In low income countries such as Uganda progress has been made towards achieving the United Nations AIDS programme 95-95-95 target however efforts are still impeded by pretreatment drug resistance and adverse drug events (ADEs) hence introduction of dolutegravir-based antiretroviral therapy as first-line treatment due to a higher genetic barrier to resistance, better tolerability and safety profile. However, recent studies have raised concerns regarding its safety in real-clinical settings due to ADEs and being a recently introduced drug there is need to actively monitor for ADEs, hence this study aimed to establish the prevalence and factors associated with ADEs among patients on dolutegravir-based regimen at the Immune Suppression Syndrome (ISS) Clinic- Mbarara Regional Referral Hospital (MRRH).A mixed design study was conducted at ISS Clinic-MRRH among 375 randomly selected patients who had been exposed to DTG-based regimen for at-least 12 weeks. These were interviewed to obtain data on socio-demographics, dietary habits and their files reviewed for ADEs. Data entry was done using Epi-data 3.0 and exported to SPSS 25.0 for analysis. Prevalence was determined as a percentage, and ADE associated factors assessed using bivariate analysis, those found significant were further subjected to multivariate analysis and considered significant at P < 0.05.The prevalence of ADEs among patients on DTG-based regimen was found to be 33.1% (124/375) with 5.6% (7/124) participants discontinued from treatment due ADEs, 4 due to hyperglycemia and 3 liver toxicity. The commonly experienced ADE was allergy at 36.3%. Male sex , WHO stage one at entry to care , stage two , stage three , were significantly associated with ADEs. Patients with undetectable viral load at initiation of DTG-based regimen were 67.6% less likely to experience ADEs .This study reports a prevalence of 33.1% of ADEs among patients on DTG-based regimen. The most commonly experienced ADE was allergy. Male sex, early HIV disease stage at entry into care and detectable viral load at initiation of DTG-based regimen were significantly associated with ADEs. It is crucial to actively monitor patients with these characteristics for ADEs. The Joint United Nations Programme on HIV/AIDS (UNAIDS) in 2014 launched the 95-95-95 strategy aimed to end the AIDS epidemic by 2030 through achieving 95% diagnosed of all people living with HIV (PLWHIV), 95% on antiretroviral therapy (ART) among diagnosed and 95% virally suppressed among treated [Progress towards achieving the 95-95-95 target has been made however, a rise in pretreatment drug resistance to first-line ART and adverse drug events (ADEs) among others pose a serious threat to strides made in low income countries such as Uganda hence need for more potent ART with higher genetic barrier to drug resistance, better safety and toxicity profile , 5.Following World Health Organization (WHO) recommendations in 2018, dolutegravir (DTG)-based ART was adopted as first-line treatment for all PLWHIV in Uganda , 7. DoluIn low income countries such as Uganda where dolutegravir-based ART has recently been introduced there is need for active monitoring for potentially new and emerging adverse drug events . ClinicaThere is scarcity of information on ADEs of DTG-based regimen in countries where it has recently been introduced such as Uganda, therefore, this study aimed to determine the prevalence and factors associated with adverse drug events among patients on dolutegravir-based regimen at the Immune Suppression Syndrome (ISS) Clinic- Mbarara Regional Referral Hospital (MRRH).This research was a mixed design study involving patients in HIV care at the Immune Suppression Syndrome Clinic of Mbarara Regional Referral Hospital, Uganda who had been exposed to dolutegravir-based antiretroviral therapy for at least 12 weeks. The objectives of the study included, to determine the prevalence of adverse drug events, identify adverse drug events experienced and establish factors associated with adverse drug events among patients on dolutegravir-based regimen at the ISS Clinic-MRRH.The ethical considerations of this study were approved by Mbarara University of Science and Technology Research Ethics Committee (MUST-REC) approval number, MUREC 1/9 02/12-19, and Faculty of Medicine through the Faculty Research Committee (FRC) approval number DMS 6.This study was conducted at the Immune Suppression Syndrome Clinic of the Mbarara Regional Referral Hospital, a government-aided hospital located in Mbarara district in the South western region of Uganda. The facility majorly serves patients from South-Western districts of Uganda including Buhweju, Bushenyi, Ibanda, Isingiro, Kazo, Kiruhura, Mitooma, Ntugamo, Mbarara, Rubirizi, and Rwampara among others. Currently, the ISS clinic serves a total number of 21,600 patients; 11,600 pediatric and 10,000 adults. The facility has an average daily attendance of 300 patients. The ISS clinic provides services including; HIV counselling and testing, elimination of mother to child transmission of HIV, HIV care, treatment and support for people living with HIV/AIDs including children, adolescents and adults.The study population consisted of both male and female patients aged 20 years and above at the time of initiation of dolutegravir-based HAART regimen and had been on the regimen for at least 12 weeks at the Immune Suppression Syndrome Clinic of Mbarara Regional Referral Hospital, Uganda.The sample size of 375 patients was determined using the Slovin’s formula  based onUnique identification codes for eligible participants were run through Microsoft excel and a sample size of 375 was generated by random draw method. An appointment list was used to identify when the patients attended clinic visit, upon which they were asked to consent and participated in the study. The method eliminated bias, provided an equal chance to every eligible patient to be selected for the study and patients participated on their official clinic appointment day.Written and informed consent was obtained from the patients to participate in the study and to use their files for obtaining data for the study. Before participants signed consent forms, they were informed that participation was voluntary and they could drop out at any time, the purpose, objectives, possible benefits and risks of the study were clearly explained and only patient identification numbers were used which maintained utmost confidentiality.Selected patients were interviewed, there-after their medical files reviewed and data on ADEs was obtained from the ART cards as recorded by clinicians. The data collection tool consisted of two sections; The first section was completed through patient interview and collected information on social demographics including; sex, age, marital status, religious affiliation, level of education and employment status, types of meals consumed before swallowing medicine, if patients received counselling instructions to follow while taking the regimen and time the medicine is taken.The second section was completed by file review and collected data on duration since HIV diagnosis, CD4 at entry into care, duration on HAART, viral load at initiation of dolutegravir-based regimen, previous ART regimen, body mass index, recorded adverse drug event since start of dolutegravir-based regimen, any treatment modification; discontinuation, comorbidities, other medications, blood glucose measurements and liver function tests.The data abstraction form for each patient/file was assigned an identification code. The filled: forms were checked for accuracy, consistency and completeness by the principal investigator. Completed forms were kept under restricted access which protected patient confidentiality and data from alteration. The first section of the data collection tool was translated to Runyankore the commonly used local language.All filled data collection forms were checked, coded and data entry done using Epi data 3.0. Data cleaning and validation was done to detect any errors. The data was exported and analyzed using statistical package for social sciences (SPSS) version 25.0. Socio-demographics were presented using descriptive statistics and categorical variables were presented using frequencies and percentages. The data was presented using text, tables, and graphs. Prevalence of ADEs was determined by obtaining the number of patients in the sample who had at least one ADE recorded in their medical file on the ART card divided by the total number of the sample size, expressed as a percentage.Adverse drug events experienced by patients were captured from ART cards in the medical files as recorded by clinicians. Severity rating of ADEs was based on the DAIDS grading of ADEs using data from medical files . ADEs weThe relationship between factors associated with adverse drug events to dolutegravir-based regimen was established using bivariate analysis. Variables found significant at bivariate level were then subjected to multivariate analysis. Variables were considered statistically significant if p-value was less than 0.05 measured with odds ratio at 95% confidence interval.Most of the study participants were male 59.5% (223/375), with majority of respondents in the age bracket of 40–49 years and 50–59 years consisting of 34.1% (128/375) each, with median age 49 years interquartile range 12. Participants who had been on HAART for 5–10 years were 78.9% (296/375), 77.9% (292/375) of the participants had undetectable viral loads at the time of initiation of DTG-based regimen, and all the participants were in WHO stage one at initiation of DTG-based regimen  of the respondents had at least one ADE recorded in their files since initiation of DTG-based regimen.The commonly recorded ADEs included; abdominal pain, hyperglycemia and hepatotoxicity each at 7.3%, paresthesia at 8.1%, headache at 11.3% allergy at 36.3%  patients who experienced hyperglycemia, five had grade 1, two had grade 2, one with grade 3 and one with grade 4, this was reported between 13 and 62 weeks of starting the DTG-based regimen.Of the 7.3% (9/124) patients who experienced liver toxicity; eight had grade one and one had grade 4, this was reported between 15 and 63 weeks of starting the DTG-based regimen. All the patients who experienced liver toxicity were concomitantly taking isoniazid preventive therapy.As result of ADEs 5.6% (7/124) participants were discontinued from DTG-based regimen, 4 due to hyperglycemia and 3 liver toxicity.At bivariate analysis male sex , being in the age bracket of 30–39 years , being married  and being employed , eating non-fatty meals before swallowing the medicines , duration of HIV diagnosis of less than 5 years , having HIV for 5–10 years since diagnosis , being in WHO stage one at entry into care , being in WHO stage two at entry into care , being in WHO stage three at entry into care , having undetectable viral load at initiation of DTG , were significantly associated with ADE among patients on DTG-based regimen , being in WHO stage one at entry to care had  WHO stage two , WHO stage three , and viral load at initiation of DTG-based regimen were significantly associated with ADEs among patients on DTG-based regimen. Patients with undetectable viral load at DTG-regimen initiation  were less likely to experience ADEs  of starting therapy and 16 months (63 weeks) of DTG-based therapy.The data on adverse drug events such as allergies was captured from medical files as recorded by clinicians hence thorough and proper investigation on each ADE could not be conducted.Existing laboratory results on blood glucose tests and liver function tests were used to capture laboratory data on adverse drug events such as hyperglycemia and liver toxicity however most patient files did not have these test results.


Evidence on the optimal time to initiate antiretroviral therapy (ART) in the presence of toxoplasmic encephalitis (TE) is scarce. We compared the impact of early vs. delayed ART initiation on mortality and neurologic complications at discharge in a Brazilian population co-infected with HIV and TE.We retrospectively evaluated data from 9 years of hospitalizations at a referral center in Manaus, Amazonas. All ART-naïve hospitalized patients were divided into early initiation treatment (EIT) (0-4 weeks) and delayed initiation treatment (DIT) (>4 weeks). The groups were compared using chi-square test and mortality at 16 weeks.+ lymphocyte count and CD4+/CD8+ ratio were 53 cells/mm3 and 0.09, respectively. Mortality rate and presence of sequelae were 4.9% (n = 23) and 41.6% (n = 195), respectively. Mortality was similar between groups (p = 0.18), although the EIT group had the highest prevalence of sequelae at discharge (p = 0.04). The hazard ratio for death at 16 weeks with DIT was 2.3 (p = 0.18). The necessity for intensive care unit admission, mechanical ventilation, and cardiopulmonary resuscitation were similar between groups.Four hundred sixty nine patients were included, of whom 357 (76.1%) belonged to the EIT group. The median CD4In patients with AIDS and TE, early ART initiation might have a detrimental influence on the occurrence of sequelae. Toxoplasma gondii, is the most common central nervous system (CNS) opportunistic infection (OI) of people living with the human immunodeficiency virus (PLHIV) , caused by the intracellular protozoan parasite  (PLHIV) –3. If le (PLHIV) , 5. In B (PLHIV) , and des (PLHIV) –9 in the (PLHIV) , 11. The (PLHIV) –14.+ T cell count, except for those with active meningeal tuberculosis and cryptococcal meningoencephalitis. In these patients, ART should be postponed 4 and 6 weeks after the initiation of tuberculous and fungal treatment, respectively  between January 2010 and December 2018. FMT-HVD is a tertiary-care referral hospital for infectious diseases located in Manaus, Western Brazilian Amazon, which receives patients seeking medical care as well as those referred from public and private health care units in surrounding localities. FMT-HVD is part of the Brazilian public health network and adopts all Brazilian guidelines for the management of sexually transmitted infections  and HIV All patients are registered in the hospital's electronic medical record (EMR), the IDoctor platform, from which data were collected after a thorough screening process. Data on demographics, clinical, radiological and/or laboratory diagnosis of TE, length of hospitalization and any supportive procedures  and outcome  were retrieved from individual EMRs and sent anonymously to the databank. Selection of eligible participants for analysis is shown in T. gondii IgG and/or IgM antibodies, and a satisfactory response after specific treatment  , and confirmed by an immunoassay test, as defined by the Brazilian Ministry of Health . TE was delines) .+, CD8+, and viral loads counts after admission (newly diagnosed HIV infection) or the most recent pre-admission CD4+, CD8+, and viral loads counts  were recorded. Data collection was carried out by two independent researchers. Any disagreements were resolved by consensus.Only new episodes of TE were registered. If a patient had other hospitalizations registered in the database due to the same cause, they were considered a duplicate, and excluded. The first laboratory data (hematology and biochemistry) after admission and either the first CD4The included patients were divided into groups according to the ART initiation time as described elsewhere . BrieflyThe primary study outcome was in-hospital death. Secondary outcomes were the presence of sequelae at hospital discharge, need for ICU, MV, CPR, and number of hospitalization days. Neurological sequelae recorded in the study were defined as the presence until medical discharge, of one or more of the baseline signs or symptoms or the development of a new one; and for their evaluation the last medical statement prior to discharge was reviewed. Patients were followed up until hospital discharge or time of in-hospital death.t-test for continuous variables. Shapiro-Wilk test was used to verify normality. Mortality at 16 weeks was compared between groups with the use of Peto-Peto-Prentince test and Cox-regression, which was performed to derive the hazard ratio (HR) two-sided 95% confidence intervals (CI) and represented with Kaplan-Meier curves. Each patient's survival time began on the date of hospitalization and ended on the date of death or hospital discharged. All data were analyzed using Stata® version 13 . Statistical significance was set as a value of p < 0.05.Socio-demographic and clinical characteristics of patients were summarized as mean and standard deviation (SD) when distributions were confirmed as normal. Otherwise, data were expressed as medians and interquartile ranges (IQR). Categorical variables are reported as frequency and percentage. Comparative statistics between ART initiation groups were performed using Chi-square test for categorical variables and the Wilcoxon test or the Student's The study protocol was approved by the FMT-HVD Ethics Review Board (ERB) . Due to the retrospective nature of data collection and analysis, the ERB granted a waiver of the requirement to obtain informed consent.n = 339, 72.3%), with a median age of 35 years (IQR: 28-44) and living in an urban area  were the most affected. Headache , limb paresis  and altered consciousness level  were the most frequent neurological signs at hospitalization. Clinical presentation at admission and laboratory baseline data are shown in A total of 2,599 patients were diagnosed with an acute neurological infection during the study period. Of these, 469 (18.0%) were ART-naïve HIV-TE patients . HIV casT. gondii, out of these, 290 (98.0%) had evidence of previous exposure to the disease with positive IgG quantitatively performed by chemiluminescent immunoassay .A total of 352 (75.0%) patients were diagnosed from radiological findings, 8 (1.7%) had positive IgM (7 with positive IgG), and 109 (23.3%) diagnosed according to clinical signs and symptoms and response to treatment . Of the n = 398, 84.9%) were the most common drugs used for TE treatment. In 151 (32.2%) individuals, corticosteroids were used as adjuvant therapy, without significant difference of distribution between groups (p = 0.80). A combination of nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs) were the most frequently used ART in both groups  (p = 0.21) or progression to death (0.96). No statistical association was found between death rate and corticosteroid use (p = 0.24).Three hundred and ten (66.1%) patients presented different coinfections; among those, 28 (9.0%) were diagnosed by the treating physicians with more than one infectious agent responsible for the neurological infection, all of them with two simultaneous etiological agents . Pyrimet, 67.9%) , withoutp = 0.80). The overall sequelae rate was 41.6% (n = 195), with a higher prevalence of sequelae in the EIT group  compared to DIT , p = 0.04. The most prevalent sequelae at discharge were limb paresis , followed by recurrent headaches with 11.1% (n = 52) (p = 0.17) , with higher mortality in the DIT group  . No stat(n = 52) . In gene = 0.17) .Opportunistic infections (OIs) are the leading cause of mortality in the HIV population . Current+ lymphocyte count and CD4+/CD8+ ratio, and a high viral load. The presence of an ANI in ART-naive patients will always bring major therapeutic challenges associated with the possibility of developing immune reconstitution inflammatory syndrome (IRIS) (The population in our study has three notable characteristics (i) ART-naïve HIV individuals, (ii) the occurrence of TE as an influential factor on the decision to start ART early or administer treatment for the coinfections first, and (iii) a large proportion of patients who at the time of inclusion in the study already had advanced HIV/AIDS disease, with low CD4e (IRIS) , 31 and e (IRIS) , 33, whie (IRIS) , 35.+ cells below 350 cells/mm3  and the Fundação de Amparo à Pesquisa do Estado do Amazonas (FAPEAM) RESOLUÇÃO No. 002/2008, 007/2018 e 005/2019—Pró-Estado and RESOLUÇÃO No. 006/2020. WM and ML are CNPq  fellows. The funders had no role in study design, data collection, manuscript preparation, or decision to publish.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Histoplasmosis causes life-threatening disseminated infection in adult patients living with untreated HIV. Although disease incidence has declined dramatically in countries with access to antiretroviral therapy, histoplasmosis remains prevalent in many resource-limited regions. A high index of suspicion for histoplasmosis should be maintained in the setting of a febrile multisystem illness in severely immunosuppressed patients, particularly in persons with hemophagocytic lymphohistiocytosis. Preferred treatment regimens for initial therapy include liposomal amphotericin B for severe disease, or itraconazole for mild to moderate disease. Subsequently, itraconazole maintenance therapy should be administered for at least one year and then discontinued if CD4 count increases to ≥150 cells/µL. Antiretroviral therapy, which improves outcome when administered together with an antifungal agent, should be instituted immediately, as the risk of triggering Immune Reconstitution Syndrome is low. The major risk factor for relapsed infection is nonadherence. Itraconazole prophylaxis reduces risk for histoplasmosis in patients with CD4 counts <100/µL but is not associated with survival benefit and is primarily reserved for use in outbreaks. Although most patients with histoplasmosis have not had recognized high-risk exposures, avoidance of contact with bird or bat guano or inhalation of aerosolized soil in endemic regions may reduce risk. Adherence to effective antiretroviral therapy is the most important strategy for reducing the incidence of life-threatening histoplasmosis. Histoplasma capsulatum, the most common endemic fungus in the United States [d States , causes d States ,3,4. Altd States , in somed States . Histopld States .This review will address the pathophysiology, clinical manifestations, and prevalence of histoplasmosis in adults living with HIV; describe the experience with various treatment regimens and discuss the antifungal regimens currently recommended by guidelines from public health agencies and professional societies; discuss the management of histoplasmosis in the setting of immune reconstitution; and review the recognized risk factors for histoplasmosis and strategies for disease prevention.H. capsulatum microconidia, after soil disruption or other activities that disperse organisms into the atmosphere, is the first stage of infection [Inhalation of airborne nfection .After being engulfed by phagocytic cells, microconidia warm to body temperature and undergo intracellular conversion to yeast, the pathologic form of the organism . Yeast mH. capsulatum infection is asymptomatic in 99% of cases. Acute pulmonary histoplasmosis is the usual manifestation of symptomatic illness. Hematogenous dissemination, although common, is usually self-limiting [H. capsulatum usually causes life-threatening progressive disseminated disease. In HIV-infected patients, symptomatic illness has been observed in 55% of cases of primary histoplasmosis [In the general population, primary limiting . Howeverlasmosis . Progreslasmosis ,11 and wThe issue of whether disseminated histoplasmosis in immunosuppressed patients occurs due to primary infection, reinfection, or dissemination of latent foci persisting after remote infection remains unsettled and controversial. This issue has broad clinical implications ,11,12: iH. capsulatum organisms contained within thick-walled calcified granulomas are no longer viable.Increases in disease incidence during outbreaks have supported the concept that primary infection or reinfection occur . Cases aTwo primary forms of PDH have been recognized in the setting of HIV infection: a subacute wasting syndrome associated with fever, chills, and profound weakness, often accompanied by pulmonary infiltrates and diarrhea, and a fulminant presentation associated with multiple-organ system failure ,3. A stuHistoplasmosis was one of the most common opportunistic infections in the midwestern U.S. in the 1980s and 1990s, affecting up to 20% of the HIV population in some midwestern cities . In KansIn recent years, the incidence of disseminated histoplasmosis in HIV-infected patients has plummeted in developed countries with widespread access to ART . ElevateIn the first few years of the AIDS pandemic, histoplasmosis carried high risk for mortality. The use of ketoconazole was abandoned because of lack of efficacy. Amphotericin B was effective initially in many cases but 60% subsequently experienced relapsed infection after treatment was stopped . Long-teOnly a few prospective clinical trials of induction or maintenance treatment have been undertaken. In patients treated with itraconazole, 200 mg bid for 12 weeks and then 200 mg daily for at least one year, 85% responded . ConversAlthough a recent Cochrane analysis concluded that the optimum maintenance regimen for histoplasmosis has not been determined, as no published study has compared <12 months to >12 months of maintenance treatment , severalHIV-infected patients with confirmed or suspected histoplasmosis should be presumed to have disseminated disease. Liposomal amphotericin B is the first-line treatment for acutely ill patients until their clinical status improves, usually a week or two. Subsequently, oral itraconazole should be prescribed. Itraconazole is the treatment of choice for mild–moderate disease and for maintenance therapy.H. capsulatum MIC90 of 0.06 µg/mL. The sum of itraconazole and hydroxyitraconazole, its active metabolite, should be used for this calculation [Absorption of itraconazole is pH dependent and varies widely from patient to patient . Drug leculation ,45,46.In light of the variability of absorption of itraconazole capsules, a new formulation, subaitraconazole, has been developed. Subaitraconazole contains the parent compound dispersed in a polymeric matrix targeted to improve absorption in the upper small intestine. Recent crossover clinical trials compared subaitraconazole to itraconazole and determined that the bioavailability of subaitraconazole was 173% higher, and patient to patient variability of serum concentrations was substantially lower, than that of itraconazole . In one In a prospective study assessing discontinuation of prophylaxis after successful immune reconstitution from antiretroviral therapy, defined as a sustained CD4 count >150/µL, no relapses occurred among 32 patients studied . CriteriH. capsulatum than itraconazole, has been less effective in clinical trials and animal models. Fluconazole use was associated with a slower decline in antigenuria in humans than itraconazole [Fluconazole, which has lower in vitro activity against conazole . Resistaconazole . Among pconazole . Resistaconazole . Given fconazole .H. capsulatum isolates collected in a clinical trial were 0.015 µg/mL, ≤0.007 µg/mL, and ≤0.007 µg/mL, respectively, compared to 1.0 µg/mL for fluconazole [Limited experience with the potential alternatives voriconazole, posaconazole, and isuvaconazole has been reported. The median MICs for these 3 drugs for conazole . Fluconaconazole , but notconazole ,52. A siconazole .H. capsulatum, was more effective than itraconazole in an animal model of histoplasmosis [Posaconazole, which has high in vitro activity against lasmosis  and has lasmosis . No proslasmosis . Isuvacolasmosis .The triazole antifungal drugs inhibit certain cytochrome p450 isoenzymes to varying degrees and thus increase the effects of other drugs metabolized by these enzymes. Further, the concomitant use of medications that induce cytochrome p450 isoenzymes causes accelerated clearance of triazoles and can lead to subtherapeutic serum concentrations of antifungal medications, potentially contributing to treatment failure. As an example, rifampin substantially increases clearance of all triazole antifungal drugs. In the setting of HIV infection multiple important interactions between antiviral and antifungal medications can occur. Serum concentrations of protease inhibitors are increased by itraconazole, fluconazole, posaconazole, and voriconazole ; conversH. capsulatum; caspofungin and micafungin were ineffective in animal models [H. capsulatum but have not been studied in animal models or humans include trimethoprim-sulfamethoxazole, ciprofloxacin, isoniazid derivatives [The echinocandins do not have in vitro activity against the yeast form of l models ,60 Thus,ivatives  and ritoivatives .M. tuberculosis and cryptococcal meningitis [Immune reconstitution inflammatory disorder (IRIS) can occur following initiation or resumption of antiretroviral therapy in severely immunocompromised HIV-infected patients with symptomatic or subclinical histoplasmosis. IRIS is manifested either by a paradoxical flare of known infection or by unmasking of previously unrecognized disease and is most often associated with prolonged fever . Featureningitis . The medningitis .The optimum management of IRIS has not been defined. As IRIS is self-limiting, experts recommend that antiretroviral and antifungal treatment should be continued. The role of steroid therapy, which could potentially exacerbate histoplasmosis, has not been established . The avaTreatment guidelines for histoplasmosis have been published by multiple organizations: the Infectious Diseases Society of America (IDSA), the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC) in collaboration with the HIV Medical Association (HIVMA) and the IDSA; the American Thoracic Society; and the World Health Organization (WHO)/Pan American Health Organization (PAHO) ,67,68,69Recent studies provided insight into antifungal prescribing practices in the U.S. Among thousands of cases of histoplasmosis identified in the MarketScan database, most of whom were outpatients, 40% who received oral therapy were treated with either fluconazole, voriconazole, or posaconazole. A second study which detected hundreds of cases by enhanced surveillance determined that 15% received one of these three alternative regimens. The numbers of patients who were HIV seropositive in these two studies were not specified. The relatively common practice of using non-preferred regimens suggests that clinicians may not be routinely following IDSA treatment guidelines ,71.Strategies for prevention of histoplasmosis in HIV-seropositive patients have been devised, based on identification of risk factors, assessment of the efficacy of itraconazole prophylaxis, analysis of outbreaks in the general population, and redefinition of the geography of the endemic area.Pneumocystis jiroveci pneumonia [In the early years of the AIDS pandemic, most diagnosed cases of histoplasmosis were identified in the traditional endemic region in the U.S. A prospective study of HIV-infected patients in Missouri showed that CD4 lymphocyte counts <300/μL significantly increased risk for histoplasmosis, and that risk increased sharply in the subgroup with CD counts <150/μL . Other ineumonia . The besFluconazole prophylaxis did not reduce risk for histoplasmosis in a placebo-controlled randomized multicenter study in which most sites were not located in the endemic region . ItraconH. capsulatum, was associated with lower disease incidence in the case control study [Given that receipt of trimethoprim sulfamethoxazole (TMP/SMX), which has in vitro activity against ol study , and thaol study , it is pAssessment of histoplasmosis outbreaks and enhanced surveillance in the general population have informed the approach to disease prevention. Findings from these investigations may be extrapolated to provide recommendations to reduce histoplasmosis risk for persons living with HIV. Outbreaks have been linked to cave or tunnel exploration; cleaning or clearing bird roosts, old chicken coops, parks, or school courtyards; demolition; excavation; exposure to chicken coops or decayed trees; use of bird or bat guano for fertilizer; and sawing rotten wood ,77. A suCertain vocations and hobbies increase the risk of histoplasmosis. The relative risk for agricultural or forestry workers, fishermen, or hunters developing histoplasmosis is almost 10-fold higher than that of the general population, and persons engaged in construction or extraction activities have almost a 5-fold increased relative risk. In general, activities associated with soil aerosolization and bird or bat guano exposure have been the most commonly identified causes of outbreaks and occupationally acquired infections .The U.S. Centers for Disease Control recommends that the following measures be undertaken to reduce the risk for histoplasmosis in HIV-infected patients with CD4 cell counts <150 cells/μL who reside in the endemic area: avoid disturbing soil contaminated with chicken or bird guano; spelunking; remodeling, demolishing or cleaning old buildings; or cleaning chicken coops . Other pIt is worth noting that the traditional histoplasmosis endemic area in the U.S. has been expanding north and westward, thus increasing the size of the at-risk population. Further, the worldwide distribution of authochthonous cases is much more widespread than previously recognized; in recent years, cases have been identified from regions as diverse as the Yangtze River region of China; Thailand; the southern half of Africa; and several other areas on all continents with the sole exception of Antarctica . Thus, iDramatic progress has been made in the treatment and prevention of histoplasmosis in adult patients living with HIV. The foremost need for immunosuppressed HIV-infected persons is for effective ART, which both reduces the risk for histoplasmosis and improves treatment outcome. Among severely immunocompromised individuals who delay seeking medical attention, are nonadherent, or reside in resource-limited regions with lack of ready access to ART, a high index of suspicion for histoplasmosis should be maintained in the setting of a febrile multisystem illness, and a preferred treatment regimen, with liposomal amphotericin B or itraconazole, should be initiated in accordance with evidence-based guidelines. Mitigation of high-risk exposures and/or use of itraconazole prophylaxis in certain patient subsets are strategies likely to reduce the incidence of life-threatening histoplasmosis.


Among the two most prevalent HIV-1 subtypes (B and C) there was a significant (p < 0.001) association of K65R with subtype C (11.26%) when compared with subtype B (9.27%). Nonetheless, evidence for K65R transmission in Brazil was found both for C and B subtypes. Additionally, artificial neural network-based immunoinformatic predictions suggest that K65R could enhance viral recognition by HLA-B27 that has relatively low prevalence in the Brazilian population. Overall, the results suggest that tenofovir-based regimens need to be carefully monitored particularly in settings with subtype C and specific HLA profiles.The success of antiretroviral treatment (ART) is threatened by the emergence of drug resistance mutations (DRM). Since Brazil presents the largest number of people living with HIV (PLWH) in South America we aimed at understanding the dynamics of DRM in this country. We analyzed a total of 20,226 HIV-1 sequences collected from PLWH undergoing ART between 2008–2017. Results show a mild decline of DRM over the years but an increase of the K65R reverse transcriptase mutation from 2.23% to 12.11%. This increase gradually occurred following alterations in the ART regimens replacing zidovudine (AZT) with tenofovir (TDF). PLWH harboring the K65R had significantly higher viral loads than those without this mutation ( According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), 690,000 individuals died in 2019 of human immunodeficiency virus (HIV) infection-related causes. Although the global number of new infections (1.7 million) has been reduced by 23%, since 2010, Latin America has presented a 21% increase. Particularly, Brazil experienced an increase of 17%, with 48,000 new reported infections and 14,000 acquired immunodeficiency syndrome (AIDS)-related deaths, in the same year [2, different DRM rates have also been found in distinct Brazilian geographic regions [Antiretroviral therapy (ART) significantly improves patients’ survival, increasing life expectancy and quality ,3,4. Fur regions ,18,19,20Mycobacterium tuberculosis (Mtb) co-infection, pregnant woman, children and new diagnoses with a sexual partner under ART [In 1996, Brazil became the first middle-income country to ensure free access to ART to all individuals infected with HIV, through the public Unified Health System ,22. Currnder ART ,22. Imponder ART .Among the surveillance drug-resistance mutations (SDRM) , K65R isThe relevant reforms made in ART protocols in Brazil during the last decades, promoting the preferential use TDF containing schemes in the absence of universal HIV-1 genotyping, raised the hypothesis that the HIV DRM profile could have changed, bringing novel treatment obstacles and clinical implications. To test this hypothesis, we retrospectively studied data from 20,226 HIV-1 infected and ART-treated individuals from all regions of Brazil, from 2008 to 2017. We used statistical and genome sequence analysis to understand, at an unprecedented scale in Brazil, the dynamics of evolution of the HIV-1 drug resistance profiles. Additionally, we also relied on immunoinformatics to investigate factors possible underlying treatment failure and transmission of DRM.n = 8962) were female and 55.7%  male. The main characteristics of the study population are shown in n = 4445), followed by the States of Rio Grande do Sul , Minas Gerais , Rio de Janeiro  and Paraná . The geographic frequency distribution for PLWH in the study population was in agreement with the official Brazilian HIV-1 prevalence reports [n = 4324), 3TC/AZT/EFV , 3TC/AZT/low-dose ritonavir-boosted lopinavir (LPV) , 3TC/LPV/TDF  and 3TC/atazanavir (ATV)/ritonavir (RTV)/TDF .The study comprised a total of 20,226 HIV-1 infected individuals, with a HIV-1 sequence genotyped between 2008 and 2017, on ART treatment, from which 44.3% . SDRM were mostly found at the RT  and included 13,845 sequences with NRTI DRM and 11,720 sequences with NNRTI DRM. The most common SDRM , K103N , and M41L . SDRM in PR were found in 5021 (24.82%) sequences and the more frequent were V82A , M46I , and I54V .We evaluated the presence of surveillance drug-resistance mutations (SDRM) in the study population, including SDRM found isolated or in combinations in the same virus, and uncovered an overall prevalence of 84.10% (mon SDRM  were then = 1874) and 2016  (p < 0.001) (n = 1180) and 2015  this was accompanied with a significant decrease in 2016  and no significant difference between 2008 and 2017 (p = 0.919). Importantly, K65R showed a clear rise along the years (n = 8) of the population. Subsequently, this mutation became more prevalent and increased significantly between 2013 and 2015 (p < 0.001). Although its prevalence suffered a decrease between 2015 and 2016 (p = 0.0124), K65R prevailed the third most common SDRM in 2016 and 2017 (p < 0.001).To investigate the temporal dynamics and evolution of the SDRM landscape in the study population we evaluated yearly SDRM prevalence from 2008 until 2017. The most common mutation across the years was M184V , notwith< 0.001) . Similar< 0.001) . K103N rhe years . In 2008and 2017 . Overalln = 72), followed by 3TC/AZT/LPV , prevailing the most common treatment till 2014  among 2880 patients. From 2015 forward, 3TC/EFV/TDF scheme became the most prevalent. In this year (n = 2744), 24.85% (682) individuals were under 3TC/EFV/TDF drug combination and 19.97% (n = 548) under 3TC/AZT/EFV. In 2017, 3TC/EFV/TDF combination was used on 40.10% (n = 543) of the individuals on ART (n = 1354).Having observed the clear increase in K65R along the studied yrs, we then decided to evaluate the ART combination schemes in use during the studied period , aiming n = 4324) and 3TC/AZT/EFV  (n = 15) of the viruses isolated from patients treated with 3TC/AZT/EFV vs. 30.64% (n = 1325) of the viruses from individuals using 3TC/EFV/TDF. This strong association of K65R with TDF containing schemes was found across HIV-1 subtypes (n = 2744) using the two schemes was more even , 5 patients (0.91%) treated with 3TC/AZT/EFV were infected with a K65R mutant, being this number significantly different (p < 0.001) from the 267 patients (39.15%) treated with 3TC/EFV/TDF combination. Also, comparing all patients revealed a significant association between 3TC/EFV/TDF and K65R (p < 0.001).As we have found a shift on the ART treatment scheme during the studied years, we decided to evaluate SDRM prevalence separating the individuals using the most common drug combinations, 3TC/EFV/TDF  . The SDRsubtypes . Focusinn = 347) viruses when compared with B  subtype  in the wildtype version and by one additional HLA (HLA-B27) in the mutant version . HLA-B27Acquired and transmitted DRM remain one of the major obstacles towards ART efficacy and AIDS treatment. In case of Brazil, previous regional studies showed distinct moderate patters of transmitted DRM prevalence ,20,27,38A high prevalence of SDRM was observed with 84.1% of the infected individuals presenting at least one drug resistance mutation. Nonetheless, 68.5% of the genotyped sequences had a SDRM to NRTIs, a value that represents a decrease to what was previously reported in the literature ,19,39,40Mtb co-infection, to pregnant woman and new diagnoses with a sexual partner on ART, since 2013 [Also in line with previous studies is the finding of M184V (65.53%), K103N 40.20%), and M41L 17.21%) as the most common SDRM .21% as t,39,40. M.20%, andnce 2013 , which mNonetheless, it is important to highlight that the percentage of PLWH infected with a virus harboring M148V remained very high and above 50% after 2013. Moreover, K103N and P225H, both frequent NNRTI SDRM, remained stable over the yrs. K103N was previously reported as one of the most commonly acquired SDRM in Brazil ,18,39,40Previous work reported that K65R mutation presented varied prevalence distribution throughout time in different Brazilian regions ,19,27. SIn 2019, 15.074 individuals were reported to use PrEP in Brazil , evidencK65R has been associated with diminished viral fitness and replication, which has been linked with decreased transmission capacity ,68. EvenDespite of the observed decreasing trend in the prevalence of some major SDRM in the studied Brazilian cohort, a high prevalence of these mutations was still verified. Indeed, our results show that the alteration performed in 2013 enlarging the criteria to include more PLWH in the recommendation for baseline SDRM testing had a positive impact but was still insufficient. We propose that the lack of universal baseline HIV-1 DRM screening to inform on effective ART regimens resulted in high levels of SDRM, such as M184V, K103N, and M41L underlying many cases of treatment failure in Brazil not only from 2008–2012 but also continuing from 2013–2017. Furthermore, we observed a clear increase in K65R reverse transcriptase SDRM that is an additional problem in Brazil that could have been aggravated by the circulation of HIV-1 subtype C and the HLA class I makeup of the population. This increase in K65R was mainly found in association with the use of TDF and is particularly relevant in combination with the high M184V levels found in the study population suggesting that the efficacy of PrEP might be compromised.Overall, our results support that some of the drugs most frequently used in Brazil might be compromised due to the high frequency of SDRM and that baseline drug resistance testing should be universal and mandatory as it is the best way to promote personalized selection of the most optimized ART regiment.n = 20,223) and complete reverse transcriptase ). HIV-1 sequencing was performed as part of the routine clinical testing with commercially available HIV-1 genotyping systems based on Sanger sequencing.The collection of the patient’s data was performed anonymously after approval by the Brazilian national ethic committee through the protocol CAAE 53757016.0.0000.5504. All records from HIV-1-infected individuals followed by the Specialized Assistance Services on Sexually Transmissible Diseases and HIV/AIDS obtained at all 27 Brazilian federative units from 01/01/2008 to 04/30/2017 were curated in a relational database. A total of 20,226 HIV-1 infected patients were selected for this study according to the following inclusion criteria: (i) be under ART treatment; (ii) have at least one associated partial HIV-1 genome sequence available . All sequences were also analyzed using the Stanford HIVdb Genotypic Resistance Interpretation Algorithm to evaluate and interpret the presence of DRM in each sequence.HIV-1 subtypes were identified by relying on the consensus from least two of the three utilized subtyping tools: SNAPPY , jpHMM  and StanAll sequences having the K65R were separated by subtype and used to query local and public databases to identify highly related HIV-1 sequences. The resulting sequences from the most common subtypes B and C were aligned with MAFFT v7.309  and usedPredictions of binding for different class 1 human leukocyte antigens (HLA) were performed with NetMHCpan 4.1 . The wilThe Allele Frequencies Database  was usedhttps://www.cdc.gov/epiinfo/index.html, accessed on 1 May 2021), relying on Mantel-Haenszel test, at significance level of 0.05, to evaluate statistical correlations. SPSS® Statistics version 26.0  was also utilized for performing mean comparison with t-test, at a 0.05 significance level.Statistical analysis was performed by using Epi Info™ version 7.2.4.0 (


Treatment with ceftriaxone, metronidazole, and mebendazole was initiated. Further CSF analysis was negative for Cryptococcus spp., but fungal culture showed the growth of black, rough colonies  infection was admitted to the intensive care unit (ICU) for holocranial headache, fever, nausea, malaise, and diarrhea. Antiretroviral therapy (ART) was discontinued eight months earlier. Medical history included prior hospitalization due to pneumomediastinum secondary to perforated esophageal moniliasis. Laboratory tests showed leukocytosis, elevated C-reactive protein levels, high HIV viral load (133.627 copies/mL), low CD4+T-cell count . Although such cases in HIV/AIDS patients are rare,A. melanogenum infections in these individuals.The prognosis of


Iran has recently included integrase (INT) inhibitors (INTIs) in the first‐line treatment regimen in human immunodeficiency virus (HIV)-infected patients. However, there is no bioinformatics data to elaborate the impact of resistance-associated mutations (RAMs) and naturally occurring polymorphisms (NOPs) on INTIs treatment outcome in Iranian patients.In this cross-sectional survey, 850 HIV-1-infected patients enrolled; of them, 78 samples had successful sequencing results for INT gene. Several analyses were performed including docking screening, genotypic resistance, secondary/tertiary structures, post-translational modification (PTM), immune epitopes, etc.The average docking energy  of different samples with elvitegravir (EVG) and raltegravir (RAL) was more than other INTIs. Phylogenetic tree analysis and Stanford HIV Subtyping program revealed HIV-1 CRF35-AD was the predominant subtype (94.9%) in our cases; in any event, online subtyping tools confirmed A1 as the most frequent subtype. For the first time, CRF-01B and BF were identified as new subtypes in Iran. Decreased CD4 count was associated with several factors: poor or unstable adherence, naïve treatment, and drug user status.As the first bioinformatic report on HIV-integrase from Iran, this study indicates that EVG and RAL are the optimal INTIs in first-line antiretroviral therapy (ART) in Iranian patients. Some conserved motifs and specific amino acids in INT-protein binding sites have characterized that mutation(s) in them may disrupt INT-drugs interaction and cause a significant loss in susceptibility to INTIs. Good adherence, treatment of naïve patients, and monitoring injection drug users are fundamental factors to control HIV infection in Iran effectively. •Integrase inhibitors (INTIs) are the first‐line treatment in HIV-infected patients.•The average docking energy in elvitegravir and raltegravir was more than other INTIs.•Phylogenic tree analysis revealed HIV-1 CRF35-AD was the predominant subtype.•For the first time, CRF-01B and BF were identified as new subtypes in Iran. Plasma samples were collected for viral load assay from 850 HIV-infected patients originating from the south of Iran; they were either antiretroviral therapy-naïve or RTIs and/or PIs treatment-experienced patients with a viral load above 1000 IU/ml enrolling at the Behavioral Diseases Consultation Center (BDCC) affiliated with Shiraz University of Medical Sciences. Medication adherence means a ratio of the number of pills doses taken in patients to the number of doses prescribed over a given period . Accordi2.2Using “FACSPresto Near-Patient CD4 Counter (BD Biosciences)”, CD4 T-cell count was performed. Aspartate aminotransferase (AST) and Alanine aminotransferase (ALT) levels (IU/L) in the serum samples were measured using the commercial enzymatic kits of Biorex-Fars Company  and DIRUI Automatic Biochemistry Machine.2.3Serum RNA was extracted by the QIAamp Viral RNA Mini Extraction Kit , and Artus HI Virus-1 RT-PCR kit (Qiagen) was utilized to define viral load in all samples. HIV-INT region was amplified by RT-nested PCR using the primers listed in 2.4Based on the RAMs and the high frequent NOPs detected in the INT sequences, 78 patients were clustered into 11 groups (1-11) and 7 models including five INTIs mutated models  and two mutants: mutant 1 and mutant 2. The high frequent NOPs in the INT protein is shown in In this study, INTs of all 11 groups and 7 models are called mutated INT genes/proteins.AB703607). For example, to build CAB mutated model, all RAMs presented in our integrase genes that were attributed to the failure of CAB were inserted in INT reference gene. In addition, mutant 1 and mutant 2 were built by the insertion of all RAMs and high prevalent NOPs in the INT reference sequence. Nucleotide and amino acid sequences of mutated INTs genes/proteins are shown in Each group encompasses distinct mutations ; also, f2.5“Expasy's ProtParam”  Table 5Table 5a 2.6PTMs of proteins are involved in the attachment of functional groups or small proteins such as disulfide bridging, phosphorylation, glycosylation, etc. to specific residue in the protein that alters the charge and the structure of the protein. NetPhos ,12, DISP2.7Secondary structural features can change the binding pocket properties or affect the stability of the whole protein  that inf2.8To determine the tertiary structure, amino acid sequences of the mutated INT proteins were submitted in “I-TASSER” ,33. Amon2.9https://go.drugbank.com/)  .Table 8M3.4Escherichia coli and yeast. Grand average hydropathy (GRAVY) signified that all INT proteins had been hydropathy with a negative score of −0.359 , C-glycosylation sites (19), and some O-glycosylation sites  was amon3.6The results of secondary structure prediction of mutant model 1 (A) and reference gene, AB703606 (B) was analyzed , and the3.7The best-refined models were regarded for validation analysis; then, the qualified models were employed for docking analysis .3.8To evaluate the effect of RAMs  and that of high frequent NOPs ] on INTIs treatment outcome, we prepared the list of amino acids involved in protein-drug interaction and the related docking scores of INTIs and mutated proteins interaction, as shown in S230 N and Q95K mutations caused a substantial loss in docking energy of groups 7 and 10 for all five INTIs. In addition, reduction in the docking value related to some of the INTIs is displayed in generated models 1, 2, groups 1 and 2. In brief, major, minor, and some of the accessory (Q95K and S230 N) mutations were attributed to E value declined; nonetheless, high frequent NOPs did not influence the binding affinity. Thus, specific mutations in the mentioned groups and models might have a pivotal role in drug resistance.Although RAMs and NOPs were distributed in different INT domains, all mutated INT proteins were docked through CCD with all INTIs. More importantly, none of the RAMs and NOPs was involved in interaction with INTIs.Of note, some motifs of amino acids  and the residues at the positions of 74, 116, 117, 118, 127, 137, 139, 141, and 199 very actively participated in many docking interactions.3.9Among suggested B cell epitopes, only those that were not placed in α-helix and β-sheet structure of protein were analyzed for antigen properties. Finally, the probable antigens were chosen as favorable epitopes .Table 123.10Based on the phylogenic Neighbor-Joining tree of HIV-INT gene sequences of HIV infected patients in Iran which was generated with the corresponding INT gene of 89 subtype reference strains  and StanConforming to the phylogenetic tree result, some new subtypes including CRF-01B and BF were introduced in Iranian patients for the first time. Of note, our data displayed RAMs found in our patients including V72I, I201V ,54, M50I4INTIs regimens are highly efficient antiretroviral agents with long‐lasting potency and reduced toxicity, which are globally accepted in treating naive and experienced individuals. The presence of mutations in INT genes that can change the structural stability and flexibility of these proteins can impact the treatment outcome ,5.In this study, we completed several bioinformatics analyses on integrase genes and proteins of the most prevalent subtype in Iran, CRF-35-AD. INT genes failed to amplify in 73 out of 151 plasma samples via an effective RT-nested-PCR. It can be inferred that the emergence of new HIV strains may influence the efficiency of nested-PCR that highlights the importance of whole-genome sequencing of HIV-1 circulating in Iran periodically.In this study, we found that good adherence even to previous ART regimes was a significant factor to decline the new mutations. Similar to our data, some studies indicated that reduced adherence was linked to some situations and signs such as digestive symptoms ,56, deveTo control HIV infection and achieve better medical outcome, we need to upgrade the surveillance at three levels: identification and treatment of naïve treatment patients, medication adherence improvement, and regular monitoring of IDUs.From the present analysis, most of NOPs lied in the catalytic core domain that is target for INTIs ; yet, suHere, RAMs including major (R263K) , minor  might confer substantial reductions in susceptibility to a wide range of INTIs .R263K appeared with G134 N ,69 and Kin accordance with some studies that observed R263Ksustained a moderate loss in potency against DTG, EVG, RAL, and BIC about 2-fold and had a detrimental effect on CAB susceptibility [The E value of interaction between INTIs with integrase genes in group 5 carrying R263Kdeclined for four INTIs: EVG, DTG, RAL, and BIC. This result is tibility ,71.In addition, one minor RAM, L74I, was found in group 8 that reduced the energy value of BIC, CAB, and EVG. This result is somehow in line with a study that illustrated L74I would have a slight effect on INTIs susceptibility . The preIn our samples, accessory mutations including G163R, Q95K, S230 N, M50I, V72I, V249I, and L74 M appeared, which can cause a substantial loss in susceptibility to INTIs alone or in combination. INTI drugs usually select G163R ; this muQ95K and S230 N mutations were another accessory mutation that had a significant reduction in susceptibility to all INTIs in the CRF35-AD subtype, while no major, minor, or other accessory mutations were identified in this group. Evidence demonstrated S230 N conferred drug resistance and reduced DTG susceptibility by 3-fold.Some studies revealed that Q95K did not affect INTIs susceptibility or viral replication, but in the presence of some other mutations enhanced resistance to RAL and EVG ,78.Other investigations need to be done to clarify the functional role of G163R, and Q95K in response to INTIs.In addition, the effect of L74 M was evaluated alone or in combination with other mutations. From our data, L74 M retained the docking energy and similar to M50I, may be responsible for the increase in free energy of binding values.In this study, M50I and R263K were not present in one patient simultaneously. Hence, M50I and R263K were inserted in INT reference, resulting in generation of 5 models, including mutant 1, 2, BIC, DTG, and CAB mutated models followed by the evaluation of the effect of these mutations on the E value. The reduction in energy value was only found in the interaction of BIC drug with BIC-mutated models and mutant 1; it can be concluded that combination of M50I and R263K possibly hurts the sustainability to BIC. In contrast to our data, some studies declared M50I along with R263K was responsible for remarkable loss in DTG ,80, BIC Ceccherini-Silberstein et al. reported that G134S in conjunction with some other mutations resulted in INT catalytic core destabilization and reduction in INTIs efficiency [The high frequent NOPs  were identified in our patients not previously reported in two earlier studies in Iran, except for G134S . In our ficiency ,77. ClinOne of the NOPs in our patients was L101 M, which has not been described previously as RAMs, but L110 M in groups 5, 7, and 9 decreased the docking energy in some INTIs that may be correlated with drug resistance in vivo. Developing the mutant virus carrying L101 M can clarify the influence of this mutation on viral fitness, integration steps, etc.According to our data, the presence of RAMs and NOPs may cause slight effect on binding energy and drug efficacy; thus, INTIs are likely to be capable of treating Iranian patients infected with the CRF35-AD subtype. This may be due to the location of the amino acid substitutions that were not in the conserved parts of the INT core domain  .To understand the effect of the NOPs and RAMs on binding affinity, performing molecular dynamics can provide a better explanation; nevertheless, the docking data in this report can also be helpful to declare the efficiency of different INTIs on Iranian patients.Based on the predicted amino acids involved in molecular docking, some motifs in the integrase proteins  and some amino acids  were involved in INTIs interaction. Therefore, these conserved regions may provide an absolute opportunity for drug development to target the integrase protein to increase sensitivity to INTIs leading to a favorable clinical treatment.Based on the affinity of the ligand-receptor complex, EVG and RAL were linked to higher free binding energy in our samples that can be considered for the optimal INTIs treatment in Iranian population.One of the reasons for the high score in our patients with EVG and RAL could be attributed to the presence of H bonds that exhibited a strong type of interaction.Viral infection use PTMs to enhance protein antigenicity and virulence properties; plus, increase protein solubilization, interferon response inhibition, and viral replication that have a significant role in viral pathogenesis.Therefore, host machinery cells remove the PMTs from viral proteins to activate immune response pathways, control the virus replication, and inhibit the viral protein synthesis to eliminate the virus.INT undergoes multiple PMTs that play versatile roles in the functions of INT and HIV-1 viral replication . PhosphoGiven the different disulfide bonds that can be formed between cysteines, special linkages are shaped according to the energy and structural constraints . Once foTherefore, disulfide bonds degradation may degrade viral proteins and provide a new area for antiviral drugs development.In this report, none of RAMs and NOPs in our sequences provided the new SUMOylation target site. Hence, other factors may have affected the position of SUMOylation. INT is susceptible to be SUMOylated at three SUMOylation sites  on three Lys residues . INT SUMOylation impairment correlated with a significant drop in integration events and inhibited replication ,90,91.Unlike the second SUMOylation site, the first and third SUMOylation sites were conserved in all our samples that can be a desired target for designing drugs to destabilize HIV-INT.Stabilization of INT is required for efficient genomic interaction which can be done via blockade of ubiquitination associated with proteasomal degradation .Here, different lysines were suggested as ubiquitin targets using bioinformatics tools. Among them, K186 and K240 were essential residues since they play a significant role in the structure and functions of INT protein . To usurVarious agents have been categorized as carbohydrate-binding agents (CBAs) that impede virus infection. To suppress the vast majority of viruses, the development of antivirals components to target special deglycosylation sites in viral proteins may provide an absolute opportunity for clinical therapies.This report defined N, O, and C glycosylation sites and, to the best of our knowledge, the influence of glycosylation on integrase proteins and HIV pathogenesis is not described clearly; thus, experimental studies are needed to elaborate on this matter .The data of ProtParam determined the notable similarity in INT mutated proteins in all patients with reference.However, the pI in different integrase proteins was slightly different, which can be described by the diversity in the number of basic amino acids, as mutated INT proteins are basic proteins. Accurate prediction of the pI of viruses is beneficial for physical/chemical treatment processes and modeling virus behavior in environment . MoreoveAttributing to the short half-lives of proteins assessed by Protparam, all INT proteins in this study were a kind of fast degradation proteins in humans, yeast, and E-coli. The rate of protein degradation is dependent on a few factors such as molecular weight, size, and surface charge ., and vaccine development. There is no general expression system to use optimally for all mentioned purposes;thus, various expression host systems should be applied for each purpose.In recent years, HIV-INT recombinant protein were used for different approaches including serological diagnostic methods, therapeutic applicationsThe effect of the RAMs and NOPs on the secondary structure was analyzed and our finding revealed that these mutations did not change various properties of the secondary structure. Accordingly, significant changes in the binding pocket of the mutated INT proteins did not happen and drug potency was retained. This finding is in the same line with docking results in this study.In our study, only epitopes located in β-turn and random coil structures were considered for further analysis because such secondary structures are mostly placed in the surfaces of the protein and are more likely to be favorable for binding to antibodies . HoweverHere, the subtyping result of our samples is different according to the kind of applied methods. . From our data, INT gene can be considered as an appropriate region for HIV subtyping in Iranian patients if only the phylogenetic tree or Stanford HIV subtyping program was applied for subtyping.Subtyping results of our patients showed that CRF-35AD subtype was the most frequent subtype in Iran, which is in agreement with other studies in Iran ,99,100. In this report, the phylogenic analysis revealed some new subtypes; CRF-01B and BF; therefore, whole-genome sequencing is essential for such samples and those that were not amplified via RT-nested-PCR to confirm the emergence of the new strains.Till now, the list and role of RAMs are not identified for the CRF35-AD subtype. By comparing the mutations that developed in our CFR-35 AD subtypes with other subtypes , it can No compelling evidence was found that HIV-1 subtype, but effectiveness, toxicities, and tolerability of ART regimens need to be considered in choosing first-line or second-line therapy, in low-income and middle-income countries . HoweverAdvanced In-silico researches in drug discovery and vaccine designing have a considerable role in HIV studies that have accelerated the rapid advancement in the production and manufacture of medicine to balance the therapeutic options by clinicians.In other words, choosing a treatment strategy is attributed to the various factors including fewer side effects, availability, acceptable tolerability, short treatment duration, efficacy, and pan-genotype activity. This study could act as a stepping stone to designing novel experiments:Applying mentioned bioinformatic approaches may be very useful to examine the efficacy of antiretroviral drugs periodically in different epidemiological settings to anticipate the most efficient HIV inhibitors. Plus, such results can be even more beneficial if all predictions will be evaluated in-vitro. Furthermore, such tools can optimize new drugs to suppress HIV infection that may lead to the restoration of strong immune responses that aim to eliminate the virus.Moreover, the molecular docking methods enable the researchers to reveal the interaction between host factors and the HIV proteins to suggest the evolutionary relationship between them that is helpful to recognize the virus behavior.INT post-modifications are essential for HIV pathogenesis; therefore, applying bioinformatics tools to unveil PTM sites, pathways, and the underlying mechanisms can propose pharmacological inhibitors. Accordingly, to disclose PMT issue bioinformatic studies are suggested for new therapeutic approaches.5Higher E value of EVG and RAL of mutated INT proteins showed these drugs may help achieve optimal treatment response in Iranian patients. Our bioinformatics analysis showed that RAMs and NOPs led to zero to modest loss in INTIs potency, suggesting that INTIs can be considered in the first-line and salvage therapy in treatment of patients infected with CRF35-AD subtype. Among different NOPs, Q95K, S230 N, and L110 M lowered the strength of INTIs docking energy in interaction with INTs that may consider such mutations as the major or minor ones in the CRF35-AD subtype. Various post-translation modifications and B-cell epitope prediction suggested particular target sites and epitope regions for future antiretroviral drugs and vaccines design, respectively. PTM sites and pathways are possible pharmacological targets for new therapeutic approaches. RT-nested-PCR test failed to amplify INT genes in 50% of the samples that might be due to the emergence of new HIV subtypes in Iran; whole-genome sequencing is strongly recommended to clarify this point. More focus on improving the quality of HIV care, good medication adherence to any types of anti-HIV drugs, and treatment of naïve patients along with better management of HIV-positive IDUs are essential factors to achieve continuous HIV care and better medical outcomes in Iranian patients.10.13039/501100004320Shiraz University of Medical Sciences with the Certificate Reference Number of REC 270710028RA. All participants signed written informed consent before participating in the study, in accordance with the Declaration of Helsinki.The ethical permission for this research study was granted by the ethics committee of the Not applicable.10.13039/501100004320Shiraz University of Medical Sciences with the Certificate Reference Number of REC 270710028RA.This work was supported by the AH: design of the study, conceptualization & supervision,FGH: performing the experiments, FGH, AH, and ZH: gave scientific suggestions and controlled experiments, MJSH, SB and ZH: data collection, NKH, AH, FGH, and ZH: data analyzing AH: resources & funding acquisition; PK, AH and NKH: statistical analysis of data, AH, FGH: writing the original draft; AH: review & editing.All authors have read and approved the final manuscript.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Ethiopia has been motivated to achieve a goal of “appointment spacing model approach care.” However, little has been documented on the predictor of mortality and challenges of sustainable HIV care. Therefore, the aim of this study was to determine predictors of mortality among adult people living with HIV/AIDS on antiretroviral therapy (ART).A retrospective cohort study was conducted on 676 adult people living with HIV who enrolled to ART clinic from September 01, 2012 - August 30, 2016. Multivariable Cox Regression analysis was done where adjusted hazard ratio (AHR)with corresponding 95% confidence interval (CI) at P value ≤ 0.05 cut of point was used to identify predictors of mortality.The total person-time contributed was 28,209 person-months with an overall mortality incidence rate of 11 per 1000 person-months observation. The cumulative mortality incidence among females over the study period was 16.8% (64/382). Severe undernourishment and moderate malnutrition at baseline, younger age, female sex, single, divorced, illiterate, lack of disclosure, advanced WHO clinical stage, seeking treatment outside catchment area, rural residence and immunological failure were found to be independent predictors of mortality.Poor nutritional status at baseline, advanced stage of HIV disease, occurrence of treatment failure, female sex, substance abuse, lack of social support, immunological failure, clinical failure, and younger age, low level of education and poor physical access to healthcare facility were found to be important predictors of mortality. Intervening, those factors as routine and part of the appointment spacing model care can improve survival of PLWHA. Globally, between 1980 and 2015, about 78 million people were infected and half of them have died of AIDS ,4.Ethiopia is among African countries hard hit by the HIV pandemic. The overall prevalence of the disease among adults, pregnant women and, women who had multi sexual partners was reported to be 0.9%, 0.4%, and more than 6%, respectively ,6. The pTo alleviate the impact of HIV/AIDS, Ethiopia introduced ART in 2003 for the first time at cost of patients, and two years later ART started to be provided for free , and 11.Ethiopia has also been implementing prevention, treatment and care interventions. The prevention activities include voluntary counseling and testing (VCT), prevention of mother to child transmission (PMTCT), behavioral change communication and community mobilization. The treatment and care theme encompasses ART, laboratory monitoring, provider initiated testing and counseling (PITC), nutritional support, palliative care and home-based care activities .Despite the efforts devoted to limit the impact of HIV, still numerous gaps and challenges remain unsolved. Among others, timely initiation of ART, retention in care and prevention of HIV related mortality, narrowing significant inequities in ART coverage, which varies between children (23%) versus adults (60%), females (54%) versus male (69%), and disparities among regions ranging from 5.6% to 93% are worth mentioning ,15.To help HIV patients fully benefit from ART, attain national goals and use resources most effectively, Ethiopia uses the HIV continuum care (HCC) framework initially created by the Centers for Disease Control and prevention (CDC) in Atlanta, USA, in 2013 . The HIVMany activities have been attempted to address negative ART care outcomes, nevertheless, there have been challenges at every stage of the HCC. These include late HIV care presentation (LP) , discontCurrently, Ethiopia is implementing a new care approach known as “appointment spacing model (ASM) care, which mainly focuses on a few visits of hospitals (two times per year) and comprehensive care at a time avoiding frequent laboratory and clinical monitoring. Hence, the approach enhances adherence and retention of ART cohorts in the treatment protocol, which in turn improves the maturity of immunity and virally suppresses viral load. Thus, the approach is thought to improve service quality, save costs, improve health outcomes, and accelerate the achievement of the 90-90-90 target by offloading workload from the already overburdened health facilities . HoweverThe overall picture shows that research is lacking to identify key factors that lead to negative ART care outcomes, including mortality. Furthermore, studies conducted in Africa have revealed that factors affecting ART care are beyond individual level. The factors are related to health care institutions such as lack of ART trained health professionals , and lacStudy setting and period: The study was conducted in the Jimma zone five public hospitals . Jimma zone is one of the 20 administrative zones in Oromia Regional State located in southwest Ethiopia. Jimma Medical Center is the only tertiary hospital in southwest Ethiopia. The other four hospitals are primary hospitals with catchment population of about a million each. At the time of the study, a total of 11,186 adults and 2,683 children were in chronic HIV care at the hospitals. The data was collected from February 15/2018 to March 16/2018 and the study involved patients on chronic HIV care at the hospitals during period of 01 September 2012 to 30 August 2016.Enrolment procedures/Retrospective cohort study: A total of 676 adult PLWHA was randomly selected from adults (≥ 18 years old) who were on chronic care follow up. The Sample size was estimated using two population proportions formula. Based on BMI measurement, those PLWHA, who had undernourishments at the initiation of ART were considered to be exposed (n1) whereas those who had normal BMI were taken to be non-exposed group (n2). Accordingly, 281 exposed and 395 non-exposed samples were estimated, implying total of 676 samples of PLWHA for the study. Patients with unknown nutritional status at ART initiation, those who defaulted, those with incomplete information and those transferred out to other facilities were excluded from the study.Data source and collection procedure: Medical records were reviewed from February 15/2018-murch 16/2018 covering a period of five years (from 01 September 2012 to 30 August 2016) using appropriate case reporting format prepared in English. Ten BSc professional nurses using data collection format collected the data. All the five hospitals have an electronic patient database called Comprehensive Care Centre Patient Application Database (C-PAD). C-PAD is an Electronic Medical Record (EMR) system database that contains patients' both clinical and non-clinical information. This was the main source of data in this study. Data were extracted using a data extraction checklist from the database. In case, data were incomplete, we tried to refer the patients' cards, registration and log books using patient medical record number and ART registration number.Data processing and analysis: Cleaned and coded data were entered to EPI-data version 3.1.4, and then exported to SPSS version 20.0 for analysis. Kaplan Meier (KM) survival function and Log rank test was used to test the statistical difference in the KM curves. Bivariate Cox regression analysis was done to estimate the unadjusted Hazard Ratios (HRs). Independent variables with P ≤ 0.25 at bivariate analysis level were entered into the multivariable Cox regression model to control potential confounders. Finally, variables, which had P confidence intervals (CIs) at multivariable analysis, were considered independent predictors of mortality among the PLWHA.Ethical approval: Waiver of the consent was obtained from the office of institutional ethical review board (IRB) of the Institute of Health Jimma University, and the reference number was (IHRPG/807/17). The data access permission was obtained from the Jimma zone five public hospitals board. We could not use any individual-level data from inception to this manuscript. The results were also maintained using aggregated report rather than individual characteristics in any aspect of the data throughout all steps and manuscript preparation. These data were not identifiable; therefore, informed consent was not required.Socio demographic characteristic of adult PLWHA in Jimma zone public hospitals: In this study, records of 382 (56.5%) females and 294 (43.4%) males were reviewed. The mean ≤ 0.05 and non-null values within respective age of the study participants at the time of ART initiation was 30.4 years (± SD 7.4); 487 (72%) of them were between 25 and 44 years of age. More than half (55.6%) of them were married and 132 (19.5%) of them were divorced ones. Most of the participants (79.3%) reported to have attended at least a primary school. About 61% of the participants (412) were urban residents and 128 (18.9%) were living outside the catchment area of the respective hospitals. Most of them chew (80%) Kchat and more than half (58.6%) of the study participants reported to have used alcohol  of the participants had history of opportunistic infections (OIs) at ART initiation. TB was the most common OI identified contributing for more than a third (35%) of the OIs cases (pulmonary TB – 29% and extra pulmonary TB – 6%). However, 71.6% of patients who were started on TB treatment were negative for Acid Fast Bacilli (AFB). The other OIs were diarrhea 101 (21.0%), chronic diarrhea (18.0%) and Herpes zoster (12.0%) Cumulative Incidence and Incidence rate of mortality: Ninety-eight (14.5%) patients died during the five-year of ART follow up period. The cumulative incidence among females was 16.8% (64/382). The total follow up time was 28,209 person-months when an overall incidence rate of 11 deaths per 1000 person-months was observed. The death rates among those PLWHAs who had severe and moderate malnutrition were 5.7 and 2.9 deaths per 1000 person-months, respectively.The overall survival probability of the adult PLWHA was 86.6%. The overall estimated mean (±SD) survival time of adult PLWHA on ART follow up was 42.8 (SD = 17.8) months. In the five-year time interval, the highest mortality was observed during 18 to 24 months of follow up, followed by the months of 30 to 36 and 24 to 30, respectively. The lowest mortality was observed during the follow up period from 48 to 54 months followed by 54–60 months of follow up, followed and during the period 6 to 12 months .The overall probability of survival among adult PLWHA on follow up in Jimma zone public hospitals showed a decrement with an increment of WHO stages. Those PLWHA on ART follow up classified as WOH stage I, II, III and IV had a survival probability of 96.3%, 94.9%, 76.5% and 48.6%, respectively .PREDICTORS OF MORTALITY AMONG ADULT PLWHA ON ART FOLLOW UP: Adult PLWHA who suffered from severe malnutrition at baseline had nearly four times  risk of death while those with moderate malnutrition had more than twice  risk of dying early compared to those with normal BMI. The risk of early death was nearly three times higher among females  compared to males. Deaths among single , divorced , and widowed  PLWHA on ART follow up were higher compared to married PLWHA on ART follow up.The risk of death among adults PLWHA decreases as educational status increases. The risk of death was more than two times among illiterate  and those who attend primary school  compared to PLWHA on ART follow up who attend secondary or above schools.Those PLWHA who did not disclose their HIV status to anyone (family or friend) had more than three times  risk of dying compared to those who have disclosed their HIV status. Those adult PLWHA with TB Co-infection at the initiation of ART were nearly three times  more likely to die within five years of treatment follow up period compared to those who did not have it. Individuals who were at stage IV HIV diseases (bedridden) at the initiation of ART were more than three times  more likely to die within five years of treatment follow up period as compared to those with working functional status.The risk of death was four times in those with elevated liver enzymes (>50 IU/L)  and nearly three times higher in those with OI  compared to their counterparts. Those PLWHA on ART follow up whose causes of death confirmed to be clinical failure  and immunological failure  were two times at higher risk of wasting syndrome  within five year treatment follow up period compared to their counterparts. The risk of death was also found to be high among PLWHA living outside catchment area of the hospital  compared to their counterparts .ART Program has created a significant change in improving both health status and life expectance of PLWHA. However, first-line drug resistance and death from HIV related causes are quiet formidable challenges in Sub-Saharan Africa, including Ethiopia. In this study, 14.9% cumulative incidence of HIV mortality was reported in patient on ART. This is lower than finding of a study conducted in Cameroon: . The varThe study revealed that mortality was found to be higher among adult PLWHA (65.3 %). This finding is in line with a study conducted Northwest Ethiopia, in which the prevalence of HIV infection among females was two times higher than males . Studiesnd and 3rd years of follow up. This could be attributed to eligibility criteria, change of guideline for ART initiation and project driven approach care as well as using test and treat immediately, regardless of CD4 count and WHO clinical staging ”.In conclusion, the incidence of HIV mortality was 11 deaths per 1000 person-months, whereas most deaths (20%) occurred during the 18–24 month follow up period interval. Females are at higher probability of dying from AIDS related causes. Marital status, functional status, education level, disclosure of HIV status, having care givers/support, abnormal test of liver function, presence of opportunistic infection, malnutrition were found to be independent predictors of AIDS related mortality.These findings imply that applying an action/intervention towards these leading cases of mortality as routine and as part of the new approach care “appointment spacing model care (ASMC)” can reduce mortality and can be a sustainable clinical care other than project driven intervention of HIV care. Further longitudinal study that explores on how to address real livelihood and methods of tracing are recommended.Finally, it is price mentioning some weaknesses of this study. First, mortality might be underestimated, since patients lost to follow-up probably include individuals dying at home without being reported. Additionally, since secondary data was used for this study, it was impossible to include some key variables such as economic status and psychological distress that need to be included in this study.There was also incompleteness of records for some of the patients enrolled on ART. On the other hand, because the study was done during the time when Ethiopia is striving to achieve its recently planned “with the new approach of ASMA,” the findings may give better insights into the problems that shall be considered to achieve the goal.


Same‐day initiation (SDI) of antiretroviral therapy (ART) for HIV consistently increases ART uptake, but concerns remain about higher attrition from care after initiation. We analysed 12‐month retention in the SLATE SDI trials.SLATE I  and SLATE II (enrolment 14 March–18 September 2018) were individually randomized trials at public outpatient clinics in Johannesburg that enrolled patients not yet on ART and administered the SLATE I or II algorithm. This included a symptom self‐report, medical history, brief physical examination and readiness questionnaire to assess the eligibility for SDI. The studies compared the offer of SDI using the SLATE algorithms to standard of care initiation procedures. ART uptake and early retention were previously reported. Using routine clinic records, we conducted a pooled analysis of retention in care and HIV viral suppression 14 months after study enrolment, a time point equivalent to 12 months potential on ART, with an additional month allowed on either end to initiate ART and to return for the 12‐month visit.n = 599, 50%; intervention arms, n = 594, 50%) and analysed by originally assigned groups. By 14 months after enrolment, 50% of intervention arm patients and 46% of standard arm patients remained in care at the initiating site ; crude relative risk 1.10 (0.97–1.23), with similar viral suppression between arms. Observed attrition from care at site by 14 months was high in both study arms, but we found no evidence that the offer of SDI led to greater overall attrition or lower rates of viral suppression 1 year after starting ART and may have generated small improvements. SDI may have shifted some attrition from before to after dispensing of the first dose of medication.We enrolled 1193 study participants (standard arms, An offer of SDI of ART, following a carefully designed protocol to identify patients who are eligible and ready to start treatment, is not inherently associated with an overall increase in patient attrition from care and leads to similar rates of viral suppression.Clinicaltrials.gov NCT02891135, registered 01 September 2016. First participant enrolled 06 March 2017 in South Africa. Clinicaltrials.gov NCT03315013, registered 19 October 2017. First participant enrolled 14 March 2018. Both studies have been described in detail elsewhere , 11, 12.2.2Both studies were conducted in South Africa. The study sites were high‐volume, public‐sector primary care clinics in urban formal and informal settings around Johannesburg, South Africa. Study participants were enrolled from March to July 2017 for SLATE I and March to September 2018 for SLATE II. Care was provided according to the relevant South African National Department of Health ART guidelines during each study . Non‐pre2.3Consented and enrolled study participants completed an interviewer‐administered questionnaire and were randomized 1:1 to either the intervention arm  or standard arm (routine clinic procedures). After randomization, standard arm patients continued their clinic visits under standard of care. Patients randomized to the intervention arms were referred to a study nurse who administered the four SLATE algorithm screens and then dispensed ART directly to those patients eligible for SDI and referred back to the facility those patients requiring additional services prior to initiation of ART. Patients in both arms were followed passively, through medical record review, and had no further interaction with study staff. Patients who required clinical follow‐up after the study enrolment visit received routine care.2.4We report here the secondary outcomes of (1) initiation of ART within 28 days and retention on ART 14 months after study enrolment and (2) suppression of viral load (to <400 copies/ml) by 14 months after study enrolment. A patient was considered retained if we observed a clinic visit or laboratory test in the patient's medical record between 11 and 14 months after study enrolment. Fourteen months was selected to allow up to 1 month to initiate ART, 12 months of follow up after treatment initiation and up to 1 month to return for the 12‐month routine clinic visit. Patients with no evidence of a clinic visit or laboratory test during this period were assumed lost to follow up.All follow‐up data were sourced from routinely collected medical records in TIER.Net , South A2.5The studies were approved by the Human Research Ethics Committee of the University of the Witwatersrand  and the institutional review board of Boston University Medical Campus. All study participants provided written informed consent.33.1n = 599, 50%) or the intervention arm  and analysed by originally assigned groups. The study population comprised predominantly women (63%) with a median age of 35 years (IQR 29–41) and median CD4 count of 293 cells/mm3 (133–487). No important imbalances with respect to the characteristics of the enrolled sample were noted.Participants were enrolled between 06 March and 28 July 2017 for SLATE I and between 14 March and 18 September 2018 for SLATE II. A total of 1193 study participants in both studies were randomized to the standard arm  and 509/594 intervention arm patients (85.7%) initiated ART within 28 days of study enrolment. Achievement of the combined primary outcome of initiation ≤28 days and retention in care at 8 months was 321/599 (53.6%) and 381/594 (64.1%) for the standard and intervention arms, respectively, revealing very high rates of attrition from these sites — 46.4% and 35.9% — by 8 months after study enrolment.3.2In Table Retention in care at the study sites by 14 months was poor in both study arms. The numerical advantage seen in the intervention arms of the trials at the 8‐month primary endpoints, however, persisted through 14 months, when 50% of intervention arm patients remained in care compared to 46% of standard arm patients. The timing of attrition from care was also consistent: more standard arm patients (25% standard vs. 14% intervention) failed to initiate ART within 28 days, while more intervention arm patients were lost after initiation (35% intervention vs. 29% standard).We traced viral load tests results between 9 and 14 months after enrolment for 365 (64%) of the 574 study patients retained in care through 14 months. Viral suppression was similar between the arms . Viral suppression rates were high among those with a test result, with only 3% observed with an unsuppressed HIV viral load result in either arm. Table Our results suggested that there may be differences between men and women in both outcomes, as shown in Table We also traced ART initiation records for patients who did not initiate within 28 days. In the combined intervention arms, 5% of participants initiated ART between 28 and 90 days after study enrolment, and one patient initiated after 90 days. Among standard arm patients, we observed an additional 7% and 3% of patients initiating 28–90 days and >90 days after enrolment, respectively. Among those with an observed ART start date, the median time to initiation in the intervention arms was 0 days , while for the standard arms, the median was 6 days . We note that patients who initiated ART during the study period but not ≤6 months after study enrolment may not have reached the scheduled date for their first viral load test by 14 months; these patients would have been among those missing viral load tests in Table In this extended analysis of the SLATE I and SLATE II trial data from South Africa, we found that attrition from care at site by 14 months was high in both studies and both arms, but we found no evidence that the timing of ART initiation led to greater overall attrition 1 year after patients had the opportunity to start ART. At the same time, it does appear that the offer of SDI shifted some attrition from before to after dispensing of the first dose of medication. For some intervention arm patients — those who were not in fact ready to start ART — it may have been easier to accept the offer of SDI and drop out of care afterwards than to refuse the offer when face‐to‐face with the care provider. We interpret this result to mean not that SDI ‘causes’ post‐initiation attrition from care, but rather that there is a certain proportion of patients who will drop out of care no matter how it is delivered, and an offer of SDI will not change this fact . What SDRecent observational studies of routine ART initiation have reported higher loss to follow‐up among patients who start ART on the same day than among those who do not , 17, 18.Our previous reports noted a number of limitations of the SLATE trials , 6. The 4We conclude that an offer of SDI of ART, following a carefully designed protocol to identify patients who are eligible and ready to start treatment, is not inherently associated with an overall increase in patient attrition from care.WDFV sits on antiretroviral initiation guideline committees both local and international, has accepted speaking honoraria from multiple manufacturers of antiretrovirals and is on several of their advisory boards. The remaining authors declare that they have no competing interests.MM, ATB, MPF, WDFV and SR conceptualized the study and designed the protocol. LV, ATB and MM collected and curated the data. MM, ATB and MPF analysed the data. MM and SR drafted the manuscript. All authors reviewed and approved the manuscript.Table S1. Results for SLATE II.Table S2. Results for SLATE I.Table S3. Results for sensitivity analyses for missing viral load data (per protocol definition).Table S4. Retention and viral suppression outcomes at 14 months after study enrolment by study arm and sex in the SLATE I and SLATE II study populations (n = 1193).Click here for additional data file.