Rapid Initiation of Antiretroviral Therapy Under the Treat-All Policy Reduces Loss to Follow-Up and Virological Failure in Routine Human Immunodeficiency Virus Care Settings in China: A Retrospective Cohort Study (2016-2022).

Following the World Health Organization's guidelines for rapid antiretroviral therapy (ART) initiation [≤7 days after human immunodeficiency virus (HIV) diagnosis], China implemented Treat-All in 2016 and has made significant efforts to provide timely ART since 2017. This study included newly diagnosed HIV adults from Tianjin, China, between 2016 and 2022. Our primary outcome was loss to follow-up (LTFU) at 12 months after enrollment. The secondary outcome was 12-month virological failure. The association between rapid ART and LTFU, as well as virological failure, was assessed via Cox regression and logistic regression. A total of 896 (19.1%) of 4688 participants received ART ≤7 days postdiagnosis. The rate of rapid ART has increased from 7.5% in 2016 to 33.3% by 2022. The rapid ART group had an LTFU rate of 3.3%, as opposed to 5.0% in the delayed group. The rapid ART group had a much reduced virological failure rate (0.6% vs. 1.8%). Rapid ART individuals had a reduced likelihood of LTFU [adjusted hazard ratio: 0.65, 95% confidence intervals (CI): 0.44-0.96] and virological failure (adjusted odds ratio: 0.35, 95% CI: 0.12-0.80). The real-world data indicated that rapid ART is practicable and beneficial for Chinese people with HIV, providing evidence for its widespread implementation and scaling up.

Characterization and Determinants of Long-Term Immune Recovery Under Suppressive Antiretroviral Therapy.

OBJECTIVE: We developed a robust characterization of immune recovery trajectories in people living with HIV on antiretroviral treatment (ART) and relate our findings to epidemiological risk factors and bacterial pneumonia. METHODS: Using data from the Swiss HIV Cohort Study and the Zurich Primary HIV Infection Cohort Study (n = 5907), we analyzed the long-term trajectories of CD4 cell and CD8 cell counts and their ratio in people living with HIV on ART for at least 8 years by fitting nonlinear mixed-effects models. The determinants of long-term immune recovery were investigated using generalized additive models. In addition, prediction accuracy of the modeled trajectories and their impact on the fit of a model for bacterial pneumonia was assessed. RESULTS: Overall, our population showed good immune recovery (median plateau [interquartile range]-CD4: 718 [555-900] cells/µL, CD8: 709 [547-893] cells/µL, CD4/CD8: 1.01 [0.76-1.37]). The following factors were predictive of recovery: age, sex, nadir/zenith value, pre-ART HIV-1 viral load, hepatitis C, ethnicity, acquisition risk, and timing of ART initiation. The fitted models proved to be an accurate and efficient way of predicting future CD4 and CD8 cell recovery dynamics: Compared with carrying forward the last observation, mean squared errors of the fitted values were lower by 1.3%-18.3% across outcomes. When modeling future episodes of bacterial pneumonia, using predictors derived from the recovery dynamics improved most model fits. CONCLUSION: We described and validated a method to characterize individual immune recovery trajectories of people living with HIV on suppressive ART. These trajectories accurately predict long-term immune recovery and the occurrence of bacterial pneumonia.

Effect of the timing of antiretroviral treatment initiation on CD4 count in children and youths living with HIV in North India.

BACKGROUND: Immediate start of antiretroviral treatment (ART) among non-hospitalized outpatient children living with HIV may improve or worsen clinical outcomes due to immune reconstitution. OBJECTIVE: Role of immediate versus post-stabilization start of antiretroviral treatment in children and youths living with HIV on CD4 count and viral load suppression. METHODS: This was a single blinded, randomized controlled trial conducted on outpatients attending a tertiary care hospital associated HIV clinic in North India. We enrolled ART-naive children and youths living with HIV aged 18 months to 21 years in a 1:1 ratio. Block randomization was done using computerized software. Children and youths living with HIV were either started with ART on diagnosis immediately within 24 h (Group A) or post stabilization at 2 weeks (Group B) as per National AIDS Control Organization (NACO) India guidelines. Both groups were comparable for baseline characteristics. RESULTS: There was no significant difference seen in CD4 counts between two groups at 6 months follow up. CD4 count increased significantly in immediate group but not in post-stabilization group at 6 months. No significant changes/differences was seen in WHO clinical staging or anthropometry; one patient developed tuberculosis in both groups. Viral load at 6 months in both the groups did not differ significantly. CONCLUSION: Immediate ART in children and youths living with HIV results in significant increase in CD4 count at 6 months follow up exemplifying immunological response to ART.

Effect of intake of probiotics and probiotic fermented foods on clinical outcomes among people living with HIV: A systematic review and meta-analysis.

OBJECTIVE: The objective of the study was to determine the effect of probiotics and of probiotic-fermented foods on CD4 T-cell count, viral load, anaemia and body mass index (BMI) among people living with HIV (PLHIV). METHODS: In this article, we systematically reviewed the evidence on the influence of probiotic supplementation on CD4 lymphocyte count, viral load and anaemia among PLHIV on highly active antiretroviral therapy (HAART) and those who were HAART-naive. Medical literature databases identified randomised trials and pre-post studies of probiotic supplementation and HIV-related outcomes, and random effects meta-analysis was conducted. RESULTS: The preponderance of the evidence suggests that probiotic supplementation only improved CD4 lymphocyte count modestly, with quantitatively greater impact among individuals who were HAART-naive compared to HAART-experienced individuals. Probiotic supplementation improved CD4 lymphocyte count by 53 cells/mm3 (95% CI: 22 to 85) from 18 studies. Probiotic supplementation however reduced haemoglobin concentration by -2.1 g/L (95% CI: -4.0 to -0.2). Although viral load remain unchanged in HAART-experienced participants following probiotic supplementation, HAART-naïve participants saw a decrease in viral load. There were too few studies on the impact of probiotic supplementation on viral load (N = 1). CONCLUSION: Probiotic supplementation resulted in a modest increase in CD4 lymphocyte count among HAART-naive individuals with no significant change observed among HAART-experienced ones. Viral load and haemoglobin concentration also remained unchanged following probiotic supplementation. Further rigorous and well-powered studies may evaluate the effect of probiotic supplementation on important clinical outcomes among PLHIV on HAART.

Use of integrase inhibitors vs protease inhibitors is associated with improved HIV viral suppression.

BACKGROUND: Current guidelines for antiretroviral therapy in pregnancy include the use of a dual-nucleoside reverse transcriptase inhibitor with either an integrase strand transfer inhibitor or a ritonavir-boosted protease inhibitor, although there is no designation of which is the preferred option. OBJECTIVE: This study aimed to compare viral suppression at delivery among patients on dual-nucleoside reverse transcriptase inhibitors combined with either an integrase strand transfer inhibitor or a protease inhibitor. A hypothesis was made that the incidence of viral suppression is higher with the use of a dual-nucleoside reverse transcriptase inhibitor backbone combined with an integrase strand transfer inhibitor than with the use of a dual-nucleoside reverse transcriptase inhibitor backbone combined with a protease inhibitor. STUDY DESIGN: This study was an observational study of pregnant patients living with HIV who received prenatal care and delivered after 20 weeks of gestation at an urban safety net hospital. All pregnant patients with HIV were referred to a centralized clinic for HIV counseling, medication management, and prenatal care. Antiretroviral therapy was continued or initiated according to protocols based on national guidance. Among patients on a dual-nucleoside reverse transcriptase inhibitor backbone combined with integrase strand transfer inhibitor vs protease inhibitor at delivery, we compared the demographics and HIV disease characteristics, including year of diagnosis, viral load, and antiretroviral therapy class. The outcome of interest was viral suppression at delivery, defined as a viral load of <50 copies/mL. RESULTS: From January 2011 to December 2021, 604 patients on dual-nucleoside reverse transcriptase inhibitor met the inclusion criteria, including 411 patients (68%) on protease inhibitor and 193 patients (32%) on integrase strand transfer inhibitor at delivery. Demographic distribution was similar, and prenatal care was initiated at 12 weeks of gestation. Among the integrase strand transfer inhibitor group, 101 (17%) were on antiretroviral therapy at initiation of prenatal care compared with 169 (28%) in the protease inhibitor group. At delivery, the frequency of viral load suppression was higher among those on an integrase strand transfer inhibitor (147/193 [76%]) than among those on a protease inhibitor (275/411 [67%]) (odds ratio, 1.59; 95% confidence interval, 1.08-2.33). Among those with a detectable virus, quantitative viral load was not different. During the study period, the use of a protease inhibitor decreased, whereas the use of an integrase strand transfer inhibitor increased. CONCLUSION: Among pregnant patients living with HIV, viral suppression was more common among those on a dual-nucleoside reverse transcriptase inhibitor backbone combined with integrase strand transfer inhibitor than among those on a dual-nucleoside reverse transcriptase inhibitor backbone protease inhibitor at delivery. Our results support the use of dual-nucleoside reverse transcriptase inhibitor with integrase strand transfer inhibitor as a first-line antiretroviral therapy regimen in pregnancy.

Preference for daily oral pills over long-acting antiretroviral therapy options among people with HIV.

OBJECTIVE: To examine the characteristics of people with HIV (PWH) who prefer remaining on daily oral antiretroviral therapy (ART), rather than switching to long-acting ART (LA-ART). DESIGN: Building upon a discrete choice experiment (DCE), we examined characteristics of individuals who always selected their current daily oral tablet regimen over either of two hypothetical LA-ART options presented in a series of 17 choice tasks. METHODS: We used LASSO to select sociodemographic, HIV-related, and other health-related predictors of preferring current therapy over LA-ART, and logistic regression to measure the associations with those characteristics. RESULTS: Among 700 PWH in Washington State and Atlanta, Georgia, 11% of participants ( n  = 74) chose their current daily treatment over LA-ART in all DCE choice tasks. We found that people with lower educational attainment, good adherence, more aversion to injections, and who participated from Atlanta to be more likely to prefer their current daily regimen over LA-ART. CONCLUSIONS: Gaps in ART uptake and adherence remain, and emerging LA-ART treatments show promise to address these challenges and help a larger portion of PWH to achieve viral suppression, but preferences for these new treatments are understudied. Our results show that certain drawbacks of LA-ART may help to maintain demand for daily oral tablets, especially for PWH with certain characteristics. Some of these characteristics (lower educational attainment and Atlanta participation) were also associated with a lack of viral suppression. Future research should focus on overcoming barriers that impact preferences for LA-ART among those patients who could benefit most from this innovation.

Antiretroviral Therapy Intensification for Neurocognitive Impairment in Human Immunodeficiency Virus.

BACKGROUND: Neurocognitive impairment (NCI) in people with HIV (PWH) on antiretroviral therapy (ART) is common and may result from persistent HIV replication in the central nervous system. METHODS: A5324 was a randomized, double-blind, placebo-controlled, 96-week trial of ART intensification with dolutegravir (DTG) + MVC, DTG + Placebo, or Dual - Placebo in PWH with plasma HIV RNA <50 copies/mL on ART and NCI. The primary outcome was the change on the normalized total z score (ie, the mean of individual NC test z scores) at week 48. RESULTS: Of 357 screened, 191 enrolled: 71% male, 51% Black race, 22% Hispanic ethnicity; mean age 52 years; mean CD4+ T-cells 681 cells/µL. Most (65%) had symptomatic HIV-associated NC disorder. Study drug was discontinued due to an adverse event in 15 (8%) and did not differ between arms (P = .17). Total z score, depressive symptoms, and daily functioning improved over time in all arms with no significant differences between them at week 48 or later. Adjusting for age, sex, race, study site, efavirenz use, or baseline z score did not alter the results. Body mass index modestly increased over 96 weeks (mean increase 0.32 kg/m2, P = .006) and did not differ between arms (P > .10). CONCLUSIONS: This is the largest, randomized, placebo-controlled trial of ART intensification for NCI in PWH. The findings do not support empiric ART intensification as a treatment for NCI in PWH on suppressive ART. They also do not support that DTG adversely affects cognition, mood, or weight.

Alerta monitoramento do horizonte tecnológico: Lenacapavir para o tratamento de HIV-1 multirresistente / Technological horizon monitoring alert: Lenacapavir for the treatment of multidrug resistant HIV-1

A TECNOLOGIA: Condição clínica: O vírus da imunodeficiência humana (HIV) é o causador da Síndrome da Imunodeficiência Adquirida (Aids), estágio avançado da infecção que debilita o sistema imunológico e deixa o organismo suscetível a doenças oportunistas. A infecção não possui cura, porém, sua progressão pode ser evitada com o uso de tratamento farmacológico antiretroviral. Dois subtipos de vírus podem causar a infecção, HIV-1 e HIV-2. O subtipo mais virulento e disseminado em todo o mundo é o HIV-1, enquanto o HIV-2 é menos infeccioso e mais frequente em países onde a doença é endêmica (4). A transmissão de ambos os subtipos ocorre por meio de relações sexuais sem proteção, compartilhamento de perfurocortantes contaminados e de mãe para filho durante a gestação, parto ou amamentação. O diagnóstico inicial é realizado por meio de testes rápidos ou laboratoriais para a identificação da presença do vírus ou detecção de anticorpos, a exemplo da Imunocromatografia e o imunoensaio de ELISA (do Inglês, Enzyme-Linked Immunosorbent Assay). Caso seja detectada a infecção, exames como o Western Blot (WB), Imunoblot (IB), Imunoblot Rápido (IBR) são utilizados como confirmatórios para o diagnóstico. DESCRIÇÃO DA TECNOLOGIA: Lenacapavir (Sunlenca®), desenvolvido pelo laboratório Gilead Sciences, é um inibidor de longa duração da função do capsídeo do HIV-1, o primeiro da classe. Esse antirretroviral impede a replicação do vírus a partir de múltiplos mecanismos de ação, afetando as principais etapas necessárias para o ciclo de vida do vírus, tais como: a captação nuclear que é mediada pela cápside do DNA viral, a montagem e libertação do vírus, e a formação do núcleo da cápside, gerando capsídeos malformados (20). Ademais, confere importante vantagem em não apresentar resistência cruzada com outros antirretrovirais. O medicamento está indicado em combinação com outros antirretrovirais para adultos com infeção por HIV-1 multirresistente e que apresentaram falha terapêutica devido à resistência, intolerância ou impossibilidade de uso por questões de segurança. INFORMAÇÕES REGULATÓRIAS: Informações sobre registro: O lenacapavir não possui registro sanitário na Agência Nacional de Vigilância Sanitária (Anvisa). Estratégia de busca: A busca teve dois objetivos, sendo que o primeiro foi recuperar registros de ensaios clínicos de fase 3 envolvendo lenacapavir no tratamento do HIV-1 e o segundo identificar resultados publicados desses estudos. Resultados de eficácia e segurança: Os resultados relatados são referentes ao estudo CAPELLA (NCT04150068), exceto os desfechos medidos em chances, que são provenientes de um estudo de comparação indireta. estudo de comparação indireta, conduzido por Chatzidaki I e colaboradores, teve como objetivo comparar lenacapavir + regime de base otimizado (RBO) versus fostemsavir + RBO e ibalizumabe + RBO versus RBO sozinho considerando os desfechos supressão virológica e alteração na contagem de células CD4+. Para tanto, uma revisão sistemática (RS) foi conduzida e os estudos identificados foram ponderados quanto à adequação para integrar análises comparativas. Tal avaliação tomou por base os seguintes critérios: desenho do estudo, semelhança das características basais dos participantes com as da coorte aleatória do estudo CAPELLA, intervenções investigadas, desfechos e pontos de tempo relatados. Assim, dados de participantes individuais da coorte aleatória do estudo CAPELLA e dados agregados dos estudos identificados na RS foram usados para conduzir comparações indiretas usando a metodologia de comparação de tratamento simulado não ancorada para ajuste da população. CONSIDERAÇÕES FINAIS: Um dos desafios do tratamento da infecção por HIV é uma adesão subótima ao tratamento e a ocorrência de resistência aos antirretrovirais. PVHIV com histórico de falhas e resistência significativa aos antirretrovirais têm opções terapêuticas limitadas e necessidade de um regime de tratamento altamente individualizado. Esses indivíduos podem não obter supressão viral sustentada do HIV. Nesse cenário em que são necessárias terapias capazes de garantir a preservação e restauração da função imunológica, evitando a progressão para Aids, o lenacapavir apresenta-se como o primeiro antirretroviral da classe inibidor do capsídeo do HIV-1, com um mecanismo de ação que interfere em múltiplos estágios do ciclo de vida do vírus. Além disso, o medicamento apresenta ação prolongada, com regime posológico de manutenção mais conveniente (duas vezes ao ano) em relação às terapias atuais, o que pode contribuir para uma melhor adesão ao tratamento e, consequentemente, com a obtenção de melhores resultados terapêuticos. O antirretroviral também parece não apresentar resistência cruzada com as outras classes disponíveis. Lenacapavir é indicado como adjuvante no tratamento de adultos com infecção HIV-1 multirresistente e falha à terapia atual e possui registro sanitário nos EUA, Canadá e países da União Europeia. A tecnologia apresentou um balanço positivo com relação à eficácia e segurança no estudo CAPELLA, uma vez que se mostrou capaz de promover redução de carga viral e supressão virológica sustentada até a semana 52, sem registro de eventos adversos graves. Adicionalmente, houve aumento na contagem de células CD4+ e redução na proporção de indivíduos com contagens inferiores a 50 células/mm3. Apesar do estudo CAPELLA apresentar algumas limitações, como tamanho amostral pequeno, diferenças nas características basais dos grupos randomizados, período de acompanhamento limitado e inclusão de indivíduos com terapias antirretrovirais muito variada, os resultados parecem promissores para uma população de difícil manejo clínico. O perfil de segurança do lenacapavir no estudo pivotal mostrou-se favorável, com registro de eventos adversos leves a moderados. Apenas um participante descontinuou a terapia em consequência de evento adverso No entanto, uma limitação do uso de lenacapavir é seu potencial de interação medicamentosa com outros antirretrovirais já utilizados no tratamento do HIV, a exemplo de atazanavir, efavirenz, nevirapina e etravirina Ademais, foi identificada resistência em cenários nos quais o lenacapavir estava em monoterapia funcional devido à ausência de antirretrovirais totalmente ativos no RBO ou adesão inadequada a esse regime. O lenacapavir também está sendo estudado para uso em associação de dose fixa oral com bictegravir no tratamento de indivíduos com supressão virológica. A despeito das evidências aqui apresentadas, para que ocorra a oferta desse medicamento no SUS, é necessária sua análise pela Comissão Nacional de Incorporação de Tecnologias no SUS (Conitec), conforme disposto na Lei nº 12.401/2011, que alterou a Lei nº 8.080/1990. Os relatórios de recomendação da Conitec levam em consideração as evidências científicas sobre eficácia, acurácia, efetividade e a segurança, além da avaliação econômica comparativa dos benefícios e dos custos em relação às tecnologias já incorporadas e o impacto da incorporação da tecnologia no SUS.

Real-world effectiveness of WHO recommended first-line antiretroviral therapies: a cohort study from a middle-income country.

We estimate the effectiveness of antiretroviral therapy (ART) among individuals receiving HIV care in Rio de Janeiro, Brazil. Adults (18y+) initiating ART between Jan/2008 and Dec/2018 (follow-up through Dec/2020) were included. First-line ART (two nucleoside reverse transcriptase inhibitors plus one antiretroviral from another class) was categorized into four categories: non-nucleoside reverse transcriptase inhibitor/NNRTI-based, protease inhibitor/PI-based, integrase strand transfer inhibitor/INSTI-based, and single-tablet regimen (STR, Tenofovir 300mg + Lamivudine 300mg + Efavirenz 600mg). Effectiveness (viral load ≤50 copies/µL) was evaluated at 6(3-9) and 12(9-15) months from ART initiation. Bayesian logistic regression models were used to quantify the association between exposure and outcomes while accounting for missing data. Overall, 1863(57%), 652(19.9%), 412(12.6%), and 342(10.5%) individuals used, respectively, NNRTI-based, PI-based, INSTI-based regimens, and STR. Compared to NNRTIs, the odds of viral suppression with INSTI-based regimens was 76% higher (adjusted OR:1.76, 95%CI:1.23-2.51) at six months but no higher at 12 months. Older age, higher education, CD4 count ≥500 cells/mm3 and viral load <100,000 copies/µL at ART initiation increased the odds of viral suppression. Viral suppression at six months was the strongest predictor of viral suppression at 12 months. These results highlight population groups that could benefit from close monitoring during the first year of ART.

A Per-Protocol Analysis Using Inverse-Probability-of-Censoring Weights in a Randomized Trial of Initial Protease Inhibitor Versus Nonnucleoside Reverse Transcriptase Inhibitor Regimens in Children.

Protocol adherence may influence measured treatment effectiveness in randomized controlled trials. Using data from a multicenter trial (Europe and the Americas, 2002-2009) of children with human immunodeficiency virus type 1 who had been randomized to receive initial protease inhibitor (PI) versus nonnucleoside reverse transcriptase inhibitor (NNRTI) antiretroviral therapy regimens, we generated time-to-event intention-to-treat (ITT) estimates of treatment effectiveness, applied inverse-probability-of-censoring weights to generate per-protocol efficacy estimates, and compared shifts from ITT to per-protocol estimates across and within treatment arms. In ITT analyses, 263 participants experienced 4-year treatment failure probabilities of 41.3% for PIs and 39.5% for NNRTIs (risk difference = 1.8% (95% confidence interval (CI): -10.1, 13.7); hazard ratio = 1.09 (95% CI: 0.74, 1.60)). In per-protocol analyses, failure probabilities were 35.6% for PIs and 29.2% for NNRTIs (risk difference = 6.4% (95% CI: -6.7, 19.4); hazard ratio = 1.30 (95% CI: 0.80, 2.12)). Within-arm shifts in failure probabilities from ITT to per-protocol analyses were 5.7% for PIs and 10.3% for NNRTIs. Protocol nonadherence was nondifferential across arms, suggesting that possibly better NNRTI efficacy may have been masked by differences in within-arm shifts deriving from differential regimen forgiveness, residual confounding, or chance. A per-protocol approach using inverse-probability-of-censoring weights facilitated evaluation of relationships among adherence, efficacy, and forgiveness applicable to pediatric oral antiretroviral regimens.

Advanced HIV disease and engagement in care among patients on antiretroviral therapy in South Africa: results from a multi-state model.

OBJECTIVE: Despite improved access to antiretroviral therapy (ART) for people with HIV (PWH), HIV continues to contribute considerably to morbidity and mortality. Increasingly, advanced HIV disease (AHD) is found among PWH who are ART-experienced. DESIGN: Using a multi-state model we examined associations between engagement with care and AHD on ART in South Africa. METHODS: Using data from IeDEA Southern Africa, we included PWH from South Africa, initiating ART from 2004 to 2017 aged more than 5 years with a CD4+ cell count at ART start and at least one subsequent measure. We defined a gap as no visit for at least 18 months. Five states were defined: 'AHD on ART' (CD4+ cell count <200 cells/µl), 'Clinically Stable on ART' (CD4+ cell count ≥200 or if no CD4+ cell count, viral load <1000 copies/ml), 'Early Gap' (commencing ≤18 months from ART start), 'Late Gap' (commencing >18 months from ART start) and 'Death'. RESULTS: Among 32 452 PWH, men and those aged 15-25 years were more likely to progress to unfavourable states. Later years of ART start were associated with a lower probability of transitioning from AHD to clinically stable, increasing the risk of death following AHD. In stratified analyses, those starting ART with AHD in later years were more likely to re-engage in care with AHD following a gap and to die following AHD on ART. CONCLUSION: In more recent years, those with AHD on ART were more likely to die, and AHD at re-engagement in care increased. To further reduce HIV-related mortality, efforts to address the challenges facing these more vulnerable patients are needed.

Long-term virological and immunological outcomes between HIV-positive individuals with and without pretreatment HIV drug resistance.

BACKGROUND: Pretreatment HIV drug resistance (PHDR) has emerged after scaling-up access to antiretroviral therapy (ART). This study aimed to compare long-term virological and immunological outcomes between HIV-positive individuals with and without PHDR. METHODS: An observational cohort study was conducted in HIV-positive individuals who had a genotypic resistance test performed prior to ART initiation. RESULTS: Of 335 participants, 39 were in the PHDR group and 296 were in the control group. ART regimen in PHDR group was adjusted at 6-10 weeks after ART initiation when results of baseline genotypic resistance test were available. Proportions of participants with undetectable viral load were significantly lower in PHDR group at 6 and 12 months (46.2% vs 79.4% (p < .001) and 74.4% vs 90.5% (p = .003), respectively). These virological responses became similar between two groups (p > .05) from 18 through 60 months. Mean change of CD4 counts of PHDR group was significantly lower only at 6 months (+59 vs + 81 cells/mm3 (p = .012); these immunological responses were similar between two groups from 12 through 60 months. CONCLUSION: Early virological response was lower in HIV-positive participants with PHDR compared to participants without PHDR. Subsequent adjustment of ART according to pretreatment genotypic resistance has contributed to the long-term virological and immunological success that is similar to participants without PHDR.

Incomplete Antiretroviral Therapy Adherence Is Associated with Lower CD4-CD8 Ratio in Virally Suppressed Patients with HIV Infection in Mexico.

Suboptimal adherence to antiretroviral therapy (ART) in people with HIV, even during sustained viral suppression, is associated with persistent inflammation, immune activation, and coagulopathy. Persistently low CD4-CD8 Ratio has been also associated with residual inflammation, is a good predictor of increased risk of death and more widely available than inflammatory biomarkers. We tested the hypothesis that the CD4-CD8 Ratio is associated with ART adherence during periods of complete viral suppression. We used the Medication Possession Ratio based in pharmacy registries as measure of adherence and time-varying, routine care CD4 and CD8 measurements as outcome. We used a linear mixed model for longitudinal data, including fixed effects for sex, age, education, date of ART initiation, AIDS-related conditions, and baseline CD4 to model the outcome. In 988 adults with a median follow-up of 4.13 years, higher ART adherence was independently associated with a modest increase in CD4-CD8. For each increasing percentage point in adherence, the CD4-CD8 Ratio increased 0.000857 (95% confidence interval [CI] -0.000494 to 0.002209, p = .213731) in the first year after achieving viral suppression; 0.001057 (95% CI 0.000262-0.001853, p = .009160) in years 1 to 3; 0.000323 (95% CI -0.000448 to 0.001095, p = .411441) in years 3 to 5; and 0.000850 (95% CI 0.000272-0.001429, p = .003946) 5-10 years after achieving viral suppression. The magnitude of the effect of adherence over CD4-CD8 Ratios varied over time and by baseline CD4 count, with increasing adherence having a larger effect early after ART initiation in people with higher baseline CD4 (>500 cells/µL) and in later years in people with lower baseline CD4 count (≥200 cells/µL). Our findings expand on previous evidence suggesting that the benefits of optimal adherence to modern ART regimens goes beyond maintaining viral suppression. These results highlight the importance of including objective measurements of adherence as part of routine care, even in patients with complete HIV suppression over long-term follow-up.

Biological parameters determining the effectiveness of monitoring of HIV / AIDS infected patients in Morocco.

Background & objective: Human Immunodeficiency Virus (HIV) remains one of the world's most serious health challenges. The development of therapeutic regimens has significantly increased survival and reduced HIV-associated morbidities in HIV-infected individuals. However, some people living with HIV may not respond as expected, resulting in treatment failure. The objective of this study is to identify and characterize, by immunological (T-cell CD4) and virological (viral load) parameters, HIV infected patients with therapeutic failure in Morocco. Methods: Prospective cross-sectional studies were conducted over a 5-years period (between January 2015 and December 2019) at the referral center of Ibn Zohr Hospital, Marrakech, Morocco. A total, of 1088 HIV-infected patients diagnosed by the rapid test (Immunochromatography) in addition to Western Blot analysis, was recruited. All patients were under the antiretroviral therapy (ART) for at least six months and followed every six months. Sociodemographic, clinical, and biological data as well as information on patient adherence were collected. Results: Out of 1088 patients, 92.46% were under treatment based on non-nucleoside reverse transcriptase inhibitors (NNRTIs) including 26.20% first line first intention and 66.26% first line second intention, and 7.54% of patients on a protease inhibitor (PI) therapy. Regarding the immunological and virological status, 76% of HIV-infected patients had a CD4 count > 200 cells/µl and 24% had a CD4 count < 200 cells / µl, while 69.5% had an undetectable viral load and 30.05% had a detectable viral load (including 11.86% with viral load < 1000 copies / ml and 18.20% viral load > 1000 copies / ml) (P-values < 0.05). Conclusion: In our study, we showed a therapeutic failure rate of 18.2% in HIV-infected patients under treatment in Marrakech region. These failures were mainly related to poor adherence and low CD4+ rates at the initiation of treatment. We concluded that immunological monitoring alone is insufficient to predict virological suppression and therapeutic success. Consequently, we recommend the HIV plasma viral load test be accessible as a routine exam.

Longitudinal Effects of Combination Antiretroviral Therapy on Cognition and Neuroimaging Biomarkers in Treatment-Naive People With HIV.

BACKGROUND AND OBJECTIVES: While combination antiretroviral therapy (cART) has dramatically increased the life expectancy of people with HIV (PWH), nearly 50% develop HIV-associated neurocognitive disorders. This may be due to previously uncontrolled HIV viral replication, immune activation maintained by residual viral replication or activation from other sources, or cART-associated neurotoxicity. The aim of this study was to determine the effect of cART on cognition and neuroimaging biomarkers in PWH before and after initiation of cART compared with that in HIV-negative controls (HCs) and HIV elite controllers (ECs) who remain untreated. METHODS: We recruited 3 groups of participants from the University of Rochester, McGovern Medical School, and SUNY Upstate Medical University: (1) ART treatment-naive PWH; (2) age-matched HCs; and (3) ECs. Participants underwent brain MRI and clinical and neuropsychological assessments at baseline, 1 year, and 2 years. PWH were also assessed 12 weeks after initiating cART. Volumetric analysis and fractal dimensionality (FD) were calculated for cortical and subcortical regions. Mixed effect regressions examined the effect of group and imaging variables on cognition. RESULTS: We enrolled 47 PWH, 58 HCs, and 10 ECs. At baseline, PWH had worse cognition and lower cortical volumes than HCs. Cognition improved after initiation of cART and remained stable over time. Greater cortical thickness was associated with better cognition at baseline; greater FD of parietal, temporal, and occipital lobes was associated with better cognition at baseline and longitudinally. At baseline, ECs had worse cognition, lower cortical thickness, and lower FD in all 4 lobes and caudate than PWH and HCs. Greater cortical thickness, hippocampal volumes, and FD of frontal, temporal, and occipital lobes were associated with better cognition longitudinally. DISCUSSION: Initiation of cART in PWH is associated with improvement in brain structure and cognition. However, significant differences persist over time when compared with HCs. Similar trends in ECs suggest that results are due to HIV infection rather than treatment. Stronger associations between cognition and FD suggest this imaging metric may be a more sensitive marker of neuronal injury than cortical thickness and volumetric measures.

Evaluation of Clinical Biomarkers Related to CD4 Recovery in HIV-Infected Patients-5-Year Observation.

Human Immunodeficiency Virus infection leads to the impairment of immune system function. Even long-term antiretroviral therapy uncommonly leads to the normalization of CD4 count and CD4:CD8 ratio. The aim of this study was to evaluate possible clinical biomarkers which may be related to CD4 and CD4:CD8 ratio recovery among HIV-infected patients with long-term antiretroviral therapy. The study included 68 HIV-infected patients undergoing sustained antiretroviral treatment for a minimum of 5 years. Clinical biomarkers such as age, gender, advancement of HIV infection, coinfections, comorbidities and applied ART regimens were analyzed in relation to the rates of CD4 and CD4:CD8 increase and normalization rates. The results showed that higher rates of CD4 normalization are associated with younger age (p = 0.034), higher CD4 count (p = 0.034) and starting the therapy during acute HIV infection (p = 0.012). Higher rates of CD4:CD8 ratio normalization are correlated with higher CD4 cell count (p = 0.022), high HIV viral load (p = 0.006) and acute HIV infection (p = 0.013). We did not observe statistically significant differences in CD4 recovery depending on gender, HCV/HBV coinfections, comorbidities and opportunistic infections. The obtained results advocate for current recommendations of introducing antiretroviral therapy as soon as possible, preferably during acute HIV infection, since it increases the chances of sufficient immune reconstruction.

Factors associated with poor outcomes among people living with HIV started on anti-retroviral therapy before and after implementation of "test and treat" program in Coastal Kenya.

OBJECTIVES: To determine the factors associated with poor outcomes among people living with HIV (PLHIV) started on anti- retroviral therapy before and after implementation of "Test and treat" program in 18 facilities in Coastal Kenya. METHODS: A retrospective cohort study design was used to study PLHIV aged > 15 years and started on ART in the periods of April to August 2016, and April to August 2017, then followed up for 24 months. Primary outcome was retention defined as being alive and on ARVs after 24 months. Death and loss to follow-up were considered as poor outcomes. Kaplan-Meier survival methods were used to describe time to primary outcome. Cox proportional regression analysis was used to determine factors associated with poor outcomes. RESULTS: 86 patients (470 before test and treat, and 316 after test and treat cohorts) were enrolled. Overall, the median [IQR] age was 39.3 [32.5-47.5] years and 539 (69%) were female. After 24 months, retention rates for the before (68%) and after (64%) test and start groups were similar (absolute difference: -4.0%, 95%CI: -11-3.1, P = 0.27). There were 240(31%, 95%CI 27 to 34%) PLHIV with poor outcomes, 102 (32%) and 138 (29%) occurred among the test and treat group, and delayed treatment patients respectively. In multivariable regression model, test and treat had no significant effect on risk of poor outcomes (aHR = 1.17, 95%CI 0.89-1.54). Increasing age (aHR = 0.98, 95%CI 0.97-0.99), formal employment (aHR = 0.42, 95%CI 0.23-0.76) and not being employed (aHR = 0.53, 95%CI 0.34-0.81) were negatively associated with poor outcomes. The risk of poor outcomes was higher among males compared to female patients (aHR = 1.37, 95%CI 1.03-1.82) and among divorced/separated patients compared to the married (aHR = 1.44, 95%CI 1.04-1.99). CONCLUSION: Retention patterns for the "test and treat" cohort were comparable to those who started ART before "test and treat". Patients who are males, young, divorced/separated, with poor socio-economic status had higher risks for poor clinical outcomes. Interventions targeting PLHIV who are young, male and economically disadvantaged provide an opportunity to improve the long-term outcomes.

Durability of switched therapy after failure of WHO-recommended antiretroviral therapy regimens in a resource-limited setting.

OBJECTIVE: The study investigated the durability of switched therapy and factors associated with the viral rebound among patients on second-line antiretroviral therapy (ART) in Uganda. DESIGN: A retrospective dynamic cohort of adults initiated on second-line ART after virological failure to first-line ART. METHODS: Patients on second-line treatment for at least 6 months between 2007 and 2017 were included. Patients were followed, until they experienced a viral rebound (viral load ≥200 copies/ml). Cumulative probability of viral rebounds and factors associated with viral rebound were determined using Kaplan-Meier methods and Cox proportional hazard models. RESULTS: One thousand, one hundred and one participants were enrolled of which 64% were women, the median age was 37 years [interquartile range (IQR) 31-43]. The preswitch median CD4 + cell count and viral load were 128 cells/µl (IQR 58-244) and 45 978 copies/ml (IQR 13 827-139 583), respectively. During the 4190.37 person-years, the incidence rate of viral rebound was 83.29 [95% confidence interval (CI) 74.99-92.49] per 1000 person-years. The probability of viral rebound at 5 and 10 years was 0.29 (95% CI 0.26-0.32) and 0.62 (95% CI 0.55-0.69), respectively. The median rebound-free survival was 8.7 years. Young adults (18-24 years) [adjusted hazard ratio (aHR) 2.49, 95% CI 1.32-4.67], preswitch viral load at least 100 000 copies/ml (aHR 1.53, 95% CI 1.22-1.92), and atazanavir/ritonavir (ATV/r)-based second-line (aHR 1.73, 95% CI 1.29-2.32) were associated with an increased risk of viral rebound. CONCLUSION: Switched therapies are durable for 8 years after failure of recommended regimens. A high preswitch viral load, ATV/r-based regimens, and young adulthood are risk factors for viral rebound, which underscores the need for more durable regimens and differentiated care services.

Risk factors of severe hepatotoxicity among HIV-1 infected individuals initiated on highly active antiretroviral therapy in the Northwest Region of Cameroon.

BACKGROUND: Hepatotoxicity due to highly active antiretroviral therapy (HAART) has gained prominent attention since it can be affected by many factors. The aim of this study was to determine the prevalence of hepatotoxicity and related risk factors of severe hepatotoxicity following HAART initiation. METHODS: A total of 100 drug-naive patients aged between 18 and 61 years were recruited. They were put on Tenofovir/Lamivudine/Efavirenz [TDF/3TC/EFV] (64), Zidovudine/ Lamivudine/Efavirenz [AZT/3TC/EFV] (22), and Zidovudine/Lamivudine/Nevirapine AZT/3TC/NVP (14) and monitored for 6months and blood samples drawn.Alanine aminotransferases (ALT), aspartate aminotransferases (AST), and alkaline phosphatase (ALP) wereanalyzed by enzymatic methods and used to classify levels of hepatotoxicity. RESULTS: A total of 37(37%) and 49(49%) patients presented with hepatotoxicity while 15% and 28% had severe hepatotoxicity at 4 and 24 weeks respectively. Serum levels of all enzymes increased significantly (p = 0.001) with increased treatment duration. Univariate analysis revealed that the risk factor of developing severe hepatotoxicity was significantly greater in patients < 30years (p = 0.02), males(p = 0.04), low BMI (p = 0.02), low monthly income (p = 0.01) earners, and patients on AZT + 3TC + NVP regimen (p = 0.01). While multivariate analysis at p < 0.09 showed that age 30-40 years, low BMI, low monthly income, and the use of AZT + 3TC + NVP regimen were independent risk factors. CONCLUSIONS: Low BMI, age group of 30-40years, low monthly income, and the use of AZT + 3TC + NVP regimen identified as risk factors for the development of severe hepatotoxicity should be considered as an important strategy by clinicians in preventing the hepatotoxicity.