, data interpretation and drafting of the manuscript. JZ was responsible for study design and data analysis. RD was responsible for data acquisition and interpretation and critical revision of the manuscript. MGL undertook study design, data interpretation and critical revision of the manuscript. TS, NK, YMAC, PP, CKCL, VS, SO, FZ, JYC, SP, AK, PCKL, TPM, EY, LM and SS were responsible for data acquisition and interpretation and critical revision of the manuscript. All authors have read and approved the final version of this manuscript.


Using a randomized controlled trial, Marc Lallemant and colleagues ask if a CD4-based monitoring and treatment switching strategy provides a similar clinical outcome compared to the standard viral load-based strategy for adults with HIV in Thailand.Please see later in the article for the Editors' Summary Viral load (VL) is recommended for monitoring the response to highly active antiretroviral therapy (HAART) but is not routinely available in most low- and middle-income countries. The purpose of the study was to determine whether a CD4-based monitoring and switching strategy would provide a similar clinical outcome compared to the standard VL-based strategy in Thailand.3) initiating non-nucleotide reverse transcriptase inhibitor (NNRTI)-based therapy. Randomization, stratified by site , was performed centrally after enrollment. Clinicians were unaware of the VL values of patients randomized to the CD4 arm. Participants switched to second-line combination with confirmed CD4 decline >30% from peak (within 200 cells from baseline) in the CD4 arm, or confirmed VL >400 copies/ml in the VL arm. Primary endpoint was clinical failure at 3 years, defined as death, new AIDS-defining event, or CD4 <50 cells/mm3. The 3-year Kaplan-Meier cumulative risks of clinical failure were compared for non-inferiority with a margin of 7.4%. In the intent to treat analysis, data were censored at the date of death or at last visit. The secondary endpoints were difference in future-drug-option (FDO) score, a measure of resistance profiles, virologic and immunologic responses, and the safety and tolerance of HAART. 716 participants were randomized, 356 to VL monitoring and 360 to CD4 monitoring. At 3 years, 319 participants (90%) in VL and 326 (91%) in CD4 were alive and on follow-up. The cumulative risk of clinical failure was 8.0% (95% CI 5.6–11.4) in VL versus 7.4% (5.1–10.7) in CD4, and the upper-limit of the one-sided 95% CI of the difference was 3.4%, meeting the pre-determined non-inferiority criterion. Probability of switch for study criteria was 5.2% (3.2–8.4) in VL versus 7.5% (5.0–11.1) in CD4 (p = 0.097). Median time from treatment initiation to switch was 11.7 months (7.7–19.4) in VL and 24.7 months (15.9–35.0) in CD4 (p = 0.001). The median duration of viremia >400 copies/ml at switch was 7.2 months (5.8–8.0) in VL versus 15.8 months (8.5–20.4) in CD4 (p = 0.002). FDO scores were not significantly different at time of switch. No adverse events related to the monitoring strategy were reported.The Programs for HIV Prevention and Treatment (PHPT-3) non-inferiority randomized clinical trial compared a treatment switching strategy based on CD4-only (CD4) monitoring versus viral-load (VL). Consenting participants were antiretroviral-naïve HIV-infected adults  are currently infected with HIV, the virus that causes AIDS. HIV infection leads to the destruction of immune system cells , leaving infected individuals susceptible to other infections. Early in the AIDS epidemic, most HIV-infected individuals died within 10 years of infection. Then, in 1996, highly active antiretroviral therapy (HAART)—combined drugs regimens that suppress viral replication and allow restoration of the immune system—became available. For people living in affluent countries, HIV/AIDS became a chronic condition but, because HAART was expensive, HIV/AIDS remained a fatal illness for people living in resource-limited countries. In 2003, the international community declared HIV/AIDS a global health emergency and, in 2006, it set the target of achieving universal global access to HAART by 2010. By the end of 2011, 8 million of the estimated 14.8 million people in need of HAART in low- and middle-income countries were receiving treatment.3 and should have their CD4 count regularly monitored to optimize HAART. In 2013, the World Health Organization (WHO) recommendations were updated to promote expanded eligibility for HAART with a CD4 of 500 cells/mm3 or less for adults, adolescents, and older children although priority is given to individuals with CD4 count of 350 cells/mm3 or less. Because HIV often becomes resistant to first-line antiretroviral drugs, WHO also recommends that viral load—the amount of virus in the blood—should be monitored so that suspected treatment failures can be confirmed and patients switched to second-line drugs in a timely manner. This monitoring and switching strategy is widely used in resource-rich settings, but is still very difficult to implement for low- and middle-income countries where resources for monitoring are limited and access to costly second-line drugs is restricted. In this randomized non-inferiority trial, the researchers compare the performance of a CD4-based treatment monitoring and switching strategy with the standard viral load-based strategy among HIV-positive adults in Thailand. In a randomized trial, individuals are assigned different interventions by the play of chance and followed up to compare the effects of these interventions; a non-inferiority trial investigates whether one treatment is not worse than another.At the time this trial was conceived, national and international recommendations were that HIV-positive individuals should start HAART when their CD4 count fell below 200 cells/mm3) was 8% in the VL arm and 7.4% in the CD4 arm. This difference in clinical failure risk met the researchers' predefined criterion for non-inferiority. The probability of a treatment switch was similar in the two arms, but the average time from treatment initiation to treatment switch and the average duration of a high viral load after treatment switch were both longer in the CD4 arm than in the VL arm. Finally, the future-drug-option score, a measure of viral drug resistance profiles, was similar in the two arms at the time of treatment switch.The researchers assigned about 700 HIV-positive adults who were beginning HAART for the first time to have their CD4 count (CD4 arm) or their CD4 count and viral load (VL arm) determined every 3 months. Participants were switched to a second-line therapy if their CD4 count declined by more than 30% from their peak CD4 count (CD4 arm) or if a viral load of more than 400 copies/ml was recorded (VL arm). The 3-year cumulative risk of clinical failure ; its 2010 recommendations for antiretroviral therapy for HIV infection in adults and adolescents are available as well as the June 2013 Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approachThe World Health Organization provides information on all aspects of 2012 UNAIDS World AIDS Day Report provides up-to-date information about the AIDS epidemic and efforts to halt itThe HIV infection and AIDSInformation is available from the US National Institute of Allergy and Infectious Diseases on NAM/aidsmap provides basic information about HIV/AIDS and summaries of recent research findings on HIV care and treatmentAvert, an international AIDS charity on many aspects of HIV/AIDS, including information on the global HIV/AIDS epidemic, on HIV and AIDS in Thailand, on universal access to AIDS treatment, and on starting, monitoring and switching HIV treatment (in English and Spanish)Information is available from HIV and AIDSThe UK National Health Service Choices website provides information  about information about this trial  is availableMore Avert; the nonprofit website Healthtalkonline also provides personal stories about living with HIV, including stories about HIV treatmentPatient stories about living with HIV/AIDS are available through  Since the mid 1990s, highly active antiretroviral therapy (HAART) has radically modified AIDS prognosis by suppressing viral replication and thus allowing immune restoration However, in low- and middle-income countries, with limited resources and restricted access to more costly second and third-line drugs, the utility of this approach is debated This was a multicenter, randomized, non-inferiority trial conducted in 21 public hospitals throughout Thailand . The primary objective was to compare the 3-y clinical outcomes of HIV-infected adults initiating HAART, followed according to a monitoring-switching strategy either based on CD4 cell count (CD4), or on VL. The secondary objectives were (i) to compare future ARV treatment options, taking into account the profile of resistance mutations; (ii) to assess virologic and immunologic responses by arm; and (iii) to evaluate the safety and tolerance of HAART.3 and absence of prior ARV therapy (except zidovudine during pregnancy or nevirapine during labor). Exclusion criteria included pregnancy, opportunistic infection or medical condition interfering with study participation, hepatitis B or C co-infection, or any of the following: hemoglobin <8.0 g/dl, neutrophil count <1,000 cells/mm3, alanine transaminase (ALT), aspartate aminotransferase (AST), or total bilirubin >5.0× upper limit of normal (ULN), serum creatinine >1.0× ULN, platelet count <50,000/mm3, pancreatic amylase >2.0× ULN, or total amylase >2.0× ULN plus symptoms of pancreatitis.Confirmed HIV-infected patients, 18 y or older, were eligible if they could be followed at a study site and provided written informed consent. Inclusion criteria included confirmed CD4-cell count of 50–250 cells/mm3), to one of two monitoring-switching strategies: (1) VL arm: switch if confirmed decreased <1 log at 3 mo or confirmed VL above 400 copies/ml thereafter; (2) CD4 arm: switch if confirmed CD4 count declined >30% from peak value (defined as the highest average of two consecutive CD4 counts) unless CD4 remained >200 cells above baseline. Using a pseudorandom number generator (Mersenne twister), a statistician produced the randomization lists and encrypted them in a database before the initiation of the study. Only the study statisticians were allowed to access the randomization lists to maintain blinding of other research staff. Randomization was performed centrally at the study coordination center in Chiang Mai, by a research assistant. The arm assigned to each patient was disclosed to the site physician after randomization. Even though blinding was not feasible, clinicians who were responsible for enrolling and following-up with study participants were unaware of the VL values of patients randomized to the CD4 arm.After treatment initiation, participants were randomly assigned in blocks of four, stratified by site and CD4 level . HIV genotypic resistance was performed retrospectively for all patients who met the per-protocol switching criteria and had detectable VL on the last sample available before switch using ViroSeq HIV-1 Genotyping system version 2.0 (Applied Biosystems). Both were performed at the Faculty of Associated Medical Sciences, Chiang-Mai University and quality assured by the Virology Quality Assurance Proficiency Program (VQA). CD4 counts were measured using a flow cytometer at each hospital laboratory with quality control from the Center of Excellence for Flow Cytometry, Mahidol University, Bangkok, Thailand and the United Kingdom National External Quality Assessment Service (UKNEQAS). Resistance mutations were identified using the 2009 International AIDS Society (US) tables. Each mutation was assigned a penalty score derived from the Stanford HIVdb Sequence Analysis Programs (version 6.0.8) and ARV drug resistance was inferred by adding the penalty scores of each mutation.Upon enrollment, participants initiated a regimen containing nevirapine or efavirenz, plus lamivudine with stavudine or zidovudine. From April 2006, tenofovir plus emtricitabine (Truvada) became available and was widely used in combination with efavirenz. When switching criteria were reached, a protease inhibitor (PI)-based regimen, usually indinavir/ritonavir or lopinavir/ritonavir, depending on availability, was provided. Before treatment switches, causes for viral rebound or immunological deterioration were investigated, with attention to adherence, toxicities, and co-infections. Drug changes within class or between classes for reasons of toxicity were not considered “protocol switches” in the analysis.3, first or new AIDS-defining event, or death. An independent committee reviewed and classified all AIDS-defining events. The main secondary endpoint was the number of drugs remaining available for treatment at the time of switch , calculated from resistance mutations The primary endpoint was clinical failure defined as confirmed CD4 <50 cells/mmOn the basis of a literature review at the time the study was planned, the Kaplan-Meier cumulative 3-y risk of clinical failure on VL monitoring was expected to be 5% per year, or 14% over 3 y The primary analysis compared the CD4 versus VL arm based on the Kaplan-Meier estimates of clinical/immunologic failure at 36 mo. All randomized patients were included in the final intent to treat analysis. Participants who died, withdrew from the study, or were lost to follow-up  were included and data were censored at date of death or at last visit. Participants who completed the study schedule were censored on April 1, 2010. Distributions were compared using the Fisher exact test and Wilcoxon rank-sum test. Additional analyses studied baseline factors associated with clinical failure using Log rank tests and Cox proportional hazards models after testing that the Cox proportional hazards model assumptions were met .In addition to the Data and Safety Monitoring Board (DSMB), a Resistance Experts Committee was constituted to provide expertise in support of the DSMB regarding resistance mutations and their clinical implications. Outcomes, safety and resistance profiles by arm, were presented during the two interim analyses.The study protocol was approved by the Ethical Committees of the Thai Ministry of Public Health, Chiang Mai University Faculty of Associated Medical Sciences, Harvard School of Public Health Institutional Review Board, and local hospitals when applicable.p = 0.03). Initial regimens were efavirenz-based in 65% and nevirapine-based in 35% of participants; 66% were in combination with tenofovir-emtricitabine and 34% with zidovudine or stavudine plus lamivudine.From May 2005 to April 2007, 716 participants were recruited and randomized: 356 to the VL arm and 360 to the CD4 arm . All parp = 0.63). At the end of study, after a median follow-up of 43.5 mo (interquartile range [IQR] 38.8–48.4), retention remained high (93.7%); the ARV regimens were PI-based in 14% of the participants , efavirenz-based in 64%, and nevirapine-based in 22% of participants; 76% were in combination with tenofovir-emtricitabine or -lamivudine.The study was completed and unblinded on April 1, 2010, after the last-enrolled patient reached 3 y of follow-up. The DSMB recommended pursuit of the study as planned at the two interim analyses. At 3 y following enrollment, 27 patients had died, 27 were lost-to-follow up, and 18 had withdrawn , with 31Compliance to scheduled visits and adherence to therapy were both excellent with no difference between arms—4.2% of patients' visits  with >15 d difference between scheduled and actual dates, and 7.3% (52/716) reporting >1 missed dose/week. Seventy-two patients experienced treatment interruption . The reasons for the first interruptions were intolerance or toxicity in 48 cases (67%), self-interruption or missed visits in 22 cases (31%), and surgery in two cases. The median duration of the first interruption was 3.8 wk (IQR 1.3–8.6) with no difference between arms.3, 33 developed a new AIDS-defining event (including nine followed by death), and 22 died  reached the primary endpoint of clinical failure: three experienced a CD4 count decrease below 50 cells/mm 22 died . Nineteep = 0.74) (p = 0.57).The Kaplan-Meier risk of clinical failure at 3-y was not significantly different between the two arms: 8.0% (95% CI 5.6–11.4) in the VL versus 7.4% (5.1–10.7) in the CD4 arm ( = 0.74) ; Table 33 , VL above 5 log10 copies/ml (p = 0.001), and body mass index (BMI) below 18.5 (p = 0.002) (p = 0.001), CDC stage B or C (p = 0.002), and low CD4 count (p = 0.04).Baseline factors associated with clinical failure by univariate analysis included US Centers for Disease Control and Prevention (CDC) stage B or C, anemia (hemoglobin ≤10 g/dl), CD4 count below median, i.e., 150 cells/mm= 0.002) . Age, sep = 0.10. However, the median time from enrollment to switch was significantly shorter in the VL arm  (Fifty of the 716 enrolled patients (14%) were switched to second-line regimens as per protocol criteria (19 in the VL arm and 31 in the CD4 arm). The 36-mo probabilities of switch for protocol were not significantly different, 5.2% (3.2–8.4) in VL versus 7.5% (5.0–11.1) in CD4, = 0.001) .Among the 31 patients who switched to a second-line regimen for protocol criteria in the CD4 arm, 15 had VL <400 copies/ml at time of switch. In six of these cases the CD4 count subsequently increased, in seven it remained stable, and in two it fell further. Of the 19 patients who switched for criteria in the VL arm, four would have switched earlier if the CD4 criteria had been used.At the time of switch, median CD4 count and VL among those with VL >400 copies/ml were not different between arms . HoweverIn the VL arm , 18 of tFDO scores were comparable in the two study arms . At the 3 (IQR 321–527) in VL and 426 (IQR 335–538) in the CD4 arm.At 3 y, the percentages of participants with VL <50 copies/ml were very high in both arms: 98.4% in the VL and 98.2% in CD4 arm. Similarly, the median CD4 cell counts at 3 y were high in both arms: 420 cells/mmp = 0.76). A total of 151 grade 3 adverse events were observed in 92 participants (73 in 45 patients in the VL arm and 78 in 47 patients in the CD4 arm). One hundred and twenty seven grade 4 adverse events were reported, 56 in 52 patients in the VL arm and 72 in 57 patients in the CD4 arm. Fifty patients (19 in the VL and 31 in the CD4 arm) changed treatment from NNRTI-based to PI-based regimens because of toxicities, most of which were rashes (11 cases in the VL arm and ten in the CD4 arm) or hepatic enzyme abnormalities (12 cases in the VL arm and seven in the CD4 arm).There were 335 serious adverse events reported during the study among 198 patients, with no difference between arms: 112 (33.4%) were possibly or probably related to HIV and 67 (20.0%) to ARV toxicity . At 3 y,3, a CD4-based switching strategy was non-inferior in terms of clinical outcomes at 3 y of follow-up, compared to a reference VL-based switching strategy. Moreover, at study end there were no differences in terms of viral suppression and immune restoration between arms. Although the duration of detectable viral replication was longer in the CD4 arm, resistance testing showed similar profiles in the two arms.In this randomized clinical trial of NNRTI-based HAART in an HIV-infected treatment-naïve population with 50 to 250 CD4/mmThree other randomized monitoring trials conducted in sub-Saharan Africa have been published 3 also found no differences in total or activated CD4 cells or FDO scores at study end The health consequences of the longer duration of viral replication in the CD4 arm of the study are difficult to gauge. The exploratory AIDS Clinical Trials Group Study A5115 that compared switching at high versus low VL thresholds in a population with median CD4 concentration of 421 cells/mmAlthough more switches were expected in the VL than in the CD4 arm, the opposite was observed. In the CD4 arm, 31 patients switched for study criteria but almost half of them (15) had VL <400 copies/ml at the time of switch. It is well known that a drop in CD4 cells does not necessarily correlate with virological failure 3 by protocol design, and fewer than anticipated primary endpoints were reached, many of them in the first 3 mo of follow-up before the switching strategy could take effect. When we compared outcomes occurring only after 3 mo, similar results were found. Even though our results are consistent with the observations made in the HBAC study and indicate that, at least over 3–5 y, monitoring by CD4 or VL leads to essentially the same outcome, they must be interpreted with caution. The long term outcomes, including response to second-line treatment have not been thoroughly studied. While the FDO score did not differ between arms, six out of 16 patients in the CD4-monitoring arm developed ≥3 NRTI mutations, in contrast to two out of 18 participants in the VL-monitoring arm. From this finding, had the study continued longer, less optimal response to second-line treatment may be observed when monitoring with CD4 only. The fairly similar resistance patterns at failure may be related, at least in part, to the low barrier to mutation toward high-level resistance in NNRTIs and 3TC. The same NNRTI and 3TC resistance mutations were probably selected in both arms, with only thymidine analogue mutation (TAM) accumulation differing, perhaps because of longer duration of failure in the CD4 arm.This study had several limitations. First, although all patients satisfied contemporary WHO criteria for starting ARV therapy, none had a CD4 cell count below 50 cells/mmThe generalizability of our findings to routine care settings must also be considered: participants in this trial were seen and counseled every month throughout the entire study. The overall rates of virologic failure and loss to follow-up were lower than those reported in other settings, most likely due to close follow up. It is also important to note that laboratory evaluations were performed every 3 mo rather than every 6 mo as recommended by WHO. It is not clear how less frequent monitoring would have affected the outcomes in this study.Economic evaluations, mostly in sub-Saharan Africa, have generated conflicting results regarding the cost-effectiveness of VL and CD4 monitoring strategies In summary, at 3 y, rates of clinical failure and loss of treatment options did not differ between the two monitoring strategies, although the longer-term consequences of CD4 monitoring are unknown. These findings confirm that access to life-saving ARV treatment should continue to be expanded even in settings without virological monitoring, and provide reassurance to treatment programs currently based on CD4 monitoring alone, as VL measurement becomes more affordable and feasible in resource-limited settings.Text S1List of hospital sites with number of patients enrolled.(PDF)Click here for additional data file.Text S2PHPT-3 protocol.pdf.(PDF)Click here for additional data file.Text S3CONSORT statement.(PDF)Click here for additional data file.


The accumulation of mutations after long-lasting exposure to a failing combination antiretroviral therapy (cART) is problematic and severely reduces the options for further successful treatments.We studied patients from the Swiss HIV Cohort Study who failed cART with nucleoside reverse transcriptase inhibitors (NRTIs) and either a ritonavir-boosted PI (PI/r) or a non-nucleoside reverse transcriptase inhibitor (NNRTI). The loss of genotypic activity <3, 3–6, >6 months after virological failure was analyzed with Stanford algorithm. Risk factors associated with early emergence of drug resistance mutations (<6 months after failure) were identified with multivariable logistic regression.Ninety-nine genotypic resistance tests from PI/r-treated and 129 from NNRTI-treated patients were analyzed. The risk of losing the activity of ≥1 NRTIs was lower among PI/r- compared to NNRTI-treated individuals <3, 3–6, and >6 months after failure: 8.8% vs. 38.2% (p = 0.009), 7.1% vs. 46.9% (p<0.001) and 18.9% vs. 60.9% (p<0.001). The percentages of patients who have lost PI/r activity were 2.9%, 3.6% and 5.4% <3, 3–6, >6 months after failure compared to 41.2%, 49.0% and 63.0% of those who have lost NNRTI activity . The risk to accumulate an early NRTI mutation was strongly associated with NNRTI-containing cART (adjusted odds ratio: 13.3 (95% CI: 4.1–42.8), p<0.001).The loss of activity of PIs and NRTIs was low among patients treated with PI/r, even after long-lasting exposure to a failing cART. Thus, more options remain for second-line therapy. This finding is potentially of high relevance, in particular for settings with poor or lacking virological monitoring. The emergence of drug resistance is one of the major threats to successful antiretroviral therapy of infection with human immunodeficiency virus-1 (HIV-1) We aimed to study the loss of genotypic activity at different time points after virological failure and the accumulation of mutations. We further sought to identify risk factors for early emergence of mutations and we aimed to describe antiretroviral treatments with a long-lasting protection of the genotypic activity after virological failure. To answer these questions, we used data from the Swiss HIV Cohort (SHCS) and the SHCS drug resistance database and compared sequences from genotypic drug resistance tests that were performed after patients had failed first-line cART.The SHCS has been approved by the following ethical committees of all participating institutions: Kantonale Ethikkommission Bern; Ethikkommission beider Basel; comité d'éthique du département de médicine de Hôpitaux Universitaires de Genève; commission d'éthique de la recherche clinique, Lausanne; comitato etico cantonale, Bellinzona; Ethikkommission des Kanton St.Gallens; and Ethik-Kommission Zürich, all Switzerland. Written informed consent has been obtained from all participants We compared genotypic drug resistance tests from individuals included in the SHCS who failed first-line cART. The SHCS is a nationwide, multicenter, clinic-based cohort with continuous enrolment and semi-annual study visits. The last considered follow-up was the 18 October 2011. The SHCS drug resistance database is linked to the SHCS and includes >14,000 sequences from genotypic drug resistance tests performed by one of the four authorized laboratories in Switzerland We did a cross-sectional analysis and restricted our study to individuals who started first-line cART with nucleoside reverse transcriptase inhibitors (NRTIs) and either a ritonavir-boosted protease inhibitor (PI/r) or a non-nucleoside reverse transcriptase inhibitor (NNRTI) and who had a genotypic drug resistance test performed after virological failure but before treatment change to second-line cART. A treatment failure was defined if at least one HIV-1 RNA was detectable (≥50 copies/mL) after previous suppression (<50 copies/mL) or when individuals did not respond to the first-line cART for at least 180 days . These individuals are further termed non-responders. If cART was changed before 90 days or if the last viral load during cART was undetectable, it was assumed that the treatment change was due to toxicity reasons and the next treatment was considered for analysis.We calculated the time with replicating virus after virological failure until the resistance test was performed. The time with replicating virus was defined as the time period when patients had detectable viral loads (>50 copies/mL). If viral loads changed between two measurements from undetectable to detectable or vice versa, it was assumed that viruses were replicating half of the time. We grouped individuals with <3, 3–6 and >6 months with replicating virus.Characteristics were compared with Fishers exact test  and Wilcoxon rank-sum test (continuous variables).http://hivdb.stanford.edu/). Drug resistance associated mutations were defined by IAS-USA The loss of genotypic activity was estimated using the Stanford algorithm (version 6.1.1). The activity of a drug was defined as lost when the Stanford penalty score was ≥30 (We identified risk factors for an early accumulation of mutations (<6 months with replicating viruses). We performed univariable and multivariable logistic regression analyses. The following variables were included in the multivariable model: sex, transmission group, age, subtype, square root CD4 cell and viral load at the time when the resistance test was performed, NRTI treatment, PI/r or NNRTI use, and the year of cART initiation. Likelihood ratio tests did not indicate significant departures from linearity for continuous variables.Adherence is an additional potential confounder. Self-reported adherence is documented only since May 2003 in the SHCS, therefore a sensitivity analysis including adherence data was performed with patients who failed cART after this date Not only the time with replicating virus but also the viral load might be predictive for the number of emerging mutations, therefore copy-years viremia was used in a sensitivity analysis instead of the time with replicating virus Statistical analyses were performed with Stata 11 SE software . All confidence intervals were two-sided, and the level of significance was set at 0.05.We included 129 patients with a virological failure on a NNRTI-containing and 99 on a PI/r-containing cART . The fra10 3.5 copies/mL [IQR: 2.8–4.6] vs. log10 2.8 copies/mL [IQR: 2.3–3.6], p<0.001). In addition, the copy-years viremia was also substantially higher in patients treated with NNRTI  compared to PI/r (216.9 years * copies/mL [IQR: 33.9–1454.6]).The median viral load at the time when the genotypic resistance test was performed was considerably higher among patients treated with a NNRTI compared to a PI/r , respectively. Restricting the analysis to patients with known baseline resistance data and without transmitted drug resistance mutations did not alter conclusions (data not shown).Adherence data was available for 157 of 169 (92.9%) individuals who failed cART after May 2003. Adherence was similar between patients treated with PI/r- or NNRTI-containing cART: 76.9% and 79.8% (p = 0.503) never missed a drug dose six months before reporting adherence.The loss of genotypic activity of NRTIs was considerably higher in patients treated with NNRTIs compared to PI/r. The loss of genotypic activity of NRTIs was already very high <3 months after failure when patients had been treated with NNRTIs (38.2%) whereas PI/r-treated patients rarely accumulated NRTI mutations in this time period . The loss of genotypic activity of NRTIs remained considerably higher among patients treated with NNRTIs compared to PI/r also after long-lasting exposure to the failing regimen: 46.9% vs. 7.1% (p<0.001) between 3–6 months and 60.9% vs. 18.9% (p<0.001) after >6 months with replicating virus. The loss of activity of more than one NRTI was quite rare in the PI/r group for all time points: 2.9%, 7.1%, 0% when compared to the NNRTI group: 14.7% (p = 0.197), 14.3% (p = 0.474), 21.7% (p = 0.002) at <3, 3–6 and >6 months after failure .We excluded non-responders (n = 48) from a sensitivity analysis. The results remained more favorable for the PI/r group: 37.5% vs. 9.7% (p = 0.016), 38.9% vs. 9.1% (p = 0.016), 57.1% vs. 16.7% (p = 0.003) NNRTI- and PI-treated individuals lost the activity of ≥1 NRTI after <3, 3–6, >6 months with replicating virus. Results were confirmed if the analysis was restricted to the 113 patients who truly failed first-line cART (patients who changed a successful cART regimen due to toxicity reasons were excluded) although the sample size was reduced: 23.1% vs. 38.5% (p = 0.673), 8.3% vs. 48.0% (p = 0.027), 22.2% vs. 65.6% (p = 0.007) after <3, 3–6, >6 months with replicating virus lost the activity of ≥1 NRTI in the PI/r and NNRTI group, respectively. The treatment with more potent NRTI combinations could be a potential explanation for the lower accumulation of NRTI mutations. PI/r-treated individuals received more often the modern and well tolerated NRTI combination TDF/FTC (40.4%) compared to NNRTI-treated individuals (17.1%). In a sensitivity analysis, we only included patients who were treated with the TDF/FTC NRTI combination (n = 62). Also in this sub-group, the loss of activity of ≥1 NRTI was higher in NNRTI compared to PI/r-treated individuals, 26.1% compared to 5% (p = 0.043), respectively.Higher copy-years viremia among patients treated with NNRTI would be a potential explanation for faster accumulation of mutations. We repeated the analysis and classified patients in 3 groups based on the copy-years viremia instead of the time with replicating virus. Each group contained 76 patients with copy-years viremia <115, 115–1491,>1491 years * copies/mL. The loss of genotypic activity of ≥1 NRTIs was 60.6% vs. 7.0% (p<0.001), 51.2% vs. 15.2% (p = 0.002) and 41.5% vs. 17.4% (p = 0.064) in group 1 to 3 among NNRTI and PI/r treated individuals, respectively. These findings demonstrate that the higher loss of activity in NNRTI-treated patients cannot solely be explained by a more intense viral replication.The loss of genotypic activity of NNRTIs occurred very early after treatment failure whereas the emergence of PI/r resistance was very rare even after long-lasting exposure to failing cART. The percentage of patients who have lost PI/r activity was 2.9%, 3.6%, 5.4% <3, 3–6 and >6 months compared to 41.2%, 49.0%, 63.0% of those who have lost NNRTI activity  . ResultsExcluding non-responders or studying exclusively patients who failed first-line treatment confirmed these results (data not shown).The most common cause for the loss of genotypic activity of NRTIs was the emergence of M184V. It occurred in 36.4% of NNRTI- and in only 9.1% of PI/r-treated individuals (p<0.001). The prevalence of additional NRTI mutations was also much higher in the NNRTI when compared to the PI/r group: K65R 10.9% vs. 1.0% (p = 0.003), M184I 7.0% vs. 1.0% (p = 0.029), T215Y 5.4% vs. 1.0% (p = 0.072). All other mutations had a prevalence of <5% in both groups .The loss of NNRTI activity was mainly caused by the emergence of K103N (27.9%), Y181C (10.9%) or G190A (6.2%). The most common PI mutations in PI/r-treated individuals were L90M (3.0%), I84V (2.0%) and M46I (2.0%).Exposure to NNRTIs was the major risk factor for an early accumulation of NRTI mutations. The odds ratio (OR) was 10.6 (95% CI: 3.9–29.1) and 13.3 (95% CI: 4.1–42.8) in univariable and multivariable models, respectively. High CD4 cell count at the time of the resistance test was the only other factor that had a weak association with a later accumulation of NRTI mutations (univariable OR: 0.9 (95% CI: 0.9–1.0), multivariable OR: 0.9 (95% CI: 0.8–1.0). No other factor was significantly associated in the multivariable model .We showed that cART containing PI/r results in a long-lasting protection of the activity of NRTIs and PI/r during sustained viral replication under therapy. In contrast, if patients are treated with NNRTI-based cART, NRTI mutations emerge much earlier and in larger numbers. These findings are of importance both, for resource-rich and resource-limited settings. In resource-rich settings, treatment failures are usually diagnosed quite early because of frequent viral load monitoring. In resource-limited settings patients often stay a long time on a failing regimen due to lacking or only infrequent viral load monitoring. In both situations, more options remain for second-line treatment if patients receive a PI/r-based cART as first-line therapy.Previous randomized and observational studies showed that the failure rate between PI/r and NNRTI is comparable in most cases but fewer mutations emerge when patients fail a PI/r treatment In general, it is astonishing how few mutations were observed overall in the 228 patients of the study who have failed therapy. Only 43% of patients had any drug resistance-associated mutation detected Although our study initially considered 5959 patients who started first-line cART, only 228 individuals qualified for our study. The sample size was too small to compare different treatment regimens in more detail. Unfortunately, sufficient longitudinal resistance data from our patients were not available; otherwise dynamics of evolution of individual drug resistance mutations could have been investigated in more detail. In addition, we cannot exclude that there are resistance associated mutations outside the sequenced region. No phenotypic resistance tests were available that could prove that viruses which do not harbor any mutations are really sensitive to the drugs.In conclusion, PI/r containing cART leads to long-lasting protection of the activity of NRTIs and PI/r despite ongoing viral replication after virological failure. Accumulation of drug resistance mutations against all three drugs of the regimen is slower and less frequent when compared to NNRTI-containing regimens, thus retaining more options for second-line therapy. These findings are of high relevance for settings, which lack the opportunities for regular virological monitoring and where the use of PI/r as first-line therapies should be considered.


Disseminated histoplasmosis is the first AIDS-defining infection in French Guiana. A retrospective cohort study studied predictive factors of disseminated histoplasmosis in HIV-infected patients between 1996 and 2008. Cox proportional hazards models were used. The variables studied were age, sex, last CD4/CD8 count, CD4 nadir, herpes or pneumocystosis, cotrimoxazole and fluconazole use, antiretroviral treatment and the notion of recent initiation of HAART. A total of 1404 patients were followed for 6833 person-years. The variables independently associated with increased incidence of disseminated histoplasmosis were CD4 count<50 per mm3, CD4 count between 50 and 200 per mm3, a CD4 nadir <50 per mm3, CD8 count in the lowest quartile, herpes infection, and recent antiretroviral treatment initiation (less than 6 months). The variables associated with decreased incidence of histoplasmosis were antiretroviral treatment for more than 6 months, fluconazole treatment, and pneumocystosis. There were 13.5% of deaths at 1 month, 17.5% at 3 months, and 22.5% at 6 months after the date of diagnosis of histoplasmosis. The most important predictive factors for death within 6 months of diagnosis were CD4 counts and antiretroviral treatment. The present study did not study environmental/occupational factors but provides predictive factors for disseminated histoplasmosis and its outcome in HIV patients in an Amazonian environment during the HAART era. Disseminated histoplasmosis is the first AIDS-related disease in French Guiana, and probably in the Amazonian area. In order to determine the factors that are associated with histoplasmosis, a retrospective looked at a cohort of HIV-infected patients between 1996 and 2008. Multiple models were used to study the relation of age, sex, last CD4/CD8 count, CD4 nadir, herpes or pneumocystosis, cotrimoxazole and fluconazole use, antiretroviral treatment and the notion of recent initiation of antiretroviral treatment with the occurrence of disseminated histoplasmosis. A total of 1404 patients were followed for 6833 person-years. The variables independently associated with the incidence of disseminated histoplasmosis were low CD4 counts, the lowest CD4 counts were most at risk; Patients with the lowest CD8 counts were also at increased risk; Antiretroviral treatment was generally associated with lower histoplasmosis incidence, but for the first 6 months following antiretroviral treatment initiation there was a transient period of increased risk of diagnosing histoplasmosis; Herpes was also associated with more histoplasmosis; Pneumocystosis and Fluconazole treatment were negatively associated with histoplasmosis. Of 156 patients with histoplasmosis, there were 13.5% of deaths at 1 month, 17.5% at 3 months, and 22.5% at 6 months after the date of diagnosis of histoplasmosis. The most important predictive factors for death within 6 months of diagnosis were low CD4 counts and no antiretroviral treatment. The present study did not study environmental/occupational factors but provides predictive factors for disseminated histoplasmosis and its outcome in HIV patients in an Amazonian environment during the HAART era. These results are useful to guide clinicians working in an area where this diagnosis is often overlooked. Histoplasma capsulatum var. capsulatum (HC) is found throughout the world, but there are great differences in the levels of endemicity There have been few prospective studies on the predictive factors of disseminated histoplasmosis in HIV patients, mostly in the United States of America st 1996 and October 31st 2008 were enrolled in the French Hospital Database for HIV (FHDH). The data is entered in the FHDH database by trained technicians from the medical records. Diagnoses were coded according to the 10th international classification of diseases. Occupational and environmental data were not available in the FHDH. The variables usually used as prognostic factors HIV positive patients followed in Cayenne, Kourou, and Saint Laurent du Maroni Hospitals between January 1The diagnosis of histoplasmosis was performed by direct examination using May Grünvald Giemsa staining and culture of tissue and fluid samples for up to 3 months. Primary prophylaxis for disseminated histoplasmosis is not given.All HIV patients in French Guiana can receive free antiretroviral treatments (including the most recent drugs) regardless of their origin or socio-economic level. Imagery, Viral loads, CD4 counts and genotyping and antiretroviral concentration measurements are available for routine care.3), last available CD8 cell count at the time of the visit , cotrimoxazole and fluconazole use, the presence or absence of HAART and the notion of recent initiation of HAART (<6 months) In this retrospective cohort study, incidence rates were obtained. Kaplan Meier curves were used to visualize the differences in the incidence of histoplasmosis between CD4 strata and between different CD4 and CD8 strata. Single failure multiple Cox proportional hazards models were used to evaluate the adjusted relationship between failure and a set of explanatory variables. Right censoring occurred after the last visit. For the first model, including 1404 patients, the failure event was a first episode of disseminated histoplasmosis. The main explanatory variables were for the time independent variables: sex, age, and a nadir of CD4 count<50/mm3, a prior history of herpes or pneumocystosis A second model was constructed in a subgroup of 156 patients with disseminated histoplasmosis with death within 6 months of diagnosis as a failure event and CD4 count, CD8 counts, age, sex and antiretroviral treatment as explanatory variables. Other treatments, such as fluconazole and cotrimoxazole were also explored.The significance level was 0.05. The Data were analyzed with STATA 12.0 .th 1991 and has led to numerous international publications.Patients included in the FHDH gave written informed consent to the use of their data for the study. Their identity was encrypted before the data was sent to the Ministry of Health and the Institut National de la Recherche Médicale (INSERM) which centralize data from Regional Coordination for the fight against HIV (COREVIH) throughout France. This cohort is approved by the Commission Nationale Informatique et Libertés (CNIL) since Nov 27A total of 1404 patients were included. This amounted to 30838 records and 6833 years at risk. There were 141 first episodes of disseminated histoplasmosis observed. The average time at risk was 4.04 years. The general characteristics of the patients at inclusion are shown in The overall incidence rate for a first episode of disseminated histoplasmosis was 1.41 per 100 person years.3. Patients with both CD4 counts <50 per mm3 and CD8 counts under 643 had the highest risk of histoplasmosis . However, the first 6 months following antiretroviral treatment initiation were a period of increased risk of diagnosing histoplasmosis .After adjustments in Cox multiple models, cotrimoxazole was not associated with any protection from disseminated histoplasmosis while herpes was associated with an increased risk of disseminated histoplasmosis . When loP = 0.016). Altogether, 12% of first histoplasmosis cases had a concomitant opportunistic infection.On the contrary, after controlling for CD4 count, and cotrimoxazole use, a history of pneumocystosis (but not toxoplasmosis) was independently associated with a decreased risk of disseminated histoplasmosis. However, there were 3 simultaneous cases of pneumocystosis and disseminated histoplasmosis. Adjustments for the annual frequency of visits did not change the observed association between pneumocystosis and protection from histoplasmosis and thus, for the sake of parsimony, this variable was excluded from the final model. No other opportunistic infection was associated with histoplasmosis in the multiple single failure model. It is of note that tuberculosis was associated with disseminated histoplasmosis in an analysis with a single covariable and in a multiple failure model (but not in the single failure model) multiple model with the same covariables  than in the USA (4.7% per year) HIV-positive men had a higher risk of histoplasmosis, and of death within 6 months if they had histoplasmosis, both of which had not been observed in the studies in the USA A less straightforward finding was the observation that CD8 counts in the lowest quartile were independently associated with the incidence of histoplasmosis, and death within six months for patients with histoplasmosis. Some studies have shown that CD8 cell depletion affected the course of fungal infections As observed elsewhere, after adjustments in Cox multiple models, antiretroviral treatment was independently associated with protection from disseminated histoplasmosis et al. reported that pneumocystosis was associated with a lower risk of histoplasmosis and that herpes was associated with a poor outcome of histoplasmosis Histoplasma, but this broad speculation should be tested in prospective studies.In 2001, Hajjeh The association of herpes with histoplasmosis may reflect the fact that clinical herpes lesions were triggered by latent histoplasmosis, or that clinical herpes reflected growing immunodepression. The single failure multiple Cox model using only the first episode of histoplasmosis did not show any link between a history of tuberculosis and histoplasmosis and was removed from the final model. However, the multiple failure model, showing relapses or reinfections showed that tuberculosis, as reported in the literature Previous studies in the American middle west had shown the occupational and environmental risk factors of HIV-associated histoplasmosis In conclusion, immunological factors such as low CD4 count, low CD8 count, low CD4 counts at the Nadir, the absence of antiretroviral treatment and/or oral fluconazole, and male gender were associated with an increased risk of histoplasmosis. Regarding mortality, low CD4 count, low CD8 count, absence of antiretroviral treatment, male gender and an age under 30 years were associated with death within 6 months.