Previous cohort studies have demonstrated the beneficial effects of antiretroviral therapy (ART) on viral load suppression. We aimed to examine the factors associated with virologic suppression for HIV-infected patients on ART receiving care at the Evandro Chagas Clinical Research Institute, Oswaldo Cruz Foundation in Rio de Janeiro, Brazil.HIV-1 RNA levels and CD4+ T-cell counts at the date closest to midyear (1 July) were evaluated for 1,678 ART-naïve patients ≥18 years of age initiating ART between 1997 and 2010. The odds ratios (OR) and 95% confidence intervals (CI) for having an undetectable viral load (≤400 copies/mL) were estimated using generalized estimating equations regression models adjusted for clinical and demographic factors. Time-updated covariates included age, years since HIV diagnosis, hepatitis C diagnosis and ART interruptions.Between 1997 and 2011, the proportion of patients with an undetectable viral load increased from 6% to 78% and the median [interquartile range] CD4+ T-cell count increased from 207  to 554  cells/μL. Pre-treatment median CD4+ T-cell count significantly increased over the observation period from 114  to 237  cells/μL (p < .001). The per-year adjusted OR (aOR) for having undetectable viral load was 1.18 (95% CI = 1.16-1.21). ART interruptions >1 month per calendar significantly decreased the odds [aOR = 0.32 (95% CI = 0.27-0.38)] of having an undetectable viral load. Patients initiating on a protease inhibitor (PI)-based first-line regimen were less likely to have undetectable viral load [aOR = 0.72 (95% CI = 0.63-0.83)] compared to those initiating on a non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimen.Our results demonstrate significant improvements in virologic outcomes from 1997 to 2011, which persisted after adjusting for other factors. This may in part be due to improvements in care and new treatment options. NNRTI- versus PI-based first-line regimens were found to be associated with increased odds of having an undetectable viral load, consistent with previous studies. Treatment interruptions were found to be the most important determinant of not having an undetectable viral load. Studies are needed to characterize the reasons for treatment interruptions and to develop subsequent strategies for improving adherence to ART. Universal access to antiretroviral therapy (ART) for human immunodeficiency virus (HIV) infection was first established in Brazil by a federal decree issued in 1996. Over time, the Ministry of Health has continued efforts to expand HIV testing and treatment programs. CD4+ T-cell count thresholds for treatment initiation have increased over time and newer first-, second- and salvage-line antiretroviral drugs with greater efficacy and lower toxicity profiles have been introduced within the National AIDS Program. The early introduction of viral load monitoring within the National ART guidelines in Brazil has also allowed for earlier detection of virologic failure and subsequent treatment modifications. Data from previous studies conducted in both high- and low-resource settings have validated the impact of ART on decreasing morbidity and mortality, and achieving virologic suppression and immune system reconstitution for HIV-infected persons .Given the importance of maintaining virologic suppression for reducing the risk of clinical progression of HIV and ultimately death, as well as decreasing HIV transmissibility , studiesThis analysis aimed to examine the virologic and immunologic response to HIV treatment, including factors associated with virologic suppression for HIV-infected patients on ART receiving care at the Evandro Chagas Clinical Research Institute (IPEC) of the Oswaldo Cruz Foundation (Fiocruz) in Rio de Janeiro, Brazil from 1997 to 2011. Our analysis, though not representative of the overall Brazilian HIV-infected population, reflects the group-level effects of provision of universal access to ART and continued efforts to improve care and treatment programs both at the national and local level.Data were obtained from the longitudinal, clinical database of HIV-infected patients receiving care at IPEC in Rio de Janeiro, Brazil. IPEC has been providing care to HIV-infected patients since 1986. The clinical database was established in 1998 and has since been updated regularly using outpatient and inpatient medical records, and laboratory results. ART regimen data, including drug type, dose and prescription dates, is documented by the medical provider in the medical record. Professional abstractors review all patient records on a continuous basis and record the information onto standardized forms, which are subsequently scanned for inclusion in the clinical database.We analyzed data for HIV-infected patients greater than or equal to 18 years of age who initiated highly-active ART for the first time during the period from January 1, 1997 through December 31, 2010. Patients initiating ART prior to enrollment in the IPEC clinical cohort were excluded from the analysis. Only patients initiating ART on a non-nucleoside reverse transcriptase inhibitor- (NNRTI) or protease inhibitor- (PI) based regimen were included. NNRTI-based regimens were defined as a NNRTI or NNRTI and PI, plus nucleoside reverse transcriptase inhibitor (NRTI) backbone. PI-based regimens were defined as a PI plus NRTI backbone only. Patients initiating on neither NNRTI- or PI-based first-line regimens were too few (n = 28) to include in our statistical analysis and were therefore excluded. End of follow-up was determined by either year of death for patients with a documented date of death or until the last year of the period of analysis, December 31, 2011.HIV-1 RNA levels and CD4+ T-cell counts at the date closest to midyear (1 July) were evaluated for all patients initiating ART between 1997 and 2011. Only HIV-1 RNA levels and CD4+ T-cell counts occurring greater than or equal to 90 days after the initiation of ART were included in the analysis to allow time for virologic response to treatment. The outcome of interest was undetectable viral load, defined as ≤400 copies/mL to account for less sensitive virus detection thresholds of older testing platforms included in the analysis.Antiretroviral regimens were classified by drug mechanism of action. No distinction was made for drug generations or agents within the same drug class. Individual ART regimens per calendar year were determined by choosing the regimen with the greatest number of documented months per calendar year. Treatment interruptions per calendar year were defined as the sum of all the periods of time with no documented ART regimen in the patient’s clinical chart, rounded to the nearest month, and not necessarily occurring consecutively.Demographic characteristics were also assessed, which included: age, gender, race, years of formal schooling, self-reported risk group and date of HIV diagnosis. Race was categorized as White and Non-White. HIV risk group was hierarchically categorized as Injection Drug Users (IDU), Men who Have Sex with Men (MSM), Heterosexual Men, Heterosexual Women, and Other. The “Other” risk group category includes hemophiliacs, occupational exposures, and transfusions. Covariates of interest included pre-treatment CD4+ T-cell count, defined as CD4+ T-cell count occurring within 180 days prior to ART initiation, and lifetime occurrence of hepatitis C diagnosis, defined as the presence of hepatitis C antibodies. Pre-treatment CD4+ T-cell counts were categorized as follows: ≤200, 201–350, 351–500, >500 and missing. Pre-treatment viral load data were not universally available.HIV-1 RNA levels were stratified as ≤400, 401–1,000, 1,001-100,000 and ≥100,001 copies/mL. Median and interquartile ranges (IQR) of CD4+ T-cell counts were computed for each calendar year. Time trends for categorical and continuous variables were tested using the Chi-square and Kruskal-Wallis test respectively, assuming a significance level of p < 0.05.Unadjusted and adjusted logistic regression models were used to describe the association of clinical and demographic factors with the odds of having an undetectable viral load. Generalized estimating equations (GEE) were used to account for repeated measures per patient. Time trends were analyzed by using calendar year as a continuous variable. The following fixed covariates were included in the model: sex, race, education level, risk group, pre-treatment CD4+ T-cell count and initial ART regimen. Missing values for race and education categories for 5 and 8 patients, respectively, were imputed based on sample distribution. Time-updated covariates included age in years , years since HIV diagnosis, ART interruptions (categorized as ≤1 month versus >1 month), and hepatitis C diagnosis (history of positive anti-HCV antibody test). ART interruptions were categorized because the variable was not linearly associated with the outcome when treated as a continuous variable (data not shown). Given that the duration of ART interruption did not necessarily represent a continuous interval of time, the variable was categorized as interruptions ≤1 month versus >1 month per calendar year. ART regimen was not included as a time-updated covariate due to limitations in the formatting of the longitudinal dataset. Patients with missing mid-year viral load outcomes were excluded from the logistic regression analysis for the years where they had no viral load outcomes. A sensitivity analysis assuming that all missing virologic outcomes were detectable was performed. Analyses were done using R-software (version 2.15.1).This study was approved by the institutional review board of IPEC. Written informed consent for enrollment in the cohort was obtained from all patients. Retrospective analysis of previously collected data delinked from personal identifying information was considered exempt by the UCLA IRB.A total of 1,678 patients initiated ART from 1997 to 2010 and contributed at least one viral load outcome to the descriptive and logistic regression analysis. There were a total of 8,870 years of follow-up included in the observation period. The median [IQR] number of months of follow-up per patient was 47  months.Table Out of the 8,770 years of follow-up, there were a total of 2,245 ART interruptions of more than one month duration. The median number of total months of treatment interruption per calendar year was 7 . The proportion of patients with a treatment interruption of more than one month duration trended downward from 64% in 1997 to 16% in 2011. Overall, 74% of patients  had at least one year with an ART interruption of more than one month duration, with a median of 2  years with an interruption per patient. The median number of months of follow-up per patient for these patients was 51  compared to 47  months for those who never had an ART interruption of more than one month duration. Demographic characteristics of the patients who never had an ART interruption were overall similar to those who had at least one ART interruption with the exception of there being a greater percentage of IDU in the latter group.The median number of viral load measurements per patient per year was 1 . Patients contributed a total of 7,278 viral load outcomes. The percentage of patients with a missing viral load outcome decreased from 44% in 1997 to 13% in 2011. Of note, over 78% of patients with a missing viral load outcome had a greater than one month ART interruption documented during the corresponding calendar year.During the observation period, the overall proportion of patients with an undetectable viral load increased from 6% in 1997 to 78% in 2011. Additionally, the median CD4+ T-cell count increased from 207  to 554  cells/μL. The proportion of midyear HIV-1 RNA levels stratified by number of viral copies and median midyear CD4+ T-cell counts per calendar year are depicted in Figure Table Older age and more years of formal schooling were positively associated with having an undetectable viral load. ART interruptions >1 month versus ≤1 month per calendar year and initiating a PI-based first-line regimen compared to an NNRTI-based first-line regimen were the factors most strongly negatively associated with having an undetectable viral load. The odds of having an undetectable viral load decreased with each year since HIV diagnosis. Patients with a pre-treatment CD4+ T-cell count between 351 and 500 cells/μL had an increased odds of being undetectable compared to those initiating with a CD4+ T-cell count ≤200 cells/μL.A total of 1,492 missing mid-year viral load outcomes  were excluded from the analysis. Sensitivity analysis assuming all missing mid-year viral load outcomes as detectable did attenuate the overall effect , but did not offset overall time trends or significantly affect the factors associated with undetectable viral load.In our observational, clinical cohort, significant improvements in virologic outcomes were observed for patients receiving ART over the study period. Between 1997 and 2011, the proportion of patients with an undetectable viral load increased from 7% to 78% and the median CD4+ cell count increased from 207  to 554  cells/μL. Time trends in virologic outcomes were only partially explained by the clinical and demographic factors tested, thus other factors not accounted for in our model, such as improvements in clinical care, treatment options and ART adherence may explain our findings. Our results are consistent with prior studies which suggest that these observed trends in virologic and immunologic outcomes may be partly attributable to improvements in treatment and care , such asSimilar to a prior study of predictors of virologic suppression , we founEven though treatment interruptions were assumed from absence of documentation of ART regimen within the patient clinical record and not confirmed with the ARV pharmacy database, it is unlikely that patients with no documented regimen were still retrieving their medications because a physician prescription is required for medication dispensation. Lack of treatment documentation in the clinical chart is therefore likely a surrogate for periods of medication non-adherence or loss-to-follow-up. We did not apply a definition of loss-to-follow-up for excluding patients from the analysis, thus all patients ever initiated on treatment were accounted for until the end of the observation period or documented date of death. The rationale for this was that vital status is exhaustively verified through active patient contact and data linkage with state-wide mortality databases using a previously validated algorithm , thus itThe number of months of follow-up per patient was only slightly higher in the group of patients with at least one versus no ART interruption throughout the study period, thus having no ART interruption is not merely an artifact of differences in follow-up time between the two groups. Given the importance of ART adherence to treatment efficacy , developWe also found older age (≥40 years)  and moreOur study was limited by the open cohort design, which is subject to bias both from the inclusion of new patients who may have improved prognoses, as well as the loss of patients with potentially poorer prognoses. We did not conduct a closed cohort analysis, however, a prior study found no difference in time trends for virologic outcomes when comparing a closed versus open cohort . Our resAnother study limitation was the inability to account for possible viral load blips in our analysis due to the limited quantity of viral load tests performed per patient per year. Despite the fact that Brazilian HIV treatment guidelines stipulate routine viral load and CD4+ T-cell count testing every three to four months for patients on ART, most patients received viral load testing only once per year .Of note, patients with a pre-treatment CD4+ T-cell count between 351 and 500 cells/μL were found to have increased odds of having an undetectable viral load in the adjusted model. Having no documented pre-treatment CD4+ T-cell count was negatively associated with our outcome in the unadjusted model. This trend persisted in the adjusted model but achieved only borderline significance (p < 0.10). Patients with missing pre-treatment CD4+ T-cell counts likely initiated treatment based on clinical criteria, and thus were likely to be severely immunosuppressed at the time of treatment initiation. Of the patients with missing pre-treatment CD4+ T-cell counts, 46% had a documented AIDS-defining clinical condition 90-days prior to or 30-days post initiating ART compared to 32% of those with a pre-treatment CD4+ T-cell count.We were unable to account for the impact of ART regimen changes (both inter- and intra-class drug changes) within our logistical regression model. However, we did find that initiating a PI- versus NNRTI-based first-line regimen was negatively correlated with the likelihood of having an undetectable viral load, consistent with prior research which showed virologic failure was less likely in patients initiating treatment with regimens containing efavirenz versus lopinavir-ritonavir . Of noteWe addressed the possible effects of selection bias due to exclusion of patients with missing viral load outcomes by modeling a worst-case scenario that categorized all missing virologic outcomes as detectable (>400 copies/mL) viral loads. Treating missing outcomes as failures did attenuate the magnitude of the effect, but did not change the overall time trends.In conclusion, we found significant improvements in virologic outcomes in a large, urban, publicly run Brazilian clinic from 1997 to 2011 that persisted after adjusting for other factors. This suggests that other unmeasured variables, such as advances in ART dosing and efficacy, for which time is a surrogate, may be contributing to the improvement in HIV-1 viral load suppression. Even though we cannot ensure our results are representative of the entire population of HIV/AIDS patients receiving care nationwide, they are very likely to represent those receiving care in large urban centers in Brazil. Moreover, the increase in the proportion of patients on ART with undetectable viral load levels within our clinical cohort may have implications for the overall community-level reduction of HIV transmission, and should encourage the continued expansion of HIV testing and treatment programs in Brazil.ART: Antiretroviral therapy; CI: Confidence intervals; FIOCRUZ: Oswaldo Cruz foundation; GEE: Generalized estimating equations; HIV: Human immunodeficiency virus; IDU: Injection drug users; IQR: Interquartile ranges; IPEC: Evandro Chagas clinical research institute; MSM: Men who have sex with men; NNRTI: Non-nucleoside reverse transcriptase inhibitor; NRTI: Nucleoside reverse transcriptase inhibitor; PI: Protease inhibitor; OR: Odds ratios.JEL has served as a consultant for Merck and Co and GlaxoSmithKline. The authors declare that they have no competing interests.DAM: concept development, statistical analysis, manuscript writing. PML: concept development, statistical analysis, manuscript draft revision. JEL: concept development, manuscript draft revision. JLC: concept development, manuscript draft revision. VGV: concept development, data collection, manuscript draft revision. RIM: data collection and management, manuscript draft revision. SWC: concept development, data collection, manuscript draft revision. JDK: concept development, manuscript draft revision. BG: concept development, data collection, manuscript draft revision. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/14/322/prepub


With the scale-up of antiretroviral therapy (ART), monitoring programme performance is needed to maximize ART efficacy and limit HIV drug resistance (HIVDR).pol region at the two time points.We implemented a WHO HIVDR prospective survey protocol at three treatment centers between 2012 and 2013. Data were abstracted from patient records at ART start (T1) and after 12 months (T2). Genotyping was performed in the HIV Of the 425 patients enrolled, at T2, 20 (4.7%) had died, 66 (15.5%) were lost to follow-up, 313 (73.6%) were still on first-line, 8 (1.9%) had switched to second-line, 17 (4.0%) had transferred out and 1 (0.2%) had stopped treatment. At T2, 272 out of 321 on first and second line (84.7%) suppressed below 1000 copies/ml and the HIV DR prevention rate was 70.1%, just within the WHO threshold of ≥70%. The proportion of participants with potential HIVDR was 20.9%, which is higher than the 18.8% based on pooled analyses from African studies. Of the 35 patients with mutations at T2, 80% had M184V/I, 65.7% Y181C, and 48.6% (54.8% excluding those not on Tenofovir) had K65R mutations. 22.9% had Thymidine Analogue Mutations (TAMs). Factors significantly associated with HIVDR prevention at T2 were: baseline viral load (VL) <100,000 copies/ml  and facility. Independent baseline predictors for HIVDR mutations at T2 were: CD4 count <250 cells/μl  and viral load ≥100,000 copies/ml .Strengthening defaulter tracing, intensified follow-up for patients with low CD4 counts and/or high VL at ART initiation together with early treatment initiation above 250 CD4 cells/ul and adequate patient counselling would improve ART efficacy and HIVDR prevention. The high rate of K65R and TAMs could compromise second line regimens including NRTIs. The 2010 guidelines recommended ART initiation for all patients with a CD4 count of ≤350 cells/mm3 and for those with WHO clinical stage 3 or 4 if CD4 testing is not available. In Uganda, applying these guidelines, the proportion of all ART-eligible patients receiving treatment was 69.4% i.e. 570,373 by the end of September 2013. However, this proportion falls to 40.0% if the 2013 WHO guidelines for ART eligibility are used  x 35 cycles, 72°C 4 min and 10°C hold. Next 2ul of 1° PCR product was mixed with a master mix containing 36.5ul distilled water, 5ul 10x PCR buffer (Invitrogen), 2ul Mgcl2 (Invitrogen), 1ul dNTPs (Qiagen), 1.5ul forward primer POLF2 (5’-CTTTARYTTCCCTCARATCACTCT-3’), 1.5ul reverse primer POLR2 (5’- GGCTCTTGATAAATTTGATATGTCCAT-3’) and 0.5ul of the platinum Taq enzyme (Invitrogen) this was cycled at 95°C 5min, x 35 cycles, 72°C 2 min and 4°C hold. Gel electrophoresis was done using 1% agarose gel to ascertain the right size of the amplified PCR product. The right size PCR product was cleaned using QIAquick PCR purification kit using manufacturer’s instructions. The cleaned products were sequenced using the Big dye terminator v3.1 cycle sequencing kit (Applied Biosystems) in a reaction of 4ul of the DNA template, 6ul distilled water,2.5ul ready reaction mix, 3ul 5x SEQ buffer, 5ul of each of 3 forward primers B (5’-GTTAAACAATGGCCATTGACAGAAGA-3’), C(5’-TGGAAAGGATCACCAGCAATATTCCA-3’) and POLF2(5’-CTTTARYTTCCCTCARATCACTCT-3’) and 3 reverse primers; F (5’-GGGCCATCCATTCCTGGC-3’), G (5’-CCATCCCTGTGGAAGCACATTG-3’) and H (5’-CTGTATTTCTGCTATTAAGTCTTTTGA-3’). Cycle sequencing was performed using the following conditions 96°c for 1min  x 25 cycles, and 4°C hold. Sequencing was done using the ABI 3500 machine (Applied Biosystems). Sequences were base-called using Sequencher v5.2.4 and sequence alignments performed using BioEdit v7.2.5  and SeaView v4.0 . Quality Assurance was done using the Calibrated Population Resistance tool (CPR), Stanford and the Los Alamos National database (LANL dbase) for the HIV Sequence Quality Analysis.Viral RNA was extracted from 140ul of plasma using the QIAmp Viral RNA mini kit (Qiagen). The entire protease (codons 1–99) and amino terminus of reverse transcriptase (codons 1–320) were amplified using one-step RT-PCR kit (Qiagen); briefly 10ul extracted RNA was mixed with 6.5ul distilled water,5ul 5x PCR buffer (Invitrogen), 1ul dNTPS (Qiagen), 0.75 ul forward primer POLF-1 (5’-www.bioafrica.net/rega-genotype/html/subtypinghiv.html) and RIP (www.hiv.lanl.gov/content/seguence/RIP/RIP.htmIL). Assigned DRMs were interpreted using 2009 WHO list for epidemiological surveys alongside with the lAS 2014 Update of DRMs of HIV-1 [DRMs classified as low, intermediate or high were assigned by submission of sequences to Stanford HIVdb Program whereas HIV-l subtypes was done using SCUEAL and REGA online software, (The outcomes of interest included baseline (T1) and follow-up (T2) factors classified according to HIVDR outcome: HIVDR prevention; possible or potential HIVDR and HIVDR as defined in the 2012 WHO protocol . The folHIVDR prevention: The numerator includes people with viral load less than 1000 copies/ml 12 months after antiretroviral therapy initiation or at the time of switch to second-line therapy. The denominator includes people receiving first-line antiretroviral therapy at 12 months with classifiable viral load results + people switching to second-line antiretroviral therapy with classifiable viral load result + people lost to follow-up + people who stopped antiretroviral therapy during the survey.HIV Drug Resistance: The numerator includes people with a viral load greater than 1000 copies/ml 12 months after antiretroviral therapy initiation or at switch to second-line therapy with HIV drug resistance. The denominator includes people receiving first-line antiretroviral therapy at 12 months with classifiable viral load results + people switching to second-line antiretroviral therapy with classifiable viral load result + people lost to follow-up + people who stopped antiretroviral therapy during the survey.Possible / Potential HIV Drug Resistance: The numerator includes people with viral load greater than 1000 copies/ml and no detected HIV drug resistance at 12-month survey endpoint + people who stopped antiretroviral therapy + people lost to follow-up + people with unclassifiable viral load at 12-month survey endpoint . The denominator includes people on first-line antiretroviral therapy at 12 months with classifiable viral load results + people switching to second-line antiretroviral therapy with classifiable viral load result + people lost to follow-up + people who stopped antiretroviral therapy during the survey.http://www.who.int/hiv/pub/drugresitance/report2012/en/.The above definitions can also be accessed at All statistical analyses were performed using STATA version 12 . Chi-square tests and Mann-Whitney-U tests were used to determine associations between patient characteristics for categorical variables and for continuous variables, respectively. This was done for HIVDRMs at both T1 and T2, and for viral failure (VF)  at T2.VF and HIVDRMs prevalence rates with 95% confidence intervals (95% CIs) were calculated. Logistic regression was used to obtain independent predictors of HIVDR prevention, VF and HIVDRMs at T2. Variables that had a p–value of less than 0.25 in simple analysis were included in the adjusted logistic regression model. AORs, 95% CIs, and p-values were calculated.Of the 427 antiretroviral-naive patients screened, a total of 425 who met the study eligibility criteria and consented to participate in the study were consecutively enrolled, started on ART and followed-up for 1 year. Two individuals were excluded, one did not provide a sample for baseline viral load testing and another was found to have previously been on ART. Patients who missed their scheduled visits were followed up to ascertain their status. Some of these had died or transferred to other ART treatment facilities while still on first-line regimens. However, if the status remained unknown and the patients hadn’t attended the clinic within the 2 months preceding the 12 month visit, and for another three months after the 12 month visit, they were considered lost to follow up. Patients lost to follow up contributed to the denominator in estimating the proportion of patients with the outcomes HIV DR prevention, potential HIVDR resistance and HIVDR. These patients were included in the analysis for HIV drug resistance because they would have taken some doses of ART with HIV being exposed to the ARVs and potentially having archived resistance.Of the 425 patients from 3 sites whose specimens were sent for VL and baseline resistance testing (done when VL was ≥1000 copies): 141 (33.2%) patients were from Masaka, 143 (33.6%) from Mbale, and 141 (33.2%) from Nsambya Home Care.The median baseline CD4+ count was 204 cells/μl, and the median baseline HIV-1 plasma RNA level was 127,929 copies/ml.Samples from 419(98.6%) patients had viral load ≥ 1000 copies/ml. Of these, 413 were successfully sequenced. HIV-1 subtype profiles were: A1 46.5% (n = 192); C 4.3% (n = 18); D 38.5% (n = 159); Recombinants 10.7% (n = 44).All patients received standard first-line ART regimens according to the Uganda National guidelines at the time of enrolment into the survey, with 78.3% being initiated on a TDF containing regimen. Two (0.5%) patients from Nsambya HC were prescribed a ritonavir boosted lopinavir-based regimen as first-line because they had Kaposi’s sarcoma.At baseline, drug resistance mutations (DRMs) were identified in 19(4.5%) of participants. NRTI-associated DRMs and NNRTIs-associated DRMs were found in 9 (2.1%) and 17 (4.0%) samples, respectively. Seven (1.7%) of the patients harboured mutations to more than one antiretroviral drug class, 3 (0.7%) had TAMs. None of the patients who exhibited DRMs reported a history of ART exposure. The most common NRTI- associated mutation was M184V (33.3%) out of the 15 NRTI mutations, whereas K103N and Y181C NNRTI mutations occurred at a frequency of 35.0% and 25.0% respectively (n = 20). There were three PI accessory mutations identified, two I85V and one F53L. These are unlikely to be ARV-selected and reflect natural polymorphic behaviour of protease.The T2 characteristics of this cohort are shown in Out of the 425 patients enrolled, 20 (4.7%) patients had died, 66 (15.5%) were LTFU, 313 (73. 7%) were still on first-line, 8 (1.9%) had switched, 17 (4.0%) had transferred out (on first-line regimen) and 1 (0.2%) stopped treatment.Retention in care  was 79.6% which was within the WHO threshold of 75–85% . Only 56Of the 321 patients retained at 12 months, the median CD4 cell count was 325 cells/μl (IQR: 200–490), which increased significantly from the median of 204 cells/μl (IQR: 92–292) at baseline (P<0.0001).At T2, out of the 321 patients with VL results, 272 (84.7%) suppressed below 1,000 copies/ml. However, using a denominator of 388 patients , the overall HIV DR prevention rate was 272/388 (70.1%) due to LTFU and this was just within the recommended WHO target of ≥70%. At individual clinics these were 64.8% at Masaka, 73.1% at Mbale and 72.3% at Nsambya (p = 0.28).The proportion of participants with potential or possible HIVDR was 20.9% (81/388) which is higher than the 18.8% based on pooled analyses from African studies  At indivAt T2, of the 19 patients with HIV DRMs at baseline: 1 died before the one year end point, 8 were LTFU, 3 were switched to second-line regimen, 2 were transferred out and 5 were still on first-line regimen. After the 12 months of follow-up, all the three patients who were switched to second-line regimen and only 1 out of the 5 who were still on first-line regimen achieved VL suppression. The 4 patients who did not achieve VL suppression at follow-up, had HIVDRMs and three of them accumulated additional mutations (data not shown).15. At individual sites, these were 12.5% in Masaka, 6.9% in Mbale and 7.7% from Nsambya (The proportion of participants with HIVDR at T2 was 35/388 (9.0%), which is higher than the 4.7% reported in the African region based on pooled analyses Nsambya . There wOut of the 49 virologically failing therapy (≥1000 copies/ml) at 12 months, 35 (71.4%) had HIVDRM, comparable to the 69.5% based on pooled analyses from Africa Of the 35 patients with mutations at T2, 80% had M184V/I, 65.7% Y181C and 48.6%  had K65R mutations. There were 8/35 individuals with TAMs (22.9%), (data not shown).The factors that were significantly associated with HIVDR prevention at 12 months were: VL < 100,000 copies/ml at baseline  and facility, with lower HIVDR prevention at the Masaka site. .Independent predictors for HIVDRMs at 12 month were: CD4 count at baseline <250 cells/μl  and baseline VL ≥100,000 RNA copies/ml had a borderline association, ..Considering only patients with VL results at follow-up, the factors that were significantly associated with VF were: Facility, with higher VF at Masaka and base line VL ≥ 100,000 copies/ml ,; there was a weak association between VF and CD4 count at baseline <250 cells/ul and patients who picked up drugs late ..This report, the first in Uganda to use a standardized WHO protocol to assess acquired drug resistance, provides information on the performance of the treatment programmes at three sites and associated factors, effectiveness of the current regimens and implications for second-line in a programme setting. The study was also undertaken after the introduction of new treatment guidelines with TDF as first drug of choice, prescribed to nearly 80% of the study participants.We followed 425 patients from the three centers; these initiated treatment at relatively low CD4 counts median of 204 cells/ul, a common observation in low income countries ,14,21,22About 4.5% of ART-naïve subjects initiating ART and with no reported prior ART exposure had resistance mutations. This is slightly less than the 5.0% reported from low and middle income countries  At baselThere was good retention in care comparable to other studies, with 79.5% of patients retained in care, which is above the WHO-required threshold of 70%;  all threAlthough 84.7% of participants with VL measurements at follow-up suppressed below 1000 copies/ml , the oveThe above results coupled with the good CD4 recovery indicate that those who are retained in care do well in terms of HIVDR prevention and immunological recovery; however at the programme level HIVDR prevention is lower probably due to the LTFU.At 12 months, overall 20.9%  were claThe proportion of participants with HIVDRM at T2 was 9.0%(35/388), higher than the 4.7% reported in the African region based on pooled analyses of 239 patients failing therapy at 12 months  and two At T2, 71.4% (35/49)of the individuals virologically failing therapy had DRMs  very mucThe resistance patterns seen in our study have been reported before in patients started on these first-line regimen containing 3TC and FTC NRTIs and EFV, NVP NNRTIs ,25. K65RIn our study, factors associated with HIVDR prevention at 12 months were baseline VL < 100,000 copies/ml and facility. Low baseline CD4 counts <250 and high VL ≥ 100,000 copies/ml were associated with presence of HIVDRMs at 12 months. Considering only patients with VL results at endpoint, the factors that were significantly associated with VF were baseline VL ≥ 100,000 copies/ml and facility. There was also a weak association between VF and CD4 count at baseline <250 cells/μl and patients who picked up drugs late.The lower HIVDR prevention and higher VF in Masaka could be due to insufficient pre-ART counselling provided by few counsellors per patients compared to the other two sites. Masaka had three counsellors supporting an average of 100 new ART patients per month compared to Mbale’s five counsellors for an average of 43 new ART patients and Nsambya’s seven counsellors for an average of 50 new ART patients. The patient’s comprehension of the importance of adherence and overall readiness for ART is likely to be compromised and hence poorer outcome for Masaka. Furthermore, this clinic engaged an additional cadre of lay health workers as adherence counsellors to assist in providing ART specific counselling. Much as these health workers received some basic training, the course was not accredited by the Ministry of Health AIDS Control Programme, hence questionable quality.To improve treatment outcomes and prevent HIVDR emergence, there is therefore a need to enrol patients into care early enough and to have facility targeted interventions such as adequate pre-ART counselling. WHO has recently revised the treatment guidelines recommending starting treatment in adults and adolescents with HIV at CD4 cut-off of <500 cells/mm3 regardless of clinical stage, Uganda adopted these in early 2013, however patients continue to enrol at low CD4 counts.The only information we could collect on adherence at all facilities was whether or not a patient had received pre-ART counselling recorded as adherence group and this did not affect out-come measures, although the non-group numbers were very few.Adherence assessment based on physical counts of pills remaining at the time patients attend clinic for refill, and self-recall of missed doses during the previous month should be recorded in the patient’s clinical cards at every visit. However, this was not always done. This assessment was done at all visits for 16% and 58% of patients in Masaka and Nsambya sites respectively and the majority (>90%) had good (of ≥95%) adherence. Mbale data was unavailable because the facility used a manual register unlike the other two which used electronic medical registers making it difficult to summarise data for all patients’ visits.Gender, age at ART initiation, education level, marital status, PMTCT exposure, viral subtype and treatment regimens did not affect 12 months HIVDR prevention and HIVDR mutation outcome.Some of the limitations of the study include the non-generalizability of these results which are more site specific rather than national or regional. In addition, 55 participants with low vireamia 50-<1000 copies/ml were not genotyped, the WHO protocol excludes these yet there could be HIVDR in these individuals as well.There was good retention in care and a high percentage of these individuals had suppressed VLs below 1000 copies/ml (84.7%). The overall HIV DR prevention rate at programme level was just within the recommended WHO target of ≥70%, and it was below this threshold at one clinic. The proportion of participants with potential HIVDR (20.9%) and the proportion with HIVDRM at 12 months (9.0%) were also overall higher than the average from other African sites. This performance could be due to the LTFU and hence the need to strengthen defaulter tracing to improve treatment outcome.The second-line regimens recommended were appropriate, however, the high rate of the K65R and TAMs is likely to compromise second-line drugs containing other NRTI backbone. More advanced disease at ART initiation was associated with lack of suppression and HIVDR. Efforts to initiate patients on treatment above CD4 250 cells/ul would contribute to improved ART efficacy and HIVDR prevention.S1 Appendix(DOCX)Click here for additional data file.


Nevirapine (NVP) induces cytochrome P450 3A4 by which rilpivirine (RPV) is metabolized. Switching NVP to RPV could result in decreased RPV exposure with subsequent virological failure and dyslipidemia because NVP is regarded as the least dyslipidemic, non-nucleoside, reverse transcriptase inhibitor. This trial evaluated the efficacy, pharmacokinetics, safety and cardiovascular risks of switching NVP to RPV.Prospective open label controlled trial. HIV-1 patients with HIV-1 RNA <50 copies/mL on once daily NVP, emtricitabine/tenofovir (FTC/TDF) switched to single tablet RPV/FTC/TDF. Eligible patients on NVP, FTC/TDF were controls. Primary endpoint was week 12 HIV-1 RNA <50 copies/mL by intention to treat analysis. Secondary endpoints were week 24 HIV-1 RNA <50 copies/mL, NVP and RPV pharmacokinetics, safety and fasting lipids, Framingham risk scores (FRS) and Adult Treatment Panel III (ATP-III) lipid goals.Of 189 eligible patients, we included 50 RPV switchers and 139 NVP controls. Week 12 HIV-RNA was <50 copies/mL in 46/50 switchers (92.0%) which was not different from the hypothesized 90% week 12 suppression rate (p=.431). Forty-four of 50 switchers had week 24 HIV-1 RNA <50 copies/mL compared to 126/139 controls . NVP plasma concentrations were below detection level in all at week 3. Mean week 1 RPV trough concentration was 0.083 mg/L and comparable to phase III trial data (p=0.747). Adverse events occurred in 36 switchers, the majority (82.0%) were grade one. Two switchers discontinued RPV for side effects. Significant changes over 24 weeks (p<0.001) were observed in switchers on total cholesterol , low density lipoprotein (LDL)-C  and high density lipoprotein (HDL)-C . The TC/HDL-C ratio increased 0.20  and systolic blood pressure decreased 6.0 mmHg . The median FRS did not change over 24 weeks . More patients achieved LDL-C  and TC  ATP-III treatment goals at week 24 on RPV.A NVP to RPV switch does not influence RPV exposure and results in adequate ongoing HIV-1 suppression. RPV could be an option for patients at risk for cardiovascular diseases.


Low-level viraemia (LLV) is observed in some patients with HIV-1 infection on stable antiretroviral therapy (ART). The significance of these findings remains controversial as it conflicts with traditional optimal clinic outcome. This study aims to evaluate the effect of LLV on the establishment of virological failure (VF) and immune deterioration.® – Excel 2012. Kolmogorov–Smirnov test, t-test and chi-square test were performed for a significant p value <0.05.Retrospective observational study of a cohort of HIV-1 infected patients of an Infectious Diseases Clinic, who presented an HIV-1 viral load of 20 to 200 cp/mL, during the year 2012. Patients who were not on ART or non-adherent in the previous 6 months were excluded. Compliance was quantified by clinical and pharmaceutical records. Adherence was defined as ≥95% compliance rate. Demographic, clinical, immunological and therapeutic data were collected from clinical records. LLV was defined as a range of 20–200 cp/mL and stratified as transient (T-LLV): only one measurement, persistent (P-LLV): 2 consecutive measurements with an interval ≥3 months and recurrent (R-LLV): ≥1 T-LLV during an 18-month follow-up. Statistical analysis was performed with Microsoft OfficeDuring 2012, 2161 HIV-1 infected patients were evaluated at our Clinic, 93% of which were on ART. LLV was documented in 378 (19%), adherence was verified in 151 (52%). The analysis of this cohort (n=151) revealed: 77 (51%) T-LLV, 13 (8.6%) R-LLV and 61 (40%) P-LLV. Mean viral load was 46 cp/mL. Mean TCD4 count was 665 cells/µL with a variation of +63 cells/µL during the study period. There was no VF documented. ART regimens were switched in 16 (11%) patients. Gastrointestinal disturbance was found in 13 (9%). Analysis showed no statistical differences between the analyzed variables , number of ART regimens, ART regimen and type of NRTI backbone) for all groups , except for mean viral load that showed significant superiority in the T-LLV(38 cp/mL) and R-LLV(36 cp/mL) vs P-LLV(58 cp/mL) .The absence of significant differences in immunological and virological outcomes in this cohort and the absence of VF in all groups, suggests a scarce impact of LLV in patient's prognosis. Prospective studies, with longer follow-up could bring more accurate information.


Etravirine(ETR) can be used for patients who have failed NNRTI-based regimen. In Thailand, ETR is approximately 45 times more expensive than rilpivirine(RPV). However, there are no data of RPV use in NNRTI failure. Therefore, we assessed the susceptibility and mutation patterns of first line NNRTI failure and the possibility of using RPV compared to ETV in patients who have failed efavirenz(EFV)- and nevirapine(NVP)-based regimens.Clinical samples with confirmed virological failure from EFV- or NVP-based regimens were retrospectively analyzed. Resistance-associated mutations (RAMs) were interpreted by IAS-USA Drug Resistance Mutations. Susceptibility of ETR and RPV were interpreted by DUET, Monogram scoring system, and Stanford University HIV Drug Resistance Database.1,279 and 528 patients failed EFV- and NVP-based regimens, respectively. Y181C was the most common NVP-associated RAM . K103N was the most common EFV-associated RAM . The results from all three scoring systems were concordant. 165(11.1%) and 161(10.9%) patients who failed NVP-based regimen were susceptible to ETR and RPV, respectively (p = 0.85). 195 (32.2%) and 191 (31.6%) patients who failed EFV-based regimen, were susceptible to ETR and RPV, respectively (p = 0.79). The susceptibility of ETV and RPV in EFV failure was significantly higher than NVP failure (p<0.01).The mutation patterns for ETR and RPV were similar but 32% and 11% of patients who failed EFV and NVP -based regimen, respectivly were susceptible to RPV. This finding suggests that RPV can be used as the alternative antiretroviral agent in patients who have failed EFV-based regimen. Recently, the guideline for the use of antiretroviral (ARV) agents in HIV-1-Infected adults and adolescents,3 as theThe cost of the medications usually will dictate the availability of ARVs, particularly second-line antiretroviral agents. In many developing countries, including Thailand, efavirenz (EFV) is the most preferred NNRTI for the first-line regimen which is also in line with the current WHO’s recommendation for the treatment of HIV-infected patients because of its potency and affordability. The other alternative choice for patients who cannot tolerate the side effects of EFV is nevirapine (NVP) but one of its limiting factor is that it can only be used in HIV-infected patients with low CD4 level.The list of available NNRTIs has now expanded to include second-generation NNRTIs such as rilpivirine (RPV) and etravirine (ETR). RPV is recently recommended and approved to be used in combination with two NRTIs for treatment-naïve adult patients with pre-treatment HIV-1 RNA < 100,000 copies/ml–7 and prOn the other hand, there are some data suggests that a presence of single NNRTI resistanceassociated mutations (RAMs) cannot significantly render RPV inactive. As a matter of fact, it would require a total of 8 changes at the HIV1 reverse transcriptase gene to severely lower the susceptibility of RPV. According to the ECHO and THRIVE studies, E138K was the most frequently selected mutation (45%) detected in ARVnaive patients who have failed RPV therapy which is also often seen with M184I (34%), confering resistance to both lamivudine (3TC) and emtricitabine (FTC),7.In contrast, the other second generation NNRTI, etravirine (ETR), is highly efficacious when used in treatment-experienced patients with boosted-darunavir (DRV/R) and thus is approved for use in these types of patients,13. The Because of this, RPV looks very attractive as a possible second-line ARV agent for Thailand which has approximately 1 million HIV-infected people. In 2014, 0.3 million HIV-infected patients were treated with antiretroviral therapy (ART) through the National AIDS Treatment Programme of which approximately 15,000 (5%) were on second-line ART and 500 patients on third-line ART. It is assumed that every year, a certain number of HIV-infected patients will fail their ART regimens and may transmit drug-resistant viruses to other high-risk populations[Hence, for resource-limited setting, alternative strategies have to be explored before resorting to using extravagant second-line regimen. At the time of writing this manuscript, the National Health Security Office (NHSO) is considering to include second generation NNRTI (RPV) in its essential list of drugs to be covered by the national program which is more affordable compared to the recommended ARV agents such as PI or INSTI or other second generation NNRTI  for the second-line ART regimen. The strategy of using RPV in patients who cannot afford or tolerate ETR is the driving force for this study because there is very limited data whether RPV can be safely used in patients with NVP or EFV failure. We therefore investigated the role of RPV compared to ETR, as the second-line ARV agent for HIV-1 infected Thai patients who experienced treatment failure from NVP- or EFV-based regimens.The findings from this study will provide invaluable information on the susceptibility and mutation patterns of RPV in patients who failed first-generation NNRTI regimens so the patients’ subsequent regimens can appropriately be selected. For resource-limited countries, a cheaper alternative choice for second-line regimen such as RPV might be extremely beneficial. Not only will this provide treatment-experienced patients with wider access to RPV but also help improve their adherence.The study was approved by the Institutional Review Board of Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand. All written informed consents were obtained from participants prior to any procedures.This cross-sectional study collected data from HIV-NAT, King Chulalongkorn Memorial Hospital, and its network hospitals in Bangkok from January 2003 to November 2010. Resistant testings for ETR and RPV were done for HIV-1-infected adults (more than 16 years of age) with HIV-1 viral load more than 1,000 copies/ml and have failed either EFV- or NVP-based regimen.RT gene was performed as previously described [http://hivdb.stanford.edu)[Viral RNA was extracted from freshly thawed patient’s plasma. RT-PCR for HIV-1 escribed . Mutatioford.edu). In brieThe number of NNRTI-RAMs per person and the differences of the distribution of NNRTI-RAMs for either EFV- or NVP-based regimen were analysed by Pearson’s chi-squared test. Susceptibility/resistance analysis within EFV- or NVP-based regimen  was analyzed by using Wilcoxon signed-rank test. Pearson’s correlation coefficients were calculated. A p-value of less than 0.05 was considered statistically significant.A total of 1,807 patients were included in this analysis. There were 1,279 patients that failed the NVP-based regimen and another 528 patients that failed the EFV-based regimen. Baseline characteristics of the patients are shown in All patients developed at least one NNRTI-RAM regardless of EFV and NVP use. The maximal number of NNRTI-RAMs detected per patient was seven. For patients that failed NVP, 25.4% had 1 NNRTI-RAM, 36.9% had 2 NNRTI-RAMs, 27.1% had 3 NNRTI-RAMs, 8.1% had 4 NNRTI-RAMs, 2.1% had 5 NNRTI-RAMs, 0.4% had 6 NNRTI-RAMs, and 0.1% had 7 NNRTI-RAMs. For patients that failed EFV, 13.1% had 1 NNRTI-RAM, 35.8% had 2 NNRTI-RAMs, 30.1% had 3 NNRTI-RAMs, 13.6% had 4 NNRTI-RAMs, 5.7% had 5 NNRTI-RAMs, 1.5% had 6 NNRTI-RAMs, and 0.2% had 7 NNRTI-RAMs . There wIt should be noted that the mutations from the patients that failed NVP-based regimen were different compared to the patients that failed the EFV-based regimen. For example, Y181C (52.7%) was the most common NNRTI-RAM detected in patients that failed NVP-based regimen compared to those that failed EFV-based regimen . Another most common NNRTI-RAM detected in patients that failed EFV-based regimen was K103N (61.2%) compared to those that failed NVP-based regimen .Aside from the mutation profiles, the susceptibilities of ETR and RPV were significantly different in patients who failed NVP- and EFV-based regimen. The overall susceptibilities of ETR (11.5%) and RPV (11.3%) were very low for patients that failed the NVP-based regimens. 144 (11.3%) patients remained susceptible to both ETR and RPV whereas 3 (0.3%) were susceptible to only ETR among those who failed NVP-based regimen , Fig 2. As for patients with EFV failure, 169 (32.0%) patients remained susceptible to both ETR and RPV , Fig 2. The results from the START study  will proSo if RPV can be used strategically as a second-line ARV, this would be highly beneficial to many resource-limited countries because nowadays, the costs of ARVs tend to dictate how many people will be treated and maintained on ART as well as those who will have access to second-line ART regimen. Hence, it is very important to make the most use out of the currently available effective antiretroviral drugs, including utilizing various strategic means, to make the second-line regimen more financially affordable. In order to make this possible, it needs to start with the use of the first-line regimen to ensure that it will have the least negative impact to what ARVs will be available for use as the second-line regimen.In Thailand and elseAs a result of this, we explored the role of RPV whether it can be safely used in patients that have failed EFV- or NVP-based regimens. Most of our patients in this study have received the backbone that is commonly used in resource-limited setting: d4T+3TC and AZT+3TC or in minority of the patients, TDF+ 3TC. We next examined the mutation profile among patients with first-line regimen failure and observed that most of the patients had thymidine analogue mutations (TAMs) with or without M184V and NNRTI RAMs. In our The most common mutation for RPV in patients who failed NVP-based regimen, compared to the EFV-based regimen, was Y181C (52.7% vs. 14.0%). This particular nonpolymorphic mutation, Y181C, is one of the worst NNRTI-RAM,20,21 anOn the other hand, K103N or K103S, a potential mutation induced by EFV, has no effect on the susceptibility of ETR and RPV. Our results highlight the advantage of EFV over NVP because it can be used with any second generation NNRTI such as ETR or RPV as the subsequent ART regimen.Another mutation that was investigated was the E138K because it was reported to be 77% prevalent in RPV-failed patients from the ECHO and THRIVE studies. HoweverWhen we analyzed the data according to the EFV-treatment failure regimen, 32% of the patients were still susceptible to RPV whereas only 11% of the patients who failed NVP-based regimen remained susceptible to RPV. This indicated that RPV can be used as an alternative, second-line antiretroviral agent for EFV-resistant patients. In resource-limited countries, this will be very cost-effective and for the patients, a lot easier to take because of its once-a-day administration and fewer side effects.Aside from its once-daily administration, its efficacy was found to be similar to EFV. In a dose finding study, 25 mg of RPV (TMC278-C204) was able to maintain viral suppression which was comparable to EFV over 96 weeks with fewer CNS adverse events, cutaneous eruptions and changes in the lipid levels. On top of that, our results suggest that RPV can be used in patients that have early failure of EFV-based regimen in resouAlso, RPV can be combined with other antiretrovirals to construct a potent second-line or third-line regimen. However, there is limited clinical data to support this assumption. Additional prospective studies evaluating the efficacy of RPV in patients who have failed EFV or NPV is warranted to validate the clinical benefits of RPV, particularly in resource-limited settings where RPV can be accessed at a lower cost. However, the use of RPV should be limited in patients with HIV-RNA less than 100,000 copies/mL.Be that as it may, there are some limitations of the study in ascertaining whether the susceptibility of ETR and RPV are from only one or a sum of resistant mutations. It is possible that patients who have a lot of resistant mutations may have been using the failed regimen for a longer duration compared to those with a shorter duration use of the failed NNRTI regimen but for some patients, we were unable to obtain this information. Also, the genotype tests were not utilized after failure of EFV- and NVP-based regimens which may yield more patients who are susceptible to ETR or RPV. The strategy of sequencing NNRTIs absolutely requires the availability of viral load monitoring and resistance testing that should be implemented in resource-limited settings.In summary, approximately one-third of HIV-infected Thai patients who failed the EFV-based regimen were fully susceptible to RPV. Compared to ETR, RPV is more cost-effective and can be used as the other alternative second-line ARV agent. However, the early detection of NNRTI failure is very important to preserve activity of RPV in the subsequent regimen.S1 Fig(TIFF)Click here for additional data file.S2 Fig(TIFF)Click here for additional data file.


Tesamorelin, a synthetic analog of human growth hormone-releasing factor, decreases visceral adipose tissue (VAT) in human immunodeficiency virus (HIV)-infected patients with lipodystrophy.2, a level associated with lower risk of adverse health outcomes, after 6 months of treatment with tesamorelin.1) To evaluate the utility of patient characteristics and validated disease-risk scores, namely indicator variables for the metabolic syndrome defined by the International Diabetes Federation (MetS-IDF) or the National Cholesterol Education Program (MetS-NCEP) and the Framingham Risk Score (FRS), as predictors of VAT reduction during tesamorelin therapy at 3 and 6 months, and 2) To explore the characteristics of patients who reached a threshold of VAT <140 cmData were analyzed from two Phase 3 studies in which HIV-infected patients with excess abdominal fat were randomized in a 2:1 ratio to receive tesamorelin 2 mg (n = 543) or placebo (n = 263) subcutaneously daily for 6 months, using ANOVA and ANCOVA models.p-values 0.054, 0.063, and 0.025, respectively). No predictive factors were identified at 3 months. The odds of a VAT reduction to <140 cm2 for subjects treated with tesamorelin was 3.9 times greater than that of subjects randomized to placebo after controlling for study, gender, baseline body mass index (BMI) and baseline VAT .Metabolic syndrome (MetS-IDF or MetS-NCEP) and FRS were significantly associated with VAT at baseline. Presence of metabolic syndrome ([MetS-NCEP), triglyceride levels >1.7 mmol/L, and white race had a significant impact on likelihood of response to tesamorelin after 6 months of therapy (interaction 2 was 3.9 times greater for tesamorelin-treated patients than that of patients receiving placebo.Individuals with baseline MetS-NCEP, elevated triglyceride levels, or white race were most likely to experience reductions in VAT after 6 months of tesamorelin treatment. The odds of response of VAT <140 cm The long-term use of antiretroviral therapy (ART) in patients with human immunodeficiency virus (HIV) is associated with the variable development of increased visceral adiposity (lipohypertrophy), loss of subcutaneous fat (lipoatrophy), dyslipidemia, and insulin resistance. These changes in body shape and metabolism are sometimes termed ‘HIV-associated lipodystrophy syndrome’ –4. Thesen = 543) or placebo (n = 263) subcutaneously (sc) daily. Efficacy and safety outcomes of these studies have been described previously ) VAT of 182.4 cm2 (83.5), consistent with markedly increased VAT. The mean (SD) FRS was 6.5% (4.3), suggestive of a low 1-year risk of CVD. Most subjects were male (85%) and Caucasian (76%). The prevalence of MetS-IDF was 73.4% and 62.8% had mean triglycerides >1.7 mmol/L. MetS-NCEP was present in 42.9% of individuals. Differences in the criteria for MetS-NCEP and MetS-IDF, including WC and number of other predictive components present, may account for the different frequencies of MetS estimated using these criteria [In total, 806 ART-treated subjects (ITT population) with HIV and anthropometric parameters consistent with excess intra-abdominal fat from two studies were included in the exploratory analyses to identify predictors of VAT response after 3 or 6 months of treatment with tesamorelin. Baseline characteristics were comparable for subjects who received tesamorelin and placebo in the two Phase 3 studies , 41. Keycriteria , 34. FRS2) compared to those without MetS-NCEP (–24.2 vs. –2.3 cm2). For MetS-IDF, the interaction test did not reach statistical significance . However, the treatment effect of tesamorelin versus placebo was numerically greater for patients with MetS-IDF (–25.6 vs. 3.7 cm2) compared to those without MetS-IDF (–20.2 vs. –1.2 cm2). The treatment effect at 6 months was not statistically different for patients with baseline FRS ≥10% and those with baseline FRS <10% .Mean changes in VAT from baseline to 6 months by treatment and risk category of FRS, MetS-NCEP and MetS-IDF are shown in 2) than for those with triglycerides ≤1.7 mmol/L (–17.2 vs. 2.2 cm2), and larger for white patients (–27.6 vs. 2.4 cm2) compared with non-white patients (–13.2 vs. 1.7 cm2). At 3 months, no significant interactions were observed between treatment and baseline covariates or disease-risk scores.Baseline triglycerides (>1.7 mmol/L vs. ≤1.7 mmol/L) and race (white vs. non-white) were the only covariates that impacted treatment effect . As shown in 2 after 6 months of treatment is shown in 2 at baseline, 23% (n = 80 of 350) of those treated with tesamorelin for 6 months reduced their VAT to <140 cm2 compared with 9% (n = 14 of 163) of those receiving placebo. Furthermore, 44% of those with baseline VAT 140–200 cm2 and 7% of those with baseline VAT >200 cm2 had a follow-up VAT measurement of <140 cm2 following 6 months of treatment with tesamorelin, compared with 17% and 2% of those receiving placebo, respectively. Overall, of the 203 and 94 subjects receiving tesamorelin and placebo, respectively, who had baseline VAT ≥200 cm2, a greater proportion of those receiving tesamorelin achieved a reduction in VAT to <200 cm2 after 6 months . When stratified by BMI categories, 29% of those who were overweight and had a VAT ≥140 cm2 reduced their VAT to <140 cm2 after 6 months of treatment with tesamorelin compared with 24% and 15% of those who were normal weight or obese, respectively. For those receiving placebo, 11% of the overweight subjects who had a VAT ≥140 cm2 achieved a VAT reduction to <140 cm2 compared with 7% of subjects who were obese. The odds of a VAT reduction to <140 cm2 for subjects receiving tesamorelin was 3.9-times greater than that of subjects randomized to placebo after controlling for study, gender, baseline BMI and baseline VAT . The odds of response of VAT <140 cm2 after 6 months in overweight subjects was 2.1 times greater than that of obese subjects after controlling for study, gender, baseline BMI, baseline VAT and treatment .The proportion of patients reaching a threshold of VAT <140 cmTesamorelin has been shown to reduce VAT in HIV-infected patients with lipodystrophy. In this analysis, we identify some predictors of response to tesamorelin. Presence of MetS-NCEP, high triglycerides, and white race were associated with a greater likelihood of responding to 6 months of tesamorelin treatment. Although VAT was significantly correlated with both MetS-NCEP and MetS-IDF at baseline, even after controlling for WC, and both measures showed the same pattern of response to treatment, only MetS-NCEP reached the pre-specified level of significance. It appears that MetS-NCEP was a more sensitive indicator of response to tesamorelin treatment than MetS-IDF in our study population. Central obesity, as defined by WC, is a required component of the IDF definition, whereas WC is only one of five factors that define MetS-NCEP . However2 has been associated with lower risk of adverse health outcomes [2 but below 200 cm2, as well as those in the overweight range for BMI measures. However, individuals with VAT >200 cm2 still lost a significant amount of VAT. Stanforth et al. [2 in normal weight subjects (BMI 18.5 to <25 kg/m2) with VAT ≥140 cm2 at baseline may have important clinical implications as a significant proportion of HIV-infected patients may present with sarcopenic obesity [A level of VAT <140 cmoutcomes , 36, 37.h et al.  showed th et al. –49. Our  obesity , which c obesity . Obesity obesity –54. Data obesity .2 [1C elevation between the tesamorelin and placebo arms, no clinically significant changes in glycemic measures have been observed [It is unclear if a reduction of VAT to below a critical threshold is necessary or if a clinical benefit can be achieved with any amount of VAT reduction, especially as this has not been studied in the HIV-infected population. Among overweight and obese individuals in the general population, the prevalence of hypertension, impaired fasting glucose levels, and MetS has been shown to increase linearly and significantly across increasing VAT quartiles –56. The 2 , 37, 59.2 –62. Furt2 . More re2  reportedobserved , 39. Nonobserved .A recent exploratory analysis of the same Phase 3 data from over 800 patients found that the metabolic benefits of tesamorelin are limited to HIV-infected patients who respond to tesamorelin with a reduction in VAT . DecreasThe analyses presented here are pooled post-hoc analyses of two studies that were not originally designed to collect data specifically for calculations of the three composite risk scores . Therefore, it was necessary to derive some of the data elements needed for the composite risk scores and to conduct data review of some of the textual data collected to extract the needed data. Additional study limitations relate to the study population and ART regimens in this analysis. As the study population consisted largely of white male patients, our findings may not apply to other ethnicities or to women. Furthermore, most patients received older, less metabolically neutral ART regimens. Lastly, study eligibility criteria required all patients to have anthropometric parameters consistent with abdominal obesity for enrollment. Thus, it remains uncertain if only treated HIV patients with the excess VAT towards the higher end of the spectrum are those most likely to benefit from tesamorelin therapy.2 at baseline were most likely to achieve a reduction in VAT below the 140 cm2 threshold, it is currently unknown whether a clinical benefit can be achieved with any amount of VAT reduction.In conclusion, patients with baseline MetS-NCEP, elevated triglycerides, or of white race are most likely to experience reductions in VAT after 6 months of therapy with tesamorelin. Furthermore, while overweight rather than obese individuals and those with VAT below 200 cm


Emtricitabine/rilpivirine/tenofovir (EVP) is a fixed-dose combination of antiretrovirals (ARV) approved by the European Medicines Agency in November 2011 and introduced in Italy in February 2013. It is a once-a-day single tablet and is licensed in Europe for use only in ARV-naïve patients with a viral load (VL) ≤100,000 copies/mL.To identify factors that may be associated with the use of EVP as first-line regimen in HIV-infected individuals starting cART from ARV-naïve in Italy.Clinical sites in ICONA Foundation Study in which ≥1 person had started EVP were selected for this analysis. From these we included all patients who started an EVP-based cART regimen as well as those starting other cART regimens after the date of introduction of EVP at the site (after February 2013 in any case) and with a VL ≤100,000 copies/mL from ARV-naïve. Characteristics at the time of starting cART were compared using chi-square test and unadjusted and adjusted logistic regression analysis. Factors investigated included: gender, mode of HIV transmission, time from HIV diagnosis, CD4 count, nation of birth, AIDS, HCV-status, age, CD8 count, VL, diabetes, smoking, total and HDL cholesterol, eGFR, blood glucose, level of education and employment and site location. Factors showing unadjusted associations with a p-value of 10% or smaller, were retained in the multivariable model.3 in EVP versus 348 in controls, p=0.002), time from HIV diagnosis to starting cART  and prevalence of students . No differences were observed for all other factors examined. The table shows estimates of the odds ratios (OR) for factors included in the multivariable model.We identified 183 patients starting EVP and 173 starting the control regimen from 23 sites. The number of patients starting EVP included at each site ranged from 1 to 12 and the number of those starting the control regimen was similar. The most frequently used drugs in the concurrent group were: TDF (75%), FTC (74%), DRV (39%), ATV/r (26%), LPV/r (9%), EFV (13%) and RAL (14%). In univariable analysis, there were differences in median CD4 count (390 cells/mmCD4 count was higher in EVP-treated patients compared to controls. Guidelines suggest avoiding initiation of EVP in presence of high VL, possibly explaining this residual difference in CD4. There was also a tendency to prescribe EVP to people with perceived lower adherence or hesitant to start or perhaps with a slow progressing disease.


Early postpartum women are more likely to develop tuberculosis than nonpregnant women mainly due to immune reconstitution after delivery. Paradoxical response (PR) during antituberculosis treatment also arises via recovery from immunosuppression. However, no study focused on PR during antituberculosis treatment in a postpartum patient has been reported.We present two sequential cases  of postpartum tuberculosis with pulmonary and extrapulmonary lesions . Both cases progressed to PR  and new contralateral effusion (Patient 2)) in a relatively short time after initiation of treatment , suggesting that immune modulations during pregnancy and delivery may contribute to the pathogenesis of both disseminated tuberculosis and its PR. The pulmonary lesions and effusion of both cases gradually improved without change of chemotherapy regimen.Physicians should recognize PR in tuberculosis patients with postpartum and then evaluate treatment efficacy. Cryptococcus neoformans, hepatitis and Herpes viruses, and Mycobacterium tuberculosis [Pregnancy is a relatively immunosuppressive state to escape maternal anti-fetus rejection. Soon after delivery, T-helper 1 suppression was shown to reverse rapidly, and cellular immune reconstitution is thought to be a major cause of postpartum exacerbation of otherwise quiescent or latent infections [rculosis . Early  showed right pleural effusion and homonymous lung infiltration Fig.  and b, wM. tuberculosis DNA in sputum and ascites utilizing PCR. Although the CA125 serum level was high (247 IU/ml), ascitic cytology did not reveal malignant cells. Further serology tests were negative for antinuclear antibody and HIV-Ab. Pulmonary and peritoneal tuberculosis were later confirmed by acid-fast bacilli cultures.However, fever recurred 4 months after the delivery with gradually worsening abdominal distention, and she was admitted to our department. Chest X-ray and CT showed residual lung infiltrations without cavity and effusion Fig.  and d. AM. tuberculosis was sensitive to all principal antituberculous drugs. Then, the lung infiltrations and effusion were gradually improved by continuation of chemotherapy . One week after the chemotherapy was started, worsening of the pre-existing lung infiltrations with new contralateral effusion was noted, and continued for 3 weeks Fig.  and f. Iapy Fig.  and h. TA 29-year-old woman underwent a cesarean section at 36 weeks gestation. Although she began to notice left lumbar backache 2 weeks after the operation, further examination was not carried out. Five months later, she was admitted to our hospital due to prominent left lumbar backache with newly appeared productive cough. An abdominal CT revealed spondylitis of the Th11-Th12 vertebra and a large low attenuation mass in the left psoas muscle, at a size of 7 cm × 5 cm × 8 cm Fig.  and f. IM. tuberculosis was sensitive to all principal antituberculous drugs, and acid-fast bacilli cultures became negative in sputum and needle aspiration specimens of the small residual psoas abscess.The patient was started on quadruple therapy (HREZ), and a CT-guided percutaneous drainage of the psoas abscess was performed. Three week after the chemotherapy was started, right side chest pain developed. Subsequently, radiological worsening of infiltrations in the right lung were observed, and continued for 7 weeks Fig.  and l. HDuring pregnancy, Th2/Th3 responses, which lead to immunosuppressive and anti-inflammatory responses, are enhanced and the Th1 response, which leads to proinflammatory responses, is suppressed, preventing the maternal immune system from assaulting the fetus. Maternal hormones and placental products play an important role in these immune modulations. Th2 response facilitates the asymptomatic mycobacterial infection and the shift from Th2 towards Th1 response during the postpartum period induces active diseases mostly with extrapulmonary or disseminated lesions from the latent state. Such pathogenesis is considered to be part of immune reconstitution syndrome (IRS) , and sim−) patients with severe tuberculosis has also been reported [The fact that initiation of anti-HIV therapy for patients with AIDS or discontinuation of anti-TNFα therapy for patients with autoimmune disease after initiation of tuberculosis treatment is a representative risk factor for PR suggests that hypersensitivity response to mycobacterial antigens following immune reconstitution is the basis of PR pathogenesis , 6. Incrreported . PR is sreported , 6. In areported , 11. How− patients [− patients as compared to HIV-positive (HIV+) patients. Breen et al. reported that the median time from starting antituberculosis treatment to PR was 87 days in HIV− patients. However, in HIV+ tuberculosis patients the median time between starting antiretroviral therapy and PR was only 11 days [− patients, PR in a postpartum patient may be attributed to the continuation of a preexisting hypersensitivity response to mycobacterial antigens after initiation of tuberculosis treatment.PR has been well described among otherwise healthy patients treated for tuberculosis , althougpatients , and the 11 days . Since tThe onset of the first patient may be retrospectively considered to be tuberclous pleurisy during the postpartum period, although antibiotics therapy seemed to be successful. The pathogenesis of tuberculous pleurisy is a delayed-type hypersensitivity immunogenic reaction to a few mycobacterial antigens entering the pleural space, and resolution of the pleural effusion usually occurs spontaneously without antituberculous chemotherapy. However, about half of untreated cases of primary tuberculous pleurisy develop into more severe forms of active pulmonary and/or extra-pulmonary tuberculosis . MoreovePeritoneal tuberculosis is occasionally accompanied by adnexal lesions, and elevated serum CA125 level may also be found in cases of pelvic inflammation as shown in our case . TherefoStaphylococcus aureus as a primary abscess [Historically the majority of psoas abscesses were caused by tuberculosis of the vertebra, one of the typical manifestations of extrapulmonary tuberculosis. More recently, psoas abscesses are mainly caused by  abscess . Althoug abscess . Our sec abscess , suggest− patients is controversial over the owing to the absence of randomized controlled studies.The prognosis of postpartum tuberculosis is relatively poor . TherefoIn summary, careful observation with systemic examinations on various extrapulmonary lesions is essential for clinical practice in postpartum tuberculous, and recognition of the PR within a relatively short time after the initiation of treatment is necessary to evaluate the effectiveness of the treatment.−, HIV-negative; HIV+, HIV-positive; HREZ, isoniazid, rifampin, ethambutol and pyrazinamide; IRS, immune reconstitution syndrome; PR, paradoxical responseCT, computed tomography; HIV


There is a lack of data comparing the protease inhibitors (PIs) atazanavir (ATV) and darunavir (DRV) in a real-world setting. This study compared persistence (time to switch/discontinuation) to therapy between ATV-treated and DRV-treated patients with human immunodeficiency virus (HIV).Retrospective, observational cohort study using US insurance claims for commercially and Medicaid-insured patients. Patients were aged ≥18 years and initiated an ATV- or DRV-based regimen boosted with ritonavir between 7/1/2006 and 3/31/2013, with ≥6 months of continuous enrolment prior to and ≥3 months of continuous enrolment following initiation; patients were required to have ≥1 inpatient or outpatient medical claim with an ICD-9-CM diagnosis code for HIV during that time period of enrolment. Patients with no claims for antiretroviral therapy (ART) any time prior to initiation were considered to be ART-naïve. Time to switch/discontinuation was defined as the number of days from initiation of the regimen until earliest of: (1) a ≥30-day continuous gap in therapy in ATV or DRV; (2) a prescription claim for an ART agent that was not part of the initial regimen (with the exception of changes in concomitant nucleoside reverse transcriptase inhibitors or the addition of integrase inhibitors); (3) censoring at a ≥30-day continuous gap in therapy in ritonavir; (4) censoring at disenrolment from insurance benefits or (5) censoring at the study end date . Time to switch/discontinuation was compared using incidence rates and multivariable Cox proportional hazards models adjusted for calendar time, patient demographics and clinical characteristics.The incidence of switch/discontinuation was higher among Medicaid patients  than Commercial patients. There were no significant differences in persistence (time to switch/discontinuation) with the initiated PI among HIV patients who initiated an ATV-based regimen versus a DRV-based regimen.


Increased human immunodeficiency virus (HIV) virulence at infection has been suggested by a meta-analysis based on viral load and CD4 T lymphocytes (CD4) count during acute infection. This result was obtained after secondary analyses of large databases, facilitating the detection of differences. Similar finding in cohorts of more modest sample size would indicate that the effect could be more substantial.Change from initial CD4 count and HIV viral load after acute HIV infection by calendar year was explored in patients treated at Lyon University hospitals. All patients admitted to our hospitals with acute HIV infection between 1996 and 2013 were included in our study. Initial CD4 count and viral load before the start of anti-retroviral treatment were analyzed. Trends over time were assessed in linear models.10/ml/year, p = 0.01).Initial CD4 count remained similar over time. However, in 2006–2013, initial viral load rose significantly (+1.12 logOur data, obtained from a single hospital cohort, confirmed findings from a large meta-analysis, showed increased initial viremia at acute HIV infection since 2006 and suggesting potentially higher HIV virulence in recent years. In 2010 in France, the number of individuals infected by HIV rose to around 150,000 . In 20123/years (p<10−4) and viral load increase of 0.018 log10 copies/ml/years (p = 0.03), between 1984 and 2010. The large sample sizes facilitated the detection of statistical significance, and even modest outcomes. However, since the effect  remained high, it could be detected in cohorts with lower sample size. Our objective was to track a potential trend towards lower CD4 counts and higher HIV viral load at PI by year in our hospitals.Despite contradictory results, these studies were reviewed in depth in a recent meta-analysis  which poCommission Nationale de l'Informatique et des Libertés] and the ethic advisory board) [All patients between 1996 and 2013 with documented acute HIV infections were found in the Lyon section of the French Hospital database based on previously-reported criteria . This day board) . The paty board) . As obse3 blood (±183.7), median was 427 (Interquartile Range IQR 259.3) and range was 95–959/mm3. Initial viral load before treatment started was known for 179 patients. Average HIV viremia was 5.23 log10 copies/ml plasma (SD 1.24) and median was 5.35 log10 copies/ml (IQR 1.5). Initial viral load ranged from 1.6 to 7.02 log10 copies/ml  . From 2006 to 2013, a significant increase was evident after adjustment for the period between PI and measurement and for initial CD4 count . These results indicate that, after 2006, HIV virulence might have changed or, at the very least, higher HIV RNA levels were detected after PI since 2006.A total of 291 patients with documented PI between 1996 and 2013 were included in the cohort. All were HIV-1. Initial CD4 count before treatment started was available for 180 patients. Average CD4 count was 450/mmopies/ml . No tren = 0.38)  Figs. In = 0.38) . From 193/year since the outbreak started was assessed by the meta-analysis. However, our patient sample was relatively small and may have lacked power to detect statistical differences. On the other hand, increased initial viral loads were observed between 2006 and 2013. This result was highly significant (p = 0.01). Such an effect, detected in a cohort of modest sample size, would suggest a change in early pathogenetic events during PI, as it has been postulated elsewher [10/ml/year, and supplements its results. Studies can detect all the more a small effect as their sample size is big, as this meta-analysis. Then, observing a similar effect in a much smaller sample as our study is a strong argument for the importance of the found effect. Indeed, we analyzed more recent data than those reviewed in the meta-analysis. They support the hypothesis of a constant effect over time. However, the trend encountered in our study was considerably higher than that assessed in the meta-analysis, so interpretation must proceed with caution.Divergence was observed in the evolution of prognostic markers, despite their correlation in our study. Indeed, no trend in initial CD4 count was emphasized by our investigation, contrary to results of the meta-analysis . A loss elsewher . It is celsewher , which pAn other study, analysing the data of about 16.000 patients, showed a trend to decreasing CD4 count at seroconversion and increasing initial viral load between the 1980s and 2002 . No moreThis observation leans towards growing virulence, as described previously . Viral lDisease stage at the time of virus transmission could be a confounding factor. Indeed, viral loads were particularly high during PI, then decreased before increasing again during later stages of the disease . The virFinally, time between seroconversion and diagnosis could be a confounding factor, since viral load is highest during the first weeks of the disease. However, systematic consideration of time between infection and viral load measurement in our multivariate analysis allows us to take this significant fluctuation into account during the first weeks of the disease and thus to control for the confounding effect. Increased initial viral load could also suggest more replication but without more virulence. To better assess HIV virulence, it is important to know patient outcomes, especially their evolution to AIDS or death.In conclusion, our highly significant study, albeit with modest sample size, strengthens the hypothesis of increasing HIV virulence based on initial viral load measurement and in accordance with “big” cohort data .S1 Fig(TIFF)Click here for additional data file.S2 Fig(TIFF)Click here for additional data file.S3 Fig(TIFF)Click here for additional data file.S4 Fig(TIFF)Click here for additional data file.


In sub-Saharan Africa (SSA), antiretroviral therapy (ART) can prolong life for HIV-infected patients. However, patients initiating ART, especially in routine treatment programs, commonly dropout from care either due to death or loss to follow-up.In a cohort of HIV-infected patients initiating ART at a public sector clinic in Uganda, we assessed predictors of dropout from care (a composite outcome combining death and loss to follow-up). From a large set of socio-demographic, clinical, and laboratory variables routinely collected at ART initiation, we selected those predicting dropout at P <0.1 in unadjusted analyses for inclusion into a multivariable proportional hazards regression model. We then used a stepwise backward selection procedure to identify variables which independently predicted dropout at P <0.05.Data from 5,057 patients were analyzed. The median age was 33 years (IQR 28 to 40) and 27.4 % had CD4+ T-cell counts <100 cells/μL at ART initiation. The median duration of follow-up was 24 months . Overall dropout was 26.9 % , 5.6 % were transferred to other service providers, and 67.5 % were retained in care. A diagnosis of Kaposi’s sarcoma (hazard ratio (HR) = 3.3, 95 % CI 2.5 to 4.5); HIV-associated dementia ; history of cryptococcosis ; and reduced hemoglobin concentration  were strong predictors of dropout. Other independent predictors of dropout were: year of ART initiation; weight loss ≥10 %; reduced total lymphocyte count; chronic diarrhea; male sex; young age (≤28 years); and marital status.Among HIV-infected patients initiating ART at a public sector clinic in SSA, biological factors that usually predict death were especially predictive of dropout. As most of the dropouts were lost to follow-up, this observation suggests that many losses to follow-up may have died. Future studies are needed to identify appropriate interventions that may improve both individual-level patient outcomes and outcome ascertainment among HIV-infected ART initiators in this setting. Sub-Saharan Africa (SSA) remains the epicenter of the HIV pandemic. In recent data, the prevalence of HIV infection averaged around 18 % to 26 % in Southern Africa and 5.1 % to 7.4 % in East Africa . HoweverFor the past decade, antiretroviral therapy (ART) has been rolled out in the region . ART canDropout from care is especially common for those receiving ART from routine treatment programs . As thesWe performed a cohort analysis of data from the electronic database of the Immune Suppression Syndrome (ISS) clinic in Mbarara, Uganda. Dropout from care among patients on ART is common at this clinic , 17. HIVWe used de-identified data that had already been collected for the patients’ clinical care. As it would have been either inconveniencing to the patients or difficult to reach them, we did not seek individual-level consent from patients to use these data. Instead, we planned to access only de-identified data and sought a waiver on the requirement for individual-level consent from the local Institutional Review Board (IRB). This waiver was granted pre-analysis by the Mbarara University of Science and Technology Institutional Review Board (MUST-IRB). The data management committee of the ISS Clinic also approved the study.Since 2007, clinic data routinely collected by nurses, counselors, physicians, and pharmacy staff on paper have been subsequently entered into an electronic database maintained in the Open Medical Records System . For thiWe investigated socio-demographic, clinical, and laboratory variables that are routinely measured at ART initiation as predictors of dropout. Socio-demographic variables included age, sex, education level, time spent travelling to the clinic, and marital status. Clinical variables included histories/diagnoses of opportunistic infections (OIs) and other comorbidities at ART initiation. We assessed only those disorders that are commonly diagnosed in this setting, and which we expected to be diagnosed with relatively good specificity. These disorders included: tuberculosis (TB), Kaposi’s sarcoma (KS), cryptococcosis, esophagitis, oral candidiasis, chronic diarrhea, HIV-associated dementia, and weight loss ≥10 %.At this clinic, TB is diagnosed using laboratory (Ziehl-Neelsen sputum smears), clinical , and radiological assessments . TB cases are defined according to standard criteria ; diagnosLaboratory measurements included complete blood count (CBC) characteristics , eosinophil counts, and platelet counts) and CD4+ T cell counts  measured at ART initiation (±3 months). We did not assess other laboratory parameters, such as, the plasma HIV RNA levels and liver or kidney function tests, because these measurements were rarely performed on patients.Data on the patients’ initial ART regimens were also obtained. At this clinic an initial ART regimen contains at least 3 antiretroviral drugs; a backbone drug, usually a nucleoside- or nucleotide-analog reverse transcriptase inhibitor (NRTI), which can be zidovudine (AZT) (the most common), tenofovir (TDF), or stavudine (D4T); a second drug also often a NRTI, which can be either lamivudine (3TC) or emtricitabine (FTC); and a third drug, usually either a non-nucleoside reverse transcriptase inhibitor (NNRTI) in the form of nevirapine (NVP) or Efavirenz (EFV), or a protease inhibitor (PI) . For example, a common initial regimen would be a combination of AZT, 3TC, and NVP. We obtained data on the specific regimen that each patient received. However, as previous studies suggest that outcomes may vary according to the backbone drug received  , we asseTime zero was the date of ART initiation and patients were followed until death, transfer-out to another service provider, loss to follow-up, or administrative censoring on 31 December 2012. The primary outcome was dropout from treatment, a composite of death and loss to follow-up . Participants were considered to be lost to follow-up if their last clinic visit was more than 180 days earlier than the date of administrative censoring in those not transferred out and not known to have died. The 180-day period is based on previous studies defining loss to follow-up in this way , 23. DeaFor purposes of this analysis, we assumed that death and loss to follow-up were the bad outcomes (hence these were combined), while transfer to another service provider or being retained in care were the good outcomes ; our binary outcome of dropout from care thus compares patients who either died or were lost to follow-up to those who were either retained at this clinic or were transferred officially to another provider.We first performed descriptive analyses on the full sample to assess the degree of missing data and to describe outcomes. We then performed multiple imputations of missing data (as described below) before using proportional hazards regression to assess predictors of dropout.In unadjusted analyses, we assessed all available sociodemographic, clinical, and laboratory variables. CBC parameters and age were modelled in quartiles; CD4+ T cell count was categorized in clinically-relevant fashion: <100, 100–199, 200–349, and ≥350 cells/μL.P values. The HR in this case is interpretable as a ratio of the instantaneous risk of dropout among patients in a given category versus those in the reference category.We set up the analysis so that, for each variable, the reference category was that, which we hypothesized pre-analysis to have the lowest risk of dropout. For example, based on some previous studies , 25, we To determine independent predictors of dropout, we included variables that had P values <0.1 in unadjusted analyses in a multivariable proportional hazards regression model predicting dropout. Using a stepwise backward selection procedure, we removed variables from the model until only those that were statistically significantly associated with dropout at P <0.05 remained. As previous studies among HIV infected patients in this setting suggest that calendar time may be associated with death, loss to follow-up, and the quality of data collected from patients , 27, we In addition to the main analysis above, which evaluated the patients’ individual-level characteristics as predictors of dropout, we evaluated whether initial ART regimens (based on the backbone drug received) predicted risk of dropout. As some previous studies suggest that TDF- or D4T-based regimens may be more associated with negative outcomes than AZT-based regimens , 28, we Between 14 and 41 % of patients were lacking data on at least one of the laboratory-measured predictors. As missing information could potentially bias our conclusions , we asseBetween January 2008 and December 2011, a total of 5,057 HIV-infected patients  initiated ART. The median age was 33 years (IQR 28 to 40); 27.4 % had CD4+ T-cell counts <100 cells/μL . TDF-based regimens were initially given to 22.3 % overall (for 19.5 % TDF was combined with either 3TC or FTC and EFV and for 2.9 % NVP was used as the third drug). A small percent (4.1 %) received D4T-based regimens (with either 3TC and NVP or 3TC and EFV).In the unadjusted analysis to evaluate predictors of dropout among those variables that are routinely collected from patients at ART initiation, we assessed 20 variables ; HIV-associated dementia ; history of cryptococcosis ; and reduced hemoglobin concentration  were strong predictors of dropout. Other independent predictors of dropout were: year of ART initiation; weight loss ≥10 %; reduced total lymphocyte count; chronic diarrhea; male sex; young age (≤28 years); and marital status  than those initially receiving AZT-based regimens. Those initially receiving D4T-based regimens had a 1.2-fold higher risk of dropout but the result was not statistically significant (95 % CI 0.92 to 1.5)  . In contOther interventions that can improve individual-level patient outcomes should also be investigated. For example, it may be that those dropping out require treatments over and above ART, which are not being provided in the present era. As some previous studies suggest that the immune reconstitution syndrome (IRIS) may lead to early death in some patients, especially those with cryptococcal disease  or KS 4, the rolOther than the patients’ individual-level characteristics, some ART regimens also might conceivably increase risk of dropout. In a previous study which compared TDF-based regimens to AZT-based regimens, patients receiving a TDF-based regimen as initial therapy had an about 1.5-fold higher risk of death at or after 90 days from ART initiation, adjusting for age, sex, CD4+ cell count, HIV disease stage, body mass index, hemoglobin concentration, and serum creatinine at ART initiation . In our A general limitation of our study is missing data. For example, if CBCs were not requested for patients that looked healthy; such patients may also be less likely to dropout, and the associations of CBC characteristics with dropout may be overestimated . HoweverAmong HIV infected patients initiating ART at a public sector clinic in SSA, several routinely collected variables predicted risk of dropout from treatment. Biological factors which usually predict death were especially predictive of dropout. As the majority of those dropping out in our study were lost to follow-up, our findings suggest that many of those getting lost to follow-up may have died. More studies are needed to identify appropriate interventions to improve individual-level patient outcomes, as well as outcome ascertainment, for HIV-infected patients initiating ART in this setting.The study was approved by the Mbarara University of Science and Technology - Institutional Review Board (MUST-IRB). We used for this analysis data that had already been collected for clinical management, but the data were de-identified before being given to the analyst. Consequently, we applied to the local IRB for a waiver on the requirement for individual-level consent by patients to participate in this study.As we used only de-identified data, we sought and were granted a waiver on the requirement for individual-level consent by patients regarding data publication. We sought for a waiver of individual-level consent because we felt that any attempts to individually contact patients would have been either more inconveniencing to the patients or in some cases difficult to implement.The data that we used for this analysis can be accessed if requested from the corresponding author.