HIV-infected children in sub-Saharan Africa may be at a high risk of staying on a failing first-line regimen and developing drug-resistance HIV variants due to lack of routine viral load monitoring. We investigated whether cumulative viral load, measured as viremia copy-years (VCY) could predict morbidity in a setting where viral load is not routinely monitored.This was a single-center prospective observational longitudinal study of HIV-infected children initiating antiretroviral therapy (ART) at the Pediatric HIV/AIDS Care program at Korle-Bu Teaching Hospital in Accra, Ghana. The main outcome was morbidity measured as frequency of hospitalizations, opportunistic infections, and outpatient sick visits. The main explanatory variable was viral load measured as VCY.10 VCY. Children in this sub-cohort had a higher frequency of sick visits compared with those with <4 log10 VCY (p = 0.03). Only 6.5 % of children with >4 log10 VCY had been identified as treatment failure using WHO clinical and immunological treatment failure criteria.The study included 140 children who initiated ART between September 2009 and May 2013 and had at least 2 viral load measurements. There were 184 hospitalizations, with pneumonia being the most common cause (22.8 %). A total of 102 opportunistic infections was documented, with tuberculosis being the most common opportunistic infection (68 %). A total of 823 outpatient sick visits was documented, with upper respiratory infections (14.2 %) being the most common cause. Forty-four percent of our study participants had >4 logHigh level of cumulative viral load may translate to virological failure and subsequent increased all-cause morbidity. Our finding of potential utility of VCY in pediatrics warrants further investigations. VCY may be a good alternate to routine viral load measurement as its determination may be less frequent and could be personalized to save cost. The advent of antiretroviral therapy (ART) has reduced HIV-associated morbidity and mortality in HIV-infected individuals. The benefits of ART have been substantial in sub-Saharan Africa, home to over 90 % of children living with HIV/AIDS . UnfortuIncrease in ART coverage will exacerbate the existing challenges with laboratory monitoring of ART in resource-limited countries. In resource-rich countries, ART is monitored routinely with laboratory measures such as blood chemistry, HIV viral load, and CD4 count for early detection of medication side-effects and drug-resistant viruses . The WHOIn many resource-limited settings, clinicians rely on clinical and immunologic criteria to identify children failing first-line therapy. These criteria have low sensitivity and positive predictive value of detecting virological failure , 17. ThuGiven the grave consequences of virological treatment failure both at the individual and population level, we designed an exploratory prospective observational study of HIV-infected children receiving care at Korle-Bu Teaching Hospital in Accra, Ghana, to study biomarkers for monitoring ART in children , 23. TheThis was a single-center prospective observational longitudinal study of HIV-infected children initiating ART at the Pediatric HIV/AIDS Care program at Korle-Bu Teaching Hospital in Accra, Ghana, from September 2009 to May 2013. Korle-Bu Teaching Hospital (KBTH) is the largest tertiary hospital in Ghana. The Pediatric HIV/AIDS Care program provides comprehensive HIV/AIDS care to over 1100 children. All study participants were on their first-line regimen. The first-line regimen available at the clinic is non-nucleoside analog (NNRTI)-based ART consisting of zidovudine (AZT), lamivudine (3TC), plus either nevirapine (NVP) or efavirenz (EFV).The rationale, organization, and recruitment of the subjects for the cohort study have been previously described . In brieThe main outcome measure was morbidity; measured as frequency of hospitalizations, opportunistic infections, and outpatient sick visits.The main explanatory variable was viremia copy-years (VCY). VCY was defined as the number of copies of HIV RNA/ml/year . Other vCD4 absolute cell count and percentage were quantified by a dual-platform flow cytometry technology using a FACSCount system  at the clinical laboratory at Korle-Bu Teaching Hospital (KBTH) according to manufacturer’s instructions. HIV viral load was measured using the COBAS® AmpliPrep and the COBAS® TaqMan® 48 Analyzer  for automated sample preparation and amplification and detection, respectively. The limit of HIV-1 RNA detection was 20 copies/mL. The laboratory participates in an external quality assurance testing program by the South African Public Health Reference Laboratory.WHO defines clinical failure as a new or recurrent clinical event indicating advanced or severe immunodeficiency  after 6 months of effective ART .3 or CD4 < 10 % for children under 5; and a CD4 count of <100 cells/ mm3 for children above five years of age [WHO defines immunological failure as a CD4 count of <200 cells/mms of age .WHO defines virological treatment failure as plasma viral load above 1000 copies/ml based on two consecutive viral load measurements after 3 months of ART, with adherence support .10 transformation of each viral load measurement was performed and the area under the curve (AUC) was calculated. Participants were stratified into 3 categories: those with <2log10 VCY (low VCY), 2–4 log10 VCY (intermediate VCY) and >4log10 VCY (high VCY). Wilcoxon Rank Sum test and Fisher's exact tests were used to compare continuous and categorical variables, respectively, among the groups. Regression analyses using logistic regression models were used to estimate the odds of having low, intermediate or high VCY. Two-sided p-values are reported for all the statistical tests used in the analysis. Analyses were performed using SAS 9.3 .Descriptive measures were used to summarize the data. Continuous variables were summarized using mean and standard deviation (SD); categorical variables were summarized using frequency and percent (%). Morbidity was measured using frequency of hospitalizations, opportunistic infections, and outpatient encounters. VCY was calculated as described above. A logWe included 140 children who initiated ART between September 2009 and May 2013 with at least 2 viral load measurements. There were no loss to follow up during the study period. Table Morbidity was measured as frequency of hospital admissions, opportunistic infections, and outpatient sick visits. There were a total of 184 hospital admissions, with pneumonia – clinical and radiological diagnosis - being the most common cause (22.8 %). A total of 102 events of opportunistic infections was documented, with TB being the most common (68 %). A total of 823 outpatient sick visits was documented within the group, with upper respiratory infections (14.2 %). Figure The mean follow up time was 4.3 years SD ± 2.4). The median number of viral load measurements was 2 with a range of 2 to 8 measurements. We did not have uniform number of viral load measurements among study participants due to periodic shortages of reagents and technical difficulties with the viral load machine. We assessed whether there was any correlation between the number of viral load measurements and the outcome measures of interest , 2 to 4 log10 VCY (N = 27), and > 4 log10 VCY (N = 62). There was no statistically significant association between any of the demographic characteristics and VCY. Moreover, WHO clinical stage of a participant could not predict the level of VCY.We investigated if any of the demographic characteristics of the study participants could predict cumulative viral load, measured as log10 VCY had statistically significant outpatient sick visits compared with the other 2 groups (p = 0.03). Of note, only 6.5 % (4 of 58) in the group with >4 log10 VCY had been identified as treatment failure using WHO clinical and immunological definitions of treatment failure. There was no significant association between VCY and number of years of follow up.We investigated whether VCY was associated with outcome measures of interest and other HIV disease characteristics. Table 10 VCY. Interestingly, only 6.5 % of the participants with >4 log10 VCY were identified as meeting the WHO criteria for clinical and immunological treatment failures [10 VCY had statistically significant increased outpatient encounters compared with participants with <4 log10 VCY. We found poor sensitivity of clinical and immunologic assessments in determining treatment failure, consistent with other pediatric studies from sub-Saharan Africa [Forty-four percent of our study participants (62 of 140) had >4 logfailures . Moreoven Africa , 10, 11.We did not find statistically significant associations between cumulative viremia and frequency of opportunistic infections or hospitalizations during the study period. However, persistent viremia may have deleterious consequences with time. Interestingly, there are reports of an association between transient viremia and virological failure –28, depl10 increase in VCY was associated with 1.70-fold increased hazard of AIDS or death among HIV seroconvertors, independent of duration of infection, age, race, CD4 cell count, viral load set-point, peak viral load, or most recent vial load [There is a paucity of data on the use of VCY, a measure of cumulative viremia, in monitoring ART in HIV-infected children. Two earlier pediatric studies found no association between cumulative viremia and virological failure or drug resistance , 40. Howial load . The autial load –45. Takeial load .The rationale for the new recommendation is to: (1) provide an early and more accurate detection of treatment failure and guide appropriate switch from first to second-line drugs to reduce the accumulation of drug-resistance mutations; and (2) help to differentiate between treatment failure and non-adherence . HoweverEven though our study is one of the first studies to investigate the utility of VCY in monitoring ART in HIV-infected children, it has several limitations. First, this is a single tertiary center study and, therefore, one has to be cautious in generalization of our findings to all HIV care centers in resource-limited settings. Also, the small sample size limits the generalization of our findings. Moreover, viral load was not ascertained at regular interval so we could not adjust for transient viremia in the analysis. Due to periodic shortage of reagents or technical problems, viral load measurements were not available at each clinic visit or on scheduled dates. Since the viral loads were not uniformly missing at random among study participants we could not use any statistical test to account for data missing at random. Furthermore, data on adherence was not uniformly available in participants’ medical records so we could not model adherence in our analyses. Most of these limitations reflect the realities of carrying out observational cohort studies in a resource-limited setting. Our findings suggest potential utility of VCY in pediatrics, and this warrants further investigations in resource-limited settings.In conclusion, an unexpectedly high proportion of our study participants had increased cumulative viral load. This may translate to virological failure on their first-line regimen and subsequent increased all-cause morbidity. Our finding supports the current WHO recommendation of viral load monitoring as the preferred method for monitoring ART in resource-limited countries. HIV treatment programs in resource-limited countries should come up with innovative and cost-effective algorithms including viral load measurement for accurate and timely diagnosis of treatment failure. VCY may be a good alternate to routine viral load measurement as its determination may be less frequent and could be personalized and therefore a potential cost-saving approach.


The aim of this study was to determine in patients with HCV genotype 2 or 3 the performance at week 4 of two assays with different sensitivities for HCV RNA detection, for the prediction of SVR and stratification for treatment duration (14 and 24 weeks). Recruitment was from two trials comparing 14 and 24 weeks treatment to patients with rapid virological response (RVR) (n = 550). RVR was originally defined as HCV RNA <50 IU/ml at week 4. Patients with an available frozen plasma sample drawn at week 4 and with follow-up data week 24 post-treatment were included (n = 429). HCV-RNA was prospectively measured with COBAS Amplicor V2, Roche (CA) (lower detection limit 50 IU/ml) and retrospectively assessed with VERSANT HCV-RNA Qualitative Assay, Siemens (TMA) (lower limit detection 10 IU/ml). Genotype 3 was present in 80% and genotype 2 in 20%. A SVR was achieved in 82%. At week 4 HCV-RNA was undetectable in 74.8% and 63% of serum samples tested with CA and TMA, respectively. CA undetectable/TMA positive was observed in 61/341 (18%) of the samples. In genotype 3 patients a relapse was seen in 9% of the patients with both CA and TMA undetectable and in 25% of the patients who were CA undetectable/TMA positive (p = 0.006). In patients allocated to 14 weeks treatment a relapse was observed in 11% of TMA undetectable patients and 26% of TMA positive (p = 0.031). In genotype 2 patients treated for 14 weeks relapse was observed in 6% of the patients with both CA and TMA undetectable week 4. Assays with high sensitivity for HCV RNA identifies patients at week 4 with high risk of virological relapse. We recommend that patients with genotype 3 and detectable HCV RNA at levels below 50 IU/ml do not receive truncated therapy with pegIFN and ribavirin. Most patients with chronic hepatitis C virus (HCV) genotype 2 or 3 infection are currently treated with pegylated interferon α (pegIFN) and ribavirin for 24 weeks and 80% achieve a sustained virological response (SVR) to this treatment ,2. This To save costs and avoid sideeffects we have previously explored the possibility of shortening therapy with pegIFN and ribavirin to patients with genotype 2 or 3 and have shown that among those who achieve rapid virological response (RVR) 80–90% will achieve SVR after 12–14 weeks of treatment –9. HowevMost studies tailoring treatment duration according to week 4 response used the Cobas Amplicor HCV monitor test (CA); with a lower detection limit of 50 IU/ml. Therefore, the EASL Clinical Practice Guidelines defined RVR as serum HCV RNA < 50 IU/ml week 4 during treatment . HoweverWe aimed at evaluating the contribution of a more sensitive assay on patients treatment monitoring by determining the relapse rates in genotype 2 and 3 patients who had a negative test with CA but a positive test with TMA at week 4 of treatment. Secondary aims were to determine relapse rates according to treatment duration (14 or 24 weeks) in those with a negative CA and positive TMA and to compare positive and negative predictive values for SVR of the two tests performed at weeks 4 during treatment.Data from one non-randomized trial (n = 122) and one randomized controlled trial (RCT) (n = 428) of short treatment to patients with genotype 2 or 3 were pooled ,7. In boThe Regional Ethics Committees approved the studies, and all patients gave written, informed consent.Patients in both trials were treated with PEG-IFN-α-2b 1,5 μg/kg subcutaneously once weekly and ribavirin 800–1400 mg/day based on body weight .Those who were HCV RNA negative (<50 IU/ml) at week 4 were defined as having RVR. In the non-randomised trial all patients with RVR were treated for 14 weeks while in the RCT patients with RVR were randomized to either 14 or 24 weeks. Patients without RVR were treated for 24 weeks in both trialsupper normal level per Platelets per Plateletslower normal level: <1.5 early stage disease and >1.5 = bridging fibrosis or cirrhosis)Liver fibrosis was assessed using the APRI score (AST per ASTPatients with an available frozen plasma sample drawn at week 4 and with follow-up data week 24 post-treatment were included (n = 429) . Among tDuring treatment Qualititative HCV RNA analysis was performed in both trials with a Cobas Amplicor HCV monitor test, version 2.0; lower detection limit 50 IU/ml. Analyses were performed in central labs in each of the three participating countries.For the current analysis plasma that had been stored at -70°C was thawed and reanalyzed with VERSANT HCV RNA Qualitative Assay , Siemens Medical Solutions. Puteaux France) with a limit of detection of ≤ 9.6 IU/ml (Commanor).HCV genotypes were determined using the VERSANT HCV LiPA 2.0 .Following a descriptive analysis, differences between the groups were analysed using Pearson’s chi-square test. P-values of less than 0.05 was considered significant.We performed three logistic regression analyses with RVR, discrepant HCV RNA result week 4 (TMA pos/CA neg) and relapse after RVR (both tests negative week 4) as dependant variables and age (<40 year vs >39 years), gender , IL 28b genotype (rs12979680 genotype CC vs CT/TT), stage of fibrosis (APRI <1.5 vs APRI >1.4) and viral load (<400 kIU/ml vs > 400 kIU/ml) as independent variables. In addition treatment duration (14 vs 24 weeks) was entered as an independent variable in the last analysisAll analyses were conducted using PASW statistic v.18.0.From the two treatment trials 429 patients with an available week 4 serum sample was included in the present analysis, 341 (79.5%) with genotype 3 infection and 88 (20.5%) with genotype 2 .The included patients had a higher RVR rate the remaining  but the two groups did not differ in age, gender, genotype and stage of disease distribution (data not shown).At week 4 serum HCV RNA was undetectable in 321/429 (74.8%) with the CA test and in 272/429 (63.4%) with TMA. A discrepant result between the two tests was seen in 73 patients, 12 CA positive/ TMA negative and 61 CA negative / TMA positive. In multivariate analysis we did not identify any predictor of having a discrepant HCV RNA result at week 4.Independent predictors of RVR (TMA negative week 4) were genotype 2 , age <40 years , viral load at baseline <400 kIU/ml  and rs12979680 genotype CC (IL 28b responder genotype) (OR 2.7 (95% C.I. 1.7–4.4).Only age >40 years independently predicted relapse among those with RVR (OR 5.0 (95% C.I. 1.8–13.7). Strikingly, among those younger than 40 years who achieved RVR only 3.8% relapsed compared to 16.8% of those older than 40 years.Week 4 HCV RNA was undetectable in 73.3% (250/341) and 59.8% (204/341) with the CA test and the TMA test, respectively. Discrepant results was seen in 17.6% (60/341) samples, 53 TMA positive/CA negative and 7 TMA negative/CA positive.Relapse was observed in 9.2% (18/197) of patients with both week 4 negative tests and 24.5% (13/53) in patients with positive TMA but negative CA (p = 0.006) .Stratifying for treatment duration we found that among patients originally classified as having RVR and allocated to 14 weeks treatment a relapse was seen in 11.1% (13/117) if TMA also was negative versus 25.7% (9/35) if TMA was positive (p = 0.031) . In thosThe week 4 PPV for SVR was 90.2% and 87.6% for negative TMA and negative CA, respectively. The sensitivity was 67.6% and 80.5% and the specificity 71.0% and 55.1% for TMA and CA test, respectively. The NPV was 35.8% for the TMA and 41.8% for the CA test.In genotype 2 patients week 4 HCV RNA was undetectable in 80.7% (71/88) and 77.3% (68/88) with the CA and the TMA, respectively. A discrepant results was found in 14.8% (13/88) of the samples (8 CA negative / TMA positive and 5 CA positive / TMA negative).A relapse was observed in 6.3% (4/63) of patients negative with both tests. In patients with discrepant test results a relapse was observed in 1/8 CA negative / TMA positive and 1/5 CA positive / TMA negative patients.The week 4 PPV for SVR was 92.6% and 93% for negative TMA and negative CA, respectively. The sensitivity was 80.8% for a negative TMA and 83.3% for a negative CA. The specificity was 50% for both assays. The NPV were 25% and 29.4% for the TMA and the CA test, respectively.In most trials exploring the effect of shortened treatment to patients with genotype 2 or 3 RVR was defined as having <50 IU/ml week 4 ,8. HowevIn the present reanalysis of two clinical trials we show that among genotype 3 patients, 9% of those with undetectable HCV RNA with both CA and TMA at week 4 relapsed while in patients with serum HCV RNA level below 50 IU/ml (CA testing) but detectable with the very sensitive TMA assay 25% relapsed when treated for only 14 weeks.The relapse rate was 9% and 5% in genotype 3 and 2 patients with RVR. In most studies a larger difference in favor of genotype 2 infections has been observed,18. We sThe great majority of patients with a negative CA also have a negative TMA test. This explains why the PPV for SVR are quite similar for the methods (90.2% and 87.6% for TMA and CA, respectively for genotype 3. A few patients had a positive TMA and a negative CA. This result may be due to degradation of HCV RNA during thawing for TMA testing and may have lead to a slight underestimate of the PPV for SVR of the week 4 TMA test.The ACCELERATE trial compared 16 and 24 weeks treatment to patients with genotype 2 or 3 independent of week 4 response. Sera drawn at week 4 during this trial have also been retested with a sensitive assay. Using tOur findings study is retrospective and frozen plasma samples were only available from 80% of the 550 participants in the original trials. A selection bias may therefore be present. The RVR rate in the sample was 75% in the present study compared to 72% in the original sample suggesting a bias towards more favorable response rates in the included sample. Age and genotype distribution and SVR rates were similar in the two samples.It should be noted that ribavirin was given weightbased in these trials and not as the standard fixed 800 mg dose. We recommend that weightbased ribavirin is used when truncated planned for those with RVR.Conclusion: Assays with high sensitivity for HCV RNA identifies genotype 3 patients at week 4 with a high risk of virological relapse. We recommend that these assays are used when truncated therapy to those with RVR is considered for patients with genotype 3.


Immunological non-response (INR) despite virological suppression is associated with AIDS-defining events/death (ADE). Little is known about its association with serious non-AIDS-defining events (nADE).Patients highly-active antiretroviral therapy (HAART) with <200 CD4+/μl and achieving HIV-RNA <50 copies/ml within 12 (±3) months were categorized as INR if CD4+ T-cell count at year 1 was <200/μl. Predictors of nADE  were assessed using multivariable Cox models. Follow-up was right-censored in case of HAART discontinuation or confirmed HIV-RNA>50.1221 patients were observed for a median of 3 (IQR: 1.3-6.1) years. Pre-HAART CD4+ were 77/μl (IQR: 28-142) and 56% of patients had experienced an ADE. After 1 year, CD4+ increased to 286 (IQR: 197-387), but 26.1% of patients were INR. Thereafter, 86 nADE  were observed, accounting for an incidence of 1.83 events (95%CI: 1.73-2.61) per 100 PYFU. After adjusting for measurable confounders, INR had a significantly greater risk of nADE . Older age , hepatitis C co-infection , a history of previous nADE  and the occurrence of ADE during the follow-up  were other independent predictors of newly diagnosed nADE.Patients failing to restore CD4+ to >200 cells/μl run a greater risk of serious nADE, which is intertwined or predicted by AIDS progression. Improved management of this fragile population and innovative therapy able to induce immune-reconstitution are urgently needed. Also, our results strengthen the importance of earlier diagnosis and HAART introduction. The introduction of highly active anti-retroviral therapy (HAART) among patients formerly naïve to treatment leads to the suppression of HIV replication in most cases. However,These patients have been demonstrated to run a greater risk of AIDS progression –9 and deIn a previous study, more non AIDS-defining events (nADE) were observed among patients with a CD4+ T-cell count <200/μl after 2 years of effective HAART than among those with higher CD4+ counts. However,The aim of the present study was to assess whether immune-recovery during virological successful HAART among late-presenters  is associated with the risk of severe non-AIDS related morbidity and mortality, independently of possible confounders.HealthNotes or NetCare, Healthware Technology SpA, Salerno, Italy), which is used to manage the everyday activity of the outpatient HIV clinic in each centre. The MASTER cohort is therefore a dynamic database, as new patients presenting to clinical centres are continuously enrolled and patient drop-out rates reflect the real clinical practice. Patients are routinely seen every 3–4 months and demographic, laboratory, clinical and treatment information are collected during each visit. Data from centres are centralized, merged and checked for consistency on a 6-month basis. The database used for the present analysis was frozen in November 2011 and includes data from 8 clinical centres .Patients were included from the observational Italian MASTER Database Cohort.,16 In brst 1996 and December 31st 2009 were selected from the Italian MASTER Cohort. Other inclusion criteria were: (1) CD4+ T-cell count <200 cells/μl before HAART initiation; (2) Two consecutive HIV plasma viral load <50 copies/ml within the first year (±3 months) of treatment; (3) Age ≥ 18 years. Patients with HIV-2 infection and those with HIV plasma viral load <50 copies/ml before HAART initiation were excluded from the study.HIV-1 infected patients who had initiated their first HAART regimen  while naïve to antiretroviral therapy between January 1The outcome of interest was the occurrence of newly diagnosed serious nADE. Serious nADE included the following: (i) any non AIDS-defining malignancy; (ii) cardiovascular events ; (iii) severe non-AIDS defining infections ; (iv) hepatic events ; (v) acute kidney injury  formula , or kidnA composite end-point, including nADE, AIDS-defining events  and deatSerious nADE were considered only if no event of that specific category  had occurred before the study baseline, in a time window covering 1 year before and 1 year after HAART initiation. In addition, episodic pneumonia did not concur to define a newly diagnosed nADE among patients with a previous diagnosis of recurrent bacterial pneumonia. Similarly, an AIDS-defining event was considered only if the patient had not experienced that particular AIDS-related opportunistic infection or neoplasm before.Uni- and multivariable logistic regression models were conducted to identify variables associated with immunologic non response at 1 year after the initiation of HAART. Predictors of non AIDS-related severe event occurring after year 1 were assessed using Kaplan-Meier estimates and adjusted Cox proportional hazard regression analysis. Follow-up accrued from the first viral load (VL) <50 copies/ml measured after 9–15 months of treatment and was right censored in case of VL >50 copies/ml or missing for ≥180 days, HAART discontinuation, loss to follow-up or  death. Patients were categorized as INR or immunological responders if their CD4+ T-cell count was <200 or ≥200 cells/μl after 1 year (range 9–15 months) of HAART, respectively.versus immunological responders), age, gender, risk factor for HIV acquisition, previous nADE, previous AIDS-defining event , hepatiThe same models and covariates (with the exception of the occurrence of AIDS-defining events during the follow-up) were used in the secondary analysis exploring predictors of the composite outcome .All statistical analyses were performed using SAS 9.2 statistical software . All P-value presented are two sided and a P-value <0.05 indicated conventional statistical significance.Patients included in the MASTER cohort study provide, at enrolment, written informed consent to include their clinical and biological data in the MASTER database for scientific purposes. The data are anonymized and the database is hosted in the “Fondazione MISI’s” headquarter, in compliance with current Italian regulations. The study was approved by the Ethical Committee of the Hospital “Spedali Civili”, Brescia (Coordinating Centre) and those of the following Institutions: University Hospital of Ferrara, Ferrara; AO Papa Giovanni XXIII, Bergamo; Ospedale Policlinico—University of Bari, Bari; San Gerardo de’ Tintori" Hospital, Monza; Hospital of Cremona, Cremona; ‘‘Santa Maria Annunziata” Hospital, Firenze; “Sacro Cuore” Catholic University, Roma.Among 1869 patients initiating HAART with a CD4+ T-cell count <200 cells/μl in the MASTER Cohort, 164 patients were not included because followed for <12 months, 477 because did not have two consecutive HIV plasma viral load <50 copies/ml within the first year of treatment and 7 because lacked of CD4+ T-cell count determination at month 12. The remaining 1221 patients were included and studied over a median of 3 years (Inter-quartile range [IQR] 1.3–6.1), accounting for a total of 4,708 person-years of follow-up (PYFU). The median age at treatment initiation was 41.2 years; the youngest patient was 18 and the oldest 75 years old. Median CD4+ T-cell count at the time of HAART initiation was 77 (IQR 28–142) cells/μl and 56% of the patients had already experienced one or more AIDS-defining illnesses before study baseline.After 1 year of treatment, median CD4+ counts had increased to 286 (IQR 197–387) cells/μl, but 319 patients (26%) had a CD4+ count below 200 cells/μl and were, therefore, classified as INR.Characteristics of the patients, overall and stratified by immunological response after 1 year of treatment, are shown in During the subsequent follow-up, 272 (85.3%) INR had at least one determination of CD4+ T-cell count ≥200 cells/μl, whilst 47 (14.7%) remained below this threshold throughout the follow-up.versus heterosexual route, OR 1.92, 95%CI 1.37–2.70), hepatitis C co-infection , previous AIDS event  and use of single PI-based HAART . Conversely, initiating HAART in latest years  and higher pre-HAART CD4+ T-cell counts  were associated with lower risk of INR.Applying a logistic regression model adjusted for age and gender, the following factors were associated with a higher risk of INR after 1 year of treatment: older age , intravenous drug use (IVDU) as HIV route of infection  and pre-HAART CD4+ T-cell count  were significantly associated with INR after 1 year of treatment, after adjustment for each other and for gender, history of previous AIDS-defining events, calendar year at treatment initiation and type of HAART initiated. The association between hepatitis C seroreactivity and a higher risk of INR was confirmed in a separate multivariable logistic regression model not including risk factor for HIV acquisition .In multivariable logistic regression models, older age , IVDU route of infection , 399 during the first year of treatment (317 AIDS-defining and 82 serious nADE) and 238 during the subsequent follow-up . Full description of all observed events is included in For the sake of the present analysis, only the first event occurring after year 1 was retained. Therefore, 86 serious nADE were considered, accounting for an incidence of 1.83 (95%CI 1.73–2.61) events per 100 PYFU. Of them, 26 (30.2%) were non AIDS-defining malignancies, 15 (17.4%) cardiovascular events, 24 (27.9%) severe infections, 15 (17.4%) renal and 6 (7%) hepatic events.During the same follow-up, excluding the events that occurred after a serious nADE, 71 AIDS-defining events and 6 deaths were observed. A detailed description of the events observed during the study time-window and their frequency among immunological responders and INR is shown in vs. full responders, HR 1.61, 95%CI 1.03–2.51), older age , previous serious nADE  and occurrence of AIDS defining event during the follow-up . The association between hepatitis C serostatus and increasing risk of severe nADE was confirmed in a separate multivariable model, not including risk factor for HIV acquisition . When CD4+ percentage change after 1 year of HAART was considered in a model including immunological response at year 1, higher CD4+ increases were only marginally associated with lower risk of nADE . Results of Cox proportional hazard models are shown in Applying a Cox regression model adjusted for age and gender, INR were at significantly higher risk of nADE than those with >200 CD4+ T cells/μl after 1 year of treatment . Other factors significantly associated with nADE were older age , IVDU as risk factor for HIV acquisition , hepatitis C co-infection , having had a previous nADE  or a previous AIDS-defining event  and the occurrence of AIDS-defining event during the follow-up . Due to high correlation (63%) between IVDU and hepatitis C serostatus, only IVDU was included in a second multivariate Cox model, where adjustments for all factors significantly associated with the outcome in the previous model and those considered to be clinically significant  were included. In this analysis, the following factors were significantly and independently associated with a higher risk of nADE: immunological response at year 1 .An independent association between INR and risk of nADE events was confirmed after stratification for pre-HAART CD4+ T-cell count .Similar results were obtained when the composite end-point of death, AIDS-defining and serious nADE was used as outcome measure. Using multivariable Cox regression analysis, the following variables were associated with increased risk of clinical progression: INR at year 1, having experienced a previous AIDS-defining event, HCV-Ab positivity. Conversely, higher CD4+ change at year 1, compared with baseline, resulted to be borderline protective. Results of this analysis are shown in Notwithstanding efforts to promote early HIV testing, 20 to 40% of patients entering in care for HIV in Western Countries present with advanced HIV disease, i.e. with a CD4+ count below 200 cells/μL. Failure In our cohort, failure to increase CD4+ T-cell count from below to more than 200 cells/μl after 1 year of effective HAART increased the subsequent risk of severe non AIDS-related event by 65%. These results are in agreement with a recent study that demonstrated that patients unable to restore their CD4+ count to >200 cells/μl after 3 years of viral suppression run a higher risk of death due to non AIDS-defining causes (particularly non AIDS-defining cancer and liver-related). This study, however, could not explore the possible association between INR and non-fatal events. A previoWhen change of CD4+ T-cell count at year 1 compared to pre-HAART levels, instead of the absolute CD4+ count at the same time-point, was used as a covariate, only a marginal, non-statistically significant association with serious nADE was found. Similarly, pre-HAART CD4+ counts were not associated with risk of serious nADE to a statistically significant extent. Previous studies suggested that absolute CD4+ cell count measurement at certain time points after HAART initiation is a more solid prognostic indicator of AIDS clinical progression than CD4+ change from baseline. Our resuInterestingly enough, patients developing a new AIDS defining event were shown to have a 2-fold increased risk to be diagnosed with a severe nADE subsequently. Therefore, the increased risk of nADE observed in INR patients could be partially (but not completely) due to their greater risk of developing new AIDS events. It has to be ascertained whether a condition of pre-existing immune dysfunction, immune activation or persistent inflammation –29 prediIn our cohort, positive HCV-Ab testing was associated with a greater risk of INR. Whether this effect is directly attributable to hepatitis C virus co-infection or to other associated conditions is still debated. A previous study suggested that HCV-Ab positive patients are more likely to have an incomplete CD4+ restoration , whereas3 is widely accepted to define HIV-related immunedepression.[Our study has some limitations that merit to be acknowledged. First, the definition of nADE included a number of different comorbid diseases, which are heterogeneous in terms of pathogenesis. The use of this composite end-point, nonetheless, is widely accepted in the literature.,13,39 Unpression. In additIn conclusion, our results indicate that increasing CD4+ T-cells >200/μl decreases the risk of severe nADE. Even among those with severe immune-suppression, non-AIDS events risk is greater than risk of AIDS, once patients are started on effective HAART. Interestingly, occurrence of AIDS is intertwined (and possibly predict) the risk of severe nADE events.S1 Table(DOCX)Click here for additional data file.


Therapy related acute myelogenous leukemia (AML) and myelodysplastic syndromes (MDS) have been classically linked to alkylating agents and topoisomerase inhibitors. They constitute about 1% of all AMLs. There is less evidence on association of taxanes (paclitaxel and docetaxel) with these myeloid neoplasms. We present a case of paclitaxel therapy related acute myelogenous leukemia after treatment of endometrial cancer with a regimen containing paclitaxel and carboplatin. A 63-year-old female underwent surgery followed by a total of 6 cycles of chemotherapy with carboplatin and paclitaxel. Six months after last cycle of chemotherapy, she was diagnosed with myelodysplastic syndrome with refractory anemia and excess blasts. Six weeks later, she had worsening anemia and thrombocytopenia which prompted a bone marrow biopsy which revealed acute myelomonocytic leukemia. A thorough literature review revealed 12 other case reports where taxanes have been implicated in the development of therapy related myeloid neoplasm. Based on the timeline of events in our patient, paclitaxel is the likely culprit in the pathogenesis of this myeloid neoplasm. This rare but significantly grave adverse effect should be kept in consideration when deciding on treatment options for gynecological malignancies. Advancements in the treatment of gynecologic cancers with newer chemoradiotherapies have significantly improved the mortality and life expectancy of patients with these cancers. But with increased use of these chemotherapeutic agents, prescribers should be mindful of the potential long term side effects of these agents. One of the most serious complications of chemotherapeutic agents is dysplasia and malignancy.Therapy related AML (t-AML) makes up about 10% of AML and has been studied and well documented in association with alkylating agents and topoisomerase inhibitors . –17. 8–172 , 19. The2 . Five of2 .As seen in the literature review, the myelodysplastic syndromes and myelogenous malignancies associated with these agents are characterized by multiple cytogenetic abnormalities and typically have a very poor prognosis. Of the four patients who received treatment for secondary leukemia, two died within a year, one died 13 months later due to progression of the primary tumor, and one survived. Of the patients who did not receive treatment, the average survival was 7.5 months. In all of the reviewed cases, only two cases had gone into remission: the first described by Christodoulou et al. was detected early in the MDS stage and was treated two months after diagnosis with bone marrow transplantation  and the


Regimen change is a major challenge for the sustainability of human immunodeficiency virus (HIV) treatment program. In a resource limited setting where treatment options are limited, designing strategies to increase the durability of original regimen are essential. However, information’s on rate of initial regimen change and its predictors is scarce in Ethiopia. Therefore, the purpose of this study was to assess the rate of initial highly active anti retroviral therapy (HAART) regimen change and its predictors among adult HIV patients at the University of Gondar Referral Hospital, Northwest Ethiopia.An institutional based retrospective follow up study was conducted among 410 adult HIV patients started HAART from January 2010 to December 2014. Simple random sampling technique was used to select patient records using computer generated random number. Data were collected from patient chart using data extraction tool. The Kaplan–Meier curve was used to estimate the median duration of regimen change. Life table was used to estimate the cumulative survival for initial regimen change and log rank test to compare regimen change survival curves between the different categories of explanatory variables. Bivariate and multivariate Cox proportional hazard model were used to identify predictors of initial regimen change.The overall incidence rate of initial regimen change was 10.11  per 100 person years (PY). Baseline WHO clinical stage III , occurrence of tuberculosis (TB) on the initial regimen , side effect on the initial regimen  and co-medication with ART  were significant predictors of initial regimen change.The rate of initial HAART regimen change was found to be high. Having WHO clinical stage III, co-medication with ART, occurrence of tuberculosis and side effect on initial regimen were independent predictors of regimen change. Hence, close follow-up and screening of patient for side effect and tuberculosis is important. The survival of HIV patient increased due to the scale up of antiretroviral therapy and changed HIV infection into chronic conditions. However, changes in treatment and poor adherence limit the therapeutic success of original regimen and sustainability of HIV treatment program since antiretroviral therapy is a lifelong therapy. As far as there is virological success, the initial regimen continues unless the need of regimen changes due to drug side effect, co-morbid illness, pregnancy and other conditions –3.Improving the long term access and sustainability of HIV treatment program by optimizing the limited available combined anti-retroviral regimen is vital. Successive regimens are inferior to that of the original regimen in related to effectiveness and duration. In addition to this; regimen change result in a number of challenges, reduce both the duration and the chance of viral control due to cross resistance between different alternative drug and overlapping toxicity between and within a class of antiretroviral (ARV) drug. Subsequently, the likelihood that successful HAART will last life time is poor , 2, 4, 5A multi-center study in North America and Europe showed that the incidence of regimen change were 14.4/100 person years (PY) . FurtherIn resource limited setting including Ethiopia where treatment options are limited; designing strategies to increase the durability of original regimen is essential. So as to achieve this goal, it is important to determine the rate and predictors of initial HAART regimen change. However, information’s on rate of initial HAART regimen change and its predictor in Ethiopia is scarce. Therefore, this study was aimed to determine the rate of initial HAART regimen change and its predictor among adult HIV patients. Results from this study will help to design appropriate measures to increase the duration of original regimen among patients on antiretroviral therapy (ART) which subsequently preserve the future treatment options.Institution based retrospective follow up study was conducted to determine the rate of initial HAART regimen change and it’s predictor among adult HIV patients at University of Gondar Referral Hospital, North West Ethiopia, from January 2010 to June 2015. The study was conducted at Gondar University Hospital ART clinic from May 25 to June 10 2015. University of Gondar Referral Hospital is a teaching Hospital which serves more than five million people of the North Gondar zone and peoples from the neighboring zones. The HIV care service of the Hospital was initiated in 2005 and has 7 outpatient rooms, one voluntary testing and counseling room, one pharmacy, and one laboratory. Since 2005 in which the hospital started ART, 7581 adults and 738 pediatrics patients are enrolled to the HIV care. Currently 4891 adults are actively following their treatment.3 or when WHO stage III and IV disease. The choice of ART drug is based on baseline clinical  and laboratory results . The first line regimen consisted of NRTI backbone zidovudine (AZT) or Stavudine (d4T) or Tenofovir (TDF) or Abacavir (ABC) with Lamivudine (3TC) and either Efavirenz (EFV) or Nevirapine (NVP). Of which the preferred first line drug is TDF-3TC-EFV and the alternative first line regimen are ZDV+3TC+EFV, ZDV+3TC+NVP and TDF-3TC-EFV. After initiation of therapy the patient is appointed at 2 weeks, at 1 month, and every month for the first 6 months and then after ever 3 months. Monitoring is done through CD4 count at baseline, every 6 months but only for exceptional case viral load is done specially to assure treatment failure suspected case.Standardized monitoring and evaluation tool and the data collection and management process are well organized and supported by electronic data base system of the hospital. During the study period, based on Ethiopian FMOH update for ART initiation criteria for adult and adolescent patients, the ART initiation criteria were either the CD4 count 350 cell/mm3), clinical failure (new or recurrent WHO stage 4 condition) or virological failure . Patients with the first date of lost to follow up, transfer out, death before the end of the follow up period and completed the follow up period without developed the event were considered as censored.Initial regimen change defined as, a switch or substitution of at least one drug from the original HAART regimen. Regimen change, which is defined in this study, as an event, through the follow up period was ascertained retrospectively when the patients is recorded as changed their regimen and start other HAART drug. According to 2008 Ethiopian federal ministry of health ART guideline which was adopted from WHO guideline; the reasons for treatment change were based on the occurrence toxicity (grade III and IV), tuberculosis, pregnancy, treatment failure and others. Treatment failure was defined as immunological failure  was calculated for the entire study period. To calculate rate of regimen change among peoples on ART, the total duration of follow up for the whole cohort in person year (PY) was used. The follow up duration for peoples on ART who did not change their regimen was calculated from the time of initiation of ART until the last visit. For those who are changing their regimen; the follow up duration was calculated from initiation of HAART to a substitution of at least one drug from the original regimen. Subsequently, the number of cases who changes their regimen within the cohort was divided by the total regimen change free follow up duration and reported per 100PY.The survival analysis technique was carried out, as this study has considered time-to-event data, Cox proportional hazard model was fitted, and a life table was used to estimate cumulative probabilities. The Kaplan–Meier curve was used to estimate the median duration of regimen change. Log rank test was used to compare survival curves between the different categories of the explanatory variables. Both bivariate and multivariate Cox proportional hazard model were used to identify the predictors. Variables with p value <0.2 in the bivariate analysis were entered into the multivariate proportional hazard model. 95 % CI of hazard ratio was computed and variable having p value <0.05 in the multivariate Cox proportional hazards model was considered as significantly and independently associated with the dependent variable. Cox proportional hazard model fitness was checked using schoenfield residual test.Ethical clearance was obtained from the Institutional Review Board (IRB) of the University of Gondar. Permission letter was obtained from the clinical director of the Hospital. The HIV care clinic head gave the consent for extracting data from records. The confidentiality of the patient was ensured by avoiding name and identification number from extracting.Four hundred ten records were analyzed. The mean age at the initiation of ART was 33.3 ± 8.7 years and 181 (44.1 %) of the participant were in the age group between 25 and 34 years. More than half of the respondents 265 (64.6 %) were female and majority 363 (88.5 %) of them were Orthodox Christian. Regarding the level of education 123 (30 %) of the respondents were completed secondary education. The majority 337 (82.2 %) of the respondents were urban dwellers. A total of 372 (90.7 %) patients had disclosed their HIV status to either their family or other relatives. Three hundred fifty nine (87.6 %) did not use any type substance  were eligible to HAART by CD4 count of which 56 (13.6 %) were also eligible clinically. The mean weight of the Participant was 53.58 ± 9.55 kg. The predominant HAART regimen initially prescribed for them were a combination of zidovudine, Lamivudine and Nevirapine (AZT-3TC-NVP), 177 (43.2 %) followed by Tenofovir, Lamivudine and Efavirenz (TDF-3TC-EFV) for 147 (35.9 %) cases.More than half 221 (53.9 %) of participants, were initiated on NVP based regimen. Nearly half 201 (49 %) of the patients were started by taking two ART pills/day and 401 (97.8 %) of the participant were taking CPT prophylaxis. One hundred seventy two (42 %) were WHO clinical stage III at the initiation of HAART. The majority, 361 (88 %) of the participant were on working functional status at a baseline. The median CD4 count at initiation of HAART and the end of follow up was 162.5 [IQR 90.5–235.5] and 291 [IQR 170–433] respectively. Nearly half, 192 (46.8 %) of study subjects were started HAART at HGB level of ≥ 13 g/dl. One hundred fifteen (28 %) of the study participants were diagnosed for opportunistic infection before initiation of HAART and after confirmation of HIV infection  of observation. Within a follow up period, a total of 88 (21.5 %) of patients were changed their initial regimen. This makes the overall rate of initial regimen change 10.11/100 PY . Regarding to the time of initial regimen change, 53 (60.2 %), 63 (71.6 %) and 80 (90.9 %) were changed their regimen within 6 months, 1 year and 3 years respectively, the remaining 8 (9.1 %) were changed after 3 years of follow up. The cumulative probability of surviving on initial regimen at the end of 6 months was 0.83; at the end of 1 years 0.81; at the end of 3 years 0.73 and the end of follow up was 0.7 . Those who were developed TB on an initial regimen had about 8.33 times at higher risk of changing their initial regimen at any time as compared to those who did not develop TB  . Those who had ART drug side effect on initial regimen were 25.27 times at higher risk of changing their initial regimen as compared to those who had not side effect  . This finding is lower than a study conducted in Thailand 13.8/100PY , Brazil Similarly, it is lower than studies done in West Africa and Kenya with a rate of 16.2/100PY and 18.6/100PY respectively , 12. ThiIn this study, being in WHO clinical stage III at initiation of ART, occurrence of TB on initial regimen, co-medication with ART and side effect on initial regimen were found to be predictors of regimen change.Those who had started HAART at baseline WHO clinical stage III were nearly two times at higher risk of changing their initial regimen as compared to those with WHO clinical stage I/II. This finding is in line with studies done in Switzerland and two Kenyan studies , 15, 16.Those who had co-medication with HAART were nearly two and half times increase the hazard of changing their initial regimen at any time as compared to those who did not take other medication. This is supported by Swiss HIV cohort and Ethiopian study at Mekelle hospital , 18. TheThose who had side effect on the initial regimen were nearly twenty five times increased the hazard of changing their initial regimen at any given time as compared to those who did not develop side effect. This finding is supported by studies done in India, Nigeria and Ethiopia , 18, 19.Those who had developed TB on initial regimen were nearly eight times at higher risk of changing their initial regimen at any time as compared to those who did not develop TB. This study is supported with a study done in India  and anotBecause of the retrospective nature of the study some important predictors which had a significant association with initial regimen change in other studies, like BMI and hepatitis B and C infection were missed.Rate of initial regimen change was found to be high and most of the change occurred within a year after initiation of HAART. Having WHO clinical stage III at initiation of ART, occurrence of TB on initial regimen, co-medication with ART and side effect up on initial regimen were found to be predictors of regimen change. Therefore, it is important to give special attention for patients who have advanced disease and taking additional medication. Strengthening care full follows up and screening for side effect and tuberculosis is important.


The Δ32-CCR5 deletion of the CCR5 receptor is protective toward coronary artery pathology and myocardial infarction. Maraviroc (MVC), a CCR5 antagonist, was recently introduced in the therapy of HIV infection; we evaluated whether this drug could modulate the atherosclerotic burden in aviremic PI-treated HIV-positive individuals who underwent MVC intensification. Thus, the effect of MVC on intima media thickness, arterial stiffness, metabolic parameters, pro-inflammatory cytokines, endothelial dysfunction, and microbial traslocation markers was analyzed in 6 aviremic PI-treated HIV-positive individuals and were compared to those obtained in 9 additional aviremic PI-treated subjects that were enrolled retrospectively from our outpatients cohort. MVC intensification resulted in a significant reduction in intima media thickness, pulse wave velocity and triglycerides compared to baseline. Notably, MVC was also associated with a significant reduction of IL-6, microbial translocation indexes, sICAM and sVCAM; these changes were maintained throughout the 6 months of MVC intensification. No significant modifications were observed in CD4 counts, HIV viral load, and cholesterolemia. Results herein support a role of CCR5 antagonists in reducing the cardiovascular risk in HIV-infection. The hampering of inflammation, microbial translocation and the improvement of endothelial function could justify the protective role of CCR5 antagonists on atherosclerotic burden. HIV infection is associated with a high burden of cardiovascular disease that results both from a direct consequence of HIV itself and from the use of highly active antiretroviral treatment and, in particular, of ritonavir-boosted protease inhibitors (PI)Recent results have shown that the Δ32-CCR5 polymorphism, the first described genetic correlate of protection against HIV infection, is associated with an increased plasma concentration of high-density lipoprotein (HDL), a reduction of triglycerides in plasmaThe likely role played by this genetic polymorphism in atherogenesis was reinforced by data obtained in the animal model. Thus, targeting CCR5 in dyslipidemic mouse models resulted in a significant reduction of both the atherosclerotic burdenMaraviroc (MVC) is an antiviral drug that acts by targeting the CCR5 receptor, one of the key protein allowing HIV penetration into the target cells. Recent results have shown that the use of this drug reduces the progression of atherosclerosis in a dyslipidemic ritonavir-treated mouse model by interfering with inflammatory cell recruitment into the plaques. Notably, the use of MVC was also shown to result in a decline of plasma lipopolysaccharide in blood910To evaluate whether MVC could have a beneficial effect on the atherosclerotic burden of HIV-infected individuals, we analysed the results of its implementation on intima media thickness, arterial stiffness, metabolic parameters, inflammatory cytokines, endothelial dysfunction and microbial translocation markers in PI-treated HIV-positive individuals.Six male HIV-infected individuals (MVC group) were enrolled in this study. Inclusion criteria were: stable PI-treatment for at least one year, undetectable viremia for at least 6 months, R5 HIV viral tropism and Framingham risk score between 10–20%. Exclusion criteria included statin treatment, immunomodulatory therapies in the last 6 months, chronic diseases .Marviroc (150 mg × 2 die) was added to current antiretroviral therapy (NRTI+PI) for six months. Patients were evaluated at baseline, 3 and 6 months after MVC intensification. The study was conducted in accordance with “Good Clinical Practice” guidelines and the Declaration of Helsinkin. Individual written consent by all subjects enrolled in the study was collected and ethical approval was granted by the Ethics Committee of L. Sacco Hospital, Milano - Italy.Nine aviremic patients in stable PI-treatment for at least one year were selected retrospectively from our out-patients cohort as the control group (PI group). These patients had the same inclusion and exclusion criteria of the MVC intensification group and were matched for sex, age and Framingham risk score. Comparisons between the two groups of patients were possible only for CD4+ T lymphocyte counts, metabolic parameters, measurement of carotid IMT and PWV, which were evaluated routinely at three-months intervals in PI-treated individuals. Immunological and microbial translocation parameters were not measured retrospectively in the PI treated group.blinded observer performed all the measurements.Measurements of carotid IMT were performed according to the guidelines of the Mannheim IMT Consensus using an ATL HDI-5000  ultrasound scanner with a 7-MHz linear transducer. Longitudinal electrocardiography (ECG)-triggered images of the right and left common carotid arteries were obtained proximally to the bifurcation and at 1- and 2-cm points, with the patient in the supine position, the head straight, and the neck extended. Measurements were performed on the posterior (far) vessel wall, and images were frozen on the isoelectric line to minimize variability during the cardiac cycle. Pulse wave velocity (PWV) was then obtained using ECG-gated pulse waveforms over the brachial arteries. PWV was calculated as the distance between recording sites measured over the surface of the body, divided by the time interval between the feet of the pressure waves. A single-LPS, sCD14, IFABP-1, sVCAM, sICAM, IL-6, and MCP-1 plasma concentrations were analyzed using commercial ELISA kits  following the manufacturer’s instructions. Plasma concentration of each protein was calculated in relation to standard curve. These parameters are analysed only in MVC treated group.p value less than 0.05 was considered statistically significant. All statistical analyses were performed with the SAS/STAT, version 9.1 software .Student’s t test was performed to assess differences between means. A Clinical and metabolic data of patients enrolled in the study are shown in Cardiovascular parameters were better at baseline in the PI group. Notably, such parameters were not modified during the study period in this group, whereas they were significantly improved during the same time period in those patients whose therapy was intensified with MVC.Thus, the PI group was characterized at baseline by a significantly better IMT  and a significantly better PWV compared to the MVC intensification group (p = 0.003) . These pvs. month 3: p = 0.007 right carotid, p = 0.004 left carotid; baseline vs. month 6: p = 0.004 right carotid, p < 0.001 left carotid)   and 2A,Bcarotid)  and 2C,DPlasmatic LPS and iFABP concentrations were significantly reduced by MVC  p = 0.0. These pPlasmatic IL-6 (p = 0.029) and MCP-1 concentrations were reduced after 6 months of MVC treatment  comparedResults of this study show that six months of MVC intensification in PI-treated individuals results in a positive effect on the atherosclerotic burden, possibly reverting the progression of atherosclerosis. Thus, the use of this antiviral drug was associated with significant improvements in triglycerides profile and cardiovascular parameters (IMT and PWV), as well as in a significant reduction of microbial traslocation, inflammatory markers and membrane adhesion molecules. The observation that no modifications in lipid profile and cardiovascular parameters could be detected in a control group of PI-treated patients who did not undergo MVC intensification strongly suggest that these effects are due to the use of MVC.in vitro and in animal modelsResults obtained in the Merit studyThe significant reduction seen in the plasma levels of membrane adhesion molecules  further confirms that MVC intensification in PI-treated patients is associated with an improvement of endothelial functions and highlight the protective effect of CCR5 inhibitors on antiretroviral induced vascular damages. Notably, MVC resulted in a significant reduction of microbial translocation as well. This observation is important considering that such translocation is believed to trigger the immunoactivation that characterizes HIV infection, and is considered to be the major culprit of atherogenesisRecent results indicate that an increase of CCR5+/CD8+ T lymphocytes heralds ischemic cardiovascular events in HIV-infected patients on suppressive cART. These CCR5-expressing cells are trapped in the atherosclerotic plaque where they have a pathologic effect, the use of MVC would impede this process and could, therefore, also be envisioned as a possibly preventative agent against the development of acute coronary syndrome (ACS)The small number of examined individuals and the observation that the control group was retrospectively enrolled could apparently hamper the validity of these results. It is nevertheless important to observe that a statistical improvement in cardiovascular parameters was only observed in the MVC groups, thus supporting the beneficial effect of MVC on such parameters.In conclusion, data herein, although preliminary, suggest a protective effect of MVC on inflammatory, metabolic and endothelial parameters associated to the atherogenesis process in HIV-infected individuals. Further analyses on the relationship between MVC and endothelial functions could lead to the identification of new and interesting fields of his therapeutic application.How to cite this article: Piconi, S. et al. Maraviroc Reduces Arterial Stiffness in PI-Treated HIV-infected Patients. Sci. Rep.6, 28853; doi: 10.1038/srep28853 (2016).


Simplification of antiretroviral therapy in patients with suppressed viremia may minimize long-term adverse effects. The study’s primary objective was to determine whether abacavir/lamivudine + atazanavir (ABC/3TC+ATV) was virologically non-inferior to tenofovir/emtricitabine + atazanavir/ritonavir (TDF/FTC+ATV/r) over 24 weeks in a population of virologically suppressed, HIV-1 infected patients.This open-label, multicenter, non-inferiority study enrolled antiretroviral experienced, HIV-infected adults currently receiving a regimen of TDF/FTC+ATV/r for ≥6 months with no history of virologic failure and whose HIV-1 RNA had been ≤75 copies/mL on 2 consecutive measurements including screening. Patients were randomized 1∶2 to continue current treatment or simplify to ABC/3TC+ATV.The primary endpoint was the proportion of patients with HIV-RNA<50 copies/mL at Week 24 by the Time to Loss of Virologic Response (TLOVR) algorithm. Secondary endpoints included alternative measures of efficacy, adverse events (AEs), and fasting lipids. Exploratory endpoints included inflammatory, coagulation, bone, and renal biomarkers.After 24 weeks, ABC/3TC+ATV (n = 199) was non-inferior to TDF/FTC+ATV/r (n = 97) by both the primary analysis (87% in both groups) and all secondary efficacy analyses. Rates of grade 2–4 AEs were similar between the two groups , but an excess of hyperbilirubinemia made the rate of grade 3–4 laboratory abnormalities higher in the TDF/FTC+ATV/r group (30%) compared with the ABC/3TC+ATV group (13%). Lipid levels were stable except for HDL cholesterol, which increased significantly in the ABC/3TC+ATV group. Bone and renal biomarkers improved significantly between baseline and Week 24 in patients taking ABC/3TC+ATV, and the difference between groups was significant at Week 24. No significant changes occurred in any inflammatory or coagulation biomarker within or between treatment groups.After 24 weeks, simplification to ABC/3TC+ATV from TDF/FTC+ATV/r maintained viral suppression was well-tolerated, and led to improvements in bone and renal biomarkers and HDL cholesterol.NCT01102972ClinicalTrials.gov 113734GlaxoSmithKline Clinical Study Register # Atazanavir (ATV) is a well-tolerated protease inhibitor (PI) whose plasma concentration and genetic barrier to resistance are improved by coadministration with low-dose ritonavir (RTV) Numerous induction-maintenance strategies in which RTV is discontinued once viral suppression has been achieved have been investigated and have been found to be effective The primary objective of the study was to determine whether abacavir/lamivudine + atazanavir (ABC/3TC+ATV) was virologically non-inferior to tenofovir/emtricitabine + atazanavir/ritonavir (TDF/FTC+ATV/r) over 24 weeks in a population of virologically suppressed HIV-1 infected patients with no history of prior virologic failure whose virus was currently suppressed on a regimen of TDF/FTC plus ATV/r) one of four preferred first-line regimens in the DHHS guidelines This paper presents the primary endpoint of the study  and associated secondary analyses including immunologic response, virologic efficacy, HIV-1 genotypic and phenotypic resistance patterns in patients who experienced confirmed virologic failure as well as the tolerability and safety of these regimens, including changes from baseline in fasting lipids and biomarkers associated with cardiovascular, bone, and renal health.HLA-B*5701-negative patients ≥18 years of age who were virologically suppressed  on a once-daily regimen of TDF/FTC (300 mg/200 mg) and ATV/r (300 mg/100 mg) for ≥6 months immediately prior to screening.The ASSURE study  was a prospective, randomized, multicenter, open-label, phase IV study in HIV-infected, http://clinicaltrials.gov; registration number is NCT01102972) as well as on the GlaxoSmithKline Clinical Trials registry . The CONSORT Checklist has been included as supplementary material (Checklist S1).The study design, outcome measures and results summary are also available on the ClinicalTrials.gov site (Protocol S1), and contains the full listing of all inclusion and exclusion criteria. The main inclusion criteria included a requirement that enrolled patients were ART-experienced, HIV-1 infected and ≥18 years of age and receiving a once-daily regimen of TDF/FTC (300 mg/200 mg)+ATV/r (300 mg/100 mg) for at least 6 months prior to the first day of Screening. TDF/FTC+ ATV/r must have been the subject’s initial regimen or first or second switch regimen. Initial regimen was defined as the first regimen received by a previously antiretroviral-naïve patient and any change of ART whether of a single drug or multiple drugs simultaneously was considered a regimen switch. Patients must not have switched due to virologic failure. If TDF/FTC+ ATV/r was the patient’s first or second switch regimen, then the subject should have received any of the following prior regimens: any currently licensed non-nucleotide reverse transcriptase inhibitor (NNRTI) in combination with either TDF/FTC or zidovudine (ZDV)/3TC; a ritonavir-boosted PI in combination with TDF/FTC or ZDV/3TC. Alternative prior regimens not listed above were allowed on a case-by-case basis. Each patient must have been virologically suppressed (defined as HIV-1 RNA≤75 copies/mL) at two consecutive time points on TDF/FTC+ATV/r which had to include the Screening visit and one additional visit at least 28 days prior to Screening. The original protocol was amended on 07 September 2010 to define virologic suppression as HIV-1 RNA≤75 copies/mL; for patients enrolled prior to that date, the original protocol required suppression of HIV-1 RNA to ≤50 copies/m.The full study protocol has been included as supplementary material , being HLA-B*5701 positive, prior abacavir exposure, creatinine clearance <50 ml/min via the Cockroft-Gault method, and known hypersensitivity to any component of the study drugs. Patients were also deemed ineligible if enrolled in one or more investigational drug protocols within 30 days of screening, if they had been immunized within 30 days prior to first dose of any study drugs or had been treated with or had an anticipated need during the study for any medications which could interact with the study medications according to the product labeling. Exclusion criteria also included treatment with immune-modulating agents within the prior 90 days, immunization with an HIV-1 immunotherapeutic vaccine, or undergoing treatment with radiation therapy or cytotoxic chemotherapeutic agents (or having an expected need for the latter during the study). Any verified Grade 4 laboratory abnormality at screening was generally exclusionary unless the investigator provided a compelling explanation, as was any other laboratory abnormality or medical condition detected at screening that the investigator determined would have precluded the patient’s participation in the study. While a baseline genotype was not required for study entry, patients were deemed ineligible if they had known HIV genotyping results that indicated the presence of any mutation in the reverse transcriptase or protease regions that was associated with resistance to any study drug and included the following reverse transcriptase mutations: K65R, K70E, L74V, M184I/V, or Y115F, a combination of two or more thymidine analog mutations: M41L, D67N, K70R, K219Q or E that must include a change at either L210 or T215, or three or more of the following HIV-1 protease mutations associated with atazanavir resistance: D30, V32, M36, M46, I47, G48, I50, I54, A71, G73, V77, V82, I84, N88, and L90. There were no restrictions on screening CD4+ cell count. Females of child-bearing potential were eligible if they had negative pregnancy tests at screening and baseline and agreed to use ≥1 protocol-prescribed method of contraception throughout the study.Protocol S1) was approved by the institutional review board (IRB) used by the 44 participating study sites. These IRBs included: Chesapeake Research Review, Inc., University (U) of Tennessee IRB, Alameda County Medical Centre IRB; Michigan State U Biomedical and Health IRB; Minneapolis Human Subjects Research Committee; Georgetown U IRB; Western IRB; St. Michaels Medical Center IRB, New York Medical College IRB, Kaiser Permanente Center for Health Research IRB and the Office of Human Research Ethics U of North Carolina IRB. All patients provided written informed consent to participate in the study.The protocol , eligible patients were randomized 2∶1 to simplify to their regimen to once-daily fixed dose combination of ABC/3TC 600 mg/300 mg;  plus ATV 600 mg  or remain on the fixed dose combination of TDF/3TC  plus ATV boosted with RTV . Randomization  and study drug provisioning were performed by GlaxoSmithKline’s Randomization and Medication Ordering System (RAMOS), which uses interactive voice-response technology.Patients were evaluated at screening, baseline, and weeks 2, 4, 12, and 24 with routine chemistry, hematology, and immunology tests conducted at each assessment. The concentrations of specific biomarkers  were evaluated at baseline and Week 24 only. Biomarker data was log-transformed prior to analysis and the change from baseline was assessed using geometric mean ratios with 95% confidence intervals. HIV-RNA concentrations were measured by the Abbott RealTime HIV-1 Assay. Adverse events (AEs) and laboratory toxicities were graded using the 2004 Division of AIDS Toxicity Grading Scale. All suspected ABC hypersensitivity events were reported as serious adverse events (SAEs). Glomerular filtration rates (GFR) were estimated using the modification of diet in renal disease (MDRD) formula Viral genotypes and phenotypes were performed at Monogram Biosciences Inc. . Genotypic mutations were defined according to International AIDS Society-USA Guidelines All other laboratory tests were performed centrally by Quest Diagnostics . Laboratory staff at Monogram and Quest performing assessments were blinded as to patient treatment assignment and sample labels included no information on assigned treatment regimen.The Intent-To-Treat (ITT) population consisted of all enrolled subjects randomized in the study, regardless of what treatment was actually received or the eventual outcome of study participation. A modified ITT population, ITT-Exposed, including all subjects who are in the ITT population and received at least one dose of study drug, was the primary population for efficacy analyses. The safety population consisted of all randomized subjects with the exception of those with documented evidence of not having consumed any investigational product. The virologic failure population for the virology analysis included all subjects who met the protocol virologic failure criterion which was defined as plasma HIV-RNA ≥400 copies/mL on 2 consecutive occasions (confirmed virologic failure). The Observed dataset contains all data collected while subjects were in the study. No missing values were imputed.The primary efficacy endpoint of this study was the proportion of patients with plasma HIV-1 RNA<50 copies/mL at Week 24 by the Time to Loss of Virologic Response (TLOVR) algorithm stratified by prior ART experience . The analysis was based on the intent-to-treat (ITT) exposed population, which included all patients exposed to at least 1 dose of any study drug. A study responder at week 24 was defined as a patient who had achieved confirmed (2 consecutive) plasma HIV-1 RNA<50 copies/mL and remained suppressed  by week 24 as defined by TLOVR algorithm. All others, including those who did not complete week 24 assessments, were defined as study non-responders.Secondary endpoints measured at Week 24 included the percentage of patients with HIV-RNA<50 copies/mL as measured by the missing/discontinuation equals failure (MD = F) analysis and in the Observed dataset, the percentage of patients with HIV-RNA<400 copies/mL as measured by TLOVR, MD = F and Observed analyses, the change from baseline in CD4+ cell count, time to virologic failure, detection of genotypic and phenotypic resistance at the time of virologic failure, change from baseline in fasting lipid profiles , grade 2–4 AEs, and all SAEs. There were two exploratory endpoints: (1) change from baseline in neurocognition scores, which will be discussed in a separate manuscript; and (2) change from baseline in eight cardiovascular/inflammation, bone, and renal biomarkers.A total of 300 patients were planned for the study. Three hundred patients with a 2∶1 ratio would provide over 90% power to assess the non-inferiority of ABC/3TC+ATV over TDF/FTC-ATV/r at the 0.05 level of significance. This sample size calculation assumed a virologic response rate (proportions of patients with HIV-1 RNA<50 copies/mL) of 89% in both treatment groups and a non-inferiority margin of 12%. Non-inferiority was defined as a 2-sided 95% confidence interval (CI) that excluded differences as large as 12% in the direction of inferiority of ABC/3TC+ATV group. The non-inferiority margin of 12% is standard in such non-inferiority trials of ART and is accepted by the FDA. To establish non-inferiority, the 2-sided 95% CI should lie entirely to the right of the value of −12%.All the statistical comparisons were based on 2-sided significance level of 0.05. Virologic response rates were compared using a Cochran-Mantel-Haenszel test stratified by initial ART regimen. Continuous variables were assessed by Wilcoxon rank-sum test, whereas binary responses were compared by Fisher’s exact test. The statistical analyses were performed using SAS Version 9.1  on a UNIX platform.This study enrolled 297 patients from clinical sites the United States and Puerto Rico; 1 patient randomized to the TDF/FTC+ATV/r was withdrawn due to a protocol violation prior to receiving any study medication such that the exposed population included 199 simplifying to ABC/3TC+ATV and 97 continuing TDF/FTC+ATV/r . PatientProtocol S1). The most common reasons for study withdrawal were consent withdrawn (3% [9/296]), adverse events (3% [9/296]), and lost to follow-up (2% [7/296]).Ninety-one percent (268/296) of randomized patients in the overall ITT-E population completed 24 weeks on study . Two patThe primary study endpoint was the proportion of patients with HIV-1 RNA<50 copies/mL at Week 24 by the TLOVR analysis. Following randomization, 86.9% (173/199) of patients in the ABC/3TC+ATV treatment group successfully maintained HIV-1 RNA below 50 copies/mL at Week 24 compared to 86.6% (84/97) of patients taking TDF/FTC+ATV/r. The adjusted treatment difference was 0.33%, and the two sided 95% CI (−7.97% to 8.64%) stratified by prior ART excluded the predefined non-inferiority margin of −12%, demonstrating the non-inferiority of the ABC/3TC+ATV simplification regimen to the TDF/FTC+ATV/r continuation regimen.Secondary analyses of HIV-1 RNA<50 copies/mL were similarly robust, with an Observed analysis response rate of 95% (171/181) vs. 98% (87/89) and an MD = F analysis response rate of 85% (169/199) vs. 88% (85/97), respectively, for the ABC/3TC+ATV and TDF/FTC+ATV/r groups. The TLOVR analysis of HIV-1 RNA<400 copies/mL also supported non-inferiority, with response rates of 88.4% (176/199) in the ABC/3TC+ATV group vs. 86.6% (84/97) for the TDF/FTC+ATV/r group, with an adjusted TLOVR treatment difference of 1.84% .P = 0.013) for the ABC/3TC+ATV group (+48 cells/µL) compared with the TDF/FTC+ATV/r group (+8 cells/µL). At Week 24, mean CD4+ cell counts were 569 and 562 cells/µL for ABC/3TC+ATV and TDF/FTC+ATV/r, respectively.The mean increase in CD4+ cell count from baseline to Week 24 was significantly larger  had full phenotypic susceptibility to all drugs tested, with no reverse transcriptase mutations and a few minor protease mutations . The second patient taking ABC/3TC+ATV experienced initial rebound at Week 2 with virologic failure confirmed at Week 4, concomitant with site reports of the patient experiencing adherence issues. Virus from this patient had reduced phenotypic susceptibility to multiple drugs, including ABC, 3TC and ATV, and numerous reverse transcriptase  and protease  mutations. The patient reported previous treatment with nevirapine plus TDF/FTC for >8 years before switching to TDF/FTC+ATV/r, but prior viral resistance was unknown because the patient had no HIV-1 genotypes available for review at screening.Rates of AEs of moderate or greater severity (grade 2–4) were similar between the two groups  of patients simplified to ABC/3TC+ATV and 2% (2/97) of patients continuing on TDF/FTC+ATV/r, with only rash and nausea reported in >1 patient. Suspected ABC hypersensitivity was reported for 1 subject who was not withdrawn from the study but restarted his original TDF/FTC +ATV/r regimen with resolution of signs and symptoms.P<0.001) in the TDF/3TC+ATV/r group compared with the ABC/3TC+ATV group. The difference was primarily driven by changes in total bilirubin; other treatment-emergent grade 3–4 lab abnormalities were infrequent and similar between groups. Fasting lipid levels (P<0.001) compared to the TDF/3TC+ATV/r group.The rate of treatment-emergent or worsening grade 2–4 and grade 3–4 laboratory abnormalities was significantly higher  was 2.0% in the ABC/3TC+ATV group and 1.5% in the TDF/FTC+ATV/r group. Over 24 weeks on randomized treatment, there was no change in 10-year risk in either group.At baseline, the median estimated glomerular filtration rate  was 93 mL/min/1.73 mP<0.001) for patients taking ABC/3TC+ATV (P<0.001) for ABC/3TC+ATV than for TDF/FTC+ATV/r. Similarly, the renal biomarker urine β2 microglobulin/creatinine ratio declined by 58% in the ABC/3TC+ATV group (P<0.001) but remained unchanged in the TDF/FTC+ATV/r group (P<0.001) between treatment groups. Conversely, there were no significant changes from baseline to Week 24 in any of the biomarkers associated cardiovascular disease, inflammation or thrombogenesis that were evaluated  either within or between treatment groups.  in all 4 measured bone biomarkers  was significant , and as the two sided 95% CI (−7.97% to 8.64%) stratified by prior ART excluded the predefined non-inferiority margin of −12%, non-inferiority of the simplification regimen was established. Confirmed virologic failure >400 copies/mL occurred in 1% of patients in both groups. The mean increase in CD4+ cell count from baseline to Week 24 was significantly larger for ABC/3TC+ATV (+48 cells/µL) than TDF/FTC+ATV/r (+8 cells/µL).There were few grade 2–4 treatment-related AEs in either group, but patients treated with TDF/FTC+ATV/r had significantly more treatment-emergent or worsening grade 2–4 and grade 3–4 laboratory abnormalities than patients taking ABC/3TC+ATV – largely driven by a higher rate of hyperbilirubinemia in the RTV-containing group. Fasting lipid levels were similar between treatment groups and varied little between baseline and Week 24, except for a significant increase in HDL in patients taking ABC/3TC+ATV.While induction-maintenance strategies in which RTV is discontinued once viral suppression has been achieved have been found to be effective and are now endorsed by DHHS guidelines Likewise, in the InduMA study, 252 antiretroviral-naïve patients received 2 NRTIs plus ATV/r for 26 to 30 weeks We found a significant improvement in markers of bone turnover following the switch to ABC/3TC+ATV but observed little change in the group maintaining TDF/FTC+ATV/r. It has previously been demonstrated that the initiation of ARV therapy is often associated with decreases in BMD that slow or stabilize over 24 to 48 weeks of therapy, and that these losses tend to be larger with TDF-containing regimens compared with non-TDF-containing regimens P<0.0001) and consistent with the results observed in our study .While the association between TDF and renal impairment is well studied, .Over 24 weeks, simplification of TDF/FTC+ATV/r to ABC/3TC+ATV maintained viral suppression, was well-tolerated, and led to improvements in CD4+ cell count, bone biomarkers, renal biomarkers, and HDL cholesterol without causing increases in other fasting lipid levels or in cardiovascular biomarkers of inflammation and thrombogenesis. This study continues through 48 weeks to provide longer-term data regarding the efficacy and safety of this ART simplification strategy.Checklist S1Checklist S1 is the CONSORT study checklist and lists the manuscript sections where details regarding the checklist items can be found.(PDF)Click here for additional data file.Protocol S1The complete EPZ113734 clinical study trial protocol.(PDF)Click here for additional data file.