Although WHO recommends viral load (VL) monitoring for those on antiretroviral therapy (ART), availability in low-income countries remains limited. We investigated long-term VL and resistance in HIV-infected children managed without real-time VL monitoring.P = 0.43), with no evidence of differences in intermediate/high-level resistance to 11 drugs. Among children with longitudinal VLs, only 5% of child-time post–week 24 was spent with persistent low-level viraemia  and 10% with VL rebound ≥5,000 copies/ml. No child resuppressed <80 copies/ml after confirmed VL rebound ≥5,000 copies/ml. A median of 1.0  additional NRTI mutation accumulated over 2 years’ rebound. Nineteen out of 48 (40%) VLs 1,000–5,000 copies/ml were immediately followed by resuppression <1,000 copies/ml, but only 17/155 (11%) VLs ≥5,000 copies/ml resuppressed (P < 0.0001). Main study limitations are that analyses were exploratory and treatment initiation used 2006 criteria, without pre-ART genotypes.In the ARROW factorial trial, 1,206 children initiating ART in Uganda and Zimbabwe between 15 March 2007 and 18 November 2008, aged a median 6 years old, with median CD4% of 12%, were randomised to monitoring with or without 12-weekly CD4 counts and to receive 2 nucleoside reverse transcriptase inhibitors  with a non-nucleoside reverse transcriptase inhibitor (NNRTI) or 3 NRTIs as long-term ART. All children had VL assayed retrospectively after a median of 4 years on ART; those with >1,000 copies/ml were genotyped. Three hundred and sixteen children had VL and genotypes assayed longitudinally (at least every 24 weeks). Overall, 67 (6%) switched to second-line ART and 54 (4%) died. In children randomised to WHO-recommended 2NRTI+NNRTI long-term ART, 308/378 (81%) monitored with CD4 counts versus 297/375 (79%) without had VL <1,000 copies/ml at 4 years .After an average of 4 years on treatment, we found no evidence that CD4 monitoring strategy affected viral suppression or resistance. Overall, 74% of the 753 children randomised to current WHO-recommended regimens were fully suppressed.We also investigated how viral load changed and resistance developed over time in a subset of children taking current WHO-recommended regimens. After the first 24 weeks on treatment, only 5% and 10% of child-time was spent with persistent lower-level viral load  or rebound to ≥5,000 copies/ml, respectively. Even among children with high viral load, intermediate- to high-level drug resistance to key second-line drugs was found only in a minority, although children with virological rebound had slight increases in resistance over 2 years.In this study, children on currently recommended WHO regimens did very well, whether or not they were monitored using CD4 counts. Therefore, getting treatment to more children remains the most important activity, even if viral load and/or CD4 monitoring is not available.Considerable variability in viral loads and substantial resuppression, particularly in children with single measurements 1,000–5,000 copies/ml, means that care needs to be taken not to switch too early to second-line drugs in order to maximise the time that children can successfully spend on first-line treatment.Among children experiencing confirmed viral rebound ≥5,000 copies/ml, resistance increased only slightly over 2 years, providing reassurance that annual VL monitoring, as recommended by WHO, is adequate in resource-limited settings. The Joint United Nations Programme on HIV/AIDS (UNAIDS) has set an ambitious target for 2020: that 90% of people living with HIV know their status, 90% of those diagnosed receive antiretroviral therapy (ART), and 90% receiving ART have viral load (VL) suppression . There aAlthough management without VL monitoring has enabled ART rollout, children with virological failure risk developing resistance, which may reduce efficacy of second-line therapy. In a systematic review of 30 studies from low-income settings in 2011 , 80% andWe therefore investigated virological outcomes and resistance in the ARROW randomised trial (ISRCTN24791884), which compared first-line ART regimens and CD4 monitoring strategies in children and adolescents in Uganda and Zimbabwe , P = 0.81; Overall, 20 children (10%) experienced pLLVL. Geometric mean VL at the start of pLLVL was 780 copies/ml  and did not increase over the subsequent (Kaplan-Meier) median >156 weeks  spent with pLLVL through the end of follow-up  experienced rebound to ≥5,000 copies/ml, most commonly following pLLVL . However, these additional NRTI mutations had little impact on predicted drug susceptibility, with only 1 child moving from no more than low-level to high-level resistance for both tenofovir and zidovudine (In 12 children on 2NRTI+NNRTI with genotyping performed both at rebound and a median 2.3 (range 0.7–2.8) years subsequently, IAS-USA major NRTI mutations increased from a median (IQR) of 2  to 2.5   of 203 single VL measurements ≥1,000 copies/ml were immediately followed by a subsequent VL <1,000 copies/ml. However, this depended on the level of VL: whereas 19 (40%) of 48 single VLs 1,000–4,999 copies/ml were immediately followed by a VL<1,000 copies/ml, this occurred in 17 (11%) of 155 single VLs ≥5,000 copies/ml  provided clinical benefit over clinical monitoring alone after the first year on ART. However, event rates were very low (new WHO stage 4 disease/death 0.4 per 100 child-years with CD4 monitoring versus 1.3 without) and 5-year survival was very high (96%). We have now extended these findings, by showing that virological suppression in the cohort as a whole was high. After a median of 4 years, 80% of children randomised to WHO-recommended 2NRTI+NNRTI–based regimens had VL <1,000 copies/ml and 74% had undetectable virus. This is similar to a recent small cohort of Kenyan children monitored for 4 years, in whom two-thirds maintained long-term virological control . VirologVL did not increase significantly over time in children with pLLVL or rebound; rather, it appeared that viraemia reached an equilibrium , similar to the set-point that is characteristic of untreated HIV infection , perhapsChildren with virological failure in ARROW had frequent NNRTI and lamivudine resistance, as expected, but retained high susceptibility to both tenofovir and zidovudine, the recommended second-line NRTI options. Perhaps more importantly, a median of 2 years’ viral replication at approximately 40,000 copies/ml led to an increase of only 1 major NRTI mutation and did not substantively alter drug susceptibility. In the PENPACT-1 trial, which compared switch at VL 1,000 versus 30,000 copies/ml in Europe and the Americas, NNRTI resistance had already developed when VL reached >1,000 copies/ml , despiteOver the longer term, substantial efforts are being made to ensure virological monitoring is available in all settings. However, challenges in training, procurement, specimen transport, and financial resources have limited its roll-out . CoveragWhere virological monitoring is used, it is important to consider the implications of detectable viraemia in children. Current guidelines recommend switching to second-line ART at a confirmed VL above 1,000 copies/ml. However, we found that it was not uncommon for single, or even confirmed, VLs above this threshold to be immediately followed by return to values below the threshold without adherence counselling . This was particularly true for VLs between 1,000–5,000 copies/ml—precisely those levels where switch might be considered to have the greatest potential to prevent resistance accumulation. Resuppression on NNRTI-based regimens despite NNRTI resistance has previously been noted in cohorts  and a trStudy limitations include the fact that this was an exploratory analysis within a clinical trial that was conducted using 2006 WHO treatment thresholds, which have now been superseded by universal ART initiation criteria; whether virological outcomes would be different in children treated using current guidelines is unknown. However, given that VLs would be expected to be lower and CD4 percentages higher with earlier treatment, our results plausibly reflect a ‘worst-case’ scenario moving forwards. Genotyping was not conducted at ART initiation, and so may have missed preexisting resistance before ART. A reported 6.8% of those in the WHO African Region with available pre-ART genotypes had 1 or more mutations in any drug class before therapy initiation in 2010 [In summary, we found that virological and resistance outcomes were good in this study, and that neither VL suppression nor predicted susceptibility of second-line treatment options were impacted by monitoring with or without CD4 counts over median 4 years follow-up in children initiating ART in Uganda and Zimbabwe. Despite being managed without real-time VL monitoring, only 20% of children on WHO-recommended 2NRTI+NNRTI first-line ART experienced pLLVL or rebound, during which time VL levels were stably maintained over relatively long periods. In rebound, genotypic resistance increased only slightly over 2 years, providing reassurance that annual VL monitoring, as recommended by WHO, is a reasonable and pragmatic approach for HIV-infected children on first-line ART in resource-limited settings.S1 TableAbbreviation: VL, viral load.(XLS)Click here for additional data file.S2 TableAbbreviation: VL, viral load.(XLS)Click here for additional data file.S3 TableAbbreviations: ART, antiretroviral therapy; NNRTI, non-nucleoside reverse transcriptase inhibitor; NRTI, nucleoside reverse transcriptase inhibitor; pLLVL, persistent low-level viral load; VL, viral load.(PDF)Click here for additional data file.S4 TableAbbreviations: NNRTI, non-nucleoside reverse transcriptase inhibitor; NRTI, nucleoside reverse transcriptase inhibitor; VL, viral load.(PDF)Click here for additional data file.S1 FigAbbreviations: ART, antiretroviral therapy; NRTI, nucleoside reverse transcriptase inhibitor; VL, viral load.(PDF)Click here for additional data file.S2 FigAbbreviations: ART, antiretroviral therapy; IAS, International AIDS Society; NNRTI, non-nucleoside reverse transcriptase inhibitor; NRTI, nucleoside reverse transcriptase inhibitor; VL, viral load.(PDF)Click here for additional data file.S3 FigAbbreviations: NNRTI, non-nucleoside reverse transcriptase inhibitor; NRTI, nucleoside reverse transcriptase inhibitor; pLLVL, persistent low-level viral load; VL, viral load.(PDF)Click here for additional data file.S1 Appendix(PDF)Click here for additional data file.S1 Protocol(PDF)Click here for additional data file.S1 STROBE Checklist(DOC)Click here for additional data file.


Adherence and CD4 cell count change measure the progression of the disease in HIV patients after the commencement of HAART. Lack of information about associated factors on adherence to HAART and CD4 cell count reduction is a challenge for the improvement of cells in HIV positive adults. The main objective of adopting joint modeling was to compare separate and joint models of longitudinal repeated measures in identifying long-term predictors of the two longitudinal outcomes: CD4 cell count and adherence to HAART.A longitudinal retrospective cohort study was conducted to examine the joint predictors of CD4 cell count change and adherence to HAART among HIV adult patients enrolled in the first 10 months of the year 2008 and followed-up to June 2012. Joint model was employed to determine joint predictors of two longitudinal response variables over time. Furthermore, the generalized linear mixed effect model had been used for specification of the marginal distribution, conditional to correlated random effect.A total of 792 adult HIV patients were studied to analyze the longitudinal joint model study. The result from this investigation revealed that age, weight, baseline CD4 cell count, ownership of cell phone, visiting times, marital status, residence area and level of disclosure of the disease to family members had significantly affected both outcomes. From the two-way interactions, time * owner of cell phone, time * sex, age * sex, age * level of education as well as time * level of education were significant for CD4 cell count change in the longitudinal data analysis. The multivariate joint model with linear predictor indicates that CD4 cell count change was positively correlated (p ≤ 0.0001) with adherence to HAART. Hence, as adherence to HAART increased, CD4 cell count also increased; and those patients who had significant CD4 cell count change at each visiting time had been encouraged to be good adherents.Joint model analysis was more parsimonious as compared to separate analysis, as it reduces type I error and subject-specific analysis improved its model fit. The joint model operates multivariate analysis simultaneously; and it has great power in parameter estimation. Developing joint model helps validate the observed correlation between the outcomes that have emerged from the association of intercepts. There should be a special attention and intervention for HIV positive adults, especially for those who had poor adherence and with low CD4 cell count change. The intervention may be important for pre-treatment counseling and awareness creation. The study also identified a group of patients who were with maximum risk of CD4 cell count change. It is suggested that this group of patients needs high intervention for counseling. As the number of visiting times increased by one unit, the log of change of CD4 cell count increased by 2.4% . The analysis revealed that the rate of change of CD4 cell count for patients without ownership of cell phone was 2.9% less as compared to patients with ownership of cell phone . The log of change of CD4 cell count for patients with fair adherence at a given visiting time was 2.9% less than those patients who had good adherence  and the log of change of CD4 cell count for patients with poor adherence at visiting time, t was 5.7% less than those of good adherent patients . From the two way interaction effects; time * ownership of cell phone, time * sex, time * level of education, age * sex, age * level of education were significantly and jointly affected both responses through linear link ; p < 0.0001]. Figure As visiting times of adult patients increased by one unit, the log of change of CD4 cell count for female patients was 0.3% greater than male patients . From Fig. From Table As visiting time of patients increased by one unit, the rate of change of CD4 cell count for non-educated patients was 1.8% less than those of tertiary educated patients . Similarly comparing primary educated patients with tertiary level, the log of change of CD4 cell count for primary educated patients was 1.2% less than tertiary levels  and the log of change of CD4 cell count for secondary educated patients was 0.8% less than tertiary educated patients  ; p < 0.0001]; the log of change CD4 cell count for primary educated patients was 3.2% greater than tertiary educated patients ; and decreasing rate of CD4 cell count for secondary educated patients was 2.3% greater than tertiary educated patients . Figure We have presented a general approach to the joint analysis of two longitudinal response variables assuming their separate analysis. The results in this study indicated that the separate models which did not include patients’ specific effects were not significantly different from joint models developed with the assumption of separate analysis. As indicated above the joint models were formed by imposing the joint multivariate distribution of random effect, Hence, the results of both separate and joint analysis were consistent. However, the joint models were simpler as compared to the separate models as their effective member of parameters was smaller. In other words, the reduction of the number of effective parameters ensures that joint models were more parsimonious/less complex in parameter estimation of longitudinal data analysis. This result complies with previous researches , 32, 33.The result in this study indicated that CD4 cell count change and adherence to HAART had been influenced jointly by some of the covariates like age, weight, baseline CD4 cell count, visiting times, sex, ownership of cell phone, first month adherence and level of disclosing the disease to family members and by their interaction effects (refer to Table 3). This result is supported by previous study [As ages of patients increase, CD4 cell count and adherence to HAART decrease. But, the decreasing rate of these response variables for patients with tertiary education is less likely as compared to that of the others. This might occur because as patients become more educated, they may have better care of their health. This result has been supported by previous study . Patientus study  on the iThe two responses were higher for urban adult patients than rural areas through time. The reason for this might be the long distance of the rural areas from health institutions, and patients in these areas may come after high destruction of CD4 cells by HIV. There are discordant other findings concerning this. For instance, the result of this study agrees with a previous study . HoweverPatients who lived with a partner had more probability to adhere the prescribed medication and had high CD4 cell count change as compared to patients who lived without partners. This can be associated with lack of social support for patients living without partner. This result had been supported by former research . The resThe interactions between variables, which were not expected during the data collection process, were identified during data analysis. The cause for these interaction occurrences was not detected and explained. Adherence to HAART, which was one of the response variables, was measured in pill count technique. This technique had a disadvantage that include patients’ switching of medicines between bottles and discarding pills before visits . DespiteLongitudinal joint models fitted for the joint data analysis under this investigation. Generalized linear mixed model was extended to multivariate cases in the data analysis process. This had been done using marginal/separate analysis as well as conditional independent random effect models and a random intercept model with correlated residual error structure. Developing joint models has helped validate the observed correlation between the outcomes emerging from the association of intercepts. The result under this investigation indicated that some covariates were significantly associated with the change of CD4 cell count; and the development of joint model for the two responses gave powerful estimation as compared to the separate or marginal model. The result of this study identified a certain group of patients who were with maximum risk of CD4 cell count change, but who had poor adherence performance. This group of patients needs high intervention in counseling and awareness creation.


Antiretroviral Therapy(ART) remarkably reduced HIV-1 infection-related mortality in children. The efficacy and safety of different ART regimen in pediatric age groups remained issues of debates and available evidence were scarce especially among children taking the of one the two prototypes (NVP or EFV) Non-Nucleoside Reverse Transcriptase Inhibitor(NNRTI) as backbone of ART regimen.versus zidovudine-lamivudine-efavirenz (AZT+3TC+EFV) ART regimen among HIV-1 infected children.Therefore, the objective of this study was to compare clinical, immunological and virological responses of zidovudine-lamivudine-nevirapine (AZT+3TC+ NVP) versus EFV+AZT+3TC ART regimen among HIV-1 infected children. Data were entered into Epi-info version 7.2.2 for clean up and exported to SPSS version 17 for analysis. Paired and Independent t-tests were used to compare the CD4 cell count, weight and virologic level at six months with corresponding baseline value; and the mean weight, CD4 gain and viral suppression across the two ART regimens at six months of ART respectively.A retrospective cross-sectional study was done by reviewing medical records of the patients to evaluate clinical, immunological and virological outcomes of NVP+AZT+3TC Medical records of 122 patients from NVP-based regimen and 61 patients from EFV group were reviewed. After six months of NVP+AZT+3TC treatment, the mean CD4 cell count difference from baseline was 215. From EFV+AZT+3TC group, the mean CD4 cell count difference from baseline was 205. The mean CD4 count difference between the two regimens was comparable (p 0.145). Similarly, optimal viral suppression was achieved in 82% (100/122) of NVP+AZT+3TC regimen and 83% (44/61) of EFV+AZT+3TC regimen which was still comparable across the two groups.There was no difference in clinical, immunological and virological outcomes among patients taking NVP+AZT+3TC or EFV+AZT+3TC ART regimen. The debversus EFV+AZT+3TC ART regimen among HIV-1 infected children.In this study, wedifferences at six months assessed clinical and immunological and virological outcomes of NVP+AZT+3TC 2A cross-sectional descriptive study was conducted from May-August 2017 by reviewing ART documents of children infected with HIV-1 who were on ART at pediatric ART clinic, Asella Teaching and Referral Hospital (ATRH)The hospital is one of the federal teaching and referral hospitals. Pediatric and child health department is one of the major departments delivering patient care service, teaching and research activities under different subunits categories. Pediatric ART clinic is one of the well-organized clinics of the hospital giving care for pediatric HIV/AIDS care and treatment.2.1versus EFV+3TC+AZT. Before and during the study period the utilization of EFV-based was low as the national guideline by then was not strongly recommending this regimen in pediatric age group. Accordingly for one patient included from EFV- based regimen two patients from NVP based regimen were included (1:2) making the sample size of (n1=61) from (EFV+3TC+AZT) and 122 from (NVP+3TC+AZT) . A simple random sampling technique was used to select patient charts from each regimens using computer-generated random number. At the time of data collection about 545 children with HIV infection were on follow up at pediatric infectious disease clinic. The sampling procedure was determined by patients’ ART regimen and to minimize sampling error and to control the effects of other NRTI patients taking AZT+3TC were included and matched under NVP+3TC+AZT 2.2Data were collected from the patients' ART documents  using standardized format. Data entry was made to EPI info software for clean up and analysis; exported to SPSS version 17 for further analysis. Paired t-test was used to compare the CD4 cell count, weight and virologic level at six months with corresponding baseline value and independent t-test was to compare the mean weight and CD4 gain at six months and viral suppression level at six between the two ART regimens.The factors considered to affect the clinical and immunologic outcomes in both groups were assessed using binary logistic regression: baseline CD4%/count, WHO clinical staging, presence of chronic diarrhea, anemia, and baseline weight, occurrence of TB, and switching of ART regimen. 95% CI with p value of less than 0.05 was considered statistically significant.2.3A total of 183 patients were included in the study. ART documents of 122 patients from NVP+3TC+AZT groups and 61 patients from EFV based regimen were reviewed. Males constitute 51% (62/120) while females were 49% (60/120) from NVP+3TC+AZT regimen. From EFV-based regimen, male comprised of 52% (32/61) and female 48% (29/61).The youngest age at the initiation of ART was 5 months from NVP+3TC+AZT regimen and 17 months from EFV-based groups with the highest being 144 and 168 months (IQR age 74-104 and 95-130 months) respectively.Baseline anthropometry showed that 20.4%(25/122) and 1.5% (2/122) from NVP+3TC+AZT regimen and 22% (14/61) and 2.5% (2/61) from EFV+3TC+AZT regimen were having moderate and severe wasting respectively.Anemia was observed in 18.3% (22/122) of patients from NVP+3TC+AZT arm regimen and 14.8% (9/61) of EFV+3TC+AZT at the initiation of ART with the majority of the cases were having mild anemia.1).About 69% (84/122) and 73% (44/61) patients were WHO clinical stage III or IV at the start of NVP+3TC+AZT or EFV+3TC+AZT regimen, respectively (Table The CD4 cell count at the start of HAART ranged from 15-2000 cell/ml with an Interquartile Range (IQR) of 235-325 cell/ml among NVP+3TC+AZT. And among patients taking EFV+3TC+AZT based ART regimen, baseline CD4 count ranged 25-2075 cell/ml with an IQR range of 260-355 cell/ml.The CD4 cell count at six months of ART was compared with baseline and among the two groups. From NVP+3TC+AZT based ART regimen the CD4 cell count range from 75-2400 c/ml with IQR of 468-632 c/ml, and mean CD4 cell count difference of 215, 95% CI (175.414-245.613). From EFV based group, CD4 count ranged from 65-2100 c/ml with IQR of 435-605 c/ml, and the mean CD4 cell count difference of 205, 95% CI (155.404-235.623). The mean CD4 count differences at six months of ART were comparable between the two groups 2).Patients who have been on NVP+3TC+AZT regimen gained mean weight of 0.78kg and 1.81kg with 95% CI (0.588-0.957 and 1.60-2.2 respectively) at three and six months of HAART. Similarly, the mean weight gain at three and six months of EFV+3TC+AZT were 0.75 and 1.70kg with CI (0.588-0.954) and 1.70kg, 95% CI (1.50- 1.95). Still, there is no significant difference in weight gain among the two groups (Table 2).After six months of ART 82% (100/122) from NVP+3TC+AZT and 83%(44/61) from EFV+3TC+AZT were having adequate viral suppression(<1000coppy/ml) .During the first six months of HAART, a total 27 patients developed tuberculosis with comparable incidence across the two groups  patients who were on NVP+3TC+AZT HAART regimen were switched to other line of ART regimen while 4(6.7%) patients from EFV-based regimen switched to other regimen indicating ART switching was more commonly seen among NVP+3TC+AZT(p<0.001).3). Similarly, normal baseline weight, absence of diarrhea and weight gain >10% at three and six months of ART were found to be a good prognostic indicator of clinical, immunological and virological outcome regardless of the ART regimen (see Table 3).Early clinical stage of the disease and mild immune suppression at the start of ART were predicting favorable clinical, immunological and virological outcomes ART among the two groups of patients  in 82%100/122) and 83%44/61) among NVP+3TC+AZT and EFV+AZT+3TC respectively. This is incongruent with WHO recommendation which highlighted no evidence of EFV virologically superior to NVP 2 and 83%. How eve1 among N3 had a significantly lower chance of achieving CD4 count of 500 cells/mm3 compared with patients with baseline CD4 350 cells/mm3 and above [Presence of chronic diarrhea during ART treatment is associated with poor CD4 cell recovery independent of the nutritional status of the patient which is in agreement with most previous studies. The reason was not clearly identified so far but could be because of associated mal-absorption and poor adherence during diarrheal episode. This research also uncovered higher baseline CD4 cell value strongly predicted good six month CD4 cell recovery and viral suppression response in both groups of patients which was supported with a large cohort study involving 861 adult patients living with HIV in Spain that showed patients with baseline CD4 count of 200 and of 201 to 350 cells/mmnd above .This study also showed optimal weight recovery after initiation of ART strongly associated with better CD4 response and viral suppression which is in line with study report from South Africa which elaborated lower percentiles of weight gain after six months of ART were associated with poor subsequent treatment outcomes and a higher risk of mortality independent of other baseline characteristics. Likewise, normal weight at the start of ART was independent predictors of favorable immunological and virological outcomes in both wings which was coinciding with other observational studies where patients who were underweight had a two-fold increased risk of poor treatment outcomes , 21versus EFV+AZT+3TC regimen. The conflicting results from different studies could be explained by study design, patient selection and possible concomitant HIV-TB treatment which could significantly affect the outcomes.This research finding concluded that there is no difference in clinical, immunological and virological outcomes among patient taking NVP+AZT+3TC


The World Health Organization (WHO) recommends viral load (VL) measurement as the preferred monitoring strategy for HIV-infected individuals on antiretroviral therapy (ART) in resource-limited settings. The new WHO guidelines 2016 continue to define virologic failure as two consecutive VL ≥1000 copies/mL (at least 3 months apart) despite good adherence, triggering switch to second-line therapy. However, the threshold of 1000 copies/mL for defining virologic failure is based on low-quality evidence. Observational studies have shown that individuals with low-level viremia (measurable but below 1000 copies/mL) are at increased risk for accumulation of resistance mutations and subsequent virologic failure. The SESOTHO trial assesses a lower threshold for switch to second-line ART in patients with sustained unsuppressed VL.In this multicenter, parallel-group, open-label, randomized controlled trial conducted in Lesotho, patients on first-line ART with two consecutive unsuppressed VL measurements ≥100 copies/mL, where the second VL is between 100 and 999 copies/mL, will either be switched to second-line ART immediately (intervention group) or not be switched . The primary endpoint is viral resuppression (VL < 50 copies/mL) 9 months after randomization. We will enrol 80 patients, giving us 90% power to detect a difference of 35% in viral resuppression between the groups . For our primary analysis, we will use a modified intention-to-treat set, with those lost to care, death, or crossed over considered failure to resuppress, and using logistic regression models adjusted for the prespecified stratification variables.The SESOTHO trial challenges the current WHO guidelines, assessing an alternative, lower VL threshold for patients with unsuppressed VL on first-line ART. This trial will provide data to inform future WHO guidelines on VL thresholds to recommend switch to second-line ART.ClinicalTrials.gov (NCT03088241), registered May 05, 2017 The management of first-line antiretroviral therapy (ART) failure is a crucial step to achieve the third pillar of the UNAIDS 90–90-90 targets, namely viral suppression in 90% of all HIV-positive individuals on treatment, and ensure successful treatment outcomes . The WorSeveral observational cohort studies and systematic reviews from resource-rich and resource-limited settings have demonstrated the emergence of major drug resistant mutations (DRMs) and a high risk of virologic failure among patients with sustained low-level viremia –16. A reIn high-income settings with easy access to VL monitoring, individualized patient management and a “watch-and-wait” strategy with monthly monitoring for patients with low-level viremia may be appropriate , 6. HoweTo our knowledge there are no published or ongoing randomized controlled trials (RCTs) from resource-limited settings assessing VL thresholds for switch to second-line ART, as summarized in the recent viewpoint of Ellman et al. in the Journal of the International AIDS Society . This maThe SESOTHO trial will be conducted in the district of Butha-Buthe, in northern Lesotho, Southern Africa. Lesotho has an estimated adult HIV prevalence of 25% . Little https://visibleimpact.org/projects/1261-molecular-hiv-monitoring-in-lesotho).Since the beginning of 2016 the district hospital of Butha-Buthe offers VL testing, thanks to a close collaboration between the Ministry of Health of Lesotho, the Swiss Tropical and Public Health Institute (Swiss TPH), Department of Biomedicine University of Basel and SolidarMed, Swiss Organization for Health in Africa. All patients on ART in Butha-Buthe district have access to routine VL monitoring and VL results are stored in an encrypted and password-protected online database , parallel-group , open-label, superiority, prospective RCT in a resource-limited setting.Patients will be screened for eligibility according to the criteria in Table Eligible patients will be invited to join the study, and informed consent will be sought from the patient by the study physician and a study nurse who speaks the local language. Eligible and consenting patients will be randomized by the study physician in a 1:1 allocation, using sealed, opaque, and sequentially-numbered envelopes, stratified by centres , demographic group  and level of VL at enrolment  with randomly-varying block sizes. The randomization list was generated by the trial statistician and the envelopes were prepared by persons independent from the trial. According to their randomized allocation, participants will either be immediately switched to a second-line ART regimen (intervention group) or remain on first-line ART . Choice of second-line ART is based on the national ART guidelines .The primary endpoint is viral resuppression (VL < 50 copies/mL) 9 months after randomization. The rationale for this time-point is that, according to national guidelines, VL should be measured 6 months after switch to second-line ART. If this VL is above 1000 copies/mL, enhanced adherence counseling is introduced and a follow-up VL is performed 3 months later . Hence, 10 VL from the first screening VL measurement (before enhanced adherence counseling) to the second screening VL measurement (i.e. VL at enrolment). According to WHO guidelines [10 VL and a second VL between 100 and 999 copies/mL harboured HIV with relevant drug resistance mutations, indicating a need for switch to second-line ART despite the large drop in VL after enhanced adherence counseling. We assume that individuals showing a > 0.5 drop in log10 VL but still with VL ≥100 copies/mL will benefit from switching to second-line ART. Therefore, we hypothesize the same outcome  in this subgroup.These endpoints are outlined in Table idelines , these iidelines . In thatAll data collected during the scheduled visits will be recorded on paper case report forms and subsequently entered into a password-protected database using EpiData (v4.0.2.101). Access and type of activity for an individual is regulated by privileges assigned to his/her user identification code and password. Data will be double-entered, and modifications are retrievable for reviewing. Apart from the informed consent form, all study documents will not contain any names but solely the study-ID. There is one master list with the subject identification code, which will be stored in a password-protected, encrypted online cloud and only accessible for pre-defined study personnel. Participant files will be maintained in storage for a period of at least 10 years after completion of the study.Participants will undergo phlebotomy at recruitment, 3, 6, 9, and 24 months after randomization. For each participant, study-ID-coded blood samples will be stored at − 80 °C at the laboratory of Butha-Buthe hospital. All samples collected fall under the biobank agreement, accepted by the EKNZ (EKNZ BASEC UBE-Req. 2016–00708) and the ethics committee in Lesotho (ID134–2016). VL determination will be done on COBAS TaqMan® HIV-1 Test, v2.0 (Roche Diagnostics) with reliable lower limit of detection of 20 copies/mL following the manufacturer’s protocol for VL analysis. Figure Studies assessing virologic outcomes in patients with a VL < 1000 copies/mL in resource-limited settings are scarce. Most studies found viral resuppression rates after switch to second-line of 60–80%  –28. Due Analyses will be performed following CONSORT guidelines  and a mop-values with alpha 0.05 level of significance. A separate detailed data analysis plan will be developed, including for the cost-effectiveness analysis.All analyses will be performed using R  or Stata . For all tests, we will use two-sided A minimum of two external monitoring visits will assess adherence to the trial protocol, accuracy of completed case report forms, and the electronic dataset. The Pharmaceutical Medicine Unit of the Division Medicines Research (MedRes) at the Swiss Tropical and Public Health Institute, which acts as an independent academic contract research organization, will perform the monitoring. The Principal Investigator agrees to allow inspectors from regulatory agencies to review records and will assist the inspectors in their duties, if requested.Given that the recruitment is projected to happen fairly quickly, determination of the primary endpoint is after 9 months, safety profiles of all drugs are well-known, and the intervention does not include any new drugs, a DSMB will not be installed.This trial has been approved by the National Health Research and Ethics Committee of the Ministry of Health of Lesotho  and the Ethics committee in Switzerland .Prior to randomization, all participants will provide oral and written informed consent: The study nurse/physician will explain the information sheet to participants. Once all open questions have been clarified and upon agreement to participate, the participant will sign the informed consent form. Iliterate participants will provide a thumb-print and a witness , chosen by the participant, will co-sign the form. For children and young adults aged < 18 years, a literate caregiver > 21 years old (person that takes care of the child/young adult) will provide oral and written informed consent. The informed consent is provided in English and the local language, Sesotho, and the participant will receive a copy of the consent form in written format to take away. The participant has the right to withdraw at any time without giving reasons. In case of withdrawal, only data collected until the time of withdrawal will be used for research purposes . A separate, detailed safety monitoring plan has been developed to handle (S)Aes, in-line with swiss and lesotho ethics regulations. The study physician is responsible for all safety procedures. If a participant develops an adverse event of Grade 2 or higher at last study visit, he/she will remain under observation by the study physician even after study termination, until the adverse event is resolved or stabilized.Participation in this study is not anticipated to cause any substantial additional risk or cost to the participant. Therefore we will not pay compensation to the participants. Free AirTime  will be provided to the study nurses/physicians for the duties of the study. We will consider a step-wise remuneration for study nurses/physicians per enrolled study participant.The trial has been launched at the two study sites with the highest patient load  and the first patient was recruited at Butha-Buthe Hospital on August 01, 2017. If necessary, recruitment will subsequently be rolled out to rural health centres. We anticipate identifying approximately 14 eligible participants/month and a 10% refusal rate, therefore we project a total recruitment period of 7 months to achive our target sample size of 80 patients.By the end of 2016, an estimated 11.7 million individuals, representing 60% of all people living with HIV in Eastern and Southern Africa, were receiving ART . In resoThis trial has several limitations: The proposed switch to second-line at a lower threshold will lead to a higher number of people receiving second-line ART, which remains 2–3 times more expensive than first-line ART . MoreoveIn summary, the SESOTHO trial aims to generate evidence to inform future WHO guidelines, regarding whether a lower VL threshold (e.g. at 100 copies/mL) for switching to second-line ART in resource-limited settings will result in higher rates of viral resuppression. To our knowledge this is the first and only ongoing RCT addressing the question of VL threshold for switch to second-line ART in Southern Africa.


To assess immunovirological response, safety and pharmacokinetic of NRTI-sparing regimen dual therapy of atazanavir (ATV) and raltegravir (RAL) in maintenance strategy.A retrospective analysis was conducted on a cohort of HIV-infected adults followed in French centers (Dat’AIDS cohort), comparing the proportions of virological and therapeutic failures between ATV + RAL and ATV/ritonavir + RAL dual therapy regimens.283 patients were assessed: 185 switched for ATV + RAL and 98 for ATV/ritonavir + RAL dual therapy. Virological failure rate at week 96 was 13.8% , without difference between the two groups . The cumulative percentages of patients remaining free of therapeutic failure at week 24, 48 and 96 of dual therapy were 74.9% , 65.4%  and 53.4% , respectively. Four out of 39 confirmed virological failures developed RAL resistance. By multivariate analysis, virological failure was associated with high HIV-1 RNA zenith (p = 0.02), low CD4+ T-cell count at baseline (p<0.001) and short duration on antiretroviral therapy (p<0.001). Before week 96, dual therapy was discontinued in 44 patients (16%) because of various adverse events, with no difference between the two groups. Minimal plasma levels were targeted in 84% and 87% of patients for ATV and RAL, respectively, and both were significantly higher in ritonavir-boosted regimen.Emerging RAL-resistance and discontinuations for adverse events resulted in moderate efficacy rates of ATV and RAL dual therapy in heavily pretreated patients. HIV-1 antiretroviral therapy (ART) is a life-long treatment. While virological success is achieved in most patients ,3 such aTo decrease drug burden, reducing from standard ART to a two or one drug-containing regimen has been evaluated, with conflicting results on virological efficacy ,8. IndeeIn these studies, a shorter time on ART before monotherapy, which was consistent with a high HIV reservoir, was predictive of virological failure . Yet, NRBesides, RAL or ATV-containing regimen may have a favorable impact on immune activation –25. AlthIn the present study, we aimed to assess viral suppression of ART-experienced patients switching to dual therapy on a large cohort of patients, allowing comparison between boosted and unboosted-ATV regimen. As secondary outcomes, we assessed safety, drug plasma trough concentrations and predictors of virological failures and dual therapy discontinuations.The Dat’AIDS cohort represents a collaboration of major French HIV treatment centers. These centers maintain prospective cohorts of all HIV-1-infected patients who provided written consent. The cohorts are implemented via a common electronic medical record . Past anWe performed a retrospective longitudinal analysis on HIV-1-positive adults participating to the Dat’AIDS cohort who were ART-experienced and were switched to ATV+RAL or ATV/r+RAL regimen between January 2008 and June 2014, whatever baseline CD4+ T-cell count or HIV-1 RNA. Comparing the efficacy, measured by the proportion of therapeutic and virological success at week 24, 48 and 96, between the two regimens was assessed as the primary outcome measure. Confirmed virological failure was defined as a plasma HIV-1 RNA > 50 copies/mL based on two consecutive measurements within a month or HIV-1 RNA > 1000 copies/mL on one sample. Therapeutic failure was defined by dual therapy discontinuation whatever the reason or confirmed virological failure. Secondary objectives were predictors of virological and therapeutic failure, safety and drug plasma levels assessment through follow-up.http://www.anrs.fr). Genotypic resistance testing was performed at virological failure and was interpreted according to the 2015 ANRS algorithm (http://www.hivfrenchresistance.org) according to the current French guidelines ).3 . Before switching to dual therapy, 56% and 20% of patients were already on an ATV and RAL-based regimen, respectively. The main reason of switching to dual therapy was for ART-related adverse events (47%). On dual therapy, patients received primarily ATV 200 mg BID (42%) and 400 mg QD (21%).A total of 283 patients were analyzed: 185 switched for ATV+RAL and 98 switched ATV/r+RAL dual therapy; characteristics are depicted in 3, 0.72 [0.65–0.89]; p<0.001) and a short duration on ART . A past history of virological failure and a detectable HIV-1 RNA at baseline were not associated with an increased risk of virological failure on dual therapy. When focusing on patients with HIV-1 RNA < 50 copies/mL at baseline (n = 227), predictors of virological failure were similar to the entire cohort.The cumulative percentages of patients remaining free of confirmed virological failure on dual therapy were 93.3%  at week 24, 89,4%  at week 48 and 86.2%  at week 96, without difference between ritonavir-boosted and unboosted strategies . Before Both past and at failure genotypic resistance testing was available in 31/39 participants with confirmed virological failure, no resistance to RAL and ATV were detected before switching. Four out of 31 confirmed virological failures with available genotypes developed RAL resistance: two of them had emerging Y143C (week 24 and week 48), one patient had N155H (week 48) and the last patient had Q148R (week 48). Neither ATV nor other RAL resistance mutations were observed.The cumulative percentages of patients remaining free of therapeutic failure at week 24, 48 and 96 of dual therapy were 74.9% , 65.4%  and 53.4% , respectively . By mult3 . Similarly, the CD4+/CD8+ T-cell increased on study, with a mean increase at week 96 of 0.21 .The CD4+ T-cell count increased, with a mean increase at week 96 of 60 cells/mmOnly mild to moderate laboratory abnormalities were found on follow-up. There was a significant elevation in total bilirubin levels, with a mean increase of 17 μmol/L at week 24 , with no difference between the two groups . HoweverA total of 155 and 135 ATV and RAL plasma measurements were assessed, respectively. Overall, median ATV and RAL concentrations were of 550 ng/mL  and 121 ng/mL , respectively. During follow-up, targeted minimum trough ATV concentrations (200 ng/mL) were achieved in 84% of patients and 87% of patients had a RAL level above the 95% inhibitory concentration (15 ng/mL) .The geometric mean trough concentrations of both ATV and RAL are shown in Both ATV and RAL high trough concentrations were not linked to therapeutic failure or discontinuations due to adverse events.Long-life ART poses significant challenge to effective and tolerated therapeutic intervention, especially among heavily pretreated and ageing patients. Indeed, treatment modification is not always simple in heavily ART-experienced patients, due to previous adverse events and/or ART resistance mutations. Evaluating a NRTI-sparing regimen in a large prospective cohort, we showed that ATV and RAL dual therapy had moderate efficacy for lengthy period of time in these patients, mostly due to adverse events and virological failures. Moreover, an emerging RAL-resistance risk at virological failure was encountered . We showed that there was no significant difference between ritonavir-boosted and unboosted strategies in efficacy and tolerance laboratory parameters, except for lipid profiles.Other studies showed moderate efficacy rates of this dual therapy –19,30. TRegarding laboratory abnormalities, dual therapy showed moderate toxicity rates as 44 16%) participants discontinued because of adverse events through week 96. Lower rates of discontinuations over a similar period and for a similar patient population have been reported with other regimen switches . Higher % particiPharmacokinetic results supported the twice-daily use of RAL 400 mg and were in keeping with data from the literature ,40,41. CTo the best of our knowledge, this is the first study that compared long-term immunovirological outcomes of switching to ATV and RAL dual therapy between boosted and unboosted strategies. Although this study has several limitations inherent to the DAT’AIDS cohort design, as the retrospective design and the mixed population (patients with both undetectable and detectable viremia at baseline) , we conf


Objectives: HIV-1 subtype C might have a greater propensity to develop K65R mutations in patients with virological failure compared with other subtypes. However, the strong association between viral subtype and confounding factors such as exposure groups and ethnicity affects the calculation of this propensity. We exploited the diversity of viral subtypes within the UK to undertake a direct comparative analysis.Patients and methods: We analysed only sequences with major IAS-defined mutations from patients with virological failure. Prevalence of K65R was related to subtype and exposure to the NRTIs that primarily select for this mutation . A multivariate logistic regression model quantified the effect of subtype on the prevalence of K65R, adjusting for previous and current exposure to all four specified drugs.Results: Subtype B patients (n = 3410) were mostly MSM (78%) and those with subtype C (n = 810) were mostly heterosexual (82%). K65R was detected in 7.8% of subtype B patients compared with 14.2% of subtype C patients. The subtype difference in K65R prevalence was observed irrespective of NRTI exposure and K65R was frequently selected by abacavir, didanosine and stavudine in patients with no previous exposure to tenofovir. Multivariate logistic regression confirmed that K65R was significantly more common in subtype C viruses .Conclusions: Patients with subtype C HIV-1 have approximately double the frequency of K65R in our database compared with other subtypes. The exact clinical implications of this finding need to be further elucidated. K65R is the signature mutation associated with tenofovir resistanceThe low prevalence of K65R seen in clinical trials and in various resistance databases would support the premise that K65R does not develop that easily in settings where virological failure is well controlled. Worryingly a recent worldwide multicentre retrospective cohort study in patients with treatment failure on tenofovir and NNRTI-based regimens found the K65R prevalence to range from below 20% in Europe and North America to 50% in sub-Saharan Africa.In vitro experiments show that the mutation is more easily selected during serial passage than with other subtypes.,Subtype C viruses are more likely to develop K65R mutations in patients with virological failure than other HIV-1 subtypes. However, additional data to support the reported subtype-dependent selection of K65R is needed especially if it can clearly distinguish between the influence of subtype, exposure groups and ethnicity.The UK national database is well placed to differentiate between these factors as it collects diverse HIV resistance and subtype data typical of the UK HIV epidemic and the aim of this study was to undertake a direct comparative analysis and to determine whether K65R is detected more frequently in subtype C viruses at virological failure.These questions are important given the global distribution of subtype C and the widespread use of tenofovir in first-line combinations.pol sequences (encoding the protease gene and at least codons 34–234 of RT) generated by Sanger sequencing are transferred electronically from participating laboratories, which use a variety of commercial or in-house assays. A quality assurance programme, in which all laboratories participate, is carried out annually. Tests in the present analysis were conducted between 1996 and 2012. As the absence of any major International AIDS Society (IAS)–USA 2013 listThe UK HIV Drug Resistance Database (UKHDRD) has collated the vast majority of genotypic resistance tests conducted in the UK since the assay was first introduced as part of routine clinical care. Partial Patients were considered eligible for the analysis if the following criteria were met: (i) clinical care was received at a centre participating in the UK Collaborative HIV Cohort (UK CHIC) Study ; (ii) at least one (non-WT) resistance test had been conducted after ART initiation; (iii) K65R had not been detected in any tests conducted prior to ART initiation; and (iv) viral subtype could be assigned based on the nucleotide sequence from a resistance test (see section below).a priori on the basis that they were known to select for K65R ,,,If the K65R mutation was ever detected (including as a mixture with WT) in an individual patient, the complete ART history until the first sample with this mutation was considered; if K65R was never detected, the patient’s complete ART history until the last sample was considered. ART history was summarized in terms of indicator variables reflecting current and previous (not current) exposure to specific NRTIs, and current and past exposure to the NNRTI and PI classes in general. Exposure was defined as taking a drug for a minimum of 30 days cumulatively, and current exposure was defined as taking the drug at the time of the resistance test or having stopped within the previous 14 days. The specific NRTIs were chosen ,Subtypes were defined using the Rega 2 subtyping tool.Multivariate logistic regression models were fitted to assess the association between viral subtype and the detection of K65R, adjusting for ART history as described above. Interaction terms between subtype and current NRTI exposure were fitted to examine if the effect of subtype on the likelihood of detection of K65R depended on the specific NRTI being prescribed; subtype B and subtypes non-B/C were grouped for this analysis. A sensitivity analysis adjusting for demographic factors (exposure group and ethnicity) in the main effects model was carried out.All analyses were performed in STATA version 13.1.In total, 5100 patients were eligible for analysis, of whom 3410 were infected with a subtype B virus, 810 with a subtype C virus and 880 with a non-B/C subtype virus. In terms of demographic characteristics, the subtype C and non-B/C groups were similar, comprising mainly black heterosexuals, whereas subtype B patients were predominantly white MSM  patients. Note that this value reflects cumulative incidence (mutation ever detected) rather than cross-sectional prevalence, and is related to the duration of drug selection pressure and the number of resistance tests performed. The frequency of K65R was highest among patients infected with a subtype C virus , approximately double that observed for subtype B  and subtype non-B/C .The association between K65R detection and viral subtype was consistently observed regardless of current or previous exposure to the NRTIs that select for K65R Figure . HoweverP < 0.001). There was no evidence of a difference between subtype non-B/C and subtype B viruses . The strongest drug selection pressure was observed for tenofovir, with patients who were taking this drug at the time of the resistance test being 5.03-fold (95% CI = 3.90–6.50) more likely to have developed K65R compared with patients who had never taken tenofovir. Current exposure to abacavir and didanosine were also significant predictors of K65R, but no effect of exposure to stavudine (either previous or current) was observed. As expected, patients taking zidovudine were less likely  to develop K65R. Those currently on an NNRTI were at an increased risk of developing the mutation  whereas those currently on a boosted PI were protected . With the exception of tenofovir, previous drug exposure had no effect on the development of K65R, which reflects the low replicative capacity of this mutation. The sensitivity analysis, additionally controlling for ethnicity and exposure group, gave very similar results, but with larger standard errors around parameter estimates: the adjusted ORs for subtype C and subtype non-B/C (relative to subtype B) were 2.04 (95% CI = 1.35–3.08) and 0.89 (95% CI = 0.57–1.38), respectively (Table Table P = 0.59)  than the other NRTIs, although a test for statistical heterogeneity was not significant  Figure .Our analysis provides strong clinical evidence that there is an increased risk of finding the K65R mutation among subtype C viruses following virological failure. Our results are in keeping with previous reports and confirm that patients with subtype C are twice as likely as those with other subtypes to develop a K65R mutation.,,et al.,Various other factors have also been shown to increase the risk of K65R development such as current tenofovir and/or NNRTIs,,,per se contributes to the high prevalence seen in countries where subtype C is prevalent. The OR of 1.95 we observed is roughly in keeping with the ORs observed in the TenoRes cohort studyThere is generally a low overall prevalence of K65R reported in various resistance databases.,Our data are consistent with previous evidence that subtype C is a strong risk factor for the development of K65R in patients with virological failure. The clinical implication may therefore be that patients who are infected with subtype C viruses are at an increased risk of virological failure because of the propensity of the virus to develop a K65R mutation when on a tenofovir-based regimen. This seems to be supported by two recent studies.Small retrospective retreatment cohort studies suggested that second-line therapy is as successful with K65R as when the mutation is not present, usually with zidovudine in the regimen. The strongest predictor of virological response was the addition of zidovudine to the retreatment regimen.A further implication of this study is that pre-exposure prophylaxis (PrEP) could potentially be compromised in countries where subtype C viruses are common. So far, PrEP studies using tenofovir ± emtricitabine have reported a low incidence of K65R acquisition when failing tenofovir-based PrEP, even when more sensitive sequencing is employed.A strength of this study is the study size, which makes it the largest comparative study to date, with more patients than the EuResist consortium study.This study included patients with a number of different NRTI exposure histories, which included some of the older NRTIs, which could be considered a weakness of the study. However, this would not have unduly influenced the results as this study mainly explored the hypothesis that the subtype C template has a predilection for developing a K65R mutation. A further consideration is the fact that the K65R mutation could have disappeared due to the adverse effect it has on replication fitness of the virus upon stopping combination ART and could therefore be underrepresented in our database. It is also possible that K65R existed as a minority variant prior to therapy as a result of undetected transmitted drug resistance, but the possibility of this is small and should not have affected our results.In conclusion, our analysis shows that patients with subtype C HIV-1 have approximately double the frequency of K65R in our database compared with other subtypes. The exact clinical implications of this finding need to be further elucidated.


Little is known about the applicability of dual treatments based on integrase inhibitors. We explored the combination of lamivudine + dolutegravir as an option when switching from standard cART in virologically suppressed patients.In this prospective cohort we enrolled patients previously switched to 3TC + DTG who were 18 years or older, with no previous resistance mutations to the used drugs, having a HIV-RNA <50 copies/ml for 6 months or longer, negative for HBsAg and on a stable (>6 months) cART.Ninety-four individuals were included. They were mostly men (77.7%) with a mean age of 53 years. They presented 159 co-morbidities including cardiovascular, bone, hepatic, kidney, and CNS diseases. Because of these pathologies, they took 207 non-ARV drugs (mean 2.2 per patient). Median duration of viral suppression was 77.5 months (IQR 61). All subjects were prospectively followed up to week 24 and all remained on dual therapy during the whole period. Neither virological failure, nor viral blip was detected.P = 0.006) without a significant (P = 0.44) change in the CD4/CD8 ratio. A significant (P < 0.0001) increment of median creatinine from 0.87 mg/dl (IQR 0.34) to 0.95 mg/dl (IQR 0.29) was observed in the first 2 months but thereafter leveled on these values  (P = 0.111 compared to 2 months). The lipid profile slightly improved. The daily cost of cART was significantly (P < 0.0001) reduced of 6.89 euros (SD 6.10).The median CD4 count rose from 658 cells/mcl (IQR 403) to 724 cells/mcl (IQR 401)  contains supplementary material, which is available to authorized users. In the first years of HIV epidemic the sequential use of nucleoside reverse transcriptase inhibitors (NRTI) as monotherapy or dual therapies rapidly led to treatment failure because of the emergence of resistance-associated mutations . Later, Dual regimens have been applied as initial therapy in ARV-naive patients or as a switch strategy in those patients who have become virologically suppressed on standard regimens –17. IdeaLittle is known about the applicability of dual treatments based on integrase inhibitors and a NRTI. We report a prospective, clinical, uncontrolled experience on patients switched, while virologically suppressed, to the combination of dolutegravir plus lamivudine that is considered by Italian Guidelines as optional (CII) .We considered for inclusion in this cohort only patients that, at the moment of therapeutic switch, had a HIV-RNA <50 copies/ml for 6 months or longer. All were negative for hepatitis B virus surface antigen, and were on a stable (>6 months) cART generally based on a nucleosidic backbone plus a third anchor agent, or, in a few cases on other complex regimens. Further, only patients with no previous resistance mutations to either integrase inhibitors or lamivudine were selected. Resistance had to be determined by genotypic analysis before the start of cART or afterward in the occasion of viral blips before the current regimen was started. Patients were not included if they had a viral failure following their last genotypic test.No experimental procedure (e.g. randomization) was applied, and drugs were used according to a considered alternative option in Italian Guidelines. In all patients, the decision to switch therapy was taken on clinical grounds as they presented a clinically relevant reason, either because of concomitant diseases, altered laboratory tests, drug adverse events or risk of drug-to-drug interactions. The drug combination was presented as a possible alternative and discussed individually according to clinical needs. The possibility to use the dual combination was discussed according to available data  and to rAll patients were switched to a dual combination of dolutegravir (50 mg once daily) plus lamivudine (300 mg once daily). The switch was independent from the decision to include the patients in this cohort. Once included, the patients were followed prospectively for at least six monthsPatients were followed accordingly to current clinical practice as indicated from Italian guidelines with visits after 2, 4, 6 month and thereafter every 3–4 months. Each visit included a physical examination and blood and urine analysis performed using standard methods. For the only seek of this analysis, the primary endpoint was the virological response, defined as the proportion of patients with HIV viral load below 50 copies per milliliter 24 weeks after the switch.Several other commonly collected data were used to evaluate possible secondary endpoints. We analyzed safety and tolerability by questioning patients at each visit and by physical examination and laboratory analysis. We evaluated immunological changes in terms of classical CD4+, CD8+ cell/counts variation and we also collected changes in creatinine and blood lipid content as possible markers of drug toxicity.t-test for paired samples was employed to identify significant changes in immunological, renal and metabolic functions. We did all statistical analyses using SPSS version 17.Data are presented as medians and interquartile range or percentages. Student’s Ninety-four individuals switched their regimen. All of them remained on lamivudine + dolutegravir dual therapy for the whole 24 weeks period. Patients continued the dual therapy thereafter and the median follow-up of the cohort was of 17.4 months (IQR 6.6) for 128.5 patient/years at the moment this report was writtenPatients were mostly men of middle age and of Italian origin. Baseline characteristics are summarized in Table The patients had a long cART history and were on average on their fourth line of therapy. Most of patients (93.6%) were, at baseline, taking a triple-drug regimen, being the most common backbones tenofovir + emtricitabine (52.1%) or abacavir + lamivudine (36.2%). The most common anchor drugs were efavirenz (28.3%) and nevirapine (13.8%) among NNRTIs and either boosted atazanavir (13.8%) or boosted darunavir (12.8%) among PIs. A previous exposure to INI was documented in 14.9% of individuals. Only 6 subjects were on a dual therapy maraviroc + boosted darunavir (2); raltegravir + boosted darunavir (2); etravirine + boosted darunavir and etravirine + raltegravir (1 each).P = 0.44) change in the CD4/CD8 ratio that varied from 0.83 (IQR 0.75) to 0.95 (IQR 0.77). A significant (P < 0.0001) increment of mean creatinine, 0.06 mg/dl in magnitude, was observed in the first two months raising the baseline value of 0.87 mg/dl (IQR 0.34) to 0.95 mg/dl (IQR 0.29), but thereafter leveled on these values being the median after 6 months 1.00 mg/dl (IQR 0.35) (P = 0.111 compared to 2 months). The lipid profile slightly changed after switching to the dual regimen: total cholesterol −7 mg/dl (p = 0.047); LDL-cholesterol −7 mg/dl (P = 0.355); HDL-cholesterol +4 mg/dl (P = 0.036) and triglycerides −31 mg/dl (P = 0.012); although differences were dependent on pre-switch type of cART, too .P = 0.002 vs baseline). One patient was lost to follow-up and two patients died between the sixth month of therapy and the end of follow-up because of variceal bleeding due to an alcoholic cirrhosis and because of pulmonary cancer with brain metastasis (one case each). Finally, by changing regimen, the daily cost of cART was significantly (P < 0.0001) reduced of 6.89 euros (SD 6.10 euros)  all patients still receiving the same ARV therapy (91/94) had a viral load was < 50 copies/ml and their median CD4 count was 763 cells/mcl (IQR 491)  use , 20, wheSo far, however, the need of maintaining the efficacy and convenience of robust cART forced clinicians to include a boosted-PI in dual-therapy regimens. Consequently, the potential benefits for some organ systems  were balanced by potential detriments in others .The integrase inhibitor (INI) class has been increasingly recognized as a first-line option, especially because of its good efficacy and tolerability , 3.In combination with two NRTI, the INI class was found to be superior to boosted-PIs , 27 or eIn fact, dolutegravir is not only as efficient as raltegravir as a first-line strategy, but, similarly to boosted-darunavir, it is characterized by a high affinity to its target, resulting in strong and sustained binding . TherefoTo date, no emergent dolutegravir-resistant virus has ever been reported in a patient in whom dolutegravir was prescribed as a first therapy . NeverthTo our knowledge, we report the largest cohort of patients simplified to the dual 3TC + dolutegravir regimen. The studied cART was effective in maintaining HIV-RNA suppression in a cohort of treatment-experienced participants. We did not observe any virological failure, or any viral blip over the 50 copies/ml threshold. The switch therapy offered hints of an improved immunological outcome even in patients who already immune-reconstituted. The reduction of mitochondrial toxicity due to the reduced utilization of NRTIs may possibly explain this result . TherapyAs far as the lipid profile is concerned, our results are substantially similar to previously reported findings using the same drug combination . We obseAlong with treatment-emergent toxicities, concomitant pathologies and the potential interactions with drugs used to treat these diseases were among the most frequent reasons for switching to the dual drug regimen. With this respect the combination of lamivudine and dolutegravir was safe and did not limit therapeutic choices . Finally, being the generic form of lamivudine available, the dual combination was economically convenient compared to all preferred regimens , 3.Clearly, this observational study has several limitations: first of all, its nature does not allow for comparison with a control group, although we tried to limit analysis bias with the prospective design; second, the limited (in number) inclusion criteria allowed for a rather heterogeneous population . We tried to limit this confounding bias by enrolling into the cohort only patients with a known therapeutic history and a controlled HIV viremia. Finally, besides maintenance of virological suppression, we analyzed only a small group of safety parameters and considered as relevant only adverse events leading to treatment discontinuation. This may be a limit in a research setting, but strictly reflects a clinical relevance.In conclusion, we demonstrated in an uncontrolled cohort of pre-treated individuals that switching to a dual cART regimen based on the association of lamivudine and dolutegravir is virologically effective up to 24 weeks, and is associated to slight improvements of the immunologic and metabolic status. This regimen should still be considered as under-investigated and its use cannot be considered routinely. However, the strategy, compared to several alternative ARV regimens, allows to reduce the risk of drug-drug interactions and to use safely concomitant medications for associated pathologies. The dual therapy, at least in our economic environment, is less expensive than most alternative ARV regimens, too.In the near future, with the availability of new nucleotidic molecules  the clin


Gay, bisexual and other men who have sex with men (MSM) are disproportionately affected by HIV in Canada. Combination antiretroviral therapy has been shown to dramatically decrease progression to AIDS, premature death and HIV transmission. However, there are no comprehensive data regarding combination antiretroviral therapy outcomes among this population. We sought to identify socio-demographic and clinical correlates of viral suppression and rebound.Our analysis included MSM participants in the Canadian Observational Cohort, a multi-site cohort of HIV-positive adults from Canada’s three most populous provinces, aged ≥18 years who first initiated combination antiretroviral therapy between 2000 and 2011. We used accelerated failure time models to identify factors predicting time to suppression (2 measures <50 copies/mL ≥30 days apart) and subsequent rebound (2 measures >200 copies/mL ≥30 days apart).Of 2,858 participants, 2,448 (86 %) achieved viral suppression in a median time of 5 months (Q1–Q3: 3–7 months). Viral suppression was significantly associated with later calendar year of antiretroviral therapy initiation, no history of injection drug use, lower baseline viral load, being on an initial regimen consisting of non-nucleoside reverse-transcriptase inhibitors, and older age. Among those who suppressed, 295 (12 %) experienced viral rebound. This was associated with earlier calendar year of antiretroviral therapy initiation, injection drug use history, younger age, higher baseline CD4 cell count, and living in British Columbia.Further strategies are required to optimize combination antiretroviral therapy outcomes in men who have sex with men in Canada, specifically targeting younger MSM and those with a history of injection drug use. Betweenpulation , with thpulation . Since tpulation . High lepulation .Despite the proven clinical benefits of cART, Canadian MSM continue to experience a sustained rate of new HIV infections compared with the general population , 11. A mWhile risk factors for HIV seroconversion among MSM have been largely explored, there is a sizable research gap regarding modern-day cART treatment responses. To date, there has not been an analysis of the clinical and social circumstances associated with virologic outcomes among MSM in Canada. The Public Health Agency of Canada has specifically identified this knowledge gap . FurtherThe Canadian Observational Cohort (CANOC) collaboration is an observational cohort study of antiretroviral-naïve HIV-positive individuals initiating cART after 1 January 2000 . This muThe human subjects activities of CANOC were approved by the Simon Fraser University Research Ethics Board, the University of British Columbia Research Ethics Board and the following local institutional review boards of the participating cohorts: Providence Health Care Research Institute Office of Research Services, The Ottawa Hospital Research Ethics Board, University Health Network (UHN) Research Ethics Board, Véritas Institutional Review Board (IRB), Biomedical C (BMC) Research Ethics Board of the McGill University Heath Centre (MUHC), University of Toronto HIV Research Ethics Board (HIV REB), and Women’s College Hospital Research Ethics Board.Local cohort studies have obtained written consent except for the following: HAART Observational Medical Evaluation and Research ; Ottawa Hospital Cohort ; UHN ; MUHC ; Maple Leaf Medical Clinic ; and Effective Anti-Retroviral Therapy cohort .Further details on the collaborating cohorts and general CANOC structure are available .Viral suppression after cART initiation was defined as the time to the first of at least two consecutive plasma HIV RNA measurements below 50 copies/mL, at least 30 days apart in the first year of treatment. We defined suppression within one year to focus on more timely virologic control . Viral rDemographic and clinical characteristics at treatment initiation (baseline) were summarized using frequencies and proportions for categorical variables and medians and interquartile ranges (Q1–Q3) for continuous variables. Demographic and clinical characteristics of participants who achieved viral suppression within one year or did not achieve viral suppression within a year were compared using Chi-square tests for categorical variables and Wilcoxon Rank Sum tests for continuous variables.p-values, and a priori information was pursued to select variables for the multivariable accelerated failure time models examining time to viral suppression and rebound. The time origins were the first antiretroviral start date and the date of the first of two consecutive viral load measurements below 50 copies/mL and above 200 copies/mL, for the suppression and rebound models, respectively. The multivariable models were fitted to an exponential distribution. All analyses were performed using SAS statistical software, version 9.3 .Univariate accelerated failure time models with interval censoring were used to explore the association between covariates and each of the two outcomes. Covariates of interest included province of residence, race/ethnicity, age, baseline CD4 cell count, baseline viral load, history of injection drug use (IDU), baseline diagnosis of an AIDS-defining illness (ADI), era of cART initiation , and third ARV class . Calendar time of reaching viral suppression was also explored as a covariate in the rebound analysis because of its potential influence on subsequent rebound . An expl3 (Q1–Q3: 130–321 cells/mm3) and the median baseline viral load was 4.96 log10 copies/mL (Q1–Q3 4.51–5.00 log10 copies/mL). Of the 2,744 participants with available hepatitis C (HCV) testing data, 331 (12 %) were seropositive. Additionally, 247 (9 %) participants had a history of IDU at the time of HIV diagnosis. At baseline, 459 (16 %) participants had been diagnosed with an ADI at or prior to cART initiation. The median rate of viral load testing was 4 tests per year (Q1–Q3: 3–5 tests).Baseline demographic and clinical characteristics of the study participants are listed in Table Table p < 0.001), calendar year of cART initiation (p < 0.001), initial composition of ARV regimen (p < 0.001), baseline viral load (p < 0.001), baseline CD4 count (p = 0.001), HCV co-infection (p = 0.001), age (p = 0.002), ethnicity (p = 0.002), having an ADI at baseline (p = 0.006), and province of residence (p = 0.011).In bivariate analysis, time to viral suppression was significantly associated with IDU history  higher proportion of participants initiated treatment comprised of a Zidovudine and Lamivudine NRTI fixed combination . In contrast, the better-tolerated and more effective [Consistent with previous research , our anaffective  Tenofoviffective . NNRTIs ffective .3) is concerning, although guidelines for the timing of cART initiation have changed significantly over the period of study. The median baseline CD4 cell count increased throughout the study timeline, likely in response to these updated guidelines. In 2000, the median baseline CD4 cell count among all participants was 183 cells/mm3, whereas in 2011, this measure was 358 cells/mm3. Although an improvement, other studies have demonstrated that PHA who initiate cART with CD4 cell measures below 350 cells/mm3 are at higher risk of AIDS and death than individuals who begin treatment at higher CD4 thresholds [The low median baseline CD4 cell count among participants (230 cells/mmresholds . Recurre3) and lower rates of adherence [Our finding that higher baseline CD4 cell count was a significant predictor of viral rebound was surprising , 39. It dherence . Going fdherence , and in dherence , 43. As This analysis discerned a few populations at risk of poorer virologic outcomes, including younger MSM and those with a history of injection drug use. Adverse treatment response was particularly evident in this latter group, who had 0.71 times the likelihood of achieving suppression, and over 2.5 times the chance of experiencing rebound. Their reduced probability of achieving and sustaining undetectable viral loads hinders UNAIDS suppression targets and has potential negative implications for future health outcomes, and on going HIV transmission. Younger MSM can face a wide array of challenges, including sexual identity issues, substance abuse, precarious employment, and housing instability . Understn = 2,073) were excluded from this analysis. Moreover, our results only pertain to MSM participants who had at least two viral load measurements within one year after initiating cART, as well as individuals with at least one year of follow-up. However, excluding this group from our analyses did not heavily bias our results, because male participants with unknown MSM status did not differ from the MSM sample significantly with regard to baseline CD4 cell count, achieving suppression, or experiencing rebound.Readers should be cautious when reviewing our findings even though our study was based on large group of MSM and 12-year follow-up period. Most notably, our study only included Canada’s three largest provinces, Ontario, Quebec and British Columbia, however, we did include most MSM as currently 85 % of PHAs in Canada live in these provinces . The proOur results show that over 80 % of HIV-positive MSM with at least one year of follow-up achieved and maintained suppressed HIV viral levels. However, 12 % of MSM who achieved viral suppression went on to experience viral rebound within the study period. To better realize the UNAIDS 90 % suppression target, further strategies are required to optimize cART outcomes in MSM in Canada, specifically targeting younger MSM and those with a history of IDU.


Millions of HIV-infected people worldwide receive antiretroviral therapy (ART) in programmes using WHO-recommended standardised regimens. Recent WHO guidelines recommend a boosted protease inhibitor plus raltegravir as an alternative second-line combination. We assessed whether this treatment option offers any advantage over the standard protease inhibitor plus two nucleoside reverse-transcriptase inhibitors (NRTIs) second-line combination after 144 weeks of follow-up in typical programme settings.We analysed the 144-week outcomes at the completion of the EARNEST trial, a randomised controlled trial done in HIV-infected adults or adolescents in 14 sites in five sub-Saharan African countries . Participants were those who were no longer responding to non-NRTI-based first-line ART, as assessed with WHO criteria, confirmed by viral-load testing. Participants were randomly assigned to receive a ritonavir-boosted protease inhibitor  plus two or three clinician-selected NRTIs (protease inhibitor plus NRTI group), protease inhibitor plus raltegravir , or protease inhibitor monotherapy . Randomisation was by computer-generated randomisation sequence, with variable block size. The primary outcome was viral load of less than 400 copies per mL at week 144, for which we assessed non-inferiority with a one-sided α of 0·025, and superiority with a two-sided α of 0·025. The EARNEST trial is registered with ISRCTN, number 37737787.vs specified non-inferiority margin 10%). In the protease inhibitor monotherapy group, 292 (78%) of 375 had viral loads of less than 400 copies per mL; p=0·003 versus the protease inhibitor plus NRTI group at 144 weeks. There was no difference between groups in serious adverse events, grade 3 or 4 adverse events , or events that resulted in treatment modification.Between April 12, 2010, and April 29, 2011, 1837 patients were screened for eligibility, of whom 1277 patients were randomly assigned to an intervention group. In the primary (complete-case) analysis at 144 weeks, 317 (86%) of 367 in the protease inhibitor plus NRTI group had viral loads of less than 400 copies per mL compared with 312 (81%) of 383 in the protease inhibitor plus raltegravir group , UK Medical Research Council, Instituto de Salud Carlos III, Irish Aid, Swedish International Development Cooperation Agency, Instituto Superiore di Sanita, Merck, ViiV Healthcare, WHO. Over 17 million people currently receive antiretroviral therapy (ART) for HIV infection worldwide, most of whom live in resource-limited settings. ART is usually delivered using the WHO-recommended public health approach, characterised by use of standardised sequential regimens and simplified monitoring and care.There are theoretical reasons why replacing the NRTIs with raltegravir in second-line therapy might be advantageous, primarily the absence of cross-resistance to first-line therapy. Three randomised controlled trialsEvidence before this studyWe searched PubMed using terms including “second-line therapy”, “protease inhibitors”, and the individual drug names, and reviewed relevant HIV conference abstracts to identify clinical trials done in patients who had failed on a first-line non-nucleoside reverse-transcriptase inhibitor (NNRTI)-based combination, which compared the standard-of-care protease inhibitor plus NRTI combination for second-line therapy with either a protease inhibitor plus raltegravir combination or with protease inhibitor monotherapy. No language or date restrictions were used. No relevant studies were identified in our initial search on March 1, 2009. An updated search on June 1, 2017, using the same terms, identified three published randomised controlled trials reporting outcomes after 48 or 96 weeks' treatment with the protease inhibitor plus raltegravir combination  that concluded that this option was non-inferior, and two randomised controlled trials reporting outcomes after 48 or 96 weeks' treatment with protease inhibitor monotherapy , which concluded that this option was inferior to standard of care.Added value of this studyThis trial provides the first comparative, randomised data on long-term (144 weeks) outcomes with the protease inhibitor plus raltegravir regimen in second-line therapy. With this longer duration of follow-up, we found that non-inferiority was not consistently demonstrated across all analyses, and there was no evidence of a safety benefit with the protease inhibitor plus raltegravir regimen compared with the standard-of-care protease inhibitor plus NRTI combination. The trial also confirms that the initial response of the protease inhibitor plus NRTI regimen is durable with longer-term follow-up and that reintroduction of combination therapy restores virological suppression after prolonged protease inhibitor monotherapy, emphasising the contribution of NRTIs to second-line regimen activity.Implications of all the available evidenceTaking into account the higher cost of raltegravir, the absence of clear advantages of protease inhibitor plus raltegravir seen in any trial and the failure to show non-inferiority consistently across all analyses after 144 weeks of treatment in this trial suggest that there is no compelling reason for national programmes to adopt this combination as the standardised second-line therapy in the public health approach to antiretroviral therapy.Here, we report outcomes after 144 weeks of follow-up from the EARNEST trial, the largest of the trials assessing protease inhibitor plus raltegravir and the only trial with follow-up beyond 96 weeks, and examine its performance in subgroups relevant for resource-limited settings. We also report outcomes after reintroduction of NRTIs after an initial period of protease inhibitor monotherapy as second-line treatment.The EARNEST trial was a randomised controlled trial done in 14 sites in five sub-Saharan African countries . Eligible patients were HIV-infected adults or adolescents older than 12 years who were no longer responding to a first-line combination of NRTIs with a non-NRTI .The protocol was approved by ethics committees in all participating countries and the UK. All participants (and caregivers of adolescents younger than 18 years) provided written informed consent.vs ≥200 cells per μL). The computer-generated, sequentially numbered randomisation list (variable block sizes) was preprepared by the trial statistician and incorporated in the online secure database. Randomisation was done by the trial manager at each centre, who could access the next number, but not the whole list. Treatment was given open-label .Patients were randomly assigned (1:1:1) to one of three treatment groups. Randomisation was stratified by centre, and screening CD4 count  plus two NRTIs (protease inhibitor plus NRTI group), plus raltegravir 400mg twice per day , or alone as monotherapy  and were followed up for 144 weeks. In the protease inhibitor plus NRTI group, NRTIs were selected by the physician without resistance testing, following WHO algorithms  and taking into account side-effects on first-line, local standard-of-care, and local drug availability. The protocol initially allowed treatment with three NRTIs in Malawi . After a data monitoring committee (DMC) recommendation based on poorer viral-load suppression and more protease inhibitor resistance in the protease inhibitor monotherapy group than in the protease inhibitor plus NRTI group, patients in the protease inhibitor monotherapy group were switched to combination therapy  after May, 2013 .Patients were assessed every 4–8 weeks, with most visits done by nurses. Adherence was assessed at each visit through structured questions, with intensive adherence counselling when lapses were identified. Treatment was monitored clinically, with full blood count, alanine transaminase, serum creatinine, and urine dipstick tests for glucose, protein, and leucocytes done at weeks 12, 48, 96, and 144 after randomisation, and CD4 cell counts every 12–16 weeks in the local site's laboratory. Additional tests were permitted at the discretion of the treating clinician to evaluate and monitor incident adverse events. Within-class ART substitutions were allowed for toxicity or poor tolerability. There was no real-time viral-load monitoring, but if a patient developed clinical or immunological failure , and an alternative regimen was available locally, sites could do open local viral-load testing  after approval from a clinical expert review committee (CERC) and change treatment if needed. In the protease inhibitor monotherapy group, after the recommendation by the DMC to reintroduce combination treatment, all trial viral-load and resistance testing results were provided to the treating clinicians who were permitted to additionally test for viral load and resistance in these patients at their discretion. Women assigned protease inhibitor monotherapy who became pregnant added NRTIs while pregnant or breastfeeding. Tuberculosis was treated using rifabutin, with ART unchanged.Stanford algorithm (version 7). Subtype was determined using REGA (version 3.0). Viral loads and genotypes were reviewed by the DMC, but not provided to treating clinicians during the trial .During the trial, viral load was measured centrally  in batches of samples stored at weeks 48 and 96 using the Abbott RealTime HIV-1 assay ; individuals who did the assays were blinded to randomised allocation. After trial closure, viral-load testing was done on samples stored at weeks 4, 12, 24, 36, 64, 80, 110, 126, and 144 . Genotyping  was done blinded on all post-randomisation samples with viral load of more than 1000 copies per mL at Janssen Diagnostics . Genotyping (reverse transcriptase) of baseline samples from patients in the protease inhibitor plus NRTI group and protease inhibitor plus raltegravir group was done at the JCRC . Drug susceptibility prediction used the Neurocognitive function and peripheral neuropathy were assessed using standard methods.The primary endpoint for the 96-week analysis,For the sample size calculation, we assumed that 75% of patients in the protease inhibitor plus NRTI group would have good disease control at week 96 and 10% would be lost to follow-up. With a one-sided α of 0·025 for the non-inferiority comparison and two-sided α of 0·025 for the superiority comparison, we estimated that 400 patients per group provided 80% power to show non-inferiority of protease inhibitor monotherapy using a 10% non-inferiority margin, and 87% power to demonstrate superiority of protease inhibitor plus raltegravir assuming 10% greater response rate.2 tests, and continuous variables using mean change from baseline and t tests or ANOVA. Time-to-event endpoints were analysed using Cox proportional hazards regression and Kaplan-Meier. Generalised estimating equations  were used to test difference between groups across all visit weeks. Prevalence of intermediate-high level resistance at week 144 was adjusted for failed or missing genotypes using sampling weights.All comparisons were according to randomised arm (intention-to-treat) regardless of ART changes after randomisation. Statistical tests were two-sided and did not adjust for multiplicity. 95% CIs correspond to a two-sided test for superiority; for non-inferiority comparisons, the focus was on the lower confidence limit. The endpoint of good disease control used multiple imputations to account for missing CD4 cell count, viral loads, and genotypes (<5% of observations). Following the statistical analysis plan, the primary analysis of all other endpoints used complete-case analyses and excluded deaths, individuals lost to follow-up, and missed visits. Binary endpoints were compared using risk differences and χOf three protocol-specified viral-load thresholds , we selected 400 copies per mL as the main outcome because it is less affected by transient, low-level viral-load blips, is closest to failure thresholds used in most contemporary treatment guidelines ,Subgroup analyses comparing protease inhibitor plus NRTI versus protease inhibitor plus raltegravir groups at week 144 were done following the intention-to-treat principle, on the complete-case population using the same non-inferiority margin of 10% to compare the two treatment groups, although we recognise that the power to determine non-inferiority is lower within subgroups and the trial was not formally powered for this  of 367 participants in the protease inhibitor plus NRTI group had viral loads of less than 400 copies per mL, 276 (75%) had viral loads of less than 50 copies per mL, and 321 (87%) had viral loads of less than 1000 copies per mL . At weekIn the protease inhibitor plus raltegravir group, 312 (81%) of 383 participants had viral loads of less than 400 copies per mL, 275 (72%) had viral loads of less than 50 copies per mL, and 321 (84%) had viral loads of less than 1000 copies per mL at week 144 . Viral-lvs protease inhibitor plus NRTI at week 144). Intermediate or high-level resistance to lopinavir was seen in 31 participants .In the protease inhibitor monotherapy group at week 144, 292 (78%) of 375 participants had viral loads of less than 400 copies per mL, 246 (66%) had viral loads of less than 50 copies per mL and 301 (80%) had viral load of less than 1000 copies per mL . In protThere was no difference between the three randomised groups at week 144 in the proportions of patients with good disease control (composite endpoint used for primary week 96 comparison), who were alive, were alive without new WHO stage 4 events, or who had CD4 counts of more than 250 cells per μL ; or in m2 , grade 3 or 4 adverse events , or events that resulted in treatment modification  approach or multiple secondary analyses, consistent with previously reported findings at 48–96 weeks from EARNEST and other trials.The explanation for these unexpected findings  is unclear, but pharmacokinetic factors might have an important role. Raltegravir has a low genetic barrier to resistance and relatively short half-life and might therefore be more susceptible to the development of resistance during episodes of non-adherence compared with tenofovir, which has a moderate genetic barrier and long intracellular half-life.The strengths of this trial are its size, follow-up duration, low withdrawal or loss to follow-up, and regular storage of samples for subsequent centralised viral-load and resistance testing. The broad eligibility criteria and pragmatic approach to delivering treatment  all enhance generalisability to programme settings in which most patients receive second-line ART, and viral-load testing remains challenging and resistance testing is rarely available.The main limitation of this study is that treatment was given open-label ; however, very few patients changed from their allocated treatment strategy and the main outcomes were laboratory parameters assayed blind to treatment received. Most patients were taking a zidovudine or stavudine-based NRTI regimen first-line, and switched to tenofovir at the start of second-line therapy. Current WHO guidelines indicate tenofovir is preferred in first-line, with switch to zidovudine for second-line. However, the virological efficacy of the second-line protease inhibitor plus NRTI regimen does not appear to depend on activity of particular NRTIs, so it is unlikely that this difference in the sequence of NRTIs used would have a substantial impact on our results.Our findings have important implications for the selection of regimens for second-line therapy in the public health approach. The good longer-term outcomes with the combination of a protease inhibitor (in this case lopinavir) with two NRTIs provides support for this regimen as the WHO-recommended preferred second-line combination.In settings where therapy can be individualised, a protease inhibitor plus raltegravir regimen could be of value in selected patients if used with regular virological monitoring and adjusted (with drug substitutions) as needed. In the public health approach, a decision to change the standardised sequence of regimens will affect millions of people, and the consequences of an underperforming regimen might not be easily detected and reversed at an individual level. This trial, with its unexpected outcomes, reinforces the need for robust randomised trials with substantial long-term follow-up to be done in resource-limited settings in the populations in whom the public health approach is used before recommendations are changed.