The availability and accessibility of effective antiretroviral therapy (ART) for people living with HIV (PLWH) has substantially improved in the past two decades in resource-limited settings. Therefore, evaluation of survival is needed in the current setting.We retrospectively analyzed secondary data of the national AIDS program database from national health security region number 4 among PLWH who were ART-naive between January 2014 and December 2018. All PLWH were followed until December 2019 to evaluate their survival status and possible risk factors related to death.3. Regarding medical care benefits, 46% had a universal health coverage scheme, 34% had a national social security scheme, and 2% had a civil servants medical benefit scheme. A total of 2142 (15%) mortalities occurred during the total follow-up period of 28,254 patient-years. The mortality rate was 7.5 (95% CI 7.2–7.9) per 100 person-years. Survival rates at 1, 2, 3, 4 and 5 years after HIV registration were 88.2% (95% CI 87.6–88.7%), 85.3% (95% CI 84.6–85.9%), 82.9% (95% CI 81.9–83.4%), 81.3% (95% CI 80.5–82.0%) and 75.1% (95% CI 73.5–76.8%), respectively. The Cox proportional hazards model showed that all-cause mortality was associated with a history of ART switching , major opportunistic infections during ART , baseline CD4 count ≤ 200 vs. > 500 cells/mm3 , age ≥ 50 vs. < 30 years , and receiving nevirapine-based regimens.A total of 42,229 PLWH were identified, of which 14,053 were ART-naive and thus enrolled in the study. Sixty-seven percent were male, the mean ± SD age was 35 ± 12 years, and the median (IQR) baseline CD4 count was 162 (44–353) cells/mmThis study demonstrated the substantial mortality rate over the consecutive 5 years of the follow-up period among PLWH who received ART in a resource-limited setting. Early case finding and prompt initiation of ART as well as continuous HIV care are a cornerstone to improve survival. Currently, there is an estimated 37.7 million people living with HIV (PLWH) globally . In ThaiAccess to ART in Thailand has continuously increased, resulting in enormous progress with virus suppression to achieve the third 90 target of UNAIDS in recent years, and the estimated number of AIDS-related deaths has gradually declined, but it is still more than 10,000 cases per year . StudiesA retrospective data review study was conducted among PLWH who were registered in the national AIDS program database at national health security office region 4, which comprised eight provinces, including the Nonthaburi, Lopburi, Singhburi, Saraburi, Ayutthaya, Angthong, Nakhonnayok, and Pathumthani provinces. All 12 health districts in the country are responsible for the approximately 3–6 million people living in the provinces of each health district [The primary outcome of interest was time from HIV registration in the database to death, which was calculated by subtracting the date of death from the date on which the patient was registered. The patients were censored at the date of the last visit if they were lost to follow-up or censored at the date of referral. The patients’ vital status in this national HIV database was checked to differentiate between those who lost to follow-up and those who had died. The secondary objectives were to determine the possible risk factors related to death. Possible risk factors along with other data collected were studied. These included patients’ demographics, i.e., sex measured as male or female, baseline CD4 cell count upon registration, history of major opportunistic infections (OIs) prior registration measured as yes or no, major OIs during the follow-up period measured as yes or no, major opportunistic infection was classified according to WHO clinical stage IV , medicalU test were used to compare categorical and continuous variables between the two groups, respectively. The Kaplan–Meier method was used to estimate the overall survival and the median time to death after HIV registration in the national HIV program database. The log-rank test was used to compare the median time to death among groups. The present study applied Cox regression for all explanatory factors effecting and adjusted all factors affected on the survival rate. Cox proportional hazards model was used to determine the chance of death after HIV registration by adjusting for confounding factors, such as sex, previous OIs, baseline CD4 cell count, medical care benefit upon national AIDS program database registration, history of ART switching due to any reason and initial ART regimen. The hazard ratio (HR) and its 95% confidence interval (CI) were estimated. All analyses were performed using STATA version 15.1 . A p value less than 0.05 was considered statistically significant.The mean ± standard deviation (SD) used when the numerical data were normally distributed while the median  was used when skewed and frequencies (%) are used to describe PLWH characteristics in each group. The chi-squared test and Mann–Whitney 3. The patients in the nonsurviving group had a higher proportion of older age, history of OIs before HIV registration, OIs during the follow-up period, received nevirapine-based ART regimen, lower baseline CD4 cell count, switching ART regimen during follow-up period than the patients in the surviving group (p < 0.05).Based upon data from the national AIDS program database, a total of 42,229 PLWH were identified of which 14,053 were ART naive and enrolled in the study. Figure A total of 11,911 (85%) PLWH were alive during the follow-up period, and 2142 (15%) mortalities occurred in a total follow-up period of 28,254 patient-years. The mortality rate accounted for 7.5 (95% CI 7.2–7.9) per 100 person-years. The probability of survival after HIV registration estimated by the Kaplan–Meier method is shown in Fig. 3 and 90% presented with CD4 counts < 500 cells/mm3. Although HIV prevalence is significantly declining in Thailand due to successful HIV prevention programs, with the rate decreasing by approximately 60% between 2010 and 2018 [This study estimated the survival rate of PLWH at a recent period of time and related risk factors associated with death based on the national AIDS program database. The overall survival rate is relatively low when compared to our previous report that was conducted over a decade ago in a tertiary HIV referral center among patients coinfected with HIV and TB . In contand 2018 , which cThe WHO estimated that of the 40 million people living with HIV/AIDS in the world, approximately 2.8 million are 50 years and older . The preIn the present study, PLWH with major OIs after ART initiation were approximately twice as likely to die than those who did not have major OIs. Although the etiology of OIs cannot be retrieved from the database, tuberculosis is the leading cause of morbidity and mortality among PLWH worldwide, including Thailand . One majThere were a number of limitations in the present study. First, it is a retrospective study reviewing secondary data; hence, some details of patients’ clinical condition may be underestimated and missed, such as, details of ART complications, characteristics of major opportunistic infections, nutritional status, baseline and follow-up weights, and baseline and follow-up WHO clinical stage. Furthermore, data regarding adherence to ART is lacking. Almost all of the PLWH in this study were initiated with NNRTI-based ART, which is less durable than the current recommended ART with integrase inhibitor-based regimen, and better treatment outcomes can be achieved despite lower adherence . IntegraIn summary, this study demonstrated the substantial mortality rate over 5 consecutive years of the follow-up period. Patients who had a history of ART switching, major opportunistic infections, a lower baseline CD4 count, an older age, and received nevirapine-based regimens had an increased risk of death. Further prospective interventional studies with the aim of decreasing morbidity and mortality are needed in Thai PLWH. Active early case finding and prompt initiation of ART, which durable and less long-term side effect regimens, as well as continuous HIV care are a cornerstone to improve survival.


Antiretroviral treatment (ART) has been associated with the development of certain cardiometabolic diseases (CMDs). The burden of CMDs amongst ART-experienced patients in sub-Saharan Africa was unknown.We quantified the burden of CMDs and identified the associated risk factors in a large treatment cohort on ART at a high-volume facility in Lesotho.In this retrospective cohort study, we extracted data from the daily dispensing electronic system and routine clinical records of 785 adults on ART between 2011 and 2015 in Maseru, Lesotho. CMD was defined as a diagnosis of hypertension, diabetes mellitus or dyslipidaemia (singly or collectively). Descriptive statistics were used to describe the disease burden; Kaplan–Meier curves and cause-specific Cox proportional hazards models were fitted to examine the impact of the ART regimen and identify the risk factors associated with the occurrence of CMD.P = 0.72). Higher body mass index (BMI) was associated with the occurrence of diabetes mellitus .Of the 785 participants, 473 (60%) were women. The median age of the group was 42 years, interquartile range (IQR), 36–51 years. The overall incidence of CMD was 5.6  per 100 person-months of follow-up. The median time to onset of CMD was 16.6 months (IQR = 7.4–23.4). ART was not associated with the occurrence of CMD (cause-specific hazard ratio [CHR] = 1.55; 95% CI = 0.14–16.85; The incidence of CMD in this relatively young patient population is low yet noteworthy. We recommend that patients living with HIV and AIDS should be routinely screened for CMD. Higher BMI is generally associated with the occurrence of CMD. Antiretroviral treatments, specifically protease inhibitors (PIs), are associated with the accelerated progression of metabolic complications in PLWH, while some non-nucleoside reverse transcriptase inhibitors (NNRTIs) are also reported to have metabolic side-effects.8Since the introduction of ART, approximately 4 million PLWH have survived beyond 50 years of age.Despite good management and control, elderly patients on ART have a higher risk of CMDs  compared to their counterparts in the general population, because of interactions between the natural risk factors that develop with aging and the effects of ART and HIV.9 Exposure to ART for longer than 6 months is also associated with higher serum triglycerides levels, total cholesterol, low-density lipoprotein cholesterol, insulin resistance and cardiovascular disease.12Cumulative exposure to ART is associated with an increase in the risk of myocardial infarction per year of exposure .13 There is a dearth of accurate estimates for the global prevalence and incidence of diabetes mellitus and dyslipidaemia among ART-experienced patients. In Brazil, patients who had been on ART for three years had a cumulative incidence of dyslipidaemia of 22.3% and diabetes mellitus of 5.8%.14The global estimated prevalence of hypertension is 34.7% among ART-experienced patients and 12.7% among ART-naïve patients.The burden of CMD in SSA is increasing parallel to the changing landscape of HIV care. It is projected that deaths attributed to cardiovascular disease will double to 2.4 million in 2030 relative to reports from 2000.15These data suggest that cardiovascular disease is becoming a major public health problem in SSA, competing with infectious diseases for limited health resources.17 The understanding of the effect of ART on the risk of CMDs is crucial to enable an accurate estimation and the assessment of appropriate interventions for the management of CMDs in PLWH.19 Understanding the interaction between ART and CMD is crucial for managing CMDs in PLWH.19 Being part of SSA, Lesotho is no exception and needs to be studied.Generally, little is known about ART-associated CMDs among ART-experienced PLWH in SSA, despite the region having the greatest burden of HIV infection and increasing access to ART.21 Of these, approximately 70% were enrolled in ART care and treatment.21 Lesotho thus has one of the highest burdens of HIV globally. In this study, we quantified the burden of CMD and identified the associated risk factors among PLWH in a large treatment cohort.There were approximately 306 000 PWLH in 2016/2017 in Lesotho, corresponding to 25.6% of the population.This retrospective cohort study used data from the daily dispensing electronic system and routine clinical records at Qoaling Filter Clinic, Maseru, South Africa, for the period May 2011 to May 2015.Qoaling Filter Clinic is a high-volume public–private partnership primary healthcare facility located in Qoaling constituency, which is approximately 8 km from the capital city of Lesotho, Maseru. In addition to HIV and AIDS care and tuberculosis (TB) management services, the clinic offers dental services, ophthalmology, antenatal care, pharmacy services, family planning, minor procedures and wound care services and outpatient department services for minor ailments and some chronic conditions. Patients access services for a fee subsidised by the government of Lesotho except for HIV and AIDS care services, which are free of charge.In Lesotho, ART is currently initiated in all people testing positive for HIV as soon as they are ready to commit to treatment, regardless of the availability of baseline laboratory tests.3), HIV serodiscordant couples with TB or hepatitis B co-infection, and HIV-infected women who were pregnant or lactating. Prior to ART initiation, mandatory baseline laboratory investigations are CD4 count, cryptococcal antigen screening for adolescents and adults with CD4 counts of < 100 cells/mm, hepatitis C serology, haemoglobin (Hb) or full blood count, Alanine Aminotranferase (ALT) and creatinine, urine dipstick , pregnancy test, blood glucose, cholesterol and triglycerides for PI-based regimens.22 The country’s 2014 guidelines on the use of ART for HIV prevention and treatment recommended ART regimens are shown in 22However, prior to 2016, a thorough clinical evaluation coupled with baseline laboratory investigations was mandatory to determine the patients’ eligibility for ART. Adults and adolescents were eligible for ART initiation under certain conditions, that is if they were at World Health Organization (WHO) clinical stage 3 or 4 (regardless of CD4 count) or WHO clinical stage 1 or 2  co-infected patients already on nevirapine because of interactions between MDR-TB medication and efavirenz.Because of its lower potency and increased risk of liver toxicity when initiated at CD4 counts of ≥ 250 cells/mmPatient records were included in the study if the patient was older than 18 years old, initiated onto the standard first- or second-line ART regimen for one year or longer and had documented viral load measurements. Patients who already had diabetes mellitus, hypertension, obesity or dyslipidaemia at ART initiation were excluded.23 Using STATA version 14 , we derived a minimum sample size of 279 participants – 118 men  and 161 women . Given the available database of patients, we increased the detection value to an HR value of 3 or greater to achieve a more optimal minimum sample of 785 patients. After the above calculation, from the facility spreadsheet of approximately 4000 patients currently on ART, we filtered the data for eligible patients.We calculated the required sample size as specified by a prospective cohort study of the incidence of lipodystrophy and metabolic disorders in patients starting on NNRTIs in Benin.We then selected 785 patients through Microsoft Excel random selection function, and extracted the pertinent data from clinical records and the daily electronic dispensing system.The primary outcome was the occurrence of CMD which include conditions like hypertension, diabetes mellitus or dyslipidaemia. We assumed that patients had hypertension if they were on antihypertensive medication, similarly had dyslipidaemia if they were on lipid-lowering medication and had diabetes mellitus if they were being treated for diabetes mellitus.The predictor variables included demographic and clinical characteristics such as age, gender, body mass index (BMI), viral load, CD4 cell count and a history of hypertension, diabetes mellitus or dyslipidaemia. The ART regimen was the main exposure variable. Other variables included treatment adherence, the date of ART initiation, ART, duration of ART in months, date of diagnosis and initiation dates of hypertension treatment, diabetes mellitus treatment and dyslipidaemia treatment.Data were captured using EpiData version 3.1 and verified using the double-entry method. Data were exported to STATA version 14.0 (Stata Corp.) for analysis.The data were summarised using descriptive statistics. The mean and standard deviation were calculated for normally distributed numerical variables, while the median and interquartile ranges (IQRs) were used to describe the skewed numerical variables. The categorical variables were summarised using frequencies and proportions.24 until the earliest of (1) the study outcome (any one of the three CMDs); (2) death; (3) loss to follow-up (defined as at least 90 days late for the last scheduled clinic visit); (4) transferring out or (5) the close of the dataset (May 2015).The person-time accrued was calculated from six months after treatment initiation, which is the earliest time possible for viral load monitoring and other recommended routine laboratory tests after baseline tests,25We measured the incidence of CMDs as the total number of new cases of CMD at every 6-month follow-up divided by the total number of patients at risk during the same period, expressed per 100 person-months of follow-up. The incidence rates were stratified by first-line and second-line regimens. To estimate the hazards of developing CMD beyond a specified 6-month period, we generated Kaplan–Meier survival curves. The log-rank test was used to compare the survival curves of participants on NNRTI and PI-based regimens.P-values < 0.05 were considered statistically significant. We used a cause-specific Cox proportional hazards regression model to investigate the impact of exposure to ART, as well as the effect of age, BMI, Hb, CD4 cell count and viral load on the development of CMDs.26All This study was approved by the Ministry of Health (Lesotho) Research Ethics Committee (reference number 56/2019) and the University of Pretoria Faculty of Health Sciences Research Ethics Committee (reference number ID36-2019).n = 473), with a median age of 42 years (IQR = 36–51) and a median duration on ART of 15 months (IQR = 3–49). The participants had a mean BMI of 25.4 kg/m2 (s.d. = 8.42) and a Hb level of 13.9 g/dL (s.d. = 1.82). Overall, 63.7% (n = 500) of participants had a CD4 count of < 500 copies/mm3. The participants were stratified according to their current ART regimen . All the PI-based regimen participants were initiated onto second-line regimens and the clinical records revealed no history of the conditions under investigation at the beginning of the study. Description of the average demographic and clinical characteristics is given in For the period 2011–2015, we randomly selected 785 participants through the Microsoft Excel random selection (simple random sampling) programme. Most of the participants were women  participants developed both hypertension and diabetes mellitus and there was only one case in each of the other multimorbidity combinations. The incidence rate was 5.6 (95% CI = 4.4–7.1), 5.7 (95% CI = 4.4–7.3) and 5.5 (95% CI = 3.3–8.9) per 100 person-months of follow-up for CMD, hypertension and diabetes mellitus, respectively .22 therefore, we found it relevant to use 6-month segments in our Kaplan–Meier survival curves. From the date of ART initiation, the median time to onset was 16.6 months for CMD (IQR = 7.4–23.4), 15.6 months for hypertension (IQR = 7.4–23.4) and 19.5 months for diabetes mellitus (IQR = 12.1–24.9).P = 0.158), hypertension  or diabetes mellitus . A higher BMI was significantly associated with the occurrence of diabetes mellitus   .29We explored the incidence of and identified the risk factors for CMDs among PLWH in a large treatment cohort in Lesotho. In this relatively young cohort of PLWH, there was a low incidence of CMDs, with the treatment regimen having little effect on the incidence or the time to onset of CMDs. A higher BMI was the only predictive factor for diabetes mellitus. Our findings provide valuable baseline information about the influence of ART on the incidence of CMDs in PLWH in Africa, especially Lesotho, which has the second-highest prevalence of HIV after Eswatini.30 In our study, approximately 90% of patients were virally suppressed, which is similar to 88% reported in 2017.31 Most patients had a CD4 count below 500 cells/mm3, which is contrary to the main goals of ART. Antiretroviral treatment aims to achieve viral suppression in the shortest time possible, sustaining viral suppression and thus allowing patients’ CD4 counts to increase.32 Most patients in our study (72.4%) demonstrated good treatment adherence, taking at least 95% of the medication in the correct amount, at the correct time.24Because we randomly selected 785 patients from a treatment database, we were able to select a sample that was representative of the population available in our patient database. Our study comprised 60.3% (473) women and 39.7% (312) men, equivalent to the ratios reported in the 2019 UNAIDS report. The UNAIDS data indicated that the numbers of women and men older than 15 years living with HIV in 2018 were 190 000 and 130 000, a ratio of 59.4% women and 40.6% men, respectively.13In Lesotho, PLWH had an incidence rate of hypertension of 5.7 (95% CI = 4.4–7.2) per 100 person-months of follow-up or a cumulative incidence of 8.5%, which is much lower than 34.7% reported by Xu et al.33Prioreschi et al. reported incidence rates of type 2 diabetes mellitus amongst PLWH ranging from 4 to 59 per 1000 person-years in PLWH on ART.In our study, PWLH had a diabetes mellitus incidence rate within the above range: 5.3 (95% CI = 3.3–8.4) per 100 person-months of follow-up or 22.3 per 1000 person-years of follow-up.34The proportions and incidence rates reported in our study are lower than those reported in other studies; however, the future projections for non-communicable disease (NCD) burdens are concerning. It is projected that the proportion of people suffering from at least one key NCD in 2035 will increase by 26% among PLWH compared to 6% among people not living with HIV. Adult PLWH will be twice as likely to suffer from at least one key NCD in 2035 compared to uninfected adults.10 As portrayed in In our study, hypertension first occurred at approximately 6 months, which is similar to findings reported by Wu et al.The main factors associated with metabolic disorders in PLWH include a high proportion of central body fat, older age, higher BMI and high calorie, sugar and carbohydrate intake.35The HIV-related factors include a high viral load and exposure to certain antiretroviral drugs, such as PIs.36 were not associated with either of the two conditions.In this study, a higher BMI was significantly associated with the occurrence of diabetes mellitus. Higher BMI is a well-known risk factor for both hypertension and diabetes; however, the HIV-associated factors such as the CD4 count and the duration and type of ART regimen20 of PLWH enrolled on ART. Our study is the first to report on the risk factors associated with CMD among PLWH, contributing to the knowledge gap identified in the SSA region.Our study was conducted in an SSA country, representing the highest HIV burden globally, with most (90.2%)Our findings can be used as a baseline for future planning for resource allocation for comprehensive management of HIV and the prediction of the likely economic implications for HIV care. The findings from this study can be used to assess the need for integration of HIV and NCD programmes. Other SSA countries of similar demographic characteristics and socio-economic status that still lack data on the burden and risk factors of CMDs and the associated risk factors can adapt the findings for baseline planning in their settings.Although we took a random sample, there were very few participants enrolled on the PI-based regimen. The findings on the PI-based group cannot be generalised to the general population receiving PI-based regimens for HIV infection management.Using secondary data is often associated with misclassification bias because of inappropriate recording of patients’ medical records; some participants shared similar unique numbers and hence, their documents were easily inappropriately filed. Finally, this study lacked ART-naïve PLWH or an uninfected age- and gender-matched group as a comparison to observe whether the incidence rates and risk factors were different between the two groups.The incidence of CMD in this patient population is low, yet noteworthy. There is a need for routine screening for CMDs in PLWH.37 Integrating and harmonising HIV and NCD care services can greatly benefit the care of PLWH.To enable early detection and early stage treatment, we recommend that routine screening for CMDs should be included as part of the standard package among PLWH on ART in countries with a high burden of HIV, such as Lesotho. It has been confirmed that ART service delivery models aimed at decongesting local health facilities, encouraging patient retention in care and enhancing adherence to medication are more effective than corresponding facility-based care and superior to individual-based models.


Acanthamoeba keratitis is challenging to treat and thought to result in poor outcomes, but very few comparative studies exist to assess whether ulcers caused by Acanthamoeba are worse than those caused by bacteria or fungus.Acanthamoeba keratitis diagnosed from January 2006 to June 2011 at an eye hospital in South India were identified from the microbiology database. Random samples of the same number of cases of bacterial and fungal keratitis, matched by year, were identified from the same database in order to compare outcomes between the three types of organism. The main outcomes were the time until the following events: re-epithelialization, discontinuation of antimicrobials, perforation/keratoplasty, elevated intraocular pressure, and new cataract.In a retrospective cohort study, all cases of smear- or culture-proven Acanthamoeba keratitis, 30 days for fungal keratitis, and 25 days for bacterial keratitis, and the median time until discontinuation of antimicrobial therapy was 100 days for Acanthamoeba keratitis, 49 days for fungal keratitis, and 40 days for bacterial keratitis. Compared to the other two organisms, Acanthamoeba ulcers took significantly longer to re-epithelialize  and had significantly longer courses of antimicrobials . No statistically significant difference was observed between the three organisms for the other time-to-event outcomes.The median time until re-epithelialization was 113 days for Acanthamoeba keratitis was more difficult to treat and had worse clinical outcomes than bacterial or fungal ulcers, highlighting the lack of adequate treatment regimens for this infection. Acanthamoeba keratitis is one of the most severe corneal infections [Acanthamoeba cysts are extremely resistant to a variety of medications, resulting in long treatment courses [Acanthamoeba keratitis are worse than those of bacterial keratitis [Acanthamoeba keratitis, few studies have compared outcomes of different causative organisms of keratitis [Acanthamoeba, bacterial, and fungal keratitis. We hypothesized that Acanthamoeba keratitis would have worse clinical outcomes than the other two organisms.fections . Acantha courses . Poor ou courses , 4. Manyeratitis , 6. Whileratitis –9, and eeratitis . Here, wAcanthamoeba keratitis from the microbiology database at Aravind Eye Hospital in Madurai, India from January 2006 to June 2011 [In this retrospective cohort study, we identified all cases of smear- or culture-proven Ethical approval for this study was obtained from the Committee for Human Research at the University of California, San Francisco, and from the Institutional Review Board (IRB) at Aravind Eye Hospital, Madurai. The IRBs waived the requirement of informed consent for this retrospective study. Data were fully anonymized before analysis. This research adhered to the tenets of the Declaration of Helsinki.Acanthamoeba keratitis with polyhexamethylene biguanide (PHMB) monotherapy without topical corticosteroids. The details of antimicrobial therapy were not recorded for this study.During the study period bacterial keratitis was typically treated with topical moxifloxacin monotherapy with or without topical corticosteroids, fungal keratitis with topical natamycin or voriconazole, and Presenting visual acuity  was recorded in the medical records in Snellen notation and transformed to logMAR acuity for all analyses; logMAR values of 1.9 and 2.3 were used to represent counting fingers and hand motion vision respectively, and values of 2.7 and 3.0 were extrapolated to represent vision of light perception and no light perception . Kaplan-Acanthamoeba keratitis cases were listed in the microbiological database at Aravind Eye Hospital-Madurai, of which 93 (81%) had medical records available for review. We randomly selected 115 bacterial and 115 fungal cases from the same time period and successfully located medical records for 95 (83%) of the bacterial cases and 103 (90%) of the fungal cases. The causative species have been reported previously; bacterial infections were predominantly Streptococcus pneumoniae (38%) and Pseudomonas aeruginosa (29%) and fungal infections were predominantly Fusarium (31%) and Aspergillus (25%) species [Acanthamoeba keratitis.From January 2006 to June 2011, 115 Acanthamoeba patients, 56 (59%) bacterial keratitis patients, and 62 (60%) fungal keratitis patients. There was not strong evidence of differential loss to follow-up by organism . Follow-up of at least 1 month was documented for 70 (75%) organism . NonetheAcanthamoeba ulcers took significantly longer to re-epithelialize  and had significantly longer courses of antimicrobials . No statistically significant difference was observed between the three organisms for the other time-to-event outcomes.Kaplan-Meier curves for time until re-epithelialization, discontinuation of antimicrobials, perforation/therapeutic keratoplasty, cataract, and intraocular pressure elevation are shown in Acanthamoeba keratitis re-epithelialized more slowly and remained on antimicrobial therapy for a longer duration of time than bacterial or fungal ulcers.In this comparative observational study, eyes with Acanthamoeba keratitis took a median of 113 days, which was about 4.5 times as long as bacterial ulcers (median 25 days) and 3.5 times as long as fungal ulcers (median 30 days). Perhaps related to this, Acanthamoeba cases were continued on antimicrobial therapy for a median of 100 days, which was 2.5 times as long as bacterial ulcers (median 40 days) and approximately twice as long as fungal ulcers (median 49 days). These findings are consistent with prior studies of Acanthamoeba keratitis where months-long treatment courses are the norm [As depicted in Acanthamoeba ulcers. This finding is consistent with previous studies have reported high rates of corneal perforation and/or need for therapeutic keratoplasty in fungal keratitis [Acanthamoeba keratitis may depend on prior exposure to corticosteroids. In one study, 43% of Acanthamoeba keratitis cases with prior corticosteroid use required therapeutic keratoplasty while only 9% without prior corticosteroids needed keratoplasty [Although the association did not reach statistical significance, perforation and/or therapeutic keratoplasty was more common in fungal than bacterial or eratitis –16. Othetoplasty . The impAcanthamoeba was typically treated with biguanide monotherapy. While monotherapy is commonly used by some cornea specialists, others prefer a combination of agents [This study should be interpreted in light of several limitations. A chief limitation is the retrospective nature of the study and inherent missing data, loss to follow-up, and potential for misclassification error, all of which can result in bias. A relatively large number of patients were lost to follow-up before 6 months, making comparisons of post-treatment visual acuity unreliable. Such high loss-to-follow-up rates are not entirely surprising since the average duration of therapy is 1–2 months and there was no incentive offered to participants to return. We attempted to address the major potential confounders in a multivariable analysis, but unmeasured confounders  could have resulted in bias. We addressed the loss to follow-up by applying a censoring weight to account for the possibility of differential loss to follow-up between the three types of ulcers. Outcomes such as a newly developed cataract or glaucoma may have been missed or gone undocumented in the chart because the data was not collected prospectively. The details of treatment were not recorded specifically for each patient. However, because the data come from the cornea clinic of a single eye hospital, all patients with a particular organism were treated according to similar protocols. Moreover, in our causal framework the treatment is intimately tied to the organism, and if anything, might be a mediating factor rather than a confounder. f agents . It is uAcanthamoeba keratitis results in worse outcomes than fungal or bacterial keratitis. In this retrospective cohort study, we confirmed that, on average, patients with Acanthamoeba ulcers had longer-re-epithelialization times and longer durations of antimicrobial therapy. Prospective interventional trials are a challenging prospect for Acanthamoeba keratitis given the paucity of cases, but would be helpful to explore optimal treatment strategies.Clinical experience suggests that S1 Data(CSV)Click here for additional data file.


Human Immuno-Deficiency Virus (HIV) remains one of the world’s significant public health challenges. Viral suppression is the key indicator for treatment success in People living with HIV (PLHIV). We determined the level of viral suppression, and its associated factors among PLHIV attending Federal Medical Centre Katsina (FMC Katsina), Nigeria.This retrospective descriptive cross-sectional study was conducted on 913 HIV positive adults enrolled in care between January 2009 and December 2019. Information on socio-demographics, clinical, immunological, Viral load (VL), and other relevant parameters were extracted from the patients’ care records. The primary outcome was the proportion of patients that achieved viral suppression. We also analyzed variables that were associated with VL suppression.Of 913, records of 831 (91.0%) registered patients were analyzed. During the period, 751 (90.4%) achieved viral suppression, 427 (51.4%) had CD4 counts  ≥ 500 and 477 (57.4%) were on HAART for ≥ 5 years. Majority, 793 (95.4%) were on first-line HAART regimen (Tenofovir-Lamivudine-Dolutegravir or Abacavir-Lamivudine-Dolutegravir), and 809 (97.4%) in the non-advanced stage (WHO stages 1 and 2). The median (interquartile range) of viral load was 20 (20–40) vs 19,989  cp/ml in virally suppressed, and unsuppressed  respectively. Factors associated with viral suppression included being unemployed , educated , having a baseline CD4 count ≥ 500 cells/µl , and being on first line HAART regimen .Our study demonstrated a good viral suppression among PLHIV on HAART. Variables associated with viral suppression included unemployment, formal education, high baseline CD4 count, and first line HAART regimen. Human Immuno-Deficiency Virus (HIV) is a leading cause of infections worldwide despite the success of highly active antiretroviral therapy (HAART) . It remaThe 90-90-90 target by UNAIDS envisages that by 2020, 90% of PLHIV will know their HIV status, 90% of people who know their HIV-positive status will be accessing treatment and 90% of people on treatment will have suppressed viral loads . HoweverViral load (VL) measurement is the gold standard for monitoring treatment success. PLHIV on HAART with unsuppressed viral load have a higher risk of disease progression, transmission, and mortality . AvailabThe objective of this study was to determine the level of viral suppression and its associated factors among HIV positive adults attending the HIV clinic at FMC Katsina, Nigeria.This retrospective cross-sectional descriptive study was conducted from January 2009 to December 2019 at FMC, Katsina. The hospital is a 1000 bed capacity, tertiary health facility. It serves as a referral center for both private and other public health facilities in the state, neighboring states, and the Niger Republic. The HIV clinic otherwise referred to as Action Aid clinic was established in 2006 and provides services for the diagnosis, treatment, and prevention of HIV, inclusive of free counseling and testing. It can accommodate about two hundred patients per clinic day and further subdivided into units. The HIV clinic units included the adult ART clinic, Paediatrics ART unit, the Prevention of Mother-to-Child Transmission (PMTCT) unit, HIV/TB co-infection unit, Pharmacy unit and the laboratory.The source of data was from the database of the HIV clinic obtained from all PLHIV enrolled in ART care from January 2009 to December 2019 at FMC Katsina. A total of 1034 clients were registered within this period. The database provided information on socio-demographics, clinical, immunological, virological and other relevant parameters of patients. A total number of 913 adult clients were enrolled within the study period and they were all considered as the study subjects. We excluded children and adolescents less than 18 years on HAART. We used VL testing data for samples corresponding to HIV positive patients who had been on HAART for at least 6 months. Where there were more than one VL results, the most recent  was used for the data. We abstracted data on VL testing results (for plasma) measured in terms of viral RNA copies/ml of blood. Before 2017, virological monitoring was carried out only in those with clinical suspicion of failure or poor adherence. Following policy change in the country and update of National guideline in 2018, all enrolled patients among the PLHIV had a minimum of yearly viral load monitoring. However, where the viral load was above the thresholds of 1000 copies/ml, intensified adherence counseling were carried out and viral load assays repeated within three to 6 months.The primary outcome was virological suppression, defined as having ≤ 1000 copies of viral RNA/ml of blood for plasma, as provided by the National guideline for treatment and control of HIV/AIDS 2018. The secondary outcome of this study was factors associated with viral suppression.Base line CD4 count: This was the CD4 count at the commencement of HAART.2), normal or healthy weight (18.5 to 24.9 kg/m2), overweight (25 to 29.9 kg/m2) and obese (≥ 30 kg/m2).Body mass index (BMI): The body mass index was determined by dividing the weight in kilogram with height in metre squared and classified using Centres for Disease Control (CDC) into underweight . The VL measurements were carried-out in 2018 and 2019.One of the authors extracted the data into Microsoft Excel spreadsheet and this was verified independently by two other co-authors to ensure accuracy and consistency of the data.This was done using Epi-info version 7 and IBM SPSS statistics for Windows, version 25 . The proportion of subjects with virological suppression was expressed as percent. We compared the socio-demograhics , BMI categories and distance from the health facility using chi-square and Fischer’s exact test where apporiate between the subjects that were virally suppressed and those without viral suppression. Besides, clinical and laboratory parameters  were also compared between those that were virologically suppressed and unsuppressed subjects using Chi-square and Fischer’s exact test as appropriate. The viral loads were summarized as median with interquartile range (IQR) and compared using Man-Whitney U test between the two groups. Based on the literature, some variables  along with other variables  with p-value less than 0.25 on the bivariate analysis were entered into binary logistic regression model to determine factors that were associated with virological suppression. The p-value for level of statistical significance was set at < 0.05.During the study period, a total of 1034 subjects including children were enrolled into care at the centre. Out of the 1034 registered subjects, 913 (88.3%) were adults. Of the 913 adults, we excluded 82 subjects . Thus, we included 831 (91.0%) in the final data analysis as highlighted in Fig. The subjects age ranged from 18 to 77 years. The mean age (standard deviation) of the subjects was 34.5 ± 9.3 years. Most of the subjects were below the age of 50 years . There were more females, 578 (69.6%) than males. A total of 709 (85.3%) were unemployed while 78.6% were married as shown in Table The median viral load was 20 (20–74) cp/ml in the study subjects. The median viral load in those that achieved viral suppression range from 20 to 925 cp/ml, while in those without viral suppression, VL range from 1170 to 2,468,443.0). In 2018, out of 87 subjects, 77 (88.5%) had viral suppression. Similarly, in 2019, out of 774 subjects, 704 (91.0%) had achieved viral suppression. The duration on HAART, TB status, WHO staging of the disease, and pregnancy status were not related to viral suppression. However, baseline CD4 count and HAART regimens were associated with viral suppression  due to missing information. Although we compared with global set target of 90-90-90, the samples were not randomly drawn. Hence, our findings may not be generalizable. Furthermore, being a retrospective study, we could not adjust for some potential confounders, which may have affected our findings.Our study demonstrates a low level of viral non-suppression among PLHIV on HAART and the target of 90% viral suppression in the PLHIV on HAART by the USAID is achievable in resource constraint settings. Also, having a high baseline CD4 count, being employed, uneducated and being on first-line HAART are predictive of viral load suppression.


Non-communicable diseases are increasing faster in HIV/AIDS patients than in the general population. We studied the association between hypertension and other possible confounding factors on viral load and CD4-cell counts in hypertensive and non-hypertensive HIV/AIDS patients receiving antiretroviral therapy (ART) at a large hospital in Eswatini over a 4-year period. We performed a retrospective longitudinal review of the medical records of 560 ART patients divided into non-hypertension and hypertension groups (n = 325 and n = 235) from July 27 to September 8, 2018. Generalized Estimated Equation was used to analyze the longitudinal data. Hypertensive patients were more likely to have improved CD4-cell counts than non-hypertensive patients . ART patients with hypertension were more likely to have detectable viral loads, though not significant (OR = 1.37 [0.77–2.43]). In non-hypertensive patients, second line ART was significantly associated with viral load (OR = 8.61 [2.93–25.34]) and adverse side effects (OR = 3.50 [1.06–11.54]), while isoniazid preventive therapy was significantly associated with CD4-cell counts (OR = 1.68 [1.16–2.45]). In hypertensive patients, factors associated with viral load were WHO HIV stage (OR = 2.84 [1.03–7.85]) and adherence (OR = 8.08 [1.33–49.04]). In both groups, CD4-cell counts significantly and steadily increased over time . Results show a significant association between hypertension and CD4 cell counts but not viral load. In ART patients with and without hypertension, the factors associated with prognostic markers were different. More attention may need to be paid to ART patients with well controlled HIV status to monitoring and controlling of hypertension status. Hypertension, is a major risk factor for cardiovascular, cerebrovascular, and renal disorders, and directly contribute to about 58% deaths attributed to cardiovascular diseases2, hence for this study it has been chosen as a marker for NCDs. It is often observed among people living with HIV/AIDS (PLHIV), especially in low- and middle-income countries3 and has been associated with risk factors such as increased body weight, increasing age, ethnicity, hypersodic diet, alcohol abuse, sedentary lifestyle, unfavorable socioeconomic factors, genetic predisposition, and other cardiovascular risk factors7. Associations between markers of prognosis of HIV infection such as viral load, duration of infection and CD4-cell count have also been associated with cardiovascular diseases9.Non-communicable diseases (NCDs) are responsible for 41 million deaths worldwide each year, and about 75% of these deaths occur in the low- and middle-income countries (which include the Sub-Saharan Africa). Cardiovascular diseases account for a large proportion 10. Almost 40 million (37.9) people were living with HIV in 2018, a year seeing 1.7 million new cases and 770,000 HIV/AIDS deaths worldwide11. Eswatini, located in the southern part of Africa, has the world’s highest prevalence of HIV/AIDS. In Eswatini 27% of the population being 15 years and older have HIV/AIDS12. However, the country has made great progress in the control of the disease. Based on the 2011 and 2017 household Swaziland HIV Incidence Measurement Surveys (SHIMS 1 and 2), which included blood sampling, Eswatini had reduced its incidence by half between 2011 and 2016 (2.4% vs. 1.70%)12.Sub-Sahara Africa  represents the most HIV/AIDS-affected part of the world, followed by Asia and the Pacific15. However, this increased survival puts PLHIV at greater risk to NCDs like among others hypertension and cardiovascular conditions16. While cardiovascular diseases have been associated with duration of infections as well as with viral load and CD4-cell counts (both prognostic markers for HIV)9, on the other hand, how the management of cardiovascular disease affects these prognostic markers for HIV are less known17. There has been several documentations or information in relation to the benefits of ART since its introduction into clinical practice. However, it remains unclear how well or how poorly NCDs are being managed in PLHIV19. It’s also unknown whether the co-existence of NCDs and HIV/AIDS will affect the progress of each other during their treatment. Nevertheless, there is evidence that the burden of NCDs like chronic cardiovascular conditions is increasing among PLHIV compared to the general population16. Due to the common co-existence of HIV/AIDS and NCDs, there is growing advocacy for integrating the healthcare of HIV/AIDS and NCDs. However, such a step is one of the most challenging as it requires the development, evaluation and promulgation of chronic care models that are culturally friendly, adoptable in resource-limited healthcare systems, and responsive to the local burden of diseases20.HIV/AIDS incidence reduction can be attributed to the introduction of antiretroviral therapy (ART). Antiretroviral therapy has transformed HIV/AIDS from a catastrophic disease to a manageable chronic disease21. WHO recommends that the viral load should be tested around 6 months after the initiation of ART, and yearly thereafter if the viral load has been successfully reduced22. CD4-cell counts provide an overall picture of the immune status of PLHIV and are often used to determine health status and decide when to initiate and discontinue the use of medications to treat opportunistic infections23.In patients who have no resistant mutations and who adhere to treatment strategies, ART-viral load reduction is expected to be achieved within 8 to 24 weeks24. About 85% (84.7) of those responded to Swaziland HIV Incidence Measurement Survey 2 reported knowing their HIV status, 87.4% of those who were HIV positive reported receiving ART, and 91.9% of those on ART reported successful viral load suppression. Prevalence of viral load suppression in all adults aged 15 years and older who were HIV positive was 73.1%. Younger HIV-positive adults (15–24 years old) were found to have the lowest success rate of reduced viral loads (50.6%) compared to all adults who were ≥ 15 years old12.In 2014, the UNAIDS launched its Fast-Track Strategy, also known as 90 (tested)-90 (treated)-90 (successfully treated) treatment target, hoping to improve the response to the HIV epidemic by various low- and middle-income countriesNo study has investigated the impact of NCDs on HIV-ART outcomes as yet, more especially in the Southern African region, especially with reference to hypertension. Therefore, we retrospectively reviewed 560 medical charts of one hospital treating PLHIV to identify those with and without hypertension and following the results of their annual viral load and CD4 cell count tests for 4 years and analyzed the data controlling for age, gender, treatment, adverse effects, adherence, and year.In this longitudinal study, we reviewed the medical charts of PLHIV at Raleigh Fitkin Memorial (RFM) Hospital in the central part of Eswatini to follow changes in viral load and CD4 cell count in ART patients with and without hypertension over a 4-year study period. As seen in Fig. 1. The reason for including patients who have been on ART for 2 years or more is that by such time, it is expected that ART would have a significant impact on the CD4-cell count and viral load. It is thus easy to determine the trend of the prognosis on the stipulated times of the study26. The main reason for excluding those who had hypertension after ART initiation is that we needed to exclude hypertension that might have resulted from ART, as it would have led to biasness in this study. The reason for excluding those who use hormonal therapy is that this factor is likely to be confounding for this study as it can directly affect the prognosis of HIV/AIDS, and/or hypertension according to some studies30.Patients 30 years old or older were the ones selected for this study because they are generally more susceptible to NCDs compared to the younger age groups. According to the WHO, 15 million of deaths attributed to NCDs occur between the ages of 30 and 69 years., is relatively 35 U/L32. For patients to be included in the study, their AST and ALT had to be < 35 U/L before ART initiation. The normal range for SCr is 45–90 µmol/L33. For patients to be included in the study, their SCr had to be < 90 µmol/L. This applied for both patients with hypertension and without hypertension.After exclusion, we were left with 560 ART patients. They were divided into 325 non-hypertensive patients. In determining the normal kidney and liver function used as criteria for eligibility, different laboratory tests were used. For liver function, the AST and ALT are laboratory tests commonly used in Eswatini hospitals for PLHIV to determine their liver function, hence they were also used in this study. For kidney function, the serum creatinine (SCr) test was used for this study as it is the commonly used test to assess kidney function in PLHIV in Eswatini. The threshold for AST and ALT according to McAuley and Park et al35. The A worse prognosis was defined as persistently having a viral load above and CD4-cells count below these thresholds. SAHCS further states that viral load ≤ 50 copies/mL is associated with the most durable benefit. Hence such threshold has been chosen for this study. According to WHO, if a patient is progressing well in ART, their viral load has to be < 1000 copies/mL after a few months’ initiation to the treatment. The findings from PARTNER 1 and 2 study further stated that at < 200 c/mL, serodiscordent couples engaging in homosexual and heterosexual intercourse, chances of the virus transmission to the HIV negative partner was ZERO. In this study, the < 50 copies/mL from SAHCS is even a better threshold as it is less than < 200 copies/mL.In this study, prognosis was not defined as survival but as improvement or worsening of the HIV disease status as defined by two dependent (outcome) variables: viral loads and CD4-cell counts. Better prognosis was defined by lower viral load, using the Southern African HIV Clinicians Society (SAHCS) 2017 Adult ART Guidelines’ threshold of defining undetectable viral loads (≤ 50 copies/mL), and a higher CD4-cell count which, according to WHO, would be a threshold of ≥ 500 cells/µL)39. The adverse effects that were experienced by the patients included: drug-induced bone-marrow suppression, lactic acidosis, hepatic toxicity, pancreatitis, and peripheral neuropathy, fat maldistribution, body habitus changes, hyperlipidemia, hyperglycemia, insulin resistance, skin rashes and hypersensitivity reactions, nausea, diarrhea, dizziness, depression, myocardial infarction, ischemic stroke, proximal renal tubulopathy and elevated creatinine, and nephrolithiasis and cholelithiasis. Adherence was categorized in this study into underuse, close adherence and overuse of prescribed ART medications based on pill counts collected from the patients’ medical records. Pill count scores below 90% (underuse) were defined as poor adherence, those between 95 and 105% (close adherence) were defined as good adherence, and > 105% (overuse) were defined as excessive. Excessive adherence is associated with the patient taking the medication more than is expected, which can suggest an overdose or the fact that the patient might be sharing the medication with someone else. The patients were divided into three age ranges, 30–40 years, 41–50 years, and > 50 years.The main independent variable for this study was the presence of hypertension. Other independent variables were also included because they could possibly affect outcomes and confounding results. Based on our literature review, these were adherence, age, sex, isoniazid preventive therapy (IPT), residence or administrative region, WHO HIV staging, year of study, and ART adverse effectsThe data from medical records were extracted using a 28-item standardized case-report form with three sections, one collecting socio-demographic data, another collecting medical history, and the other collecting laboratory results. The data were collected from July 27, 2018 to September 8, 2018 by the principal investigator. To ensure anonymity and confidentiality, no identifying information (such as names) was recorded. Instead, each patient was assigned an identification code to be matched anonymously with his or her data.2) test was used to compare proportional differences between different levels of categorical independent variables. For multivariate analysis, the Generalized Estimated Equations model was employed to study the relationship between independent variables and dependent variables in a whole group analysis and subgroup analysis. Odds ratios (OR) were reported with 95% confidence intervals (CI). P-values < 0.05 were considered significant. All statistical operations were performed using IBM SPSS version 22 (https://www.ibm.com/support/pages/downloading-ibm-spss-statistics-22).Group continuous variables were analyzed descriptively and expressed as median with interquartile range (IQR) and mean ± standard deviation (SD) and categorical variables were expressed as frequency and percentages. Chi-square  at the Eswatini Ministry of Health on July 24, 2018. The need for written consent was waived by the NHRRB because anonymity of the participants was ensured during the patients’ files review, and there was no direct contact or interaction with participants. All methods were carried out in accordance with the relevant guidelines and regulations which pertain to the use of humans as participants of a study.p-value < 0.001).As can be seen in Table P-value = 0.003). Ninety-eight percent of all participants were receiving first line treatment. Those receiving first line treatment had a significantly higher prevalence of hypertension than those receiving second line treatment . Almost 3.8% of the participants  had adverse side effects to ART, with no significant difference between the two groups. Most of the hypertensive patients were taking diuretics (33.6%), and about 31.5% were on lifestyle modifications, which has to do with healthy habits like regular exercise, low fat and salt diet among others. About 19.1% of the participants were taking a combination of diuretics + ACE inhibitors or beta blockers.As can be seen in Table Table p-value = 0.17). Hypertensive participants had a 2.6% (95% CI 2.4–2.8%) and 6.8% (95% CI 6.3–7.3%) probability of having viral loads of ≥ 50 copies/mL in 2015 and 2016, respectively. This increase was marginal and the overall trend was insignificant . The difference between the two groups was also insignificant . As can be seen in Fig. p-value < 0.001). There was also a significant difference in the increased probability between the two groups  overall, except in 2017 when hypertensive participants showed only a slight decrease.According to Fig. 95% CI 6.–7.3% proA Generalized Estimated Equations model was used to study the association between possible confounding factors  and our outcome variables. As can be seen in the whole-group analysis in Table As can be seen in the subgroup analysis in Table In our analysis of all ART patients, the present study found a significant association between hypertension and CD4 cell counts but not viral load. This means that hypertensive patients were more likely to have improved CD4-cell counts compared to non-hypertensive patients. In non-hypertensive patients there was a significant association between improved CD4-cell counts and being female, IPT, undetectable viral load, and time of study. In hypertensive patients, the variables significantly associated with improved CD4-cell count were younger age, 2nd line of ART, better adherence, and time of study.42. The hypertensive patients were found to be more likely to have higher CD4-cell counts compared to non-hypertensive patients. It is important to note that both patients had the same follow-up in the study and in hospital in general, not unless they feel the need to come to the hospital. Other studies found no significant difference in CD4-cell counts in ART patients with and without hypertension44. Our results could be explained by the possibility that patients being treated and counseled for hypertension may have better lifestyle habits as they attempt to bring it under control and this may consequently lead to better immune system functioning. For instance, patients with hypertension are expected not to engage in smoking, alcohol use or any other substance abuse, have restricted diet that is with less fats and sodium. However, it is interesting to note that people with hypertension usually have higher BMIs45. Koethe et al. have reported an association between pre-ART BMI and 12-month change in CD4-cell counts  and concluded that a BMI indicative of threshold obesity predicted greater CD4-cell count gains at the beginning of ART46.This study found an increase in CD4-cell counts over time in both groups of patients, as has been previously reported47. However, a review of eight cohort studies of European populations reported that more women than men seroconverted to HIV, developed AIDS and died with higher CD4-cell counts48.We also found male ART patients to be less likely to have CD4-cell count improvement than females in both groups. One study of 7,354 patients initiating ART between April 2004 and April 2010 in South Africa also found men on ART have less CD4-cell improvement than women50. Therefore, the combination of IPT and ART probably lead to a boost in immunity. We found this to be significant among those without hypertension but insignificant among those with hypertension, possibly suggesting an interaction between hypertension or hypertension medications and IPT.We also found that patients receiving IPT were more likely to have higher CD4-cell counts. IPT contributes significantly to prevent incidences of active TB among PLHIV51. One prospective 12-month cohort study associated adherence levels of 100%, 80–90%, and 0–79% with CD4-cell count increases of 179, 159, and 53 cells/µL, respectively, 52. In our subgroup analysis, overmedication was associated significantly with better CD4-cell counts, more particularly with hypertensive patients. Close adherence was also associated significantly with better CD4-cell counts, more particularly with hypertensive patients. However, based on the literature, close adherence is important for everyone, regardless of whether they have hypertension or not. Despite its seemingly lack of effect on immunity, overuse could possibly lead to increased drug toxicity in some patients.We found patients with close adherence to prescriptions to be more likely to have higher CD4-cell counts than those under medication, similar to a longitudinal study in the Hunan and Hubei provinces of China53.We found patients receiving second line ART to have higher CD4-cell counts than those receiving first line treatment, especially among those with hypertension. Antihypertensive drugs could possibly affect effectiveness of ART. For example, two kinds of ART drugs, NNRTIs (like Nevirapine and Efavirenz) and PIs, are metabolized primarily by CYP34A in the CYP450 system, the same pathway is involved in the metabolism of the hypertension drugs indapamide, calcium channel blockers, and losartanPatients with detectable viral loads were found to be less likely to have higher CD4-cell counts . This association was found to be more significant in those without hypertension , suggesting that the additional healthcare benefitted those patients with hypertension by improving their immune systems.55. However, one observational study of HIV patients in Australia found no long-term decline in CD4-cell counts in ART patients56, suggesting that the level of immune recovery achieved during the first 5 years of treatment was sustained through long-term ART. It is possible that the presence of hypertension might contribute to decreasing CD4-cell counts in those who are older, though this would require further studies.While age was not found to be associated with CD4-cell counts in the whole group analysis, we did find an association between age and increased and decreased CD4-cell counts in patients with hypertension in the subgroup analyis. Among these patients, those 41–50 years old were less likely to have higher CD4-cell counts than those being 30–40 years old. Healthy individuals also gradually become immunodeficient over the long term43.As there was no significant association of hypertension with viral load, this means hypertensive patients and non-hypertensive patients have about the same likelihood of achieving viral load suppression when they are on ART, after controlling for other confounding factors. In a cross-sectional study aimed to estimate the prevalence of hypertension and describing the characteristics of patients with hypertension infected by HIV/AIDS in the state of Pernambuco in Brazil, the results reveal that there was no difference between hypertensive and pre-hypertensive patients with regard to parameters related to HIV infection and treatment such as viral load. One then can conclude that having hypertension does not prove to be a predisposing factor for one to not achieve viral load suppression57. For patients on 2nd line treatment to have more likelihood for detectable viral load is likely to be more related to poor adherence. As the 2nd line treatment is associated with more adverse effects compared to the 1st line58, that can possibly make patients on the 2nd line not to adhere appropriately on the treatment as a way to avoid the adverse effects, yet by doing so they increase the viral load. This also explain why in our subgroup analysis patients with adverse effects were more likely to have detectable viral load compared to those who experienced no or less adverse effects. This happened more particularly with the group of patients without hypertension .One factor was found to have a significant association with viral load in the whole group analysis, and that was ART line of treatment. Patients on the 2nd line of treatment were more likely to have a detectable viral load, compared to patients on 1st line. In a systematic review and meta-analysis aimed to summarize reported rules and reasons for virological failure among people on 2nd line therapy in resource-limited setting, the researchers found that the cumulative pooled proportion of adult patients failing virologically was 21.8% at 6 months, 23.1% at 12 months, 26.7% at 24 months and 38% at 36 months59. A “blip” is when the viral load increase above 50 copies/mL temporary and then drops back60.Based on the changes or trend of viral load with time, the results in this study reveal fluctuating predictive probability of viral load to be detectable for hypertensive and non-hypertensive patients. For patients with hypertension, the predictive probability was more significantly higher in 2016 compared to the other years. The fact that the viral load temporary increased significantly in 2016 can be due to what is known as “blip” and is normal. It can also be possibly due to that the patients might have flue/cold or other short illness or they have just been vaccinatedThe findings of the study can assist the country (Eswatini) and the southern African region at large by reflecting on the effectiveness of HIV/AIDS and non-communicable disease programs that are currently taking place in the country, in order to determine the country’s progress in achieving Sustainable Development Goal 3 of Good Health and Wellbeing, and the 90-90-90 world target set by UNAIDS in 2014. The findings can also illustrate the possible effectiveness of integrating HIV and non-communicable services. The research findings and recommendations also have a potential for contributing to and extending the scientific body of public health knowledge. They have a potential to facilitate amendments of existing guidelines dealing with HIV/AIDS care and treatment, and NCDs.The study encountered some limitations. Firstly, it is based on a retrospective analysis of already collected data from chronic patient files. The variation of clients’ ART initiation and hypertension diagnosis and treatment initiation dates were factors that proved to be confounding for this study, hence a causal relationship could not be established, even though the study was longitudinal. Also, these variations made it hard for the researchers to collect important information related to variables such as BMI, as some files would not have all the necessary information needed to formulate such a variable as it would be missing. Therefore, the missing information pertaining to variables  proved to be the largest limitation for this study. However, efforts have been made to account for them in the discussion section, based on findings from other researchers.ART patients with hypertension were more likely to have higher CD4-cell counts compared to ART patients without hypertension in the whole group analysis. Underuse and overuse of medications, advanced HIV stages, adverse effects, line of treatment, age and sex predicted higher viral loads (ART failure) and lower CD4-cell counts in patients with hypertension. From such findings, one can conclude that patients with hypertension or with NCDs for that matter can also progress very well in treating HIV, more so if they observe their lifestyle habit and care for their NCDs treatment. More attention may need to be paid to ART patients with well controlled HIV status to monitor and control their hypertension status. Medical professionals, who may be overly concerned to control HIV/AIDs, may want to return their focus to the possible development of other chronic diseases, particularly hypertension, because these non-communicable diseases could later result in ART failure.


Objectives: The aim of this study was to evaluate the effect on immune activation of switching from a triple-drug to a dual-drug regimen in HIV-1 infected patients on successful combination antiretroviral treatment (cART). Immunadapt is a prospective study evaluating the impact of cART simplification on immune activation.Methods: We prospectively collected blood samples in HIV-1 infected patients on stable and successful cART switching from triple to dual regimens as a simplifying strategy. We compared immune activation markers: high sensitivity CRP, IL-1, IL-6, IL-8, IP-10, MCP-1, TNF-alpha, soluble CD14 (sCD14), soluble CD163 (sCD163), lipopolysaccharide binding protein, and D-dimer before cART change and at least 6 months after the switch. Patients were stratified according to low or high risk factors of immune activation .Results: From April 2019 to May 2020, 20 subjects were included . Fourteen patients were prescribed Dolutegravir + Rilpivirine and six received Dolutegravir + Lamivudine. After 6.9 months, a significant sCD163 increase  was observed in subjects with high risk factors, despite maintaining a viral load <50 cp/ml.Conclusion: cART simplification in favor of dual therapy is associated with macrophage activation in patients at risk of immune activation despite sustained virological control. Risk factors should thus be considered before generalizing such strategies. Triple-drug antiretroviral regimens are the standard of care for controlling HIV viral replication. Thanks to such strategies, life expectancy has dramatically increased in HIV+ patients .These regimens typically include two nucleoside reverse transcriptase inhibitors (NRTI), associated with one of the following drug classes: a non-nucleoside reverse transcriptase inhibitor (NNRTI), an integrase strand transfer inhibitor (INSTI) or a protease inhibitor (PI) , 3.However, the increasing prevalence of aging-related comorbidities, i.e., cardiovascular, renal and metabolic disorders, , requireIn successfully treated patients, simplification of cART in favor of certain dual-drug regimens has been shown to maintain virological control, with potential reduction of long-term adverse effects , 8. SeveEven in naïve patients, dual therapy with Lamivudine, a NRTI, and Dolutegravir, an INSTI, has been approved and proven non-inferior in terms of virological control in plasma and semen when compared with standard triple-drug regimens .However, as triple-drug regimens have the potential to achieve adequate penetration in tissue and cellular reservoirs, concerns have been raised about the effects of dual therapies on immune activation, which is a well-known predictor of clinical events and mortality in HIV-infected patients . In partFew studies have investigated markers of immune activation in patients simplifying their treatment , 14.Our aim was to measure trends in immune activation markers according to risk factors for immune activation in patients simplifying their treatment from a 3-drug- to a 2-drug regimen.Immunadapt is a single-arm prospective study, aiming to assess the impact on immune activation markers of switching from a triple-drug to a dual-drug therapy in people living with HIV on stable cART. Patients were selected among those followed in the Department of Internal Medicine in Cannes General Hospital and the Infectious Diseases Department in Nice University Hospital, France. Each individual routinely followed in our Departments and filling the inclusion criteria received a proposal to participate to this study. Therefore, the decision of the antiretrovirals prescribed did not depend from the researchers of the study, but only from the physician who took in care each subject for its routine follow-up. Recruitments were continued until attempting the goal of 20 inclusions, which was the estimated sample size necessary for the analysis.© viral load or Aptima HIV Quant Dx, Hologic), switching from a triple-drug to a dual-drug regimen as a simplification strategy.Inclusion criteria were HIV-1 infected subjects on stable and successful cART  and patients gave written informed consent to participate.via flow cytometry.Measurement of immune activation was performed just before cART switch and at least 6 months later. In case of viral replication >50 copies/ml during follow-up, patients were excluded from the analysis. IL-1, IL-6, IL-8, IP-10, MCP-1 and TNF-alpha were measured using ProcartaPlex ImmunoAssays (Life Technologies SAS), while sCD163 and sCD14  and lipopolysaccharide binding protein  were measured with ELISA kits. T-cell activation markers were quantified Demographic and main viro-immunological characteristics were recorded.During follow-up, plasma viral load was quantified 2 months after the switch. Viro-immunological parameters were measured at the end of follow-up, i.e., at least 6 months after treatment simplification, together with immune activation markers.Viral blips were defined as transient low-level viremia (LLV), between 50 and 500 copies/ml, preceded and followed by suppression, i.e., below the quantification limit of the assay . To asseDuring follow-up, clinical events and newly prescribed co-medications were also recorded.The main demographic and viro-immunological characteristics of the population are described.We firstly measured changes from the baseline to the end of follow-up for the entire population. Considering the small sample of the study size and that CD4/CD8 at inclusion and IP-10, MCP-1 and LBP trajectories did not follow a normal distribution , variables were compared using matched Wilcoxon-Mann-Whitney test.Patients were then stratified into those at low and high risk of immune activation, the latter defined by at least one the following parameters: low CD4 nadir, prior AIDS-defining condition or VLLV during follow-up . DiffereBetween April 2019 and May 2020, 20 individuals were included in the study . Main comorbid conditions were hypertension (55% of subjects), dyslipidemia (30%), hepatitis C (15%) and diabetes (10%).Reasons for switching antiretroviral therapy were either reducing the number of pills or limiting potential long-term side effects of antiretrovirals. Mean duration of current antiretroviral regimen at switch was 55.7 months (SD 40.6). In the 2 years prior to inclusion, VLLV was detected at least once in 9 patients and a viral blip in one patient with a viral load of 100 copies/ml 17 months before inclusion. Nine subjects had been receiving a combination of 2 NRTIs and 1 NNRTI, nine had been treated with 2 NRTIs and 1 INSTI, while the remaining two patients had been receiving either 1 NRTI, 1 NNRTI and 1 PI or 1 NRTI, 1 INSTI and 1 NNRTI.Prescribed dual cART consisted in a combination of Dolutegravir and Rilpivirine for 14 patients, and Dolutegravir and Lamivudine for the remaining 6 patients.The mean follow-up period was 6.9 months. Each subject maintained a viral load below 50 copies/ml from the start to the end of follow-up. However, 3/20 individuals had VLLV at inclusion, while at the end of follow-up there were 7/20 subjects with VLLV.No significant co-medications with potential interference on immune activation were prescribed during follow-up. One individual suffered an ischemic stroke and one a pulmonary embolism, both just before the end of follow-up. No clinical event nor intolerance to treatment occurred among the remaining 18 individuals.p < 0.05, 3.6 vs. 3.0 pg/mL, p < 0.05, respectively) and sCD163 increase .From the inclusion to the end of follow-up, switching from a triple to a dual regimen was associated with IP-10 and sCD14 values decrease  vs. +0.5% (SD = 24.6), Besides, neither abacavir- nor tenofovir- containing regimen before the switch were associated with the trajectory of inflammatory markers (data not shown). The prescription of integrase-inhibitor also did not correlate with such markers (data not shown).p = 0.17, + 28.3 vs. 346.8%, p = 0.35, respectively).In a subgroup of 11 individuals in whom T-cell activation subsets were also available, neither CD4+CD38+HLA-DR+ nor CD8CD38+HLA-DR+ cells differed between the group at low and high risk of immune activation . The patients/participants provided their written informed consent to participate in this study.MV, JD, RF, and CP designed the study. MV wrote the manuscript. RF and CP performed the statistics and interpreted the data. MT, RC, and PC analyzed immune activation markers. All authors contributed to the article and approved the submitted version.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.


Background and purpose — Platelet-rich plasma (PRP) is broadly used in the treatment of knee osteoarthritis, but clinical outcomes are highly variable. We evaluated the effectiveness of intra-articular injections with Autologous Conditioned Plasma (ACP), a commercially available form of platelet-rich plasma, in a tertiary referral center. Second, we aimed to identify which patient factors are associated with clinical outcome.Patients and methods — 140 patients (158 knees) with knee osteoarthritis (Kellgren and Lawrence grade 0–4) were treated with 3 intra-articular injections of ACP. The Knee Injury and Osteoarthritis Outcome Score (KOOS), pain , and general health  were assessed at baseline and 3, 6, and 12 months’ follow-up. The effect of sex, age, BMI, Kellgren and Lawrence grade, history of knee trauma, and baseline KOOS on clinical outcome at 6 and 12 months was determined using linear regression.Results — Mean KOOS increased from 37 at baseline to 44 at 3 months, 45 at 6 months, and 43 at 12 months’ follow-up. Mean NRS-pain decreased from 6.2 at baseline to 5.3 at 3 months, 5.2 at 6 months, and 5.3 at 12 months. EQ5D did not change significantly. There were no predictors of clinical outcome.Interpretation — ACP does not lead to a clinically relevant improvement  in patients suffering from knee osteoarthritis. None of the investigated factors predicts clinical outcome. Platelet-rich plasma (PRP) has emerged as a potential treatment for osteoarthritis (OA). High levels of growth factors and cytokines present in platelets stimulate production of cartilage extracellular matrix, proliferation of chondrocytes, and migration of chondrocytes in vitro  has been proven in the setting of RCTs , history of knee trauma, and baseline Knee Injury and Osteoarthritis Outcome Score (KOOS) on clinical outcome. Since there is no consensus on whether PRP is more effective in mild or advanced OA  between March 2017 and October 2018. A minimal follow-up of 1 year was chosen, because the effect of ACP reaches its maximum between 6 and 12 months  could be included . 43 patiPatients underwent anteroposterior and lateral view radiographies prior to treatment. Kellgren and Lawrence grade was assessed by 3 blinded observers. In any case where 1 observer rated the radiograph with 1 grade lower or higher than the others, the grade of the 2 observers was accepted. If the grades of 2 observers were 2 or more apart, agreement was reached in a consensus meeting. Interobserver reliability was assessed using a 2-way random intraclass correlation coefficient. The internal consistency of the Kellgren and Lawrence grade was good with a Cronbach’s alpha of 0.89.The Arthrex ACP Double-Syringe System  was used for preparation of ACP. 15 mL of peripheral blood was drawn and centrifuged at 360G for 5 minutes to separate the blood components. Approximately 3–6 mL ACP was drawn into the inner syringe and injected into the knee joint using a superolateral approach with the patient in supine position.Using the CELL-DYN Emerald hematology analyzer , 28 random samples of leftover material from ACP syringes were analyzed anonymously in order to characterize the administered PRP. Platelet, erythrocyte, and leucocyte concentration were measured in duplicate. The volume of injected material was documented.Patients completed all questionnaires using an online survey tool  at baseline and at 3, 6, and 12 months’ follow-up. Possible scores ranged from 0 to 100 (worst–best) for KOOS and EuroQol 5 Dimensions (EQ5D), and 0–10 (best–worst) for Numeric Rating Scale for pain (NRS pain). Dutch translations of KOOS  . Baseline patient factors are reported by means and standard deviation (SD) or number of patients and percentages. Outcomes are shown as average and 95% confidence intervals (CI). Missing data were not imputed; patients with missing outcome variables were not included in the analysis of those specific variables. P-values < 0.05 were considered significant.5) was estimated as an average population change using generalized estimating equations (GEE). ΔKOOS5 was compared with the minimal clinically important difference (MCID) recommended for KOOS . Change from baseline . Variables reaching a p < 0.05 in the multivariate model were retained.Correlation between the ΔKOOSThis study was submitted to the institutional ethical review board of the University Medical Center Utrecht  and was conducted according to the World Medical Association Declaration of Helsinki. Written informed consent was obtained from all individual participants included in the study. This research was supported by the Dutch Arthritis Foundation (LLP-12). The study dataset is available from the corresponding author upon reasonable request. The authors declare that they have no competing interests.Of all patients, 89% filled out the survey at baseline, 87% at 3 months, 76% at 6 months, and 75% at 12 months’ follow-up.9/L, leucocyte concentration was 6.0 (10)×109/L, and erythrocyte concentration was 0.07 (0.08)×109/L. The average volume of the injected ACP from which these 28 samples were derived was 4.4 (0.8) mL.Platelet concentration of 28 random anonymous samples of 18 patients was 513 (184)×105 increased at 3, 6, and 12 months after treatment , 6 months (CI 4.7–11), and 12 months (CI 2.8–9.0) after treatment. At 6 months, 28% of patients reached the MCID of 8 or higher, 23% reached the MCID at 12 months. The change from baseline was comparable and statistically significant in all KOOS subscales . At 3 months, patients who were lost to follow-up at 12 months had a ΔKOOS5 of 6.8 (CI 1.9–12), and patients who completed the follow-up had a ΔKOOS5 of 7.2 (CI 4.6–9.8). The missing values in KOOS5 at 12 months were imputed using the values of KOOS5 at 3 months in order to assess the effect of this loss to follow-up. The KOOS5 of the complete dataset, including the imputed data, is 43 (CI 40–46).At baseline, age, BMI, history of knee trauma, Kellgren and Lawrence grade, and KOOS5. At 6 months, the patients who later returned for a second series had a ΔKOOS5 of 15 (CI 9.4–21), whereas the patients who did not return for a second series of ACP injections had a ΔKOOS5 of 5.4 (CI 2.2–8.6). At 12 months, the patients who returned for a second series of injections had a ΔKOOS5 of 9.5 (CI 4.2–15), and the others had a ΔKOOS5 of 4.7 (CI 0.1–8.2).After more than a year, a second series of ACP injections was given to 31 patients (34 knees). At baseline, these 31 patients did not differ from the others in sex, age, BMI, Kellgren and Lawrence grade, history of knee trauma, and KOOS5 were not associated with clinical outcome (KOOS5)  . The var5 after 3, 6, and 12 months’ follow-up. None of the investigated patient factors predicted clinical outcome, in contrast to our hypothesis. The highest change from baseline (ΔKOOS5) was observed at 6 months and did not exceed the MCID for KOOS  population in our clinical practice and to evaluate the influence of patient factors on treatment outcome. At the same time, the small number of included patients with Kellgren and Lawrence grade 0 and 4 limits generalizations in these groups. Effectiveness will need to be investigated in a larger cohort of patients with early (non-radiographic) or end-stage (grade 4) OA. Third, a relatively large patient group was lost to follow-up. However, the average KOOS–10 Roos , but the–10 Roos , and doeThere was no clinically relevant improvement in the majority of patients, nor did most patients return for additional ACP treatment. No predictors of improved clinical outcome were identified. In the limited number of patients who reached the MCID, the effect of ACP decreased between 6 and 12 months, necessitating a second series of treatment after 1 year. In our view, ACP should not be used in daily clinical practice in the current form and population. Future research should try to improve the clinical outcome of this treatment by optimization of the composition of PRP and/or patient selection, before implementation in daily practice. This study demonstrates the gap between efficacy in RCTs and effectiveness in clinical practice, which underlines the importance of evaluating effectiveness after market approval.


The inadequacy of HIV viraemia and resistance monitoring in Africa leads to uncontrolled circulation of HIV strains with drug resistance mutations (DRM), compromising antiretroviral therapy (ART) effectiveness. This study describes the DRM prevalence and its therapeutic impact in HIV-infected pediatric patients from Kinshasa .pol analysis, predicted ARV-susceptibility by Stanford and phylogenetic characterization.From 2016–2018, dried blood were collected from 71 HIV-infected children and adolescents under ART in two hospitals in Kinshasa for HIV-1 DRM HIV-1 sequences were recovered from 55 children/adolescents with 14 years of median-age. All had received nucleoside and non-nucleoside reverse transcriptase inhibitors , 9.1% protease inhibitors (PI) and only one integrase inhibitor (INI). Despite the use of ART, 89.1% showed virological failure and 67.3% carried viruses with major-DRM to one (12.7%), two (47.3%), or three (5.5%) ARV-families. Most children/adolescents harbored DRM to NNRTI (73.5%) or NRTI (61.2%). Major-DRM to PI was present in 8.3% and minor-DRM to INI in 15%. Dual-class-NRTI+NNRTI resistance appeared in 53.1% of patients. Viruses presented high/intermediate resistance to nevirapine (72.9% patients), efavirenz (70.9%), emtricitabine/lamivudine (47.9%), rilpivirine (41.7%), etravirine (39.6%), doravidine (33.3%), zidovudine (22.9%), among others. Most participants were susceptible to INI and PI. Great diversity of variants was found, with a high rate (40%) of unique recombinants.The high DRM prevalence observed among HIV-infected children and adolescents in Kinshasa could compromise the 95-95-95-UNAIDS targets in the DRC. It also reinforces the need for routine resistance monitoring for optimal rescue therapy election in this vulnerable population to control the spread of resistant HIV in the country. Over the last years, scale-up of HIV antiretroviral treatment (ART) has had a major impact on HIV-related illness, averting AIDS-related deaths, preventing new HIV infections, and resulting in cost savings . DespiteSince non-nucleoside reverse transcriptase inhibitors (NNRTI) based ART continues to be used in first-line ART in the DRC as in many Sub-Saharan Africa countries, an increase in pre-antiretroviral-treatment drug resistance (PDR) to NNRTI over 10% is expected in this region over the next 15 years. This PDR rate will be responsible for 16% of AIDS deaths and 9% of new HIV infections in Sub-Saharan Africa in 2016–2030 . DRM to Nearly 1.7 million children, 1.6 million adolescents, and 3.5 million young people are currently infected with HIV-1 worldwide, 90% living in Sub-Saharan Africa . The WHOIn the Democratic Republic of Congo (DRC), the coverage of people living with HIV receiving ART was 57% in 2018, but only 25% among children , althougFor all these reasons, the aim of this study is to analyze HIVDR prevalence and its therapeutical impact on the children and adolescent population from Kinshasa (DRC). To find out the current situation of these populations in the DRC is particularly important due to their lifelong-treatment with more years under ART than adults.Dried blood specimens (DBS) from HIV-infected children and adolescents under clinical follow-up in paediatric units at Monkole and Kalembelembe Hospitals in Kinshasa (DRC) were collected in 2016–2018. DBS samples were prepared by spotting 70 μl of venous blood collected by venipuncture in EDTA-anticoagulant tubes into each dot on a Whatman 903 Protein Saver Card . They were dried separately overnight at room temperature, sealed in a zip-lock bag with desiccant, and stored at −20°C until transported in dry ice to the HIV-1 Molecular Epidemiology Laboratory in Madrid, Spain, where samples were stored at −80°C until further analysis.pol coding region by RT-PCR and nested-PCR using primers designed by WHO .Although children and adolescents had both been under ART exposure for 6 years [IQR: 1–8.5], the number of children under 1vs. 4 years) and 1st ART (12 vs. 4 years). Besides, adolescents showed higher exposure to several drugs than children, including tenofovir, stavudine and efavirenz (Table 1). Regarding HIV-1 variants, 52.8% children/adolescents carried pure subtypes at pol  and 43.6% recombinants, being mainly URF (40%). CRF included 1 CRF27_cpx and 1 CRF47_BF. The remaining variants were unclassified (U) variants (Table 1).Moreover, adolescents presented a significantly higher delay in HIV diagnosis than children  were infected with viruses carrying major-DRM to one (12.7%), two (47.3%) or three (5.5%) ARV families, without significant differences among children and adolescents’ groups. Only a third (32.7%) of the treated study cohort did not present major-DRM at sampling, despite having virological failure with no suppressed viral load in 88.2% of them. When also considering minor-DRM to PI and INI, 38 (69.1%) were infected with viruses carrying DRM to one (12.7%), two (43.6%), three (10.9%), or four (1.8%) ARV families .S1 Table). All viruses harboring DRM to NRTI also contained DRM to NNRTI. Only one 15.5 years old adolescent with 13.3 years of ART experience carried viruses with resistance to the 4 drug families, although with minor DRM to INI.Of the 36/49/40 successfully sequenced samples at PR/RT/IN, DRM to NNRTI were present in 73.5% , DRM to NRTI in 61.2% , major-DRM to PI in 8.3%  and minor-DRM to INI in 15% . Dual-class NRTI+NNRTI resistance was present in 44.9%  children/adolescents , K70R/N and T215Y/F (14.3% each), M41L/L210W (12.2% each). DRM to NNRTI were presented in 73.5% of population: K103N/H/S (42.9%), Y181C/G190A (24.5% each), V108I/K101E/H (18.4% each) and H221Y/V106I (12.2% each). The three subjects with major DRM to PI carried M46I (8.3%) and two also had I54V, only one of them had previous experience to PI. Minor DRM to INI were found in 15% of subjects with available IN sequences, 9.1% children, and 22.2% adolescents. When comparing the rate of infections with resistant viruses carrying major DRM in children (0–14 years) vs. adolescents (15–21 years) under study, no significant difference was observed (S1 Table).Fig 3A). The rate of children and adolescents carrying viruses resistant to NRTI was 2 times higher in those having been under ART for more than 5 years  . Fig 3B shows the steadily tend to increase of infections with resistant viruses with ART exposure time.Infections with resistant viruses were associated with ART exposure time. DRMs to all ARV families were higher in those patients having been under ART for more than 5 years (pol genotype were infected with viruses susceptible to PI (88.9%) and INI (87.5%). A high resistance level was observed in 70.8% subjects to nevirapine, in 64.6% to efavirenz, in 45.8% to emtricitabine, or lamivudine, 37.5% to rilpivirine, and at lower rates for other ARV, except for INI .Most children and adolescents with available .When considering both high or intermediate resistance level to NNRTIs, most (72.9% and 70.9%) subjects presented high and intermediate resistance to nevirapine and efavirenz, respectively, and 41.7% to rilpivirine, 39.6% to etravirine, and 33.3% to doravidine. For NRTI, half (47.9%) of the subjects carried viruses with high and intermediate resistance to lamivudine and emtricitabine, 22.9% to zidovudine, 18.8% to abacavir, and 14.6% to tenofovir. For PI, these rates were lower than 10% and absent for INI This study represents the first characterization of HIV drug resistance among HIV-infected children and adolescents in the DRC. Moreover, it provides the most recent data of resistance to ARV drugs in Kinshasa and the DRC. While all published studies from DRC reported resistance data in naïve –28 or trIn the DRC and other Sub-Saharan Africa countries, HIV monitoring is limited due to a weak Public Health System and administration. Molecular diagnosis and VL testing are poorly accessible, mainly centralized in a national laboratory or restricted to some specific private hospitals. Moreover, resistance monitoring is not routinely available in the DRC . For theAccording to the published data in samples from ART-naïve adults collected from 2002–2014 in DRC, the reported pre-antiretroviral-treatment drug resistance (PDR), a predictor of treatment failure, ranged from 0%-2.4% to PI, from 0–18.3% to NRTI, and from 0–9.8% to NNRTI, and unknown for INI –28. Our Since 2013, the WHO has recommended using PI-based ART regimens for children. In 2018, the WHO formally encouraged the phase-out of NNRTIs across age groups, with the introduction of dolutegravir for children with approved dose. However, in 2017, globally nearly 77% of children were still receiving nevirapine in first-line ART due to limited supplies of child-friendly drug formulations . PreviouA limitation of this study is that samples were collected for ART treated subjects in two hospitals in Kinshasa, and it could not be representative of the situation on a city or country-wide level. However, Monkole and Kalembelembe hospitals are considered in the top 5 of clinical centers with more HIV-infected children and adolescents under ART in Kinshasa. Further analyses are required to monitor the current transmission of drug-resistant strains in ART-naive HIV-infected children and adolescents in the DRC.pol sequences. Furthermore, the presented data are the first resistance information available for children and adolescents under ART in the country. Previous reports showed that HIVDR in naïve adults was very low in the DRC before the year 2007 [pol amplifications. It could be explained by the low viraemias reported in some of them due to ART control. Moreover, we cannot exclude that some negative PCR could be due to the high viral genetic variability in viral targets for primers used for pol amplication. A recent study reported the temporal trends of HIV-1 subtypes and recombinants in the DRC during a 43-year period (1976–2018) and in Kinshasa from 1983 to 2018, showing a high number of different HIV-1 variants currently circulating in that city, with an increase of complex and unique recombinants in the last years [The sample size, although modest, was similar to other related resistance studies among treated patients in the DRC, analyzing from 55  to 93 2 pol sequear 2007 , 27, altear 2007 . Understear 2007 . Howeverst years .Multiple studies have demonstrated that the percentage of patients with drug resistance goes up steadily as time on treatment increases , 39, as Thus, all generated results were communicated to clinicians in Kinshasa for better care of pediatric patients under study, providing useful data for ART regimen optimization. This work provides unique information related to these vulnerable populations in Kinshasa and in the rest of the country, where nearly 3 million children and adolescents are HIV infected without VL and resistance monitoring. We also reinforced the use of DBS as field-friendly and an useful specimen to carry out resistance analysis in low-middle income countries as the WHO recommends in the absence of plasma [DRM monitoring is also crucial to control infection in these countries, where most paediatric HIV occur. Also, it is important to reinforce adherence support, and to implement routine VL quantification and resistance testing in the DRC national guidelines, strengthening the country’s laboratory services. Our findings also support alternative ART regimens based on PI and INI instead of RTI in HIV-infected children and adolescent population in that country. These improvements would help to control the spread of resistant viruses among new HIV infections, getting the DRC closer to WHO’s 95-95-95 targets .S1 Table(PDF)Click here for additional data file.S2 Table(PDF)Click here for additional data file.S1 Fig(PDF)Click here for additional data file.