Paediatric HIV spontaneous controllers (HSCs) are a unique and understudied population with potential to inform alternative treatment options for patients living with HIV. As HSCs are so rare and often not recognised prior to antiretroviral treatment (ART) initiation, it can be difficult for clinicians to optimally manage this group. We describe the diagnosis, history and management of three paediatric HSCs, two girls and a boy who were followed for 2, 1.25 and 10.4 years, respectively, before starting ART. All had low but detectable viral loads throughout follow-up but mostly marginally low CD4:CD8 ratios. The reason for starting ART in all was a gradual tendency to poorer virological control. This case series should assist in recognising paediatric HSCs. Clinical dilemmas arising in the management of paediatric HSCs include arriving at a correct HIV-positive diagnosis, correct diagnosis as an HSC, as well as whether to initiate ART. Decision-making for initiation of ART in paediatric HSCs should be individualised. Factors supporting ART initiation in these patients included increased frequency of viral load blips, increasing detectable viral load, CD4 percentage and CD4:CD8 ratio. Other factors included Hepatitis C serology and highly sensitive C-reactive protein. All three patients ultimately required ART, which supports universal initiation of ART in paediatric HSCs, but further research is required. Elite controllers maintain an undetectable viral load in the absence of ART, whilst viraemic controllers maintain low but detectable viral loads  copies/mm3) in the absence of ART.6 A useful definition is to have at least three low or undetectable viral loads over more than a year.4 Transient elevated viral load ‘blips’ are generally acceptable as long as the next viral load measurement returns to the previous trend.7 In this case series, viral loads < 1000 HIV-1 RNA copies/mm3 were used to define the previous trend.Human immunodeficiency virus (HIV) controllers are a unique and rare group of individuals living with HIV who can control HIV replication without combination antiretroviral therapy (ART). The term ‘HIV controllers’ is an ambiguous term and refers both to those who have never taken ART  and those receiving time-limited ART shortly after primary infection (often referred to as post-treatment controllers). We propose the term HIV spontaneous controllers (HSCs) to describe those who can control HIV without ART exposure. Whilst most HSCs are adults, a small number of children have been thus described.9 Therefore, having additional treatment options available is vital.Whilst ART is the mainstay of current HIV management, it does not come without side effects and drug interactions.10 This same principle applies for paediatric HSCs, who may be immunologically different from adult HSCs.11 Paediatric HSCs do also present important clinical dilemmas that are sometimes difficult to answer. These include misdiagnosis as HIV-negative,12 undisclosed administration of ART mimicking an HSC and whether to start ART.13 This case series presents three paediatric HSCs who were followed-up at a research unit in Cape Town, South Africa between 2013 and 2020 . Her adherence was suboptimal, often missing doses on weekends. Her earliest viral load was 100 HIV-1 RNA copies/mm3 after four months of ART. Patient 1 was exclusively breastfed until six months of age, which continued to a variable degree until four years of age. As the child’s HIV diagnosis was made at two years of age, antivirals in breastmilk may have contributed to the suppressed viral load at diagnosis. Unfortunately, ART blood levels were not measured. The child’s acquisition of HIV was presumed to be perinatal as she was diagnosed relatively young. The mother had HIV, no blood products were given and there was no suspicion in the family or by the researchers of sexual abuse of the child.This girl presented at the age of two years nine months. She is mixed race and has a father of African descent. HIV was diagnosed at the age of two years eight months and she was referred for participation in an ART study. Her mother reports her own HIV diagnosis at approximately three months gestation (three years prior to the patient’s diagnosis) and reports not taking ART either as prevention of mother-to-child transmission (PMTCT) or for herself. Neither information on the nature of the mother’s diagnosis nor any clinic records to confirm the lack of ART were available. The mother reported that the child tested HIV-negative after birth, but there was no record of this. The infant received nevirapine for one month as PMTCT. The mother commenced tenofovir, emtricitabine and efavirenz in February 2013, when her CD4 count was 209 cells/mm3 (35.20%). An HIV DNA PCR  was indeterminate, cycle threshold (Ct) > 33 and relative fluorescence increase (RFI) < 5. At the same time point, the plasma viral load  was 132 HIV-1 RNA copies/mm3. A series of confirmatory tests, namely HIV antibody test , HIV Unigold FDA test  and HIV Western blot test  were all positive.Human immunodeficiency virus diagnosis was through a 4th generation single HIV Ag/Ab combination assay  at two years nine months of age. At this time her CD4 count was 1817 cells/mm3. Subsequently, three monthly viral loads over 14 months suggested elite control  was referred to the research site for screening for an ART study. His mother’s HIV status was diagnosed during pregnancy at an unknown gestation, and she reported not receiving ART during pregnancy. Clinic records were not available for verification. The boy received nevirapine as PMTCT for 10 days after birth, which is not the standard of care, but the mother reports not being instructed appropriately on administration.3. His HIV status was then confirmed with a positive HIV1/2 Ab/Ag Elisa  and a positive HIV-1 RNA/DNA PCR , Ct ≤ 33 and RFI ≥ 5.According to the mother, his HIV was diagnosed at birth but ART was not started. Clinical records for verification were unavailable. There was no subsequent history of ART according to the mother or the child, with no other caregiver on ART in the household. Antiretroviral therapy drug levels were again not performed. When screened for an ART study in March 2017, his viral load was 62 HIV-1 RNA copies/mm3 in June 2018, requiring ART initiation  was at the age of 13 years  and a confirmatory positive HIV Antibody Elisa test . Her viral load remained undetectable until she presented to the research site at 16 years old. Her positive status was confirmed again with a positive HIV Combo Ag/Ab assay  and a positive HIV qualitative PCR , Ct ≤ 33 and RFI ≥ 5.Her HIV was diagnosed using an unknown test. She was not initiated on ART and her first viral load  were below the detectable limit, confirming her status as an HSC. Recurrent viral load blips, a persistently low CD4:CD8 ratio with no other detectable cause and a CD4 percentage lower than 40% favoured the initiation of ART. Factors that did not support this were her Hepatitis C serology, which was negative, and a highly sensitive C-reactive protein (CRP) test, which was 0.7 mg/L (will discussed further). She agreed to initiate ART after discussing these concerns. She commenced tenofovir, lamivudine and dolutegravir, and three months later her viral load was still < 20 HIV-1 RNA copies/mm3. No further CD4 or CD8 results were available after initiating ART.Her viral load remained undetectable for the following four years, except for viral blips, all followed by undetectable results. In 2019–2020, she had two consecutive detectable viral loads at 52 and 122 HIV-1 RNA copies/mm15 but the incidence of post-treatment control is higher than that in HSCs.11 Another difference is that HSCs have much higher levels of HIV-specific CD8+ T-cell responses than post-treatment controllers.16 As has been mentioned, HSCs can be divided into elite and viraemic controllers based on the level of viraemia, but another group of patients similar to viraemic controllers called transient aviraemics (TAs) have also been described.1 These patients have undetectable viral loads on less than three occasions in one year, not meeting the criteria of elite control.1 Another term used before widespread accessibility to viral load testing was the term ‘non-progressor’. This is relatively common in children compared to adults and includes patients who maintained age-appropriate normal CD4 counts in the absence of ART despite high levels of viraemia.11Different terms have been used to categorise patients who suppress HIV viraemia or maintain CD4 counts in the absence of ART. As has been described above, we propose the term HSC to distinguish patients who spontaneously suppress viraemia and those that do so after prior ART (post-treatment controllers). Post-treatment control has been postulated by some to represent HSCs who were started on ART before virological testing,19 There is very little data to estimate the prevalence of paediatric HSCs but Vieira et al. has suggested that it could be as much as 5–10-fold lower than in adults.1 There is a female predominance in both adult and paediatric elite controllers,5 thought to be due to higher levels of immune activation that is more effective at suppressing replication in acute infection.11 Two of the three patients described in this case series are female. A predominance of control in people of African descent is observed in adult HSCs5 as well as some paediatric cohorts,1 but further research is required. In this case series, the patients are either mixed race with paternal African ancestry (Patient 1) or of African ancestry from maternal and paternal sides (Patients 2 and 3).Paediatric HSCs are a distinct group from adult HSCs but are exceedingly rare, and little research has been done on them. The estimated prevalence of HSCs in adults is very low, ranging between 0.18% and 0.56% of adults living with HIV.11 Mechanisms of HIV control in children are also believed to be different, as HLA class I alleles associated with control in many adult controllers are often not present in paediatric controllers.20 Differences in immune systems and mechanisms of control also seem to affect the time taken for paediatric and adult controllers to achieve control. Vieira et al. found in a case series that 11 paediatric controllers took a median of 6.5 years to achieve control, as opposed to adults who achieve a viral set point six weeks after infection.1 In adults various mechanisms of control have been proposed: specific viral and host immune factors , host immune responses (CD4+ and CD8+ T-cell responses) and host genetic factors (e.g. HLA-B*5701).21 Recently, Vieira et al. described two distinct mechanisms leading to the loss of virological control in three paediatric TA patients.22 In two of the patients, an initial strong CD8+ T-cell response to an immunodominant epitope of the HIV genome initially maintained control but subsequently led to escape mutations that were not suppressed by variant-specific responses. The third patient had transient viraemic episodes that did not result in escape mutations or drop in CD4 count, but were subsequently controlled by a strong CD8+ T-cell response.22 This highlights the balancing act between immunotolerance and a strong immune response required to achieve and maintain control. Vieira et al. has also described different immunophenotypes in paediatric controllers and non-progressors compared to adults. Paediatric non-progressors have an initial immunotolerant environment with low levels of activation which would otherwise reduce CD4 counts, whilst paediatric elite controllers show a strong, polyfunctional CD8+ T-cell response at the time of aviraemia.23 The HIV reservoirs in adult elite controllers are much smaller than in those on ART, and although replication-competent provirus can be detected, it appears to be in deep latency and not transcriptionally active.24 However, Turk et al. recently found only replication-incompetent virus in one adult elite controller, which would negate the need for ART initiation.25 There are as yet no similar data in paediatric HSCs, to our knowledge.Differences between adult and paediatric HSCs relate to their respective immune systems. Paediatric patients are much more immunotolerant than adults, which typically prevents the development of an effective CD8+ T-cell response to HIV with consequent higher average viral loads.5 Transient viral blips with return to undetectable levels are associated with subsequent loss of control.5 Other factors preceding loss of control include poor T-cell responses to HIV, viral replication and ongoing evolution and markers of CD8 T-cell activation and exhaustion.27 HIV-1 control is believed to occur early after seroconversion in adults, but there is limited data on what happens during acute infection.28 Elite controllers have a lower risk of progressing to AIDS and longer maintenance of a CD4 count above 350 cells/mm3 compared to viraemic controllers.4 Hepatitis C co-infection, although a risk factor for complications  in adult elite controllers, was not a risk factor for loss of HIV control.29Little is known about the natural history of HIV control in children. Adult HSCs maintain control for between 1.5 and 11.3 years.30 Both Patients 1 and 2 could also have been receiving undisclosed ART and the only way to unequivocally prove the diagnosis as an HSC is to perform ART drug-level testing. This was done in Patient 3.Adult and paediatric HSCs present various clinical dilemmas, including confirming their HIV-positive status. Low levels of viraemia can give negative or indeterminate results on standard HIV-1 DNA/RNA and antibody tests. Patient 1, for example, had an indeterminate DNA PCR test and low levels of viraemia, requiring antibody testing and more sensitive viral testing. Confirmation of HIV-positive status was less equivocal with Patients 2 and 3. Once an HIV diagnosis has been confirmed, caution should be shown before labelling a patient with a low or undetectable viral load as an HSC. Patient 1 could have received ART via breastmilk in sufficient quantities to suppress viraemia. A similar case has been reported by Strehlau et al., where an initial HIV negative diagnosis was questioned when testing of stored samples showed the presence of proviral DNA in the child. They hypothesised that viraemia was suppressed by ART in breastmilk.33 which is not a concern in HSCs. However, high levels of viraemia are not the only concern as adult HSCs have higher levels of inflammatory markers than HIV seronegative and ART-suppressed patients.34 This chronic inflammatory state increases the risk of cardiovascular disease due to early atherosclerosis.36 What implications these findings in adults have for paediatric HSCs is unclear and more research is required. The prospect of paediatric HSCs maintaining control and aging into the realm of adult HSCs also presents questions. How will the stronger immune response present in adult patients impact the delicate balance of immunotolerance and increased activation present in paediatric HSCs? They may lose viral control or could have reduced life expectancy due to chronic inflammation.Another clinical problem is whether HSCs should initiate ART. High levels of viraemia are considered the driving force behind decline in CD4 counts and disease progression,37 Factors to be considered include the following: levels of viraemia, CD4 count, CD4:CD8 ratio, disease progression, markers of heightened inflammation and T-cell activation, risk of HIV transmission, presence of replication-competent provirus and patient preference.25 For Patients 1 and 2, the decision to start ART was simple due to increasing viraemia, along with low CD4:CD8 ratios. Patient 3 required more in-depth assessment. As mentioned above, Hepatitis C co-infection has been identified as a risk factor for complications in adult elite controllers,29 but Patient 3’s serology was negative. Highly sensitive CRP is a marker of HIV disease progression and cardiovascular disease, independent of CD4 counts and HIV-1 RNA levels.39 Her CRP level was 0.7 mg/L, which is reassuring as a level below 1.2 mg/L is associated with slower HIV disease progression38 and below 3.3 mg/L with slower development of cardiovascular disease.40 As mentioned, the concerning factors supporting ART initiation were low CD4:CD8 ratio, more frequent viral load blips and a CD4 percentage below 40%. Bansal et al. had shown that a CD4 percentage below 40% in adult HSCs was associated with increased markers of T-cell and monocyte activation.41 Patient 3 agreed to initiate ART and has since maintained viral suppression.Decision-making regarding ART initiation in patients who maintain control must be individualised.Paediatric HSCs are a very important population to study and advance the HIV ‘Cure Agenda’. Mechanisms by which they can spontaneously suppress HIV viral replication may hold the key to future novel therapeutic approaches and curative measures, and further research is urgently needed. Clinical dilemmas involved in their care include appropriate diagnosis of HIV, confirmation of an HSC diagnosis and whether ART initiation is appropriate. Paediatric HSCs therefore require specialised and individualised care, despite comprising a small section of the paediatric population living with HIV.


Factors associated with the achievement of VS, LL-HIVDNA, and CD4/CD8 ≥ 1 were assessed by a Cox regression model. We enrolled 144 patients : 110 (76%) started a four-drug-based therapy, and 34 (24%) a three-drug regimen. Both treatment groups showed a comparable high probability of achieving VS and a similar probability of reaching LL-HIVDNA and a CD4/CD8 ratio ≥1 after 48 weeks from ART initiation. Higher baseline HIV-1 RNA and HIV-1 DNA levels lowered the chance of VS, whereas a better preserved immunocompetence increased that chance. Not statistically significant factors associated with LL-HIVDNA achievement were found, whereas a higher baseline CD4/CD8 ratio predicted the achievement of immune recovery. In PHI patients, the rapid initiation of either an intensified four-drug or a standard three-drug INSTI-based regimen showed comparable responses in terms of VS, viral reservoir size, and immunological recovery.The optimal therapeutic approach for primary HIV infection (PHI) is still debated. We aimed to compare the viroimmunological response to a four- versus a three-drug regimen, both INSTI-based, in patients with PHI. This was a monocentric, prospective, observational study including all patients diagnosed with PHI from December 2014 to April 2018. Antiretroviral therapy (ART) was started, before genotype resistance test results, with tenofovir/emtricitabine and either raltegravir plus boosted darunavir or dolutegravir. Cumulative probability of virological suppression [VS] (HIV-1 RNA< 40 cp/mL), low-level HIV-1 DNA [LL-HIVDNA] (HIV-1 DNA < 200 copies/10 Current HIV treatment guidelines recommend starting a long-life antiretroviral therapy (ART) during primary HIV infection (PHI) ,2. This One of most relevant benefits of starting ART during PHI is the achievement of lower levels of immune activation during ART-mediated viral suppression , which hDespite the progresses achieved in the management of PHI, the best treatment strategy for this phase of HIV infection is still debated, and direct comparisons between different therapeutic approaches are still limited ,18,19,20INSTIs might represent key drugs to be first administered during PHI thanks to their good tolerability, the more rapid decay of viremia they induce compared to other antiretrovirals, and the high concentration they achieve in genital secretions . In thisThe aim of this study was to evaluate and compare the efficacy and feasibility of two INSTI-based treatment strategies in patients starting ART during PHI: a RAL-intensified four-drug regimen and a dolutegravir (DTG)-based triple regimen.3 in 84 (58.3%) patients, whereas 35 (25%) subjects had a CD4/CD8 cell ratio ≥ 1. Median HIV-1 RNA and HIV-1 DNA at baseline were 5.6 log10 copies/mL (IQR 4.8–6.6) and 4.4 log10 copies/106 PBMC (IQR 3.8–4.8), respectively. Fiebig stages at baseline were II/III in 22 (15.3%), IV in 45 (31.2%), V in 41 (28.5%), and VI in 33 (22.9%) participants. Overall, ART was started within a median time of 5 days (IQR 3–9) from HIV diagnosis, with an intensified four-drug regimen in 110 (76.4%) patients and with a three-drug regimen in 34 (23.6%) patients. Specifically, 123 patients (85.4%) started ART within 14 days from HIV diagnosis, of whom 102 in the first 7 days. At baseline, the four-drug and three-drug ART groups did not differ for the main characteristics except for the time from HIV diagnosis to ART initiation, which was slightly shorter for the former (p = 0.021).A total of 144 patients were included in the study and followed for a median observation time of 21 months (IQR 8.4–34). The main baseline characteristics of the study population are shown in Over the study period, linkage to care was 93% .The results of GRTs, available for 140 of the 144 patients, showed that mutations conferring resistance to NNRTI  were detected in 12/140 (8.7%) patients, whereas mutations conferring resistance to NRTI  were found in 2/140 (1.4%) subjects. Although neither major PI nor INSTI mutations were detected, two patients, both in the intensified ART arm, harbored a virus with the T97A accessory resistance mutations, conferring potential low-level resistance to first-generation INSTI, according to the Stanford HIV drug resistance database (score 10). Only for one of these latter patients the initial ART was modified .p = 0.232) . Conversely, a more preserved immune competence at treatment start  and having acquired HIV through heterosexual compared to homosexual intercourses  favorably predicted the achievement of virological suppression (n = 17). Over the follow-up, five patients experienced virological failure (four in the four-drug group and one in the three-drug group), with an incidence rate of 2.5% (95% CI 1.0–5.9) without differences between the treatment groups (p = 0.526).Overall, during the follow-up, 130 subjects (90.3%) achieved virological suppression. The estimated probabilities of achieving an HIV-1 RNA below 40 copies/mL after 12, 24, and 48 weeks of therapy were 56% , 82% (95% CI 73.2–88.6), and 98% (95% CI 92.3–99.5%) for patients starting the four-drug ART and 75% , 79% (95% CI 63.4–90.1), and 96% (95% CI 84.8–99.7) for patients starting the three-drug regimen, without statistically significant differences between the two treatment groups (= 0.232) a. The me= 0.015] b. When epression . These fp = 0.223) , while afterwards it was comparable   subjects achieved low-level HIV-1 DNA. The cumulative probabilities of reaching this outcome in the four-drug and three-drug arms were 1.4 (95%CI 0.2–9.3) and 6.5% (95%CI 1.7–23.4), respectively, at 12 and 24 weeks, and 7.4% (95%CI 2.8–18.7) and 9.9% (95%CI 3.3–27.7), respectively, at 48 weeks, without significant differences between the two groups (= 0.223) c. When cmparable d. At mul= 0.058) .p = 0.845) (p = 0.011)  a. At mul= 0.011) .p = 0.408) and week 48 of ART (p = 0.443).No differences in self-reported adherence between the two treatment groups were found at week 24 (p = 0.232) and a similar chance of reaching low-level HIV-1 DNA (<200 copies per 106PBMC), which was lower than 10% after 48 weeks of ART .In this observational study, including patients diagnosed with PHI from December 2014 to April 2018, both an intensified four-drug regimen based on RAL and DRV/b and a DTG-based triple ART, showed a comparable virological efficacy with a very high probability of achieving HIV-1 RNA suppression , in the setting of PHI, was explored in two small studies which showed a rapid and sustained virological suppression, a significant immunological recovery, and an optimal safety of this regimen ,24. NeveWhen exploring predictive factors, as expected, the virological burden as well as the immunological competence at baseline positively predicted virological suppression. The achievement of low-level HIV-1 DNA seemed to be associated with pre-therapeutic HIV-1 DNA levels and the timing of ART initiation. Although these associations did not reach statistically significance, these findings are consistent with previous studies reporting a correlation between the size of viral reservoir and both the pre-treatment HIV-1 DNA level ,31 and tp = 0.845). This rapid normalization of the CD4/CD8 ratio, already observed in the setting of PHI [The immune recovery was comparable between the intensified- and the standard-ART arms. Notably, the probability of achieving a CD4/CD8 ratio ≥1 within the first year of ART initiation approached 50% in both groups  and acceptability, as already demonstrated in previous reports ,20.This study has some limitations, including the limited size of the population, examined, particularly in the three-drug arm, its observational nature, which is prone to bias due to unmeasured confounders, and the short follow-up.This is a retrospective analysis of prospectively collected data from the SIREA  cohort. SIREA is a monocentric cohort study set up in 2014, enrolling patients, aged at least 18 years, diagnosed with PHI at the National Institute for Infectious Diseases “Lazzaro Spallanzani” in Rome, Italy. Demographic and epidemiological data and symptoms at HIV diagnosis were collected and recorded for all participants in an anonymous form at baseline. Viro-immunological and therapeutic data along with blood specimens were collected at baseline and, afterward, at each time point, as reported below. All consecutive patients enrolled in the SIREA cohort from December 2014 to April 2018 who started ART with tenofovir/emtricitabine (TDF/FTC) associated with either boosted darunavir (DRV/b) and RAL or DTG were included in the present analysis.HIV serodiagnosis was performed with the fourth-generation HIV-1/2 Architect HIV antigen (Ag)/antibody (Ab) Combo assay, Abbott . Reactive serum samples underwent confirmation with HIV-1 Western Blot (WB)  using World Health Organization (WHO) criteria (two env products reactivity). An avidity test was carried out, on confirmed positive samples lacking p31 reactivity, to discriminate between recent (<6 months) and late infections. PHI was diagnosed and staged using the Fiebig system, which categorized the infections on the basis of the following criteria: (1) positive HIV viremia (at least 2000 copies/mL) with negative fourth-generation HIV assay (Ab/Ag Combo) (Fiebig I); (2) positive HIV Ab/Ag Combo test and negative (Fiebig II/III) or undetermined WB test (Fiebig IV); (3) positive HIV Ab/Ag Combo test and incomplete WB test ; (4) positive HIV-1 enzyme immunoassay (EIA) with a complete WB test but a documented negative HIV-1 EIA within the previous 6 months or with an avidity test <0.8 (Fiebig VI) ,36. HIV-At enrollment, the subjects underwent a complete clinical and viroimmunological evaluation, including GRT. ART was started, generally before the GRT results, with one of the following regimens: (a) 4-drug ART consisting of TDF/FTC 245/200 mg plus RAL 400 mg twice daily (BID) plus either DRV/ritonavir (DRV/r) 800/100 mg or, from November 2016, DRV/cobicistat (DRV/c) 800/150 mg or (b) 3-drug ART with TDF/FTC 245/200 mg plus DTG 50 mg once daily (QD) from May 2015. Virological and immunological data  were collected at baseline (defined as the date of ART initiation), on day 2 (except for HIV-DNA), at week 2, week 4, week 8, week 12, week 24, week 36, and week 48 and thereafter every six months. Adherence was evaluated through a self-reported visual analogic scale (VAS) ranging from 1 to 100, at the same time points, except for baseline and day 2.The primary outcome was to estimate and compare the probability of virological suppression between patients on the 4-drug regimen versus patients on the 3-drug regimen. Secondary outcomes were to evaluate and compare the probabilities of the groups of reaching low-level HIV-1 DNA and a CD4/CD8 ratio ≥1, the trend of HIV-1 RNA and HIV-1 DNA decay, the evolution of CD4 cell count, and the self-reported adherence. Additionally, factors associated with the achievement of the main virological and immunological outcomes were assessed.Virological suppression was defined as the first achievement of HIV-1 RNA < 40 copies/mL. Virological failure was considered as either incomplete suppression  or viral rebound . In this study, the amount of HIV-1 DNA defining a low-level HIV-1 DNA was set at <200 copies/106 PBMC based on the ANRS 116 SALTO study in which this threshold was associated with a lower probability to reassume therapy after ART interruption . The samt-test or Mann–Whitney U-test for continuous variables, as appropriate, or Chi-square test for categorical variables.Categorical variables are described as absolute numbers and percentage frequencies; continuous variables are quoted as medians and interquartile range (IQR). The baseline characteristics of the two groups were compared using Student’s t test. Self-reported adherence was assessed by VAS at baseline and at weeks 24 and 48. The mean adherence VAS scores at weeks 24 and 48 were compared between the two groups using the Student’s t-testKaplan–Meier curves were used to estimate the probability of primary and secondary outcomes, and log-rank test was used to compare the survival distributions of the two groups. Factors associated with virological suppression, CD4/CD8 ratio ≥1, and low-level HIV-1 DNA achievement were evaluated by a multivariable Cox proportional hazard model. The covariates included in the models were chosen a priori as potentially associated with the outcomes. The adherence, measured by visual analogic scale (VAS) at various time points, was included in multivariable models as a time-updated covariate. Mean changes from baseline of HIV-1 RNA and HIV-1 DNA levels as well as CD4 cell count at each time point were assessed and compared between the two treatment arms using the Student’s p-value < 0.05 was considered to be statistically significant. All analyses were performed using STATA 15.1 software.An intention-to-treat (ITT) approach, ignoring switches to first-line therapy, was adopted for all the analysis. Additionally, an on-treatment (OT) approach, censoring patients who switched to first-line therapy, was applied for the primary outcome. A two-tailed In this study, we provide further evidence that in PHI patients, an intensified four-drug regimen including RAL and DRV/b and a DTG-based standard regimen showed comparable responses in terms of virological suppression, viral reservoir size, and immunological recovery. These data support the use of second-generation INSTI-based triple regimens as first-line ART in this setting, also in order to limit cost and pill burden. Moreover, our findings confirmed that a rapid ART approach in this stage of infection is related to a high acceptability and viro-immunological response.


This study aims to determine the factors influencing HIV-related mortality in settings experiencing continuous armed conflict atrocities. In such settings, people living with HIV (PLHIV), and the partners of those affected may encounter specific difficulties regarding adherence to antiretroviral therapy (ART), and retention in HIV prevention, treatment, and care programs. Between July 2019 and July 2021, we conducted an observational prospective cohort study of 468 PLHIV patients treated with Dolutegravir at all the ART facilities in Bunia. The probability of death being the primary outcome, as a function of time of inclusion in the cohort, was determined using Kaplan–Meier plots. We used the log-rank test to compare survival curves and Cox proportional hazard modeling to determine mortality predictors from the baseline to 31 July 2021 (endpoint). The total number of person-months (p-m) was 3435, with a death rate of 6.70 per 1000 p-m. Compared with the 35-year-old reference group, older patients had a higher mortality risk. ART-naïve participants at the time of enrollment had a higher mortality risk than those already using ART. Patients with a high baseline viral load (≥1000 copies/mL) had a higher mortality risk compared with the reference group . One-fourth of deaths in the cohort were direct victims of armed conflict, with an estimated excess death of 35.6%. Improving baseline viral load monitoring, starting ART early in individuals with high baseline viral loads, the proper tailoring of ART regimens and optimizing long-term ART, and care to manage non-AIDS-related chronic complications are recommended actions to reduce mortality. Not least, fostering women’s inclusion, justice, peace, and security in conflict zones is critical in preventing premature deaths in the general population as well as among PLHIV. Globally, AIDS-related deaths have decreased since their peak in 2004, from 1.9 million in 2004 to 680,000 in 2021 [In the Democratic Republic of Congo (DRC), AIDS-related deaths decreased by 60% in 2018 . HoweverSince 2017, armed conflict has negatively affected the provision of healthcare services in Bunia, the capital of the eastern province of Ituri, neighboring Uganda. Bunia is surrounded by violent combat zones, where the army and militia fight on a daily basis. Intermittently, clashes also occur in Bunia itself. Restricted access to healthcare services due to armed violence has been documented worldwide, such as in South America, where armed conflicts in Colombia have led to the forced displacement of millions of families . In suchAlthough the mortality rate among PLHIV has declined in the DRC, the chance of survival is not the same for all. Mortality predictors include advanced AIDS clinical stages, the presence of comorbidities and opportunistic infections, lower body mass index, gender, and high viral load during the first two years of illness ,11,12,13Between July 2019 and July 2021, we conducted an observational prospective cohort study involving 468 adults living with HIV and receiving DTG-containing ART. Participants were recruited from all the health facilities offering ART in Bunia. At enrollment, we included ART-naïve participants as well as those already on ART.Upon enrollment, ART-naïve participants received a DTG-containing regimen . For participants already receiving ART, we switched their previous (DTG-free) treatment to the DTG-containing regimen. Previous DTG-free treatment included Stavudine (D4T) or Zidovudine (AZT), combined with Lamivudine (3TC) and either Nevirapine (NVP) or Efavirenz (EFV). Every six months, participants underwent a follow-up evaluation, which included a physical examination, a review of adverse events and concomitant medicines, as well as HIV-1 RNA VL, a hemogram, and liver, urine, and renal function tests . As partART facilities offered outreach follow-ups, which included home visits or phone calls by community health agents to participants or their families. Community health agents informed facility data clerks after every outreach visit to participants. After three unsuccessful home visits, community health agents called participants up to five times. We deemed participants lost to follow-up (LTFU) if they were not seen at their designated ART facility for at least 90 days following the previous missed visit and had not transferred to another ART facility. The LTFU date was defined as the day of the last visit to the facility according to the medical records. If a family member, neighbor, or community leader reported the participant’s death, we categorized the status of that participant as dead .We gathered sociodemographic data , clinical data , and biological data , syphilis serology, and hepatitis B serology (AgHBs)). We divided participants into three groups according to their treatment status before enrollment: (1) patients with ART experience before enrollment, (2) self-reported ART-naïve patients with baseline VLs of <50 copies/mL, and (3) self-reported ART-naïve patients with baseline VLs of ≥50 copies/mL . Based oDeath was the primary outcome. We investigated the cause of death in every case, notably deaths after fighting or ambush episodes.We recorded data using Epi Info 7 Version 7.2.0.1. software . We checked the data for completeness before entry and performed data double entry.We calculated proportions, where the main outcome variable was death. We determined the incidence rate of recorded death events per 1000 person-months (p-m) from the date of enrollment. For participants known to have transferred out or LTFU, we censored the data at the date of the last appointment. For participants still in active care at the end of the study period, data was censored on the date of their last clinic visit. We used Kaplan–Meier curves to determine the probability of death as a function of the time of inclusion in the cohort, the log-rank test to compare survival curves based on determinants, and Cox proportional-hazard modeling to measure predictors of death from enrollment to the endpoint, which was set on 31 July 2021. We included the following variables in the Cox regression model: sex, age, WHO HIV clinical stage, baseline serum creatinine, baseline viral load, and treatment status before enrollment.p < 0.05. We performed all tests using Stata software version 14 .The proportionality test based on Schoenfeld residuals verified compliance with the assumption of the proportionality of risks. We assessed multicollinearity using variance inflation factors (VIFs) greater than 4.0. To identify the profile of patients who died because of armed conflict, we reported their causes of death according to six potential determinants . The proportionality test based on Schoenfeld residuals verified compliance with the assumption of the proportionality of risks. All the tests were two-sided, with the level of significance was set as The Kinshasa University School of Public Health’s institutional review board for research subjects approved the study protocol (no. app.: ESP/CE/094/2018 of August 2018). Before participating in the study, all participants signed a written informed consent form. Before analysis, all data were anonymized and deidentified .Of the 468 enrolled participants, 69.4% were women, 65.6% had no education or only primary education, and 56% lived alone. The average age of the participants was 38.97 years (SD: 11.94). Other characteristics are presented in At baseline, 219 individuals (46.8%) were diagnosed with WHO HIV stage I or II. A third of the participants (33.8%) had an abnormal blood creatinine level, and one out of four (27.6%) was anemic. Regarding baseline treatment status, 62.2% were already receiving ART (experienced patients), 19.9% self-reported as naïve with a baseline VL of <50 copies/mL (new but with VL suppressed), and 17.9% self-reported as naïve with a baseline VL of ≥50 copies/mL (new but with high VL) .During the study period, more than a quarter of the cohort was LTFU . The overall number of person-months (p-m) followed up was 3435.22, with 33.48 LTFU per 1000 p-m. After 1, 3, 6, 9, and 12 months, 12.0%, 21.4%, 26.5%, 28.6%, and 28.8% were lost to follow-up, respectively.The mortality of PLHIV on ART after 12 months was 4.9% (95% CI: 3.3–7.3), with an overall incidence rate of 6.70 deaths per 1000 p-m.After adjustment, older participants had a higher risk of death than the reference group (<35 years) (adjusted hazard ratio (aHR) for the 35–45 age group: 5.14; 95% CI: 1.09–24.18; aHR for the >45 age group: 5.47; 95% CI: 1.13–26.38). ART-naïve participants with a baseline VL of <50 copies/mL  had a higher risk of death than participants already receiving ART . Participants with a high baseline VL (≥1000 copies/mL) had a higher mortality risk than the reference group  .Among the 23 reported deaths, 6 (26.1%) were directly related to armed conflict. Although not statistically significant, the proportion of deaths as a direct result of armed conflict was higher among women and among those who were at stage I or II. While statistically insignificant, patients who died from armed conflict were younger than their counterparts . ExcludiIn this prospective study, we analyzed the pattern of mortality in a cohort of 468 PLHIV receiving DTG-containing ART from health facilities located in the conflict-affected city of Bunia, eastern DRC. The factors associated with increased mortality were being aged 35 and above, having no ART before study enrollment, and high baseline VL. The death rate was 6.70 per 1000 person-months. One in four deaths was due to armed conflict.p = 0.429). A larger sample size of at least 1000 would be necessary to detect a statistically significant difference with a two-tailed p-value ≤ 0.05 and to determine whether armed conflict plays a significant role in raising the mortality rate among PLHIV.Armed conflict can affect cohort mortality rates directly or indirectly: directly if PLHIV fall victim to hostilities, or indirectly if the population’s forced displacement or fear of movement restricts their access to HIV treatment and care . The deaThe findings correspond to those of previous research in low-income countries, which also found that mortality is associated with patient age, baseline VL, and the status of treatment before enrollment ,18. The As previously documented in Kenya, Mozambique, Rwanda, and Tanzania, the risk of death is significantly higher in older than younger PLHIV enrolled in ART programs . In a stIn our study, ART-naïve patients had a higher risk of death compared with patients already receiving ART at baseline. Increased treatment experience among patients already receiving ART and the resulting VL suppression at baseline could explain their lower rate of death compared with ART-naïve patients. In the study undertaken in Goma, the likelihood of non-suppression remained significantly lower among ART-naïve patients with a baseline VL of ≥50 copies/mL compared with patients already receiving ART before being included in the study .In terms of policy and practice implications stemming from our research in Bunia, we recommend strengthening baseline VL measurement for all PLHIV. Currently, routine baseline VL testing for all PLHIV is not recommended and cannot be undertaken in all healthcare facilities in Bunia (VL tests are sent to Kinshasa). Efforts should be devoted toward increasing the availability of low-cost equipment for VL measurement. Early ART initiation among patients with a high baseline VL, and optimizing long-term ART and care to also manage non-AIDS-related chronic complications, could help limit mortality ,23. MostThis study has several limitations, the first being that, due to insecurity, we could not always fully follow up and ascertain the real outcomes of the participants who were documented as LTFU (we report a higher LTFU compared with previous studies ,25. SecoOne-fourth of deaths in the PLHIV cohort was directly due to armed conflict, with an estimated excess death rate of 35.6%. To reduce mortality, we recommend strengthening baseline VL measurement among all PLHIV, initiating ART early in PLHIV with high VL, and optimizing ART and care to also manage non-AIDS-related chronic complications. Not least, fostering women’s inclusion, justice, peace, and security in conflict zones is critical in preventing premature deaths in the general population as well as among PLHIV.


Background: The introduction of tenofovir alafenamide (TAF) in antiretroviral therapy has deeply modified the choice of the backbone for different treatment regimens, allowing the prevention of the bone and renal toxicity that was related to the previous formulation of tenofovir disoproxil fumarate (TDF). At the same time, literature data show an onset of dyslipidemia after a switch from TDF to TAF. To better understand the possible role of TAF in dyslipidemia, antiretroviral-naïve HIV-infected patients were evaluated, comparing those treated with TAF/emtricitabine with those with abacavir/lamivudine. Methods: We enrolled 270 antiretroviral-naïve HIV-infected patients in an observational, retrospective, longitudinal, multicenter study; they started treatment from 2017 to 2019 and were followed up for at least 72 weeks. We divided patients into two groups, one treated with a TAF-based backbone in their antiretroviral regimens (TAF group) and one without TAF (NO TAF group), to evaluate possible differences in the dynamics of lipid profiles from baseline(T0) to week 24 (T24), 48 (T48) and 72 (T72). Results: No significant differences were observed at baseline between the 2 groups. In the TAF group we observed a significant development of hypercholesterolemia throughout the follow-up (p < 0.0001), not evident in the NO TAF group, that instead showed a significant increase in high-density lipoprotein (HDL). There were no significant differences between the two groups regarding triglycerides, low-density lipoprotein (LDL) and cardiovascular risk index (CRI). A cholesterol-lowering treatment with statin, finally, was prescribed in 6 patients in both groups during the study. At binary logistic regression analysis, no factor was independently associated with hypercholesterolemia, except for higher age at T0. Conclusions: This real-life study shows that in HIV-naïve patients, TAF was associated with hypercholesterolemia throughout the follow-up. The clinical significance of this hypercholesterolemia will have to be clarified in further studies. Antiretroviral therapy (ART) for human immunodeficiency virus (HIV) infection has considerably changed in recent years. In particular, the introduction of tenofovir alafenamide (TAF) has deeply modified the choice of the backbone, allowing the prevention of bone and renal toxicity related to previous formulations of tenofovir disoproxil fumarate (TDF) ,2,3,4. HTo better understand whether dyslipidemia is a TAF-related event or a loss of the protective effect of TDF, we evaluated in the present study the dynamics of lipids in the first 72 months of ART among HIV-naïve patients treated with TAF plus emtricitabine (FTC) compared with those treated with abacavir plus lamivudine as a backbone. We performed an observational, retrospective, longitudinal, multicenter study. We enrolled all the 270 consecutive HIV-naïve outpatients who started treatment in the period from January 2017 until December 2019 and were followed up for at least 72 weeks. Eleven Italian Infectious Disease Centers specialized in HIV treatment  were involved in the study and have cooperated in previous clinical investigations using the same clinical approach and the same laboratory methods.Inclusion criteria were: (1) a confirmed diagnosis of HIV infection, (2) being naïve to antiretroviral therapy, (3) an age of 18 years or older. Exclusion criteria were: (1) past or present use of lipid-lowering drugs, (2) use of boosted protease inhibitors (bPI) in their antiretroviral regimen that may induce dyslipidemia , (3) useHIV infection was classified according to the revised CDC classification system for HIV-infected adolescents and adults, 1993 . EnrolleAll patients underwent clinical examinations and laboratory tests at enrolment, after one month from the beginning of ART treatment, and every 3–6 months subsequently according to the current guidelines . ClinicaBeing a retrospective real-life study, we considered, as evaluable data, those obtained from patients in a window of about 2 weeks before or after the different timing points of follow-up.All procedures performed in this study were in accordance with with the 1964 Helsinki declaration and its later amendments or comparable ethics standards. Informed consent was obtained from all participants included in the study.The primary outcome was the evaluation of the development of dyslipidemia at the different time points of the study and its correlation to the backbone of choice in HIV-naïve patients. The evaluation of a relationship between an antiretroviral regimen with a metabolic impairment is important, above all when it concerns lipids. There are many data in the literature that identify dyslipidemia as a cardiovascular risk factor . This isAntibodies to HIV-1 and -2 were sought using a commercial ELISA  and positive results were confirmed by Western blot . The HIV viral load was assessed by real-time PCR with the lowest detection limit of 40 copies/ml.Lymphocyte subsets  were evaluated by flow cytofluorimetry using monoclonal antibodies and a fluorescence-activated cell sorter scan . Serum lipids and routine analyses were performed applying standard procedures. t-test for comparison between two groups and by the one-way analysis of variance (one-way ANOVA) for comparison including 3 or more groups; in the case of non-normally distributed variables the Mann–Whitney U test and the Kruskal–Wallis one-way ANOVA were used for comparison between 2 or more groups, respectively; categorical variables were compared using Fisher’s exact test. Odds ratios (OR) with 95% confidence intervals (CI) were estimated using a binary logistic regression model using the Firth method based on penalized likelihood to identify possible independent associations between hypercholesterolemia and 8 characteristics of the patients enrolled . This analysis was applied to each timing of the follow-up. A p-value below 0.05 was considered statistically significant.Continuous variables were summarized as mean and standard deviation or median and range, and categorical variables as absolute and relative frequencies. For continuous variables, the differences were evaluated by Student’s The characteristics at enrolment of the 270 HIV-naïve patients included in the study are summarized in Of the 270 naïve enrolled patients, 141 were included in the TAF group, and 129 in the NO TAF group. In the TAF group, 79 were treated with TAF/FTC+elvitegravir/cobicistat, 30 with TAF/FTC+dolutegravir, 29 with TAF/FTC+rilpivirine and 3 with TAF/FTC+raltegravir. In the NO TAF group, all 129 subjects enrolled were treated with abacavir/lamivudine+dolutegravir. p = 0.01). All lipid parameters  were similar in the 2 groups, except for serum HDL which was higher in the TAF group  and at the same time a parallel increase in percentage of LDL ≥ 130 mg/dl  (p = 0.05). There was a progressive increase of pathological LDL values from T0, but unlike with the TAF group, we did not note statistical significance . In the NO TAF group, there was, instead, an evident significant increase in HDL throughout the follow-up   . In the = 0.001) . There wFinally, we performed a binary logistic regression analysis to evaluate the factors independently associated with hypercholesterolemia, considering sex, age and the two adopted antiretroviral backbone regimens. No factor was independently associated with hypercholesterolemia except at T0 for an age higher than 50 years old  . The same binary logistic regression analysis was performed considering all the different types of treatment in TAF group, screened for different third drug of a regimen, obtaining the same results .Moreover, all different antiretroviral regimens used for treatment showed the same viro-immunological efficacy with a percentage of HIV suppression at T72, from 90% to 94% . No diffp = 0.09), although without statistical significance , many studies have recently examined long-term metabolic disorders. The evaluation of relationship between an antiretroviral regimen and a metabolic impairment is important, above all when it concerns lipid alterations. There are many data in the literature that show dyslipidemia as a cardiovascular risk factor . Cardiovascular diseases (CVD) represent one of the most important causes of mortality and morbidity in the industrialized world. People with hyperlipemia in fact are at roughly twice the risk of developing CVD as compared to those with normal total cholesterol levels . PatientThis may explain the wide use of lipid-lowering drugs in general population to avoid hypercholesterolemia . StatinsIf management of dyslipidemia is so important for prevention of CVD in general population, this is even more crucial in patients with HIV infection. People living with HIV (PLWHIV) in fact have a 2-fold higher risk of having a cardiovascular event than HIV-negative individuals . On the These studies enrolled mostly experienced patients and so it is not completely clear if the increase in lipid levels was a side effect of TAF, if it was related to TDF discontinuation, or if it was due to both factors, as suggested by other studies. In Sword 1 and 2 studies, in particular, patients who were efficaciously treated with a standard triple regimen  were switched to dual regimens based on the association of dolutegravir/rilpivirine. After the switch, in spite of TDF discontinuation, the patients showed a good profile of tolerability without an onset of dyslipidemia . On the In conclusion there are few available data in the literature regarding the dynamics of lipid profile, evaluated in clinical practice, in HIV-naïve patients treated with TAF-based ART vs. no TAF-based ART. To better understand the direct impact of TAF in the evolution of dyslipidemia, we designed the present study enrolling a group of HIV-infected patients, naïve to antiretroviral treatment and, thus, potentially free from any confounding factors. Our preliminary real-life data showed that in naïve patients, TAF was associated with a higher percentage of development of hypercholesterolemia throughout the follow-up, although not confirmed at binary logistic regression analysis. Instead, in the subjects treated with NO TAF-based ART, the development of hypercholesterolemia was not statistically evident, being associated only with a significant HDL increase, with a potential protective effect exerted by this fraction of cholesterol. In any case, in both groups no changes in CRI levels were observed. This study has some limitations, i.e., having a retrospective design. Moreover, the study was concluded in December 2019, consequently, no patient had been treated with bictegravir because this drug was not available at that time. However, to the best of our knowledge, there are few data in the literature on the lipid profile in antiretroviral-naïve HIV-infected patients, treated in real-life with TAF vs no TAF. In conclusion, our study, based on data of real-life, highlights that the use of TAF-based regimen in ART-naïve HIV-infected patients, seems to be correlated to dyslipidemia along the follow-up. This may induce a higher CVR in this group of patients because the elevation of total cholesterol and LDL correlate with the development of atheromatous plaques and so with CVD, as evident in literature . Our datFurther observations on a larger number of patients and perhaps the contemporary collection of data obtained with the Doppler of the supra-aortic trunks, will be able to confirm our observations and will help to better define CVR in this setting.


Hepatotoxicity due to highly active antiretroviral therapy (HAART) has gained prominent attention since it can be affected by many factors. The aim of this study was to determine the prevalence of hepatotoxicity and related risk factors of severe hepatotoxicity following HAART initiation.A total of 100 drug-naive patients aged between 18 and 61 years were recruited. They were put on Tenofovir/Lamivudine/Efavirenz [TDF/3TC/EFV] (64), Zidovudine/ Lamivudine/Efavirenz [AZT/3TC/EFV] (22), and Zidovudine/Lamivudine/Nevirapine AZT/3TC/NVP (14) and monitored for 6months and blood samples drawn.Alanine aminotransferases (ALT), aspartate aminotransferases (AST), and alkaline phosphatase (ALP) wereanalyzed by enzymatic methods and used to classify levels of hepatotoxicity.p = 0.001) with increased treatment duration. Univariate analysis revealed that the risk factor of developing severe hepatotoxicity was significantly greater in patients < 30years (p = 0.02), males(p = 0.04), low BMI (p = 0.02), low monthly income (p = 0.01) earners, and patients on AZT + 3TC + NVP regimen (p = 0.01). While multivariate analysis at p < 0.09 showed that age 30–40 years, low BMI, low monthly income, and the use of AZT + 3TC + NVP regimen were independent risk factors.A total of 37(37%) and 49(49%) patients presented with hepatotoxicity while 15% and 28% had severe hepatotoxicity at 4 and 24 weeks respectively. Serum levels of all enzymes increased significantly (Low BMI, age group of 30–40years, low monthly income, and the use of AZT + 3TC + NVP regimen identified as risk factors for the development of severe hepatotoxicity should be considered as an important strategy by clinicians in preventing the hepatotoxicity. Several studies have been conducted to determine the risk factors of hepatotoxicity in patients with HIV. These factors include age, gender, type of HAART, viral load, hypertryglyceridemia, hyperglycemia, history of tuberculosis therapy and hepatitis B and Hepatitis C co-infection, alcohol abuse, higher baseline ALT or AST , 5, 7–10This was a hospital-based longitudinal analytical study conducted at the HIV Outpatient Clinic in Ndop, Santa, Bali, and Bafut District Hospitals and the Regional hospital of Bamenda of the NWR of Cameroon from February 2016 to November 2016. The sampled sites better represent the different backgrounds of individuals from the entire NWR of Cameroon. Bafut, Santa, Bali, and Ndop are in rural areas while Bamenda is from urban settings. The National Ethics Committee of Cameroon approved the study protocols with ethical approval number No 2016/01/689/CE/CNERSH/SP, and all patients gave their written consent before enrolment. The eligibility criteria included a confirmed HIV-1 infection, HAART naïve, negative for viral hepatitis B or C, not on tuberculosis treatment, and willingness to be followed up for at least 24 weeks.Data were obtained with the aid of a pre-tested questionnaire and with the consultation of the patient’s record. These include information on; age, sex, weight, level of education, monthly income, history of alcohol and cigarette use, type of HAART, concomitant use of other drugs within 4 weeks before enrolment, WHO clinical staging, and the year the patient was first diagnosed of HIV. Patients routinely visited the HIV clinic every 4 weeks and were either on Tenofovir (TDF) + Lamivudine (3TC) + Efavirenz (EFV) or Zidovudine (AZT) + Lamivudine + Nevirapine (NVP) or AZT + 3TC + EFV according to Cameroonian HIV-1 first-line treatment guidelines. On each of these visits, clinical evaluation and assessment for adherence to HAART using self-report and pill counts were performed.About five ml of venous blood was collected from each subject and processed to obtain serum. Measurement of Alanine aminotransferase (ALT), aspartate aminotransferase (AST), and alkaline phosphatase (ALP) was done using the SPINREACT commercial kits as described by manufactures’ manual and guided by the controls using the Urit 3300 machine . Case definitions for the various hepatic enzymes were determined based on sex with respect to the reference range considered as up to 40.0 U/L, 38.0 U/L and between 69 and 117.0 U/L for males; and up to 32.0 U/ L, up to 31.0 U/L and between 69 and 117.0 U/L for females; for ALT, AST, and ALP respectively.xULN), grade 2 (2.51-5.0xULN), Grade 3 (5.1-10xULN ) and, grade 4 (> 10xULN) [Hepatotoxicity was graded using the levels of ALT, AST, and ALP according to classified AIDS Clinical Trials Group classifications as; grade 1 (1.25-2.5 10xULN) . Severe  10xULN) , 12.The clinical assessment and laboratory results were recorded and double-checked using Microsoft Excel database and analyzed using Statistical Package for the Social Sciences version 20. Categorical variables were expressed as frequencies and proportions and compared using the Chi-square test while continuous variables were expressed as means ± standard error of mean (SEM) and compared to the different treatment durations using the unpaired t-test. The fixed covariates considered to be possible risk factors for the liver elevated enzyme (LEE) at baseline parameters were explored using univariate logistic regression with unadjusted odds ratios and adjusted odds ratios for multivariate analyses to identify risk factors associated with severe hepatotoxicity. The level of significance was set at 5% throughout the analyses.+ T cell count of < 200 cells/mm3 and were placed on TDF + 3TC + EFV treatment respectively  age of the100 patients with HIV was 36.53(0.56) years and ranged from 18–61 years. The majority 53(53.0%), 43(43.0%), 57(57.0%), and 64(64.0%) were female, within the age range 30–39 years, had CD42 = 68.18; p = 0.000). Of this, 22% and 21% had mild-to-moderate (Grades 1 and 2) toxicity at 4 and 24 weeks while 15% and 28% had severe hepatotoxicity (Grades 3 and 4) at 4 and 24 weeks respectively as shown in Fig. All the patients 100 (100%) had no significant LEE at baseline. Using ALT, AST, ALP or a combination of any of them showed that 37(37%) and 49(49%) patients presented with hepatotoxicity at 4 and 24 weeks respectively. This difference was significant (χp = 0.001), AST  and ALP  Fig. Median ALT, AST and ALP increased significantly with increase in treatment duration at 4weeks and 24weeks; ALT  kg/m2 and 168.0 (25.3) cells/mm3 respectively. From univariate regression analyses, severe hepatotoxicity was significantly (p < 0.05) high in the age group < 30 years, males, patients with low monthly income , low BMI (> 18.5 Kg/m2), and patients who took AZT + 3TC + NVP treatment. The prevalence of severe hepatotoxicity among those who consumed alcohol and smoked cigarettes or tobacco only showed a trend (p = 0.07) and (p = 0.09) respectively. In addition level of education, year of diagnosis, WHO staging, were not predictive (P > 0.05) for the development of severe hepatotoxicity (Table 2The mean (SD) BMI and CD4+3Socio-demographic variables  , and SteIn this study, a decline in the number of cases on Grade 1 and 2 hepatotoxicities with those in Grade 3 and 4, increasing. This change could not be confirmed based of the short period of follow-up. It will therefore be appropriate if a longer period of follow up could be conducted to fully confirm the observed trend on the hepatotoxicity trend .Mycobacterium avium complex, Candidaalbicans, Toxoplasma gondii, Leishmania species, Strongyloidesstercoralis, Cytomegalovirus, etc[The high prevalence of hepatotoxicity after one month of treatment is a clear indication that some liver diseases such as cytomegalovirus and mycobacterium infections, and AIDS-related neoplasms such as lymphoma and Kaposi’s sarcoma  are ofteirus, etc, 10.On the other hand, since HIV-1 infected patients could be co-infected with other infections, we could not rule out the possibility of these patients having taken othercombinations of non-ART medications orherbal concoctions, which could also have had adverse liver effects either alone or in combination. SecondlOur data reveal that elevated transaminases showed a significant positive linear relationship with an increase in the duration of treatment irrespective of the ARV regimen . Thus, tAge was found to be a predictor of severe hepatotoxicity contrary to previous studies, . Our finGender was analysed to see if it had an impact on hepatotoxicity. However, in this study, no association was observed according to multivariate analysis. The findings concurred with previous studies , 14 but Our observations suggest that body weight could bea major factor in determining the serum level of liver enzymes. Low BMI was found to be an independent predictor of severe hepatotoxicity. A finding that confirms that good nutritional status at the start of HAART could be protective against early hepatotoxicity , 4. StudMonthly income has been shown to play an important role in the life of individuals. In this study low monthly income was another significant predictor of severe hepatotoxicity from the multivariate model. This group of persons usually have increased consumption of dietary fat and thus increase in their BMI that accounted for the increase in the liver enzyme. It has been reported that lower monthly income is associated with negative effects on the quality of life such as anxiety and depression symptoms that worsen their clinical conditions as a result making them prefer herbal and cheaper drug concoctions , 22.The prevalence of severe hepatotoxicity associated with NVP 57.1%) based regimen in this study was similar to other studies .1% based, 13. FurAlcohol consumption which is associated with elevated liver enzyme levels is most prevalent in most countries , 16, 18.+ T cells count and lowering of BMI hence a minor risk to liver toxicity [Cigarette smoking has significantly been associated with increased levels of ALP and to a lesser extent AST and ALT , 26–28. toxicity , 29.+T cell count was a minor risk factor for liver toxicity since low CD4+T cell count showed a trend with hepatotoxicity only in the univariate analysis. Our data also revealed that the high CD4+T cell count after 24 weeks is associated with a higher risk of hepatotoxicity in the adjusted multivariate analysis though it was insignificant. Similar findings have been reported by Price and Thio [+ T cell count is a risk factor to the development of severe hepatotoxicity [Interestingly, in our study low CD4and Thio  This restoxicity , 10, 13.Age group, Low baseline BMI, low monthly income, and use of AZT + 3TC + NVP regimen were identified as independent risk factors for developing severe hepatotoxicity. Severe hepatotoxicity may arise more frequently with increased use of HAART. Thus, there is a need to educate the community of the potential risk factors associated with severe hepatotoxicity in other to improve patient management and care.The use of NVP based regimen should not be recommended for low BMI patientsand patients > 40 years. The HAART regimen of those with severe hepatotoxicity should first be altered and followed up before discontinuation.This study had some limitations as follows. The study design did not allow us to establish age, gender, and type of HAART balance ratio at recruitment. In addition, adequate drug adherence assessment and serum drug level estimation could not be performed due to the lack of facilities for such tests. The use of traditional herbs was not considered in this study with concurrent non TB medication. Lastly, liver histology could not be performed in these patients.


Evidence on the efficacy of antiretroviral therapy (ART) regimen switches on the mortality of patients with HIV drug resistance (HIVDR) is limited.We aim to provide policy guidance for ART regimen selection and evaluate the effectiveness of ART regime switches for people living with HIV and HIV-1 drug resistance.This retrospective observational cohort study included 179 people living with HIV and HIV-1 drug resistance from 2011 to 2020. The time that participants switched treatment regimens either to protease inhibitor (PI)–based ART regimens (PIs) or nonnucleoside reverse transcriptase inhibitor (NNRTI)–based ART regimens (NNRTIs) was taken as an observation starting point and followed up every 12 months. The parametric g-formula was used to estimate the 5-year risk of mortality under the situations of (1) natural course, (2) immediate switch to NNRTIs, (3) immediate switch to PIs, and (4) if CD4(+) T cells<200 switched to PIs.The follow-up time of the 179 patients ranged from 30 to 119 months. The median follow-up time was 90 months. During a follow-up of 15,606 person-months, 27 individuals died in the cohort. The estimated 5-year risk of mortality under natural course, immediate switch to NNRTIs, immediate switch to PIs, and if CD4(+), and switch to PIs if T cells<200 were 11.62% (95% CI 7.82-17.11), 31.88% (95% CI 20.79-44.94), 2.87% (95% CI 0.32-7.07), and 5.30% (95% CI 2.07-10.21), respectively. The risk ratios (RRs) of immediate switch to NNRTIs, immediate switch to PIs, and switch to PIs if CD4(+) T cells<200, compared with natural course mortality rate, were 2.74 (95% CI 2.01-3.47), 0.25 (95% CI: 0.04-0.54), and 0.46 (95% CI 0.22-0.71), respectively. The risk differences were 20.26% (95% CI 10.96-28.61), –8.76% (95% CI –13.34 to –5.09) and –6.32% (95% CI –9.75 to –3.11), respectively.Our study found that a PI-based ART regimen was beneficial for reducing mortality in people living with HIV and HIV-1 drug resistance. More effort should be given to find HIV-1 drug resistance earlier to ensure a timely adjustment to PI-based ART, thereby maximizing the benefit of early switch treatment for people living with HIV and HIV-1 drug resistance. The widespread use of antiretroviral therapy (ART) has effectively prolonged the life span of people living with HIV and has reduced the risk of HIV transmission . HoweverA protease inhibitor (PI)–based ART regimen includes 2 nucleoside reverse transcriptase inhibitor (NRTI) drugs , and 1 of the PI drugs  . BoostedIn China, only a few studies have compared the differences in immunological outcomes and drug resistance between PIs and NNRTIs among people living with HIV ,21, moreTo fill these research gaps, we conducted a 9-year retrospective cohort study to compare the impact of switches to other NNRTIs and switches to PIs on mortality in Sichuan, where the largest population of people with HIV resides in China . The parA retrospective observational cohort study was conducted based on the National Free Antiretroviral Treatment Program database of Sichuan. This confidential, nonpublic database is managed by the Chinese Center for Disease Control and Prevention. Each province, municipality, and autonomous region has access to data within its jurisdiction.Participants of this study were selected from the database according to the following inclusion criteria: people living with HIV who (1) were under NNRTIs based ART regimens for 12 months in Sichuan during 2011-2014; (2) failed those NNRTI-based ART regimens with viral load ≥1000 copies/ml; (3) were tested for HIV-1 genotype resistance and confirmed to have HIV-1 drug resistance; and (4) received at least 1 test of CD4(+) T cells and viral load during the follow-up period. The exclusion criteria included people living with HIV (1) without immunological outcomes after switching ART regimen during the follow-up period; and (2) who did not have the demographic information  in the baseline database. A total of 2037 people living with HIV tested for HIV-1 genotype resistance, and 197 were confirmed to have HIV-1 drug resistance. Of these 197 people with HIV, 18 were excluded without detecting CD4(+) T cells and viral load during the follow-up period. Finally, 179 people with HIV were included in the final analysis.In 2011, the first person living with HIV entered the cohort, and the last one entered in 2014. The starting point of observation was defined as when the person with HIV switched treatment regimens, and each person living with HIV was followed up from the entry date to the date of death or the end of this study (December 2020). A total of 179 participants met the inclusion criteria and were included in this study. They were followed up approximately every 12 months for documentation of their CD4(+) T cell count, viral load, and drug resistance. We estimated and compared the mortality risks of 3 simulated ART regimen switch scenarios with the real-world scenario , including (1) immediate switch to NNRTIs, (2) immediate switch to PIs, and (3) switch to PIs if CD4(+) T cells<200The Ethical Committee of Sichuan Center for Disease Control and Prevention approved this study (No. SCCDCIRB2021-025). This study was conducted in accordance with the Declaration of Helsinki.The NNRTI and PI regimens were carried out following the approved guidelines . NNRTI rThe CD4(+) T cell count and viral load were collected at the starting point every 12 months of follow-up to evaluate the immunological reconstruction effect. ART regimens and survival status were also included in the follow-up. To deal with missing CD4(+) T cell count during the followed-up period, we used the expectation-maximization-bootstrap algorithm for multiple imputations . The impAll baseline characteristics were taken as covariates—demographic and HIV-related characteristics and immunological outcomes. Demographic characteristics included age, gender, and education level. HIV-related characteristics included transmission patterns, history of sexually transmitted diseases, and history of tuberculosis treatment.All participants provided blood specimens to measure CD4(+) T cell count at the starting point and during follow-up after switching treatment regimens, measured using flow cytometry . Real-time molecular beacon detection was applied to detect the viral load of HIV . Reverse transcription-polymerase chain reaction (RT-PCR) was used to amplify a 1300-bp fragment of the HIV pol gene for drug resistance mutation analysis and viral subtype determination. Successfully amplified sequences were analyzed for HIVDR using the Stanford University HIV Drug Resistance Database. All experimental protocols followed the manufacturer's instructions. People living with HIV with low or higher drug resistance to one or more drugs were considered as having HIVDR -28.Adjustment is usually used for confounders in regression models , which is equivalent to estimating the hazard ratios of a specific stratum and then averaging the information-weighted hazard ratios. When some of these confounding factors are also causal intermediates, the effects of exposure are adjusted . HoweverSpecifically, the procedure of the parametric g-formula had 3 steps. First, we fit separate logistic regression models for the treatment and viral load and linear regression models for CD4(+) T cell count. All regression models included time-varying covariates  T cell count) and baseline variables . The assumed relationships between all variables are depicted in The RRs and risk differences (RDs) and their 95% CIs were estimated to compare the mortality risk between the natural course and 3 hypothetical ART switch strategies. To explore the validity of our parametric assumptions, we compared the observed (nonparametric estimates) means of the outcome and time-varying covariates with those predicted by our models (parametric g-formula estimates) . All staA total of 4 sensitivity analyses were performed in this study to ensure the stability of the results. First, we excluded people older than 60 years at baseline since they may have a higher risk of death. Second, CRF01_AE was the primary subtype of people living with HIV in Sichuan; thus, we restricted to the subset of participants with the CRF01_AE subtype to estimate the mortality risk. Third, we fit linear regression models for the viral load as a continuous variable to estimate the results. Fourth, we reexamined the hazard ratios using a time-dependent Cox proportional risk model.A total of 179 participants  were included in our study. The initial conditions of people living with HIV among the 3 switched ART groups were comparable except for the age, CD4(+) T cell counts, and viral load . Of the The follow-up time of 179 patients ranged from 30 to 119 months, and the median follow-up time was 90 months. During a follow-up of 15,606 person-months, 27 individuals from the cohort died. The overall mortality was 1.73 per 1000 person-months . The obsThe estimated 5-year risk of mortality under natural course was 11.62% (95% CI 7.82-17.11). The estimated 5-year risk of mortality of the 3 ART regimen switch scenarios of an immediate switch to NNRTIs, immediate switch to PIs, and switch to PIs if CD4(+) T cells <200 was 31.88% (95% CI 20.79-44.94), 2.87% (95% CI 0.32-7.07), and 5.30% (95% CI 2.07-10.21), respectively . The morUsing the parametric g-formula, the RRs of immediate switch to NNRTIs, immediate switch to PIs, and switch to PIs if CD4(+) T cells<200, compared with natural course mortality rate, were 2.74 (95% CI 2.01-3.47), 0.25 (95% CI 0.04-0.54), and 0.46 (95% CI: 0.22-0.71), respectively, and the RDs were 20.26% (95% CI 10.96-28.61), −8.76% (95% CI −13.34 to −5.09), and −6.32% (95% CI −9.75 to −3.11), respectively. The effect of the sensitivity analyses estimates of the 5-year risk of mortality, RRs, and RDs of the 3 ART regimen switch scenarios were robust -4. The CThis retrospective cohort study compared the mortality risk of ART switch regimens among people living with HIV with resistance to NNRTIs using the parametric g-formula method. It provided real-world evidence on the efficacy of PIs and NNRTIs switches. Our results indicate that switching to NNRTIs resulted in a higher mortality rate during the 9- year follow-up period. The 2 scenarios showing a switch to PIs were associated with lower mortality rates. This finding suggests that an immediate switch to PIs after confirmation of drug resistance can help reduce the mortality of people living with HIV and HIV-1 drug resistance.The 5-year risk of mortality was 8.76% lower for an immediate switch to PIs and 6.32% lower when switched to PIs if CD4(+) T cells<200 compared to the natural course group, which means that in a hypothetical cohort of 100 patients with drug resistance, PIs would prevent about 6-8 deaths over 5 years. On the contrary, the 5-year risk of mortality was 20.26% higher for an immediate switch to NNRTIs when comparing the natural course scenario, meaning that NNRTIs would have an increase of 20 deaths over 5 years.People living with HIV who switched to PIs had a lower mortality risk. Possible reasons for this might be that PIs could cross the resistance gene barrier and act on the resistant strains to inhibit virus replication  or that A few studies reported that the resistance rates of NNRTIs and NRTIs were 80%-92% and 95%-100% after the failure of the NNRTI-based ART regimen, respectively ,38. WithOur study has 2 strengths. First, we simulated interventions to evaluate the risk, risk difference, and risk ratio of mortality by contrasting estimates from idealized study settings with those from more realistic settings. Compared with standard statistical calculations, the parametric g-formula can be more easily used to evaluate the causal effect of complex interventions . In partNonetheless, several limitations should be considered. First, as in all nonrandomized studies, our approach provided consistent (unbiased) estimates of the cumulative incidence of mortality under several assumptions: all variables  T cell count, viral load, treatment, and death) were measured without error; patients' ART treatment at different CD4(+) T cell counts are exchangeable within levels of measured covariates, in that there are no unmeasured confounding variables . HoweverOur study found that the PI regimen helped improve the survival time of people living with HIV and HIV-1 drug resistance. More efforts should be conducted to detect HIV-1 drug resistance earlier to ensure timely regimen switches, thereby maximizing the benefit of early switch ART regimens for people living with HIV and HIV-1 drug resistance and reducing their mortality.


We investigated risk factors for sustained virological non-suppression  among children and adolescents accessing HIV care in public sector clinics in Harare, Zimbabwe and Blantyre, Malawi.Participants were enrolled between 2016 and 2019, were aged 6–19 years, living with HIV, had chronic lung disease (FEV z-score < -1) and had taken antiretroviral therapy (ART) for at least six months. We used multivariate logistic regression to identify risk factors for virological non-suppression after 48 weeks, among participants who were non-suppressed at enrolment.p < 0.001). Of those who were non-suppressed at enrolment, 87/136 (64.0%) were still non-suppressed at 48 weeks. Among this group non-suppression at 48 weeks was associated with not switching ART regimen ; p = 0.014) and with older age. Twelve participants switched regimen in Zimbabwe and none in Malawi.At enrolment 258 participants (64.6%) were on first-line ART and 152/347 (43.8%) had virological non-suppression. After 48 weeks 114/313 (36.4%) were non-suppressed. Participants non-suppressed at baseline had almost ten times higher odds of non-suppression at follow-up .Secondary cohort analysis of data from BREATHE trial (Clinicaltrials.gov  The scale-up of paediatric antiretroviral therapy (ART) programmes in sub-Saharan Africa has resulted in dramatically improved survival of children with HIV and a growing population of adolescents living with HIV. Several studies have shown that virological outcomes of children and adolescents are worse than those of adults. The most recent Population Based HIV Impact Assessment (PHIA) survey in Zimbabwe, which was done from 2015–16  used the 1000 copies/ml cut-off to define viral non-suppression, which was pragmatic with no guidance on how to address low-level viraemia. This has since been updated, and the WHO consolidated guidelines of July 2021 [Less than half of participants (47.9%) were virally suppressed at both time points. Participants who had a low-level viraemia (VL 50–999 copies/mL) at enrolment were more likely to progress to a viral load ≥ 1000 copies/mL by 48 weeks, compared to those who were fully suppressed at baseline, although this finding was not statistically significant  , which suly 2021  advise eIt is not surprising that there was strong evidence for an association between staying on the same ART regimen and having unsuppressed viral load at follow-up, given that the majority of participants had been on ART for several years and could have developed resistance mutations to their current treatment. There was also strong evidence for an association of older age (16–19 years) with unsuppressed viral load at follow-up, despite this age group being more likely to have had an ART regimen change compared to younger participants. This could point to ongoing adherence problems in older adolescents, and the need for tailored adherence interventions for this group. Longer duration on ART was also associated with the outcome, possibly due to treatment fatigue and increased risk of having developed treatment resistance due to previous episodes of poor adherence.Nearly 70% of participants who were unsuppressed at baseline and who remained on first line ART still had unsuppressed viral loads after 48 weeks. Because genotypic resistance testing was not available, it is not possible to know what proportion of these participants had resistance to first line drugs versus the proportion who had suboptimal adherence to an effective regimen, and could potentially suppress their viral load with the correct adherence support. There is accumulating evidence of ART resistance levels among adolescents in Zimbabwe. Out of 102 children and adolescents in Harare with virological failure in 2012, 67.6% had ≥ 1 clinically significant mutation . In 2016No regimen switches were reported in Malawi, while in Zimbabwe only 14 participants switched from a first line NNRTI to a second line PI-regimen. In both these countries, outpatient medical records include a paper health passport that is patient-held, and which the participants could bring along to study visits. It is possible that more regimen switches could have taken place and not been recorded in these health passports, or that a patient may have several health passports, but local clinical staff confirmed that it is likely that no Malawian and only few Zimbabwean participants switched to second line ART. Previous studies have described similar findings , 21. It We acknowledge several study limitations. The main aim of the BREATHE trial was to assess a change in lung function in response to azithromycin treatment, rather than virological outcomes . Some inEarly adherence interventions are important to ensure sustained viral suppression. This should start at diagnosis and ART initiation and continue throughout the lifelong treatment period. Enhanced adherence support should be available for all patients with detectable viral load levels while on ART, ideally starting from low viraemia levels, and intensified for those ≥ 1000 copies/mL. This will protect the first line regimen by decreasing the risk of resistance mutations developing and avoid the need for second line regimens that are more expensive, have higher pill burdens and more side effects.Participants who did switch regimen were much less likely to have viral non-suppression at follow-up. This emphasizes the importance of correct and timely management of unsuppressed viral load. Further research to understand the reasons for low rates of regimen switches from first to second line ART for children and adolescents with virological failure could be in the form of ART record reviews to assess clinical practice, interviews with clinical staff and adherence supporters to determine their knowledge, attitudes, skills and confidence levels in managing adolescents with unsuppressed viral loads, and reviewing data on drug stock-outs, unavailability of viral load testing, and missed or late appointments. The findings of such research can guide policy makers and implementers to take measures to ensure CALHIV have access to the support and treatment they need to sustain viral suppression.