The objective was to study the adverse drug reaction (ADR) profile in HIV patients receiving first-line antiretroviral therapy. This was a prospective, observational study that included 171 HIV patients with a follow-up at six months. Demographic details, medical history, details of HIV infection including most recent CD4 count, details of antiretroviral therapy, and other concomitant medication were recorded. Adverse drug reactions were elicited by reviewing patient records and also by interviewing the patient/attendants directly. 171 patients completed the study out of which 88 (51.5%) were males and 83 (48.5%) were females. The study subjects included HIV-positive, treatment naïve patients who were started on treatment regimens recommended by the NACO guidelines. The ADRs observed were a fall in haemoglobin or absolute anaemia in response to zidovudine, nonspecific symptoms like headache, and a nonspecific feeling of being unwell in response to tenofovir, stavudine, and efavirenz; dyslipidaemia, pancreatitis, peripheral neuropathy, and lactic acidosis in response to stavudine; generalised rash in response to nevirapine and one case of nephrotoxicity to efavirenz. Majority of the ADRs satisfied the ‘probable' category (60.1%), and the rest were “possible”. ADRs to zidovudine and nevirapine superseded all others. Gastrointestinal effects were the most commonly observed group of ADRs, with nausea being the most common ADR, the others being gastritis and diarrhoea. The other ADRs included rash, hepatotoxicity, blood dyscrasias like anaemia, neutropenia, and thrombocytopenia, and fatigue. Few cases of lactic acidosis, peripheral neuropathy, headache, lipoatrophy, and pancreatitis were reported. Development of these drugs and in particular their use as Consolidated Guidelines on the use of Antiretroviral Drugs for Treating and Preventing HIV Infection, Recommendations for a Public Health Approach, were published by the World Health Organization (WHO) in 2016. These guidelines outline a detailed schema for diagnosis, treatment of HIV, and the related opportunistic infections, what to expect during the first six months of treatment, monitoring response to treatment, dealing with antiretroviral drug toxicities and substitutions, managing comorbidities, HIV prevention including pre- and postexposure prophylaxis, switch of antiretroviral regimen, and the general care of the HIV-positive individual. These guidelines also encompass details on how to provide the various services in different age groups and vulnerable groups including adolescents [The has to be initiated in all adults with severe or advanced HIV clinical disease  and adults with CD4 count ≤350 cells/mm3 [In India, the National AIDS Control Organization (NACO) publishes guidelines regularly, outlining the steps for diagnosis and treatment of HIV infection, the most recent ones being those published in 2013. According to these guidelines, the ideal time to start ART is before the patient presents with an opportunistic infection . HoweverThe aim of treatment is to bring about viral suppression to levels as low as possible for a time period as long as possible. More often than not, once started the therapy has to be continued for life. Many of these drugs are known to cause adverse effects, which can range from being mild to even life threatening , 4. A stMany studies have been conducted in Western and African population to study the adverse effect profile to ART, but such studies are scanty in the Indian population. In addition, results from different studies have raised more questions, paving the way for further research in HIV therapeutics in order to optimize treatment with the available resources.This study was designed to study the toxicity profile towards the commonly used first-line antiretroviral drugs (ART).The study was conducted at a tertiary care teaching hospital in South India; the study population consisted of HIV-positive subjects of either gender who were on ART. It was conducted after approval from the institutional ethics committee was obtained. It was an observational longitudinal study, with a follow-up at 6 months, and the sample size was calculated to be 171 HIV-positive patients who were on ART.HIV-positive patients aged more than 18 years on ART or those who were to be initiated on ART, whose baseline CD4 cell counts were available, were included in the study. Severely ill patients whose life expectancy was less than one week at recruitment, patients on antitubercular treatment/other drugs known to cause renal or hepatic toxicity at the time of recruitment, patients with history of alcohol abuse at the time of recruitment, and patients who were not compliant with ART were excluded from the study.Data was collected from the patient case sheet after each clinic visit and also by interviewing the patient directly. The patients' demographic details were recorded at the baseline visit. Demographic data collected included age, gender, height, weight, and socioeconomic status. Any other new symptoms and/or any other new diagnoses were also recorded.CD4 cell count was recorded at baseline and at six months. Other laboratory investigations that were collected at baseline included blood counts, liver function tests, renal function tests, blood sugar, and fasting lipid profile (whatever available). Any clinically indicated additional investigations and results were also recorded.  Regimen I: AZT +3TC +NVP  Regimen II: d4T + 3TC+NVP  Regimen III: AZT +3TC +EFV  Regimen IV: d4T + 3TC + EFV  Regimen V: TDF + 3TC + NVP  Regimen VI: TDF + 3TC + EFV  Regimen VII: Second line regimen containing protease inhibitor  Regimen VIII: Any other regimenDetails regarding HIV infection were also collected with respect to mode of infection, duration of illness, clinical signs and symptoms, WHO staging of the disease, presence opportunistic infections. Details on antiretroviral treatment collected included type of regimen that was initiated, date on which it was started, switch-over to any other regimen, and the reason for the switch. ART regimen was categorized as follows, in accordance with the NACO guidelines :  Regime Details of other concomitant medications received by the patients were also collected with the dose, duration, and indication. certain being defined as an event or laboratory test abnormality with plausible time relationship to drug intake which could not be explained by disease or other drugs, probable/likely being defined as an event or laboratory test abnormality with a reasonable time relationship to drug intake, which was unlikely to be attributed to disease or other drugs; possible being defined as an event or laboratory test with a reasonable time relationship to drug intake but which could also be explained by disease or other drugs; unlikely being defined as an event or laboratory test abnormality with a time to drug intake that made a relationship improbable (but not impossible); conditional/unclassified being defined as an event or laboratory test abnormality for which more data was needed for proper assessment; and unassessable/unclassifiable being defined as a report suggesting an adverse reaction but which could not be judged because information was insufficient or contradictory and data could not be supplemented or verified [WHO definition of ADR was used . ADRs were evaluated using standard clinical signs and symptoms. WHO-UMC causality scale was used to assess the causality and the ADRs were classified into certain, probable/likely, possible, unlikely, conditional/unclassified, and unassessable/unclassifiable, withverified .Adverse drug reactions were elicited by reviewing patient records and also by interviewing patient/attendant directly whenever possible. The details of ADRs collected included suspected drugs involved, treatment given for ADRs, and the outcome. Naranjo's algorithm was also used for causality assessment .The collected data was entered in MS-Excel and analysis was done using SPSS, version 16.0. For qualitative data, statistical test Chi square was done, and wherever appropriate, Fischer Exact test was done. Continuous data was analysed by using Student's “t” test. p-value <0.05 was taken as statistically significant. Baseline characteristics were compared by applying the Student's t test and Levene's test for equality of variances.A total of 171 patients completed the study of 6 months duration. Data from these patients was available for analysis. The study subjects included HIV-positive, treatment naïve patients who were started on ART regimens recommended by the NACO guidelines. The CD4 cell counts were assessed at baseline and at 6 months. Routine blood investigations were done at baseline and thereafter whenever warranted.All the mentioned baseline characteristics were matched between genders, except for haemoglobin. On applying Levene's test for equality of variances, the difference in haemoglobin between genders was found to be statistically significant . A positive correlation was seen between baseline haemoglobin and baseline CD4 cell count . A positive correlation was also observed between the baseline body mass index (BMI) and baseline haemoglobin . Six different treatment regimens were instituted in patients, based on various factors such as baseline haemoglobin and availability of drugs at the time of institution of therapy. Some difference was seen in the institution of various treatment regimens between gender, but this was not statistically significant (p=0.109). Out of 171 patients, 79 of them experienced at least one ADR, of which 34 were female patients and 45 were male patients. The causality of ADRs was assessed using World Health Organization (WHO) ADR probability scale and the Naranjo's algorithm . The ADRZidovudine and nevirapine were the two drugs towards which the maximum number of ADRs was seen. Out of 171 patients, 109 were on a zidovudine containing regimen, and 26 of them developed an ADR to zidovudine, of which 7 were females and 19 were males. The ADRs included either absolute anaemia or a fall in haemoglobin. In such patients, since the baseline haemoglobin was high, the fall in haemoglobin was not large enough to cause overt anaemia. Out of these 26 patients, 8 patients also developed thrombocytopenia, and 9 patients developed neutropenia. On the development of ADR with zidovudine, it was replaced by another NRTI, like tenofovir or stavudine. Two patients developed an ADR to both zidovudine and nevirapine.Reaction to nevirapine was seen in 26 patients out of the 135 patients receiving nevirapine containing regimen; of these 15 were female patients and 11 were males. Generalised papular rash was observed in all these patients and hepatotoxicity in eight of these patients. Nonspecific symptoms like nausea and vomiting were also seen.At the time of initiation of this study, stavudine as a part of first-line ART was slowly being phased out, due to intolerable side effects that it had been proven to cause over the years. Hence, there were only 39 patients out of 171 who were on a stavudine containing regimen. Of these, 12 patients developed an ADR towards stavudine . The symptoms ranged from nonspecific symptoms like nausea to raised lactate levels, dyslipidemia, and lipoatrophy. Three cases of lactic acidosis and one case of pancreatitis was seen. Two cases of peripheral neuropathy attributable to stavudine were also seen.Thirty-six patients were initially started on an efavirenz containing regimen, of which nine patients developed an ADR. Six of them were male patients and three were female. There were general symptoms like insomnia, headache, and nausea in these patients. Hepatotoxicity occurred in six of them with raised transaminase levels. Efavirenz was also substituted for nevirapine in patients who developed an ADR towards nevirapine .Twenty-three patients out of 171 were started on a tenofovir containing regimen. Tenofovir was also given instead of zidovudine in those patients who developed a reaction in response to zidovudine. Four patients out of these developed an ADR towards tenofovir of which two were male patients and two female. Of these, one male patient developed nephrotoxicity with proteinuria. Generalised weakness was seen in the other three patients.All patients had an adherence of >95% to the prescribed regimen. On the development of any ADR or intolerance towards the medication, spontaneous reporting was done and suitable steps like change in regimen or counselling regarding medications or both were done as indicated.The aim of the present study was to study the pattern of the occurrence of adverse drug reactions to the first-line antiretroviral drugs. All baseline characteristics between genders were matched and no significant difference was seen, except in haemoglobin. As already known, haemoglobin was found to be significantly lower in female patients in comparison to males at baseline and this has been previously reported in another study . This phThe results from prior studies regarding the incidence of ADRs have been varying. Various studies have reported a prevalence of ADRs to ART as low as 19.5% to as high as 86% . AnotherART is the treatment of choice in HIV patients; these drugs once started have to be continued lifelong. Hence, toxicity to these drugs is a very important issue in the management of HIV-infected patients, as this determines the compliance of patients to the therapeutic regimen that has been initiated. The most common regimen used was a combination of zidovudine, lamivudine, and nevirapine, accounting for 52.6% of the patients, followed by a combination of stavudine, lamivudine, and nevirapine (18.71%). This was in accordance with the guidelines being followed in the period during which the study was conducted . HoweverIn our study, ADRs to zidovudine and nevirapine superseded all others. The reason for this could probably be that these two drugs were the most frequently employed first-line drugs among the various regimens employed. Hence the number of ADRs observed towards these two drugs was also higher. Gastrointestinal intolerance, anaemia, thrombocytopenia, and dermatological adverse effects were the commonly observed ADRs, along with others like hepatotoxicity, dyslipidemia, pancreatitis, lactic acidosis, and peripheral neuropathy.Nevirapine has been known to cause dermatological reactions like itching and rash, which are a part of the hypersensitivity spectrum. This has been studied previously in animal models and it was seen that 12-hydroxylation of nevirapine producing the metabolite 12-OH-nevirapine causes the rash; 12-OH-nevirapine when administered was also seen to cause a rash .Zidovudine is known to cause bone marrow suppression which in turn can cause anaemia and thrombocytopenia. WHO definition of anaemia was used, wherein a haemoglobin level of less than 12 gm/dl is considered as anaemia in females, and less than 13 gm/dl is considered anaemia in males . In our β-oxidation. Hence, the metabolic pathway of pyruvic acid is shifted towards increased lactate production, and fatty acids are converted to triglycerides that accumulate in the hepatocyte cytoplasm. Not all patients develop lactic acidosis; this could be due to acquired deficiencies in riboflavin and thiamine cofactors required for oxidative phosphorylation, which may predispose to the development of lactic acidosis [Lactic acidosis, peripheral neuropathy, and pancreatitis also were seen in our study. Patients who developed lactic acidosis presented with abdominal pain, nausea, and vomiting. Lactic acidosis and peripheral neuropathy are well-documented adverse effect of stavudine, with a previous study reporting high incidence of lactic acidosis in HIV-infected patients receiving stavudine as a single agent –18. Pancacidosis , 16. PerADRs due to efavirenz were largely nonspecific, with some patients showing raised serum transaminase levels suggestive of hepatotoxicity. Efavirenz is known to be hepatotoxic, albeit not as much as nevirapine. A case report has also suggested that the risk of hepatotoxicity with efavirenz could be higher if used along with tenofovir , 20. TheOur study had certain limitations; baseline and sixth-month virological load were not done routinely unless indicated, and hence correlation between the virological response which can affect the response to therapy and the occurrence of ADRs was not possible. Also, the follow-up period was for six months only, and in order to draw a conclusion, longer follow-ups would be required. Since the patients included were treatment naïve, no patients on Protease Inhibitors were included, and hence the toxicity profile towards the same could not be studied.Gastrointestinal effects were the most commonly observed group of ADRs, with nausea being the most common ADR, the others being gastritis and diarrhoea. The other ADRs also included rash, hepatotoxicity, blood dyscrasia like anaemia, neutropenia and thrombocytopenia, and fatigue. Few cases of lactic acidosis, peripheral neuropathy, headache, lipoatrophy, and pancreatitis were also reported.


The high genetic diversity of HIV-1 has been shown to influence the global distribution, disease progression, treatment success, and the development of an effective vaccine. Despite the low HIV prevalence in Cameroon, all the major HIV subtypes alongside several circulating recombinant forms (CRFs) and unique recombinant forms (URFs) have been reported in Cameroon. To date, HIV-1 diversity in some parts of Cameroon has been largely studied however, information on circulating HIV-1 subtypes in the Northwest region (NWR) of Cameroon is dearth. Therefore the aim of this study was to determine the current circulating HIV-1 subtypes among adults in the NWR of Cameroon.pol gene was performed on 81 samples. The samples were collected from drug naïve patients aged between 18 and 61 years residing within the rural and urban towns in the NWR during the period between February and April 2016. Viral RNA was extracted from plasma, reverse-transcribed, further amplified by nested-PCR before sequencing using an in-house protocol. Generated sequences were then phylogenetically analyzed together with references using MEGA 7.The genetic analysis of the reverse transcriptase region of the Phylogenetic analysis revealed a broad viral diversity including CRF02 _AG (74.1%), F2 (7.4%), D (7.4%), G (3.7%), A1 (1.2%), CRF22_01A1 (2.5%), CRF06_cpx (1.2%), CRF09_cpx (1.2%), CRF11_cpx (1.2%). Three close epidemic clusters were found among F2 (1) and CRF02_AG (2) variants. For the first time we are reporting the CRF22_01A1 subtype in this region.Our findings update HIV-1 subtypes information in Cameroon and uphold previous studies that CRF02_AG is the most prevalent subtype. This CRF02_AG subtype may have important public health, research, and clinical consequences. Studies involving other parts of the country like the NWR have not been adequately evaluated. The few studies undertaken in this region, even though sample sizes have been small (< 30 samples), have revealed a number of new strains , 12. DueA cross sectional study was conducted and five ART clinics systematically sampled; Bafut, Bali, Ndop and Santa District Hospitals and Bamenda Regional hospital of the NWR of Cameroon. Study participants were enrolled on the day of antiretroviral therapy (ART) initiation from February 2016 to April 2016. A standardized questionnaire and patient record file were used to collect demographic.The National Ethics Committee of Cameroon approved the study protocols (NO2016/01/685/CE/CNERSH/SP). The purpose of the study and research procedures were fully explained to participants in the language  best understood by the clients. Signed informed consent was obtained from each of the participants prior to the interviews and blood collection.(HAART) naïve patients, male or female aged ≥18 years while the exclusion criteria were pre-exposure to HAART, and patients looking severely ill . Of the 100 patients enrolled, 81(81%) samples were sequenced in required reverse transcriptase coding regions giving a successfully sequencing performance of 81%.A total of 100 HIV-1 patients were enrolled from February 2016 to April 2016. The eligibility criteria were HIV-1 Highly active anti-retroviral therapy + T cell counts was performed using a FACS Calibur flow cytometer  equipped with automated acquisition and analysis software according to the manufactures instructions [The CD4ructions .pol-RT gene corresponding to 2075–3703 bp (the position is given referring to theHXB2 strain) was amplified by nested PCR using in-house protocol. Of the 100 samples, 81(81%) were successful amplified, purified, and directly sequenced using ABI 3130 genetic analyzer  according to previously published in-house protocol with the following primers as shown on Table Five milliliters of whole blood was drawn from each subject into an EDTA (Ethylene Diamine Tetra acetic Acid) tube and centrifuged at 3000 rpm for 5 min. Two plasma aliquots of 1 ml each were collected from each patient and stored at − 80 °C until transported in an ice box to the Molecular Biology Laboratory of CIRCB-Yaoundé for analysis at CIRCB-Yaoundé where the samples were stored at − 20 °C. Plasma Viral RNA was extracted from 1 ml plasma using the QIAamp Viral RNA Mini kit  according to the manufacturer’s instructions. Extracted RNA was transcribed to cDNA using in-house RT –PCR protocol using a one-step kit . Partial HIV-1 http://www.hiv.lanl.gov/content/sequence/RIP/RIP.html).Generated sequences were aligned using CLUSTAlW version 1.8.3 with subsequent inspection and manual modification with pair wise evolutionary distances estimated by Kimura’s two-parameter method with bootstrap analysis of 1000 replicates. Resulting trees were visualized using Fig tree software. Bootstrap resampling (1000 data sets) of multiple alignments was performed to test the statistical robustness of the trees . Baseline characteristics of study patients were described using frequencies and percentages.+ T cell count was 194.3 (8–498) cells/mm3 and a greater part of the participants had CD4+ T cells count of < 200 cells/mm3 59.3% (48). The majority of the patients were residents in an Urban setting 54.3% (44)  were female. The mean (range) CD4From the 81 samples that were successfully amplified and sequenced, analysis of these sequences revealed; four pure subtypes and five CRF; F2 (6: 7.4%), G (4: 4.9%), D (3: 3.7%),A1 (1: 1.2%) pure subtypes and CRF02_AG (60: 74.1%), CRF22_01A1 (2: 2.4%), CRF06_cpx (1: 1.2%), CRF09_cpx (1: 1.2%) and CRF11_cpx (1: 1.2%) CRFs  patients were infected with HIV variants that carried resistance associated mutations associated with Nucleoside reverse transcriptase inhibitor (NRTI); 8.6% (7/81), Non nucleoside reverse transcriptase inhibitor (NNRTI); 4.9% (4/81) and protease inhibitors (PI); 1.2% (1/81). In this study, the most common mutations were K219Q  and E138A  which confers resistance to NRTIs and NNRTIs respectively. Singleton mutations that were associated with NRTI included: D67N, K70R, T215F, T215TA, M184MV, M184 V, D67N, K70R, K70 T, and M41ML; while that of, NNRTI was K103 N, V108I, V179E, and Y181C and for PI was I54IFV. Dual-class drug resistance mutation involving both NRTI and NNRTI was observed in three patients (3.7%).Previous studies have shown that CRF02_AG is the dominant virus circulating in Cameroon. This study showed that CRF02_AG was the dominant HIV-1 subtypes in circulation involving 74.1% of the entire samples analyzed  in this study falls within the 48.6–80% range of previous studies conducted in Cameroon and other countries in West Africa, Central Africa, and Europe , 19–21. Compared with previous studies from different urban towns in Cameroon, the prevalent subtypes after CRF02_AG were F2, G, and D contrary to detected G, F2, and D  and D, FThe CRF22_01A1 variant seen in this study with a very low prevalence has not been reported in the NWR , 12.The Phylogenetic analysis of these sequences showed clusters with reference sequences from Cameroon and surrounding countries indicate possible local origins. This implies that transmissions of these viral strains are within the country.Transmitted drug resistance (TDR) was however determined in this study. Overall prevalence of TDR was 11.1%. This prevalence was found to be higher compared to those detected (7.2%) in West and Central Africa in 2016 . The mod, [The high prevalence of NRTI over NNRTI mutations detected was contrary to previous finding in other urban centres in Cameroon , 26. How, . This hi, , 30. The, . Detecti, , 32. Nev, , 33. Bas, . The detOur data show an increasing diversity of HIV-1 in the NWR. This study confirmed previous findings that CRF02_AG subtype is still the most predominant subtype. In addition, the overall prevalence of TDR among recently diagnosed individuals in Northern region of Cameroun was moderate. We suggest that there is need for implementation of effective measures that could strengthen monitoring and guide ART usage and surveillance of HIV genetic diversity.


To evaluate clinical outcomes after either immediate or deferred initiation of antiretroviral therapy in HIV-1-infected patients, presenting late with pneumocystis pneumonia (PCP) or toxoplasma encephalitis (TE).Phase IV, multicenter, prospective, randomized open-label clinical trial. Patients were randomized into an immediate therapy arm  within 7 days after initiation of OI treatment) versus a deferred arm (starting ART after completing the OI-therapy). All patients were followed for 24 weeks. The rates of clinical progression  and other grade 4 clinical endpoints) were compared, using a combined primary endpoint. Secondary endpoints were hospitalization rates after completion of OI treatment, incidence of immune reconstitution inflammatory syndrome (IRIS), virologic and immunological outcome, adherence to proteinase-inhibitor based antiretroviral therapy (ART) protocol and quality of life.61 patients  were enrolled. No differences between the two therapy groups in all examined primary and secondary endpoints could be identified: immunological and virologic outcome was similar in both groups, there was no significant difference in the incidence of IRIS (11 and 10 cases), furthermore 9 events  occurred in each group.In summary, this study supports the notion that immediate initiation of ART with a ritonavir-boosted proteinase-inhibitor and two nucleoside reverse transcriptase inhibitors is safe and has no negative effects on incidence of disease progression or IRIS, nor on immunological and virologic outcomes or on quality of life. Among the approximately 36.7 million people infected with the human immunodeficiency virus (HIV) worldwide , the popLate diagnosis of HIV infection often only follows after patients present with opportunistic infections (OI) requiring immediate treatment, a situation which poses numerous management dilemmas and risks due to overlapping drug toxicities, potential pharmacokinetic interactions with antiretroviral drugs and the risk of developing immune reconstitution inflammatory syndrome (IRIS) , 16–21. Late presenting patients with OIs are underrepresented or excluded in most ART therapy-studies and a limited number of studies address the optimal timing of ART initiation during the course of treatment of an OI. An active AIDS-defining illness is almost always among the exclusion criteria. This situation has resulted in a striking lack of evidence concerning the antiretroviral treatment of such patients. Consequently, the best antiretroviral regimen and the best timing for starting antiretroviral therapy in treatment-naive patients with advanced infection have not yet been established  and guidThe objective of the current study was to compare the rates of clinical progression in early versus deferred initiation of ART in two study groups with treatment naïve patients, presenting with pneumocystis pneumonia (PCP) and toxoplasmic encephalitis (TE). The ART consisted of atazanavir/ritonavir (ATV/r) and tenofovir-disoproxil fumarate (TDF)/emtricitabine (FTC).This study  was planned and conducted as a phase IV, multicenter, prospective, randomized open-label clinical trial. A biostatistician was involved in planning of the study. Recruitment was conducted in 16 specialized infectious diseases care clinics in Germany, recruitment period was September 2011 until May 2015. All feasible patients in these centers were screened for inclusion.All patients gave written informed consent. Inclusion criteria were defined as HIV-1-infected adults and either ART-naïve or patients with no antiretroviral therapy for at least 6 months prior to screening and no evidence for prior virologic failure due to resistance against nucleoside reverse transcriptase inhibitors (NRTIs) and protease inhibitors (PIs), who have developed either pneumocystis pneumonia (PCP) or toxoplasma encephalitis (TE). Exclusion criteria included renal failure (defined as CrCl < 60 mL/min), patients who were unable to initiate ART or with current contraindications against ATV/r, AIDS-defining events other than PCP or TE, pregnancy or women of childbearing potential wanting to become pregnant. After statistical calculations we planned 210 patients to include into the study to gain statistically significant evidence. The sample size calculation was carried out with Pass 2008 . The underlying assumption was a reduction of the primary event rate from 25 to 10% with a statistical power of 80% and a type I error of 5% within a balanced study design. In addition, a maximum dropout rate of 7.5% is assumed for the 194 necessary patients. This results in the final total number of 210 subjects.All patients were recruited in an in-hospital setting. All study centers were HIV-care experienced infectious-diseases units of hospitals with associated outpatient care centers in urban settings.® and Reyataz® for this clinical trial. Randomization was performed by the principal investigator within the electronic case report form (eCRF). After entering the information that the patient had given written informed consent the decision when to start ART (“immediate” or “deferred”) was provided by the e-CRF system. The day of randomization was considered to be baseline in both arms. Follow up period was over 24 weeks (with visits every 4 weeks). The in-patient care not directly related to the study procedures was up to the specific study site (for example the choice of treatment of the OI or the time of discharging the patients). In other words, the decision to discharge a patient was made on clinical grounds. There was a documentation of the hospitalization days (see next section).Antiretroviral treatment consisted of Ritonavir boosted Atazanavir (ATV/r) plus 2 nucleosidic non reverse transcriptase inhibitors (NRTIs). The immediate treatment group (IT) started ATV/r + 2 NRTIs immediately after HIV/AIDS diagnosis (as soon as possible but no later than 7 days after initiation of OI treatment). The deferred treatment arm (DT) started ART after completion of OI treatment, which was achieved for PCP at the earliest at day 21, for TE at the earliest at day 28, but no later than 6 weeks after randomization. Patients were followed up for a total of 24 weeks. Bristol-Myers Squibb provided the study sites with Norvirhttps://rsc.niaid.nih.gov/sites/default/files/table-for-grading-severity-of-adult-pediatric-adverse-events.pdf). For abnormalities not found in the toxicity tables, a grade 4 event was defined as potentially life-threatening . Patients who dropped out of study observation before the end of week 12 were counted as clinical progression . Secondary endpoints were defined as incidence of immune reconstitution inflammatory syndrome (IRIS) within 24 weeks after inclusion, virological outcome , parameters for quality of life (SF 36 score at inclusion and at 24 weeks) and adherence of ART (pill count) and the number of hospitalization days.The primary endpoint was defined as clinical progression  within 24 weeks after inclusion in the study. For G4 events, standardized toxicity grading tables were used  could not be applied every time due to low inclusion of patients (see results). In those cases, Chi-square was replaced by Fisher’s exact test. All analyses were performed using SAS 9.4 . All tests were fully functional despite the small study populations.All participating sites had local ethical approval due to national laws. All subjects provided written informed consent.We screened 67 patients overall, 6 patients couldn’t be included . 31 patients were randomized to the immediate arm and 30 patients to the deferred arm, of whom 29/31 and 24/30 completed the follow up period of 24 weeks. Mean age, gender- and race-distribution were comparable in both groups  had all new or relapsing OI or grade 4 events diagnosed. A new or relapsing opportunistic infection occurred in 4 of 31 patients in the immediate arm and in 1 of 30 patients in the deferred arm. In total, seven (7) grade 4 adverse events occurred throughout the observation period: in 3 of 31 immediate group patients and in 4 of 30 deferred group patients. Serious adverse events were reported for either 2 out of 31 immediate group patients and 6 out of 30 deferred group patients dropped-out.Of the 61 randomized patients, 8 of 11 patients with TE and 10 of 50 patients PCP had an event, however, these were similarly distributed between the IT and DT groups . 242 (88%) were graded as grade 1 or 2 adverse events. Most prevalent AE were: allergy to antibiotics (12), herpes infection , mucosal candida infection (8), nausea (7), fever (7), respiratory tract infections  (5), cytomegalovirus (CMV) infection (5), diarrhea (5), Kaposi sarcoma (3).The distribution of grade 1 and 2 adverse events was relatively equal between the study arms. Although not statistically significant, grade 3 and 4 events appeared to be more common in the DT group (see Table 24 AE (8.76%) were assessed as related to study treatment . The dose of study drug was not changed for grade 1 and 2 AEs however, drug treatment was discontinued after the grade 4 AE (the patient was in the DT group). No serious adverse drug reaction (SADR) or suspected unexpected serious adverse reaction (SUSAR) was recorded in either treatment group. The drop-out rate after treatment initiation was 2/31 (6.45%) in the IT group and 6/30 (20%) in the DT group.In total, 18 SAEs occurred during the clinical trial. Two of them, occurring within the same patient, were reported as fatal .No significant difference or trends were detectable amongst secondary endpoints. This includes hospitalization days, IRIS incidence, immunological and virologic outcome, the proportion of patients with changes in the antiretroviral regimen or the SF36-scores Table .This trial was conducted to gain more evidence regarding the ideal timing of initiation of ART in late presenting HIV positive patients who present with either PCP oder TE.The major strength of this study is that it provides data for the important question when to start ART in a very vulnerable group of HIV-infected patients with two common opportunistic infections.The protease-inhibitor (PI) atazanavir/ritonavir (ATV/r) was chosen as core agent, recommended in several both national and international guidelines at the time of study planning and initiation 2010–2011  , 31. ATVIn general, the study medication was well tolerated, most adverse events were mild. There were no unsuspected adverse events related to the study medication. Only few adverse events were severe adverse events and only few drop-outs occurred. The total number of these events  were equally low in both treatment groups, considering the severity of the underlying condition.A review of the available literature regarding timing of ART in HIV positive patients with opportunistic infections was performed. To our knowledge only one randomized clinical trial, performed by the AIDS Clinical Trial Group (ACTG 5164) seems similar and comparable to our study population and setting . In thisThere was no statistically significant difference in the primary endpoint and both arms achieved similar CD4 T-cell counts and viral load declines by week 24. Importantly, the immediate arm had fewer deaths/AIDS progressions (p = 0.035), longer time to death/AIDS progression , and shorter time to achieving an increase in CD4 T-cell counts to > 100/μL (11.8 versus 4.2 weeks). The authors concluded that, although there was no significant difference between immediate and deferred ART in the primary endpoint , immediate ART reduces death/AIDS progression over 48 weeks. However, there are major differences in the study settings to our trial because different antiretroviral regimens have been used and heterogeneous opportunistic infections were allowed. The initiation of ART in the immediate arm was 12 days, compared to 45 days in the deferred arm. To get better comparability, we’ve chosen a defined ART regimen with boosted Atazanavir as the third agent. This was an appropriate, frequently recommended and used regimen at time of study planning 2010–2011 , 33. We This study shows no evidence that an immediate antiretroviral combination treatment with ATV/r and 2 NRTIs (TDF/FTC) in patients with an acute AIDS-defining opportunistic infection (toxoplasmosis or pneumocystis pneumonia) has any positive or negative effect on the overall outcome of patients with advanced HIV-related immunosuppression (CDC class C). The primary endpoint ‘clinical progression’  occurred equally in both treatment arms. Secondary endpoints as hospitalization days after completion of OI treatment, incidence of IRIS, virologic outcome at week 24 were also distributed equally in each treatment group. There were also no significant differences in self-reported bodily or psychological well-being using the SF36 body score and SF36 psychological score questionnaire between the two treatment groups.Other trials with different study populations, mostly in resource poor countries and with different OI  showed worse outcomes, if ART was initiated sooner, compared to deferred initiation , 28, 29.The overall message regarding those OI (tuberculosis and cryptococcosis) was, not to defer ART at low CD4 cell counts, unless patients are suffering from neurologic affection, especially cryptococcal meningitis –37.However, some further limitations deserve to be mentioned. Due to the small size of the two treatment groups, minor differences in primary and secondary endpoints of incidence rates of SAE might not have been detectable.Another limitation is the fact, that nowadays a majority of patients is treated with an integrase inhibitor as the core agent in first-line ART. Data from the IDEAL trial probably cannot be applied for this treatment selection, because the incidence of treatment-associated immunological reconstitution might be higher with integrase inhibitors (INI). Therefore, it would be necessary to run another trial using INI as the core agent.Furthermore, epidemiology, diagnostics and therapy in both PCP and TE are evolving, possibly leading to limitations in transferring the results to current populations , 39.Despite a multicenter approach with much effort in 16 German HIV care experienced study centers only 61 of the planned 210 patients could get enrolled into the study. For the most part, in our opinion this was caused by the severity of the underlying condition . Additionally, difficulties occurred due to multiple potential drug interactions due to supportive drugs. E.g. ATV/r and proton pump inhibitors, often used in critical care patients, couldn’t be coadministered. These difficulties should be considered in the planning of potential future early treatment evaluation trials with novel integrase-based HIV regimens, that have fewer side effects.In summary, this study supports the hypothesis that immediate initiation of antiretroviral therapy with a ritonavir-boosted proteinase-inhibitor and a combination of two nucleoside reverse transcriptase inhibitors in treating the above mentioned OI is save and has no negative effects on incidence of disease progression or immune reconstitution inflammatory syndrome, nor on immunological and virologic outcome or on quality of life.We have to emphasize the lack of both, other studies in this important field of HIV medicine and long-term observations. For long term analysis, monitoring the study population after several years is planned. Further investigations should investigate other OI and use other, modern ART-regimens.


Though these results are descriptive, they suggest that HIV-positive patients with CLcr of 30–49 mL/min would have similar AE risks in comparison to patients with CLcr ≥50 mL/min when initiating antiretroviral therapy delivering doses of 300 mg of lamivudine daily through 96 weeks of treatment. Overall improvements in CLcr were observed for patients with baseline CLcr 30–49 mL/min.A retrospective analysis of the randomized controlled DART  trial in HIV-1-positive adults initiating antiretroviral therapy with co-formulated zidovudine/lamivudine plus either tenofovir, abacavir, or nevirapine was conducted to evaluate the safety of initiating standard lamivudine dosing in patients with impaired creatinine clearance (CLcr). Safety data collected through 96 weeks were analyzed after stratification by baseline CLcr (estimated using Cockcroft-Gault) of 30–49 mL/min (n = 168) versus ≥50 mL/min  and treatment regimen. The Grade 3–4 adverse events (AEs) and serious AEs , maximal toxicities for liver enzymes, serum creatinine and bilirubin and maximum treatment-emergent hematology toxicities were comparable for groups with baseline CLcr 30–49 versus CLcr≥50 mL/min. No new risks or trends were identified from this dataset. Substantial and similar increases in the mean creatinine clearance (>25 mL/min) were observed from baseline though Week 96 among participants who entered the trial with CLcr 30–49 mL/min, while no increase or smaller median changes in creatinine clearance (<7 mL/min) were observed for participants who entered the trial with CLcr ≥50 mL/min. Substantial increases (> 150 cells/ mm For HIV-1-positive patients with impaired renal function whose creatinine clearance (CLcr) is between 30–49 mL/min, the current recommended dose of lamivudine (3TC) is 150 mg once-daily . This dosing recommendation is based on pharmacokinetic data from the NUCA1004 study in HIV-1-positive patients, in which an approximately 2-fold increase in 3TC exposure in plasma was observed for patients with CLcr 30–49 mL/min following oral administration of a 300 mg 3TC tablet; however long-term safety data were not available in that study . The trial was conducted at three centers in Uganda and one in Zimbabwe. Each participant received 3TC/ZDV twice-daily (BID) as an FDC (150 mg 3TC and 300 mg ZDV) in combination with a third drug, which was either once-daily (QD) tenofovir  for 2,469 trial participants, nevirapine  for 547 trial participants or abacavir  for 300 trial participants . Tri. Tri3]. Participants gave written informed consent both for screening and, if eligible, enrollment. The trial was approved by research ethics committees from the participating study sites in Uganda  and Zimbabwe  as well as by ethics committees in the United Kingdom .Previously collected on treatment data were analyzed through 96 weeks, including Grade 3–4 AEs and SAEs . Trial participants underwent clinical examinations at baseline, weeks 4 and 12 and every 12 weeks thereafter. Full blood count and selected biochemistry test results  and CD4 cell counts were collected on the same schedule. Local laboratories determined serum creatinine and no specific calibration was undertaken across centers. Plasma HIV-1 RNA, and resistance testing were not performed prospectively. Treatment switches were guided by immunological  and clinical parameters only. Additional details, including full inclusion and exclusion criteria for the original trial, are available as supplementary information .Although the randomization schedule assigned the participants to LDM vs CDM, for the purpose of this retrospective analysis that randomization was combined, and treatment groups were summarized according to the third drug in the regimen and by baseline CLcr category. All available clinical laboratory data for trial participants was summarized for Week 0, 24, 48 and 96 and grouped by ART regimen and by baseline CLcr categories for subsequent analysis. The DAIDS grading scale was used for laboratory grading and the National Kidney Foundation (NKF) grading scale was used for the creatinine clearance grading , 4.The incidences of safety events were compared between participants with baseline CLcr ≥50 mL/min, 30–49 mL/min and <30 mL/min. In participants with available CLcr data at Week 24, the incidence of safety events that occurred in the first 24 weeks were also compared between those participants whose baseline CLcr was 30–49 mL/min and remained <50 mL/min at Week 24 versus those whose baseline CLcr was 30–49 mL/min and increased to ≥50 mL/min by Week 24, and those from whom the baseline and Week 24 CLcr results were ≥50 mL/min. The Cockcroft-Gault formula (CGF) was used to calculate CLcr  and SAEs were reported for 12 participants in the 3TC/ZDV/TDF group .Overall, 283/3316 participants experienced SAEs (including 2 participants whose baseline CLcr was <30 mL/min). In The change from baseline to Week 96 for the hematology parameters  in partiA small number of participants had Grade 3 or 4 hematological toxicities , and theOverall, the maximal toxicities determined by measurements of alanine aminotransferase (ALT), aspartate aminotransferase (AST), serum creatinine and bilirubin reported across the treatment and CLcr groups were similar, with very few Grade 3 and 4 laboratory toxicities (<1%) and no trend of increase in toxicities grades over time.3, were indicative of a population which was more strongly immunosuppressed at initiation of ART as compared with ART-naïve HIV-positive trial participants in resource-rich countries [The baseline demographics of the DART trial population, including the median enrollment CD4 cell count of 86 cells/mmountries . As seenountries , there wountries .The incidence of overall Grade 3–4 AEs and for specific hematological, hepatic and gastrointestinal events over 96 weeks of treatment were comparable between participants who had moderate renal impairment (CLcr 30–49 mL/min) at baseline and those with better renal clearance at baseline CLcr (≥50 mL/min). The maximal treatment-emergent hematological and chemistry toxicities over 96 weeks of treatment were also comparable across these two renal function groups. Although the overall percentages of any grade 3 /4 hematological events were comparable for participants with CLcr 30–49 mL/min vs those with CLcr ≥50 mL/min , rates ipost hoc data analysis. The sample size for trial participants with baseline CLcr of 30–49 mL/min was small, relative to the overall DART trial population. In keeping with the trial protocol, routine HIV-1 RNA and resistance testing were not prospectively undertaken and therefore treatment switches were guided by immunological (CD4+ cell counts) (LCM group only) and clinical parameters only. Limited clinical safety data (Grade 3 and 4 events only) were collected and used to classify AE events using a coding system developed by the DART Team of investigators based on diseases likely to occur in an African setting. Data from some of the 225 participants who underwent planned ART interruptions were excluded from this post hoc analysis after the start of the interruption as their inclusion would have made interpretation of AEs difficult. Despite these limitations, our data provide useful information regarding the safety of the use of a 3TC-containing FDC in patients with CLcr 30–49 mL/min compared with the safety of 3TC-containing FDC in patients with CLcr ≥50 mL/min.There are several limitations of this There have been two recent publications on the use of higher-than-recommended doses of 3TC in patients with renal impairment. One study enrolled 34 HIV-positive patients with varying degrees of renal function and used physiologically-based pharmacokinetic modeling to simulate drug concentrations over time using areas under the curve (AUCs) and drug profiles by CLcr . The autpost hoc analysis of clinical trial data up to 96 weeks of observation, no new or additional risks associated with the use of a standard dose of a 3TC or a 3TC-containing FDC in participants with moderate renal impairment (with CLcr levels of 30–49 mL/min) compared to participants with CLcr ≥50 mL/min were suggested. Though post hoc analyses are intrinsically limited, the results of this analysis are consistent with recent reports from the literature regarding the safety of a standard 3TC dose when used in HIV-positive patients with moderate renal impairment.In this descriptive S1 File(PDF)Click here for additional data file.


This study assessed the satisfaction of patients receiving antiretroviral treatment (ART) in Vietnam and its multilevel predictors. Cross-sectional data were collected from January to September 2013 in eight outpatient clinics in Hanoi and Nam Dinh provinces. Patient satisfaction was evaluated using the Satisfaction with HIV/AIDS Treatment Interview Scale. Multivariable Tobit regression was utilized to measure the associations between these factors and satisfaction with treatment services. Generalized Mixed-effect Regression model was used to estimate the effect of satisfaction with the quality of service on the change between the initial and the latest CD4 cell count. Among 1133 patients, most of them were completely satisfied with the 10 domains measured (65.5% to 82.5%). “Service quality and convenience” domain which was attributed by the waiting time and administrative procedure had the lowest score of complete satisfaction. Compared to central clinics, provincial clinics were negatively associated with the overall satisfaction . Patients rating higher score in “Consultation, explanation, and guidance of health care workers”, “Responsiveness of health care workers to patients’ questions and requests” and “Perceived overall satisfaction with the quality of service” were related to improvement in immunological treatment outcomes. Our results revealed the high level of satisfaction among ART patients towards HIV care and treatment services, and this had a high correlation to treatment outcomes. Interventions should focus on reducing administrative procedures, providing sufficient guidance and comprehensive services which integrate physical with psychological care for improving the health outcome of the ART program. Efforts to eliminate the global HIV/AIDS burden have achieved substantial progress in recent years , thanks In literature, the significant role of patient satisfaction indicators in evaluating the service quality has been well-documented –10. AsseIn developing countries, patient satisfaction has received increasing attention in recent years –19. A nuA cross-sectional study were collected from January to September 2013 in eight outpatient clinics in Hanoi and Nam Dinh provinces. Hanoi and Nam Dinh are two provinces among those having the highest number of HIV-infected patients in the North of Vietnam . In whicThese clinics were chosen based on following inclusion criteria: 1) Offering ART services based on the official guideline of Vietnam Ministry of Health ; 2) ReflThe eligibility criteria for selecting participants were: 1) being available at one of the clinics within the study period; 2) aged 18 years old or more; 3) accepting to enroll in the study, and 4) having the capacity to answer interview from 15–20 minutes. Participants would be excluded from the study if they suffered from serious diseases during the interview time. We utilized a convenient sampling technique to recruit the respondents. The information of 1113 patients were entered into the analysis.After agreeing to participate in the study, they were invited to a private room to assure their confidentiality. Then, interviewers introduced the objectives of this study and explained to patient’s that withdrawing from the interview would not affect the continuation and quality of their HIV care and treatment services. Finally, we collected written informed consents from patients who agreed to answer the survey. The study protocol was approved by the IRB of Vietnam Authority of HIV/AIDS Control.Patients interviews lasted 15 to 20 minutes and were conducted using the structured questionnaires by well-trained researchers of the Hanoi Medical University. The data collectors received a two-day intensive training session and participated in the pilot study with 20 patients in order to ensure the quality of data collected. The training session included the introduction of study purpose, data collection plan, and manners to communicate and interview HIV patients. None of the clinic staff was in involved in this procedure to avoid any social desirability bias.We asked patients to report information on their socio-economic background . We also extracted clinical data regarding patients’ HIV stages and their ART treatment duration from their record books. HIV stages were determined based on the World Health Organization clinical staging of HIV/AIDS for adults and adolescents including stage I (asymptomatic), stage II , stage III , stage IV (AIDS) . The numWe evaluated patient satisfaction by employing the Satisfaction with HIV/AIDS Treatment Interview Scale (SATIS) Vietnamese version. This tool has been used successfully to assess patient satisfaction among HIV patients in previous studies in Vietnam , 32. TheData were analyzed using STATA version 12 . One-way ANOVA and Chi-square test were used to examine the differences in socioeconomic characteristics, clinical factors, and patient’s satisfaction among clinics in different level of health systems. Multivariable tobit regression was employed to examine the associations between three components of satisfaction and overall satisfaction with related factors. Generalized mixed-effect model, with gaussian family and identity link, was used to estimate the effect of each item of SATIS instrument as well as overall satisfaction on the change of initial and the latest CD4 cell count. A value of p <0.05 was considered the statistical significance.The study protocol was approved by the IRB of Vietnam Authority of HIV/AIDS Control’s Scientific Research Committee (28/QD-AIDS). All respondents were asked to provide written informed consents. They could withdraw at any time without any influences on their current treatment.Among 1133 patients, the majority were males (58.7%), 57.3% had less than high school education, 61.2% lived with spouse/partners, and 41.4% were self-employed. The mean age was 35.5 (SD = 6.9) years old. Most of participants received treatment in Hanoi (88.4%), health center/AIDS center (51.5%), urban areas (77.2%) and district clinics (51.4%) .About 42% of the respondents were at stage I of HIV . The perPatients’ satisfaction measured by SATIS is described in Patients receiving treatment in provincial clinics had lower satisfaction in all domains than those in central clinics. Otherwise, patients enrolled in clinics in Hanoi had higher satisfaction than those in Nam Dinh province. Receiving treatment in rural clinics correlated with higher satisfaction in “Service quality and convenience”, “Availability and responsiveness”, and overall satisfaction.After adjusting for socio-economic and clinical characteristics, Our study attempted to set some light on the satisfaction of patients receiving ART in Vietnam. Using SATIS instrument, a high proportion of patients was found to be satisfied with three sub-domains “Service quality and convenience”, “Availability and responsiveness” and “Competence of health workers”, suggesting the acceptance for quality of services. Higher level of satisfaction with the capacity of medical staff in communicating with patients was positively associated with higher number of CD4 cell count.The improvement of quality of ART services plays a vital role since ART services were recommended to initiate as soon as possible, and these services have rapidly scaled up . OverallWhen investigating the relationship between patients’ satisfaction and treatment outcomes, we found that higher perceived overall satisfaction with the quality of service was positively associated with the change of the number of CD4 cell count. Previous studies revealed that patient satisfaction with healthcare services was related to retention in and adherence to ART treatment, which acts as a critical factor of HIV suppression , 38. OurNoticeably, we found that patients who received ART treatment in provincial hospitals were less likely to satisfy with HIV care and treatment services in all dimensions. Patients usually expect that national hospitals will provide better care and treatment services which base on larger intake capacity, better techniques and famous doctors , 41. In This is one of the very first studies assessing patients’ satisfaction regarding ART treatment services in a diverse level of healthcare delivery model in Vietnam. Findings from our study have an important contribution to the expansion of ART services as higher satisfaction were strongly associated with better HIV treatment outcomes. Our study suggests several implications. First, the administrative procedures should be shortened and followed the guidelines which may reduce the inconvenience for ART patients. Second, to enhance the level of satisfaction in provincial hospitals, the capacity of health workers, a better quality of treatment services and sufficient guidance for ART patients should be under consideration. Third, integrating physical with psychological care is critical as ART patients prefer for comprehensive care clinics instead of ART treatment alone. Finally, the information regarding satisfaction of ART patients should be collected regularly because determining the flaw of health services as well as enhancing the quality of these services should be based on expectations and the feedback of patients.The strengths of this study are utilizing the validated instruments to assess patient satisfaction towards ART treatment and quality of services. This study also conducted on a large pool of ART patients in various clinics with multiple levels of the health system . However, several limitations should be acknowledged. Convenient sampling technique may limit the ability to generalize the findings to the whole population. Second, causal relations between patients’ satisfaction and health outcome cannot be established due to the cross-sectional design. Third, we collected data based on self-reporting which may cause recall bias. Social desirability bias should be acknowledged as patients were asked to assess health facility which they received treatment. To handle social desirability bias, patients were invited into a private counseling room and be interviewed by researchers who were not staff of the hospital. All answers and personal information of patients were secured and only used for study purpose. Finally, since only data of the initial and latest CD4 cell count were examined, data of number CD4 cell count during the therapy were not reported. A further longitudinal study in the future is necessary to address these limitations and improve the planning of ART program in Vietnam.In conclusion, our results revealed the high level of satisfaction among ART patients towards HIV care and treatment services and this had a high correlation to treatment outcomes. However, results were different across service models. Interventions should focus on reducing administrative procedures, providing sufficient guidance and comprehensive services which integrate physical with psychological care for improving the health outcome of the ART program.S1 Fig(PDF)Click here for additional data file.


It has been hypothesized that schistosomiasis negatively influences immune reconstitution in people living with HIV starting antiretroviral therapy (ART). In this study, we investigated the effect of schistosomiasis on the course of HIV infection in patients starting ART in a rural part of Tanzania.Retrospective study including patients prospectively enrolled in a HIV cohort in Ifakara, south-central Tanzania between January 1, 2013 and April 1, 2015. Schistosomal circulating anodic antigen (CAA) was assessed in pre-ART cryopreserved plasma. Regression models were utilized to estimate the effect of CAA positivity on virological and immunological failure and a composite outcome of death/loss to follow-up (LFU).At ART-initiation 19.1% (88/461) of patients were CAA-positive. A tendency of higher CD4 increases was seen in CAA-positive patients , 87–285 cells/μl) compared to CAA-negative patients  after 10 months of follow-up. After adjustment for baseline risk factors, CAA-positivity showed no association with virological or immunological failure. In CAA-positive patients, 22.7% (20/88) died or were LFU, compared to 29.5% (110/373) of CAA-negative patients (hazard ratio (HR): 0.76, 95% confidence interval (CI), 0.47–1.22, p = 0.25). After adjustment for age, sex, body mass index, educational attainment, WHO-stage, tuberculosis status, and year of ART initiation, CAA-positivity showed a trend of a decreased hazard of death/LFU , while CD4 count at baseline  and MXD  >1,100 cells/μl  were identified as independently protective factors.Schistosomiasis is prevalent in this HIV cohort and may be beneficial for immunological reconstitution, while no effect on virological failure was apparent. A positive effect of schistosomiasis-induced immunomodulation on survival and retention in care needs confirmation in future studies. Schistosoma) both exert chronic modulatory effects on the host’s immune system. Coinfections, meaning the host is simultaneously infected with both pathogens, are common in sub-Saharan Africa. In this situation the induced immune modulation of one pathogen may affect the course of the disease induced by the other pathogen. One study showed that coinfection with Schistosoma in people living with HIV who begin antiretroviral therapy (ART) may have deleterious effects on the reconstitution of the HIV-induced immunosuppression. In the current study, we investigated the effect of Schistosoma coinfection on the recovery of the patient’s immune system, on the efficacy of ART to suppress HIV replication, and on a combined endpoint of lost to follow-up or death. We found that schistosomiasis may have beneficial effects on immune reconstitution, while no deleterious effect was detected on HIV-suppressive efficacy of ART. Surprisingly, our data suggest that schistosomiasis-induced immunomodulatory effects might be beneficial for survival and retention in care. Future studies are warranted to confirm these findings. In the era of increasing access to ART in sub-Saharan Africa, the issue of schistosomiasis-HIV coinfection may have major consequences on the outcome of HIV treatment programs.Infections with HIV and blood flukes ( Schistosoma prevalence reaches up to 30% in HIV cohorts [Schistosoma and HIV mutually interfere on several levels, which may impact the course of the associated diseases [Ascaris lumbricoides-HIV coinfected population found higher levels of immune activation, HIV-RNA concentrations, and lower CD4 T-cell counts in individuals with Th-2 bias, as indicated by high A. lumbricoides fecal egg counts, eosinophilia, and IgE response, compared to patients with high A. lumbricoides fecal egg counts, low eosinophil count, and low IgE responses [Schistosoma-HIV coinfected patients after antischistosomal treatment [The geographic distributions of HIV/AIDS and schistosomiasis largely overlap in sub-Saharan Africa, where  cohorts –4. In sediseases ,6. As bodiseases . Schistodiseases ,9. Propediseases . In lineesponses . In a streatment , and simreatment ,14.Schistosoma coinfection on the course of HIV infection in people living with HIV (PLWH) under antiretroviral treatment (ART) [Schistosoma-HIV coinfected patients starting ART, the odds for immunologic treatment failure were four times higher and CD4 cell count increases were significantly lower compared to PLWH without concurrent schistosomiasis [Schistosoma prevalence and massive roll out of ART in HIV cohorts, Schistosoma-induced treatment failure would have major implications for ART programs.To our knowledge, only two studies have investigated the effect of nt (ART) ,16. EfraSchistosoma coinfection has a negative impact on the course of HIV infection in patients starting ART. To test the hypothesis, we aimed to assess the effect of Schistosoma coinfection on patients’ response to ART in terms of (i) loss to follow-up (LFU) or mortality; (ii) immunological failure; and (iii) virological failure. The study was conducted in a well characterized HIV cohort in a rural part of south-central Tanzania and employed a highly sensitive diagnostic approach for schistosomiasis.The working hypothesis of the current study was that Schistosoma infection. Patients with positive test results were treated with praziquantel .The Kilombero and Ulanga Antiretroviral Cohort (KIULARCO) received ethics approval from the institutional review board of the Ifakara Health Institute (IHI) and from the National Health Research Ethics Review Committee of the National Institute for Medical Research of Tanzania. All patients provided written informed consent at inclusion in the KIULARCO cohort and parents or guardians provided informed consent on behalf of all participants under the age of 18 years. We re-tested all circulating anodic antigen (CAA)-positive patients for This study was carried out in Ifakara, a primarily rural region of south-central Tanzania. Patients were recruited from KIULARCO, an ongoing, open, prospective observational HIV cohort of PLWH followed at the Chronic Disease Clinic in Ifakara (CDCI). Further details of the KIULARCO cohort are given elsewhere ,18. WithThe study was a retrospective analysis of cryopreserved plasma samples and of data collected within the existing HIV cohort. The study included all patients who were enrolled in KIULARCO, started ART between January 1, 2013 and April 1, 2015, were older than 15 years, not pregnant, had a CD4 count performed at a maximum of 90 days before to 1 week after ART-start, and had at least one pre-ART plasma sample stored (at a maximum of 30 days before ART-start).Schistosoma infection status of each study participant at the moment of ART initiation was retrospectively assessed by testing 50 μl of pre-ART cryopreserved plasma for the presence of CAA with a lateral flow (LF) test with SCAA20 dry format [Schistosoma mansoni and S. haematobium (the two schistosome species endemic in Tanzania) and is shed into the host circulation during active infection. After successful treatment with praziquantel, antigen levels decrease within days [The y format ,20. Negay format ,20. CAA hin days . In addihin days –23. Prevhin days .Because isolated eosinophil count in peripheral blood is not part of routine diagnostic procedures in the KIULARCO, we used MXD  as approximate value. Cut-off for elevated MXD value was set at 1,100 cells/μl .The association between CAA-positivity and virological failure was assessed in a subgroup of study participants. Patients who were continuously CAA-positive  were frequency-matched with two controls (CAA-negative pre-ART and 6–13 months after ART-initiation) for age, CD4 cell count, and tuberculosis status at baseline. In these patients, plasma HIV RNA levels were tested in a cryopreserved plasma sample drawn 6–13 months after ART-initiation.TM Real-Time PCR System , with a detection limit of 60 viral RNA copies/ml of plasma. CD4 counts are routinely obtained after staining fresh whole blood samples with labeled antibodies: CD4, CD3, CD8, and CD45 in TruCount tubes .Plasma HIV RNA from 400 μl plasma was extracted using the NucleoSpin Virus kit  according to the manufacturer’s protocol. Viral RNA quantification was performed with the Brilliant III Ultra-Fast QRT-PCR Master Mix  using the StepOneData were extracted from a readily available electronic database of KIULARCO. The baseline was defined as the date of ART initiation. Continuous variables were summarized with medians and interquartile ranges (IQR) and categorical variables with frequencies and percentages.Association of CAA-positivity at ART-initiation with death or LFU was assessed with a multivariate Cox regression model. LFU was defined as no visit to the outpatient clinic for more than 6 months. The time of the event was defined as the day of the last follow-up visit documented in the database. Results were presented with hazard ratios (HR) and 95% confidence intervals (CIs). The assumption of proportional hazards was confirmed by Schoenfeld’s global test (p = 0.08).The association of CAA-positivity at ART initiation with immunological failure was assessed with a multivariate logistic regression model. Immunological failure was defined as CD4 count falling below baseline or persistently <100 cells/μl at the time of the first measurement of CD4 cell count ≥6 months after ART-start. Results were presented with odds ratios (ORs) and 95% CIs.a priori as potential co-factors/confounders and were included in the multivariable model (no variable selection was done): age (divided by 10), body mass index (BMI), and CD4 count at baseline (divided by 25) were used as continuous variables. Categorical variable included sex, educational attainment (none and primary school vs. secondary school and college/university), and WHO clinical stages of HIV disease (stage 1 and 2 vs. stage 3 and 4). The variable “active tuberculosis” was defined as diagnosis of tuberculosis at baseline or during follow-up. The variable “MXD value” was dichotomized in normal vs. elevated . The variable “year of starting ART” was added to the model used to assess the association of CAA-positivity with death/LFU. The variable “delay to CD4 testing”  was added to the model used to assess the association of CAA-positivity with immunological failure. Linearity of the relationship between continuous explanatory variables and the log odds of the dependent variable was tested by adding polynomial terms of each continuous explanatory variable. Polynomial terms showing a significant association with the log odds of the dependent variable were included in the model.For both models the following variables were considered For the analysis of CAA-positivity as a risk factor for virological failure , a logistic regression model was employed, controlling for the following potential co-factors/confounders (defined as above): sex, BMI, educational attainment, WHO clinical stages of HIV disease, MXD value, and delay to HIV RNA testing. Results were presented with ORs and 95% CIs.Data were anonymized and analyzed using STATA version 12.1 .2 , and median CD4 count was 173 cells/μl . CAA-positive patients had higher CD4 counts, higher MXD values, and there was a lower proportion of females  were CAA-positive. The median CAA titre at ART initiation was 163 pg/ml . After a median time of 36 weeks on ART , 36 remained CAA-positive, 17 became CAA-negative, and 35 had no follow-up plasma sample. In the group of 373 initially CAA-negative patients, 214 patients were continuously CAA-negative at ART-initiation and in the follow-up testing after a median time of 35 weeks , four became CAA-positive, and 155 had no follow-up plasma sample.Of 88 CAA-positive patients at ART initiation, 20 (22.7%) died or were LFU, compared to 110 out of 373 (29.5%) of CAA-negative patients . The median survival time in CAA-positive patients was 20.1 months , compared with 19.8 months  for CAA-negative patients.Baseline risk factors for death or LFU are presented in A follow-up CD4 count was available for 69 out of 88 (78.4%) of CAA-positive and for 287 out of 373 (76.9%) of CAA-negative patients. CAA-positive patients showed a median difference from baseline in CD4 of +182 cells/μl , compared to +147 cells/μl  in CAA-negative patients. Median time from ART initiation to measurement of CD4 count was 37.9 weeks  for CAA-positive patients, compared to 37.9 weeks  in CAA-negative patients. MXD values had no effect on CD4 count changes .Sixty-seven patients (18.8%) met at least one WHO criterion for immunological failure. CAA positivity showed no effect on the risk of immunological failure . Baseline risk factors for immunological failure are presented in One continuously CAA-positive patient and three continuously CAA-negative patients were excluded from the analysis due to non-availability of plasma samples for HIV PCR. After a median time of 43.4 weeks  of ART, eight out of 35 (22.9%) persistent CAA-positive patients had HIV RNA concentrations above 1,000 cp/ml, compared to 12 out of 67 (17.9%) of continuously CAA-negative patients after frequency matching for tuberculosis-status, CD4 count, and age. After adjustment for baseline risk factors, positive CAA status showed no association with virological failure [Schistosoma-HIV coinfection falsely negative tested Schistosoma coinfected patients would lead to misclassification and consequently to an underestimation of the effect under investigation. In such circumstances, the use of highly sensitive tests should be considered.The high prevalence of concomitant active schistosomiasis in this study, as determined by a highly sensitive assay  and of schistosomal and helminth infection in general in other studies in PLWH corroborate the potential importance of helminth-HIV coinfection ,16. Our hed data). We do nhed data),26,27. Thed data)–30. FromSchistosoma coinfection with an elevated risk for immunological failure or decelerated CD4 count gain in PLWH starting ART [S. mansoni, compared to controls without Schistosoma infection [In contrast to the findings of Efraim and colleagues, our study did not show an association of ting ART . Considenfection . Our resnfection –33.The rate of virological failure was substantial, which is a frequent problem, especially in rural settings of sub-Saharan Africa –36. EsseSchistosoma spp., which may exert beneficial effects in the setting of ART-induced immunological reconstitution. Immune reconstitution inflammatory syndrome (IRIS) is a condition seen in PLWH with profound CD4 T cell depletion and is characterized by an overwhelming inflammatory response to pathogens due to a recovering T cell count after initiation of ART. IRIS is a common cause of early mortality of patients starting ART in sub-Saharan Africa [Schistosoma-induced immunomodulation may have an attenuating effect on IRIS-related morbidity and mortality and by this means, improve the clinical outcome of PLWH starting ART.The protective effect of schistosomiasis in PLWH starting ART in our study is counterintuitive. Possible explanations of the results include immunomodulatory properties of n Africa . SchistoThe statistically significant association of elevated MXD values with a reduced risk of death and LFU may support this assumption. MXD value is composed of absolute cell counts of monocytes, eosinophilic, and basophilic granulocytes, which are independent from HIV infection and disease status –41. In tSchistosoma infection had elevated MXD values.Preceding studies in KIULARCO identified an important burden and variety of helminthic infections. Because immunomodulatory effects are a consistent feature of helminth infection, we believe that the weaker effect of schistosomal infection on survival/retention in care in our study may possibly be explained by competing immunomodulatory effects of other undetected helminths as our diagnostics in this study were focused on schistosomiasis. Indeed, about a quarter of PLWH without Our study has several shortcomings that are offered for discussion. First, clinical data of KIULARCO are collected prospectively, but CAA was identified retrospectively in cryopreserved plasma samples with the immanent weaknesses of a retrospective study design. Second, due to a suboptimal ascertainment of mortality in our cohort, we employed a composite outcome of death/LFU, limiting our conclusions regarding the impact of schistosomiasis on mortality. However, LFU is a common issue in ART programs in resource-limited settings and mortality is inversely associated with the rate of LFU . On the Schistosoma coinfection on immunological and virological response to ART but suggests that helminth-induced immunomodulatory mechanisms might enhance survival of PLWH starting ART.In conclusion, testing for CAA in plasma revealed a 19.1% prevalence of active schistosomiasis in PLWH starting ART in the KIULARCO in rural south-central Tanzania. This observation corroborates concerns of limited sensitivity of microscopy-based diagnostics, which might be additionally compromised in HIV-infected populations and may impede treatment for patients with a potentially life-threatening disease . Our stuOur results need confirmation in future studies, which should consider (i) the dynamic aspect of HIV infection and therefore preferentially chose a longitudinal study design, including clinical outcomes; and (ii) that individuals are often coinfected by multiple parasitic worms that may affect the course of the HIV infection by comparable but interindividually variable immunomodulatory effects. To avoid misclassification, comprehensive, highly sensitive helminth diagnostics and markers of the host’s immunological response should be employed. Among these highly sensitive tests, the used CAA-test is a promising candidate and further use and developments may improve the acceptance as a future standard test.In the era of massive rollout of ART in sub-Saharan Africa and other tropical and sub-tropical countries, the issue of helminth-HIV coinfection may have major ramifications on the outcome of HIV treatment programs. Further research, especially in PLWH initiating ART, is urgently needed.S1 STROBE Checklist(DOC)Click here for additional data file.S1 Dataset(DTA)Click here for additional data file.


HIV therapeutic vaccination aims to improve the immune responses against HIV in order to control viral replication without the need for combined antiretroviral therapy (cART). iHIVARNA-01 is a novel vaccine combining mRNA delivery and T-cell immunogen (HTI) based on conserved targets of effective antiviral T-cell responses. In addition, it holds adequate stimuli required for activating antigen presenting cells (APC)s and co-activating specific T-cells (TriMix), including human CD40L, constitutively active TLR4 (caTLR4) and CD70. We propose that in-vivo targeting of dendritic cells (DCs) by direct administration of a HIV mRNA encoding these immune modulating proteins might be an attractive alternative to target DCs in vitro.This is a phase-IIa, randomized, double-blinded, placebo-controlled, multicenter study in chronically HIV-1 infected patients under stable cART. One of the three study arms is randomly allocated to subjects. Three vaccinations with either HIVACAT T-cell immunogen (HTI)-TriMix (iHIVARNA-01), TriMix or water for injection (WFI)  are administered by intranodal injection in the inguinal region. Two weeks after the last immunization (week 6) cART is stopped for 12 weeks. The two primary endpoints are: (1) safety and tolerability of intranodal iHIVARNA-01 vaccination compared with TriMix or WFI and (2) induced immunogenicity, i.e., increase in the frequency of HIV-specific T-cell responses between baseline, week 6 and 12 weeks after treatment interruption in iHIVARNA-01-treated patients as compared to the control groups, immunized with TriMix-mRNA or WFI measured by an IFNγ ELISPOT assay. Secondary endpoints include the evaluation of time to viral rebound, plasma viral load (pVL) at w18, the proportion of patients with control of viral load, induction of T-cell responses to new HIV epitopes, polyfunctionality of HIV-specific T-cells, CD8+ T-cell in-vitro HIV suppressive capacity, the effect on viral reservoir , assessment of viral immune escape by mutation and mRNA expression profiles of host immune genes.This trial aims to direct target DC in situ with mRNA encoding HTI and TriMix for co-stimulation. Intranodal injection circumvents laborious DC isolation and handling in the laboratory. The trial extends on the safety results of a phase-I dose-escalating trial. This candidate vaccine could complement or even replace cART for chronic HIV infection and could be applicable to improve the care and cost of HIV infection.2016-002724-83 (22 September 2016); ClinicalTrials.gov, ID: NCT02888756. Registered on 23 August 2016.EudraCT The online version of this article (10.1186/s13063-019-3409-1) contains supplementary material, which is available to authorized users. Lentivirus. The virus infects human CD4+ T-cells but also various mononuclear myeloid cells, including dendritic cells (DCs), monocytes/macrophages. It integrates into the host genome after reverse transcription to double-stranded deoxyribonucleic acid (DNA). In untreated patients, the infection progresses to acquired immunodeficiency syndrome (AIDS) – as characterized by a decline in CD4+ T-cells [Worldwide, an estimated 37 million people are infected with the human immunodeficiency virus (HIV) . HIV is  T-cells . In 2015Therapeutic vaccination has emerged as a strategy which aims to improve the immune responses against HIV in order to control viral replication without the need for cART . To dateThe iHIVARNA-01 is intended for therapeutic vaccination of HIV-1-infected patients. It is a combination of mRNA sequences that aim to provide (1) an effective HIV immunogen to induce T-cell responses against relatively conserved, vulnerable portions of the virus, referred to as HIVACAT T-cell immunogen (HTI) as well as (2) adequate stimuli required for activating APCs and co-activating specific T-cells (TriMix). The former is designed to induce T-cell responses with specificities associated with superior HIV control in vivo and covering a wide range of HLA class I- and class II-restricted, HIV-derived epitopes . The Tri1the safety and tolerability of intranodal iHIVARNA-01 vaccination compared with TriMix-mRNA or placebo, focusing on the nature, frequency and severity of local adverse events  and systemic adverse events the immunogenicity of an immunization schedule with HTI-TriMix (iHIVARNA-01) to increase the frequency of HTI-specific T-cell responses between baseline and 2 and 14 weeks after the last injection  as compared to the control groups, immunized with TriMix-mRNA only or placeboThis study will evaluate the safety, tolerability and immunogenicity of iHIVARNA-01. The primary objectives are to evaluate:the magnitude and the kinetics of the HIV-specific CD4+ and CD8+ T-cell responses generated by the immunization schedule in the three groups by two methods  at baseline and at weeks 6 and 30the ability of the immunization schedules to prolong time until viral rebound after discontinuation at week 6 as compared to control groups TriMix or placebothe suppressive effect on plasma viral load in vivo after analytical treatment interruption (ATI) from week 6 to week 18 compared to two control groups, receiving TriMix only or placebothe proportion of patients with control of viral load below detectable level 12 and 24 weeks after start of ATI the percentage of patients who generate a vaccine-induced immune response to new HIV epitopes present in the HTI sequenceinduction or enhancement of the CD8+ T-cell in-vitro HIV-suppressive capacitythe effect on reservoir as measured by proviral DNA and the cell-associated viral RNA viral immune escape by sequencing of HIV and to conduct sieve-effect analyses in rebounding virus after cART interruptionhost protein mRNA expression profiles in whole blood at baseline and week 6 and week 18storage of fecal samples for future exploratory analysis of gut microbiota composition and diversityThe secondary objectives are to evaluate:This is a phase-IIa, randomized, double-blinded, placebo-controlled outpatient-clinic-based multicenter study in chronically HIV-1 infected patients under stable cART. Enrolled and randomized patients will be treated in one of the three study arms, comprising two stages.n = 40, control – TriMix n = 15 and placebo – water for injection (WFI) n = 15) is randomly allocated and stratified per center. An injection is given at weeks 0, 2 and 4. Stage II consists of the post-immunization and analytical treatment interruption (ATI) period (cART is stopped) and lasts from week 6 to week 18. Patients with an undetectable viral load at week 18 will remain off cART up to week 30. Study end is at week 30. In case a patient still has an undetectable (< 50 copies/mL) viral load, they may continue cART interruption in consultation with the treating physician. cART can be re-initiated for medical reasons at any time and/or if the CD4+ T-cell counts drop below 50% of baseline or below 350 cells/mL.Stage I consists of an immunization period from week 0 to week 6, while on cART. The immunization is done by an intranodal injection in a prominent lymph node in the inguinal region. The study arm (verum – HTI-TriMix (iHIVARNA-01) Refer to Fig. Age ≥ 18 years of ageVoluntarily signed informed consentProven HIV-1 infection (with documented antibodies against HIV-1 and a detectable plasma HIV-1 RNA before initiation of therapy)On stable treatment with cART regimen  for at least 3 yearsNadir CD4+ ≥ 350 cells/μL Current CD4+ cell count ≥ 450 cells/μLHIV-RNA below 50 copies/mL in the last 6 months prior to randomization, during at least two measurements For heterosexually active women, using an effective method of contraception with partner  from 14 days prior to the first vaccination until 4 months after the last vaccinationFor heterosexually active men, using an effective method of contraception with their partner from the first day of vaccination until 4 months after the last vaccinationIf sexually active, willing to use a reliable method of reducing the risk of transmission to their sexual partners during treatment interruption (including PrEP)To be eligible to participate, a patient must meet all of the following criteria (inclusion criteria):Treatment with a non-cART regimen prior to the cART regimenPrevious failure to antiretroviral and/or mutations conferring genotypic resistance to antiretroviral therapyNon-subtype B HIV infectionActive hepatitis B virus and/or hepatitis C virus co-infectionHistory of a CDC class C event ;Pregnant woman (screened with a positive pregnancy test), lactating or intending to become pregnant during the studyHistory of malignancy ≤ 30 days  prior to screeningActive infection with fever (38 °C or above) ≤ 10 days of screening and/or first vaccinationTherapy with immunomodulatory agents , including cytokines , immunoglobulins and/or cytostatic chemotherapy ≤ 90 days prior to screening. This does not include seasonal influenza, hepatitis B and/or other travel-related vaccines9/L) and/or current use of anti-coagulant medication ; usage of nonsteroidal anti-inflammatory drugs (NSAIDs)  is allowed; however, it is advised to interrupt therapy 10 days ahead of vaccinationCongenital, acquired or induced coagulation disorders, such as thrombocytopenia :Refer to Fig. Review of screening data will be performed according to the inclusion and exclusion criteria. Female patients undergo a pregnancy test (repeated prior to each vaccination), which should return negative in order to continue with study participation. When the former criteria are met, a patient will be enrolled to the study. The investigator blindly assigns the patient to one of the treatment groups by allocating the next free randomization code for the clinical site to the patient. This randomization code list was generated by an independent statistician prior to start of the study . The label containing the randomization code was attached to the appropriate IMP at the central production facility in order to keep the blind for both the sponsor and investigators. The IMP is administered using ultrasound guidance by a radiologist sufficiently trained in ultrasound imaging and tissue biopsies. Injections will be given alternated between the right and left prominent inguinal lymph node. Patients will be monitored during the first hour after immunization by recording vital signs  on the case record form (CRF), as well as any local reactions and systemic events (refer to Table Two weeks after the third vaccination (week-6 visit), cART will be interrupted. Female subjects will only be allowed interruption after a negative pregnancy test. In the visits at weeks 8, 10, 14, 18, 24 and 30, information on concomitant medication, a physical examination and laboratory tests  is possible by contacting unblinded pharmacy personnel at the sponsor’s pharmacy. This service is available 24 h a day. In case of accidental IMP breakage, loss, temperature excursions, etc., backup IMP is available at the study sites. The investigator can use a backup IMP vial by enquiring about the correct backup vial code at the pharmacy of the sponsor. Since this pharmacy has an unblinded list, the correct backup code can be issued.ATI is needed in the search for an HIV cure . During According to the regulations of the European Union and as dictated by Dutch governmental law serious adverse events (SAEs) will be reported to the accredited Ethical Committee (EC) that approved the study within a period of maximum 15 days after the sponsor has first knowledge of the SAE. SAEs that results in death or are life-threatening will be reported within 7 days. Suspected unexpected serious adverse reactions (SUSARs) that have arisen in this trial  will be reported via an online portal. All SUSARs will be submitted in a line-listing twice a year. An annual safety report of SAEs and safety analysis will be submitted to the ECs and competent authorities. The sponsor will suspend the study if there is sufficient ground suggesting that continuation of the study will jeopardize patient health or safety. A Data Safety Monitoring Board (DSMB), an independent group of experts, advises the sponsor and will at least meet on four occasions prior to and during the study.Refer to “Primary and secondary objectives” above.10 in the change from baseline of cumulative frequencies of HTI-specific PBMC, a type 1 error of 5%, a power of 90%, as determined by a two-sided, non-parametric test , taking into account the weighting for case group ratio of more than 2:1, a sample of 40 in the HTI-TriMix arm and 15 in each control arm will allow to detect a difference of at least 0.7log10 between any HTI-TriMix arm and the controls arms, allowing for 10% of non-assessable patients.Analysis will be performed using an intention-to-treat approach. Assuming a standard deviation of 0.5logIn the challenging research field of HIV immunotherapy, we use the iHIVARNA-01 candidate vaccine in the search for cure. The strategy of the iHIVARNA consortium consists of a DC-based approach by intranodal administration of a newly developed HIV immunogen (HTI) and TriMix. Many of the immunotherapy strategies so far have relied on immunogens that cover regions of the virus that are frequently targeted by the immune system in the majority of chronic HIV-infected patients. These immune responses, even when enhanced, in general do not prevent disease progression , 14. HTIIn addition, co-stimulatory molecules are delivered in the formula of TriMix, consisting of CD40L, CD70 and TLR4a mRNA. TriMix was used in several trials, showing promising results in the field of tumor immunology , 16, 17 Concerning the administration of the vaccine, iHIVARNA was designed to target DCs. Promising results were achieved in former studies where autologous DCs were loaded ex vivo, with inactivated virus or electroporated with mRNA-encoding HIV proteins . The curThe iHIVARNA phase-I, open-label, dose-escalation trial (NCT02413645) proved that this IMP is safe and well tolerated in HIV-1-infected patients on cART. The iHIVARNA phase IIa, is designed as a randomized, placebo-controlled, double-blinded trial. The three-arm design comprises (A) the full IMP (HTI and TriMix), (B) a placebo consisting of TriMix alone and (C) a placebo consisting of injection fluid. Arm B is important to be able to distinguish effects of general immune activation by TriMix from the effects of the full vaccine with the HIV-specific immunogen.The trial will evaluate the safety and immunogenicity of iHIVARNA-01 in chronically HIV-infected patients under stable combined antiretroviral therapy and includes an analytical treatment interruption. Besides these primary endpoints, several secondary endpoints will be evaluated. The commonly known T-cell ELISPOT essay is extended with analysis of multiple cytokine expression after in-vitro stimulation , 24. AlsControl of in-vivo viral replication will be studied after analytical treatment interruption and different endpoint approaches will be considered, i.e., time to viral rebound, levels of pVL and the proportion of patients with undetectable viremia after 12 weeks of treatment interruption. Effects on the viral reservoir will be measured with various assays during the immunization period, including ultra-sensitive plasma virus polymerase chain reaction (PCR) and PCR-based approaches to measure cell associated viral RNA and DNA. In case of viral rebound, the evolution of the virus will be followed with deep sequencing to evaluate mechanisms of immune escape and/or a potential sieve effect on the rebounding viral populations after the immunotherapy . These rTo summarize, the trial has a comprehensive set of assays that will be used to establish the effects of the immunotherapy in vitro and in vivo. If this candidate would be able to obtain the functional cure in at least a proportion of patients it could be complementary to cART or even replace cART and would improve the overall care and cost of HIV-1 infected patients.Recruiting patients since 27 March 2017.Additional file 1: Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) 2013 Checklist populated for for iHIVARNA phase IIa. (DOC 120 kb)