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Abdullahi A, Diaz AG, Fopoussi OM, Beloukas A, Fokom Defo V, Kouanfack C, Torimiro J, Geretti AM. A detailed characterization of drug resistance during darunavir/ritonavir monotherapy highlights a high barrier to the emergence of resistance mutations in protease but identifies alternative pathways of resistance. J Antimicrob Chemother 2024; 79:339-348. [PMID: 38153241 PMCID: PMC10832591 DOI: 10.1093/jac/dkad386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 11/26/2023] [Indexed: 12/29/2023] Open
Abstract
BACKGROUND Maintenance monotherapy with ritonavir-boosted darunavir has yielded variable outcomes and is not recommended. Trial samples offer valuable opportunities for detailed studies. We analysed samples from a 48 week trial in Cameroon to obtain a detailed characterization of drug resistance. METHODS Following failure of NNRTI-based therapy and virological suppression on PI-based therapy, participants were randomized to ritonavir-boosted darunavir (n = 81) or tenofovir disoproxil fumarate/lamivudine +ritonavir-boosted lopinavir (n = 39). At study entry, PBMC-derived HIV-1 DNA underwent bulk Protease and Reverse Transcriptase (RT) sequencing. At virological rebound (confirmed or last available HIV-1 RNA ≥ 60 copies/mL), plasma HIV-1 RNA underwent ultradeep Protease and RT sequencing and bulk Gag-Protease sequencing. The site-directed mutant T375A (p2/p7) was characterized phenotypically using a single-cycle assay. RESULTS NRTI and NNRTI resistance-associated mutations (RAMs) were detected in 52/90 (57.8%) and 53/90 (58.9%) HIV-1 DNA samples, respectively. Prevalence in rebound HIV-1 RNA (ritonavir-boosted darunavir, n = 21; ritonavir-boosted lopinavir, n = 2) was 9/23 (39.1%) and 10/23 (43.5%), respectively, with most RAMs detected at frequencies ≥15%. The resistance patterns of paired HIV-1 DNA and RNA sequences were partially consistent. No darunavir RAMs were found. Among eight participants experiencing virological rebound on ritonavir-boosted darunavir (n = 12 samples), all had Gag mutations associated with PI exposure, including T375N, T375A (p2/p7), K436R (p7/p1) and substitutions in p17, p24, p2 and p6. T375A conferred 10-fold darunavir resistance and increased replication capacity. CONCLUSIONS The study highlights the high resistance barrier of ritonavir-boosted darunavir while identifying alternative pathways of resistance through Gag substitutions. During virological suppression, resistance patterns in HIV-1 DNA reflect treatment history, but due to technical and biological considerations, cautious interpretation is warranted.
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Affiliation(s)
- Adam Abdullahi
- Takemi Program in International Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, Cambridge, UK
- Institute of Human Virology Nigeria, Abuja, Nigeria
| | - Ana Garcia Diaz
- Department of Virology, Royal Free London NHS Foundation Trust, London, UK
| | - Olga Mafotsing Fopoussi
- Biomedical Sciences Department, University of West Attica, Athens, Greece
- Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention & Management (CIRCB), Yaoundé, Cameroon
| | - Apostolos Beloukas
- Biomedical Sciences Department, University of West Attica, Athens, Greece
- National AIDS Reference Centre of Southern Greece, School of Public Health, University of West Attica, Athens, Greece
| | - Victoire Fokom Defo
- Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention & Management (CIRCB), Yaoundé, Cameroon
- Department of HIV Medicine, Hôpital Central de Yaoundé, Ministry of Public Health, Yaoundé, Cameroon
| | - Charles Kouanfack
- Department of HIV Medicine, Hôpital Central de Yaoundé, Ministry of Public Health, Yaoundé, Cameroon
| | - Judith Torimiro
- Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention & Management (CIRCB), Yaoundé, Cameroon
| | - Anna Maria Geretti
- Department of Infectious Diseases, Fondazione PTV, University of Rome Tor Vergata, Rome, Italy
- Department of Infection, North Middlesex University Hospital, London, UK
- School of Immunity and Microbial Sciences, King’s College London, London, UK
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Parbie PK, Abana CZY, Kushitor D, Asigbee TW, Ntim NAA, Addo-Tetebo G, Ansong MRD, Ofori SB, Mizutani T, Runtuwene LR, Nishizawa M, Ishikawa K, Kiyono H, Ampofo WK, Matano T, Bonney EY, Kikuchi T. High-level resistance to non-nucleos(t)ide reverse transcriptase inhibitor based first-line antiretroviral therapy in Ghana; A 2017 study. Front Microbiol 2022; 13:973771. [PMID: 36090108 PMCID: PMC9459847 DOI: 10.3389/fmicb.2022.973771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 07/14/2022] [Indexed: 11/21/2022] Open
Abstract
Expanding access to effective antiretroviral therapy (ART) is a major tool for management of Human Immunodeficiency Virus (HIV) infection. However, rising levels of HIV drug-resistance have significantly hampered the anticipated success of ART in persons living with HIV (PLWH), particularly those from Africa. Though great strides have been made in Ghana toward achieving the UNAIDS “95-95-95” target, a substantial number of PLWH receiving ART have not attained viral suppression. This study investigated patterns of drug resistance mutations in ART naïve as well as ART-experienced PLWH receiving first-line regimen drugs from Ghana. In a cross-sectional study, blood samples were collected from HIV-1 infected adults (≥18 years) attending HIV/AIDS clinic at the Eastern Regional Hospital, Koforidua, Ghana from September to October 2017. Viral RNA isolated from plasma were subjected to genotypic drug resistance testing for Protease Inhibitors (PI), Reverse Transcriptase Inhibitors (RTI), and Integrase Strand Transfer Inhibitors (INSTI). A total of 95 (84 ART experienced, 11 ART naïve) HIV-1 infected participants were sampled in this study. Sixty percent (50/84) of the ART-experienced participants were controlling viremia (viral load < 1,000 copies/ml). Of the 95 patient samples, 32, 34, and 33 were successfully sequenced for protease, reverse-transcriptase, and integrase regions, respectively. The dominant HIV-1 subtypes detected were CRF02_AG (70%), and A3 (10%). Major drug resistance associated mutations were only detected for reverse transcriptase inhibitors. The predominant drug resistance mutations were against nucleos(t)ide reverse transcriptase inhibitors (NRTI)—M184V/I and non-nucleos(t)ide reverse transcriptase inhibitors (NNRTI)—K103N. In the ART-experienced group, M184V/I and K103N were detected in 54% (15/28) and 46% (13/28) of individuals, respectively. Both mutations were each detected in 33% (2/6) of ART naïve individuals. Multiclass resistance to NRTI and NNRTI was detected in 57% of ART-experienced individuals and two ART naïve individuals. This study reports high-level resistance to NNRTI-based antiretroviral therapy in PLWH in Ghana. However, the absence of major PI and INSTI associated-mutations is a good signal that the current WHO recommendation of Dolutegravir in combination with an NRTI backbone will yield maximum benefits as first-line regimen for PLWH in Ghana.
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Affiliation(s)
- Prince Kofi Parbie
- AIDS Research Center, National Institute of Infectious Diseases, Tokyo, Japan
| | - Christopher Zaab-Yen Abana
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
- West African Center for Cell Biology of Infectious Pathogens (WACCBIP), University of Ghana, Accra, Ghana
- Department of Biochemistry, Cell and Molecular Biology, College of Basic and Applied Sciences, University of Ghana, Accra, Ghana
| | - Dennis Kushitor
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Theodore Worlanyo Asigbee
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
- Joint Research Center for Human Retrovirus Infection, Kumamoto University, Kumamoto, Japan
| | - Nana Afia Asante Ntim
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
- Joint Research Center for Human Retrovirus Infection, Kumamoto University, Kumamoto, Japan
| | - Gifty Addo-Tetebo
- Eastern Regional Hospital Koforidua, Ghana Health Service, Koforidua, Ghana
| | | | - Sampson Badu Ofori
- Eastern Regional Hospital Koforidua, Ghana Health Service, Koforidua, Ghana
| | | | | | - Masako Nishizawa
- AIDS Research Center, National Institute of Infectious Diseases, Tokyo, Japan
| | - Koichi Ishikawa
- AIDS Research Center, National Institute of Infectious Diseases, Tokyo, Japan
| | - Hiroshi Kiyono
- The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
- Future Medicine Education and Research Organization, Institute for Global Prominent Research, Graduate School of Medicine, Chiba University, Chiba, Japan
- Department of Medicine, Chiba University-University of California San Diego Center for Mucosal Immunology, Allergy and Vaccines (cMAV) University of California San Diego, San Diego, CA, United States
| | | | - Tetsuro Matano
- AIDS Research Center, National Institute of Infectious Diseases, Tokyo, Japan
- Joint Research Center for Human Retrovirus Infection, Kumamoto University, Kumamoto, Japan
- The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Evelyn Yayra Bonney
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
- *Correspondence: Evelyn Yayra Bonney,
| | - Tadashi Kikuchi
- AIDS Research Center, National Institute of Infectious Diseases, Tokyo, Japan
- Tadashi Kikuchi,
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Man X, Wei R. Advancements in the prevention of hepatitis B recurrence by nucleos(t)ide analogue monotherapies after liver transplantation. EUR J INFLAMM 2022. [DOI: 10.1177/1721727x221139254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Previous studies have shown that the recurrence rate of HBV (hepatitis B virus) after liver transplantation (LT) can be as high as 80% without any preventive measures. Therefore, prevention of HBV recurrence after LT is always an essential part of clinical work worldwide. The NAs that have been approved for HBV treatment include lamivudine, adefovir dipivoxil, entecavir (ETV), and telbivudine, tenofovir disoproxil fumarate (TDF), and tenofovir alafenamide (TAF). They are often combined with HBIG to prevent HBV recurrence after LT clinically. However, NAs with a higher genetic barrier, such as ETV, TDF, and TAF, can improve liver function by strongly inhibiting HBV replication and reducing the risks of HBV resistance. Recently, some NAs with a higher genetic barrier, such as ETV, TDF, and TAF, have been adopted as monotherapy for preventing the recurrence of hepatitis B after LT in multiple organ transplant centres and have achieved effective outcomes. This article aims to review the advances for NAs monotherapy in prophylaxis for HBV recurrence after LT.
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Affiliation(s)
- Xie Man
- Department of Gastroenterology, the Affiliated Hospital of Qingdao University, China
| | - Rao Wei
- Division of Hepatology, Liver Disease Center, the Affiliated Hospital of Qingdao University, China
- Department of Organ Transplantation, the Affiliated Hospital of Qingdao University, China
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Application of next generation sequencing in HIV drug resistance studies in Africa, 2005–2019: A systematic review. SCIENTIFIC AFRICAN 2021. [DOI: 10.1016/j.sciaf.2021.e00829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Villa G, Abdullahi A, Owusu D, Smith C, Azumah M, Sayeed L, Austin H, Awuah D, Beloukas A, Chadwick D, Phillips R, Geretti AM. Determining virological suppression and resuppression by point-of-care viral load testing in a HIV care setting in sub-Saharan Africa. EClinicalMedicine 2020; 18:100231. [PMID: 31922120 PMCID: PMC6948257 DOI: 10.1016/j.eclinm.2019.12.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 11/27/2019] [Accepted: 12/02/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND This prospective pilot study explored same-day point-of-care viral load testing in a setting in Ghana that has yet to implement virological monitoring of antiretroviral therapy (ART). METHODS Consecutive patients accessing outpatient care while on ART underwent HIV-1 RNA quantification by Xpert. Those with viraemia at the first measurement (T0) received immediate adherence counselling and were reassessed 8 weeks later (T1). Predictors of virological status were determined by logistic regression analysis. Drug resistance-associated mutations (RAMs) were detected by Sanger sequencing. FINDINGS At T0, participants had received treatment for a median of 8·9 years; 297/333 (89·2%) were on NNRTI-based ART. The viral load was ≥40 copies/mL in 164/333 (49·2%) patients and ≥1000 copies/mL in 71/333 (21·3%). In the latter group, 50/65 (76·9%) and 55/65 (84·6%) harboured NRTI and NNRTI RAMs, respectively, and 27/65 (41·5%) had ≥1 tenofovir RAM. Among 150/164 (91·5%) viraemic patients that reattended at T1, 32/150 (21·3%) showed resuppression <40 copies/mL, comprising 1/65 (1·5%) subjects with T0 viral load ≥1000 copies/mL and 31/85 (36·5%) subjects with lower levels. A T0 viral load ≥1000 copies/mL and detection of RAMs predicted ongoing T1 viraemia independently of self-reported adherence levels. Among participants with T0 viral load ≥1000 copies/mL, 23/65 (35·4%) showed resuppression <1000 copies/mL; the response was more likely among those with higher adherence levels and no RAMs. INTERPRETATION Same-day point-of-care viral load testing was feasible and revealed poor virological control and suboptimal resuppression rates despite adherence counselling. Controlled studies should determine optimal triaging modalities for same-day versus deferred viral load testing. FUNDING University of Liverpool, South Tees Infectious Diseases Research Fund.
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Affiliation(s)
- Giovanni Villa
- Institute of Infection & Global Health, University of Liverpool, Liverpool, United Kingdom
- Department of Global Health & Infection, Brighton & Sussex Medical School, University of Sussex, Brighton, United Kingdom
| | - Adam Abdullahi
- Institute of Infection & Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Dorcas Owusu
- Kwame Nkrumah University of Science & Technology, Kumasi, Ghana
| | - Colette Smith
- Institute of Global Health, University College London, London, United Kingdom
| | - Marilyn Azumah
- Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Laila Sayeed
- Centre for Clinical Infection, James Cook University Hospital, Middlesbrough, United Kingdom
| | - Harrison Austin
- Institute of Infection & Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Dominic Awuah
- Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Apostolos Beloukas
- Institute of Infection & Global Health, University of Liverpool, Liverpool, United Kingdom
- Department of Biomedical Sciences, University of West Attica, Athens, Greece
| | - David Chadwick
- Centre for Clinical Infection, James Cook University Hospital, Middlesbrough, United Kingdom
| | - Richard Phillips
- Kwame Nkrumah University of Science & Technology, Kumasi, Ghana
- Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Anna Maria Geretti
- Institute of Infection & Global Health, University of Liverpool, Liverpool, United Kingdom
- Corresponding author at: Institute of Infection & Global Health, University of Liverpool, 8 West Derby Street, Liverpool L69 7BE, United Kingdom.
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Bavaro DF, Di Carlo D, Rossetti B, Bruzzone B, Vicenti I, Pontali E, Zoncada A, Lombardi F, Di Giambenedetto S, Borghi V, Pecorari M, Milini P, Meraviglia P, Monno L, Saracino A. Pretreatment HIV drug resistance and treatment failure in non-Italian HIV-1-infected patients enrolled in ARCA. Antivir Ther 2020; 25:61-71. [PMID: 32118584 DOI: 10.3851/imp3349] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND An increase in pretreatment drug resistance (PDR) to first-line antiretroviral therapy (ART) in low-income countries has been recently described. Herein we analyse the prevalence of PDR and risk of virological failure (VF) over time among migrants to Italy enrolled in ARCA. METHODS HIV-1 sequences from ART-naive patients of non-Italian nationality were retrieved from ARCA database from 1998 to 2017. PDR was defined by at least one mutation from the reference 2009 WHO surveillance list. RESULTS Protease/reverse transcriptase sequences from 1,155 patients, mainly migrants from sub-Saharan Africa (SSA; 42%), followed by Latin America (LA; 25%) and Western countries (WE; 21%), were included. PDR was detected in 8.6% of sequences (13.1% versus 5.8% for B and non-B strains, respectively; P<0.001). 2.1% of patients carried a PDR for protease inhibitors (PIs; 2.1% versus 2.3%; P=0.893), 3.9% for nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs; 6.8% versus 2.1%; P<0.001) and 4.3% for non-nucleoside/nucleotide reverse transcriptase inhibitors (NNRTIs; 6.3% versus 3.1%; P=0.013). Overall, prevalence of PDR over the years remained stable, while it decreased for PIs in LA (P=0.021) and for NRTIs (P=0.020) among migrants from WE. Having more than one class of PDR (P=0.015 versus absence of PDR), higher viral load at diagnosis (P=0.008) and being migrants from SSA (P=0.001 versus WE) were predictive of VF, while a recent calendar year of diagnosis (P<0.001) was protective for VF. CONCLUSIONS PDR appeared to be stable over the years in migrants to Italy enrolled in ARCA; however, it still remains an important cause of VF together with viral load at diagnosis.
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Affiliation(s)
- Davide Fiore Bavaro
- Department of Biomedical Sciences and Human Oncology, Clinic of Infectious Diseases, University of Bari Medical School, Bari, Italy.,These authors equally contributed to this work
| | - Domenico Di Carlo
- Pediatric Clinical Research Center 'Romeo and Enrica Invernizzi', University of Milan, Milan, Italy.,These authors equally contributed to this work
| | - Barbara Rossetti
- Infectious Diseases Unit, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | | | - Ilaria Vicenti
- Dipartimento di Biotecnologie Mediche, Università di Siena, Siena, Italy
| | | | | | - Francesca Lombardi
- Università Cattolica del Sacro Cuore, Roma Italia, Istituto di Clinica Malattie Infettive, Rome, Italy
| | - Simona Di Giambenedetto
- Università Cattolica del Sacro Cuore, Roma Italia, Istituto di Clinica Malattie Infettive, Rome, Italy.,Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma Italia, UOC malattie infettive, Rome, Italy
| | - Vanni Borghi
- Clinica Malattie infettive, Azienda Ospedaliero Universitaria di Modena, Modena, Italy
| | - Monica Pecorari
- SSD Virologia, Azienda Ospedaliero-Univeristaria Policlinico Modena, Modena, Italy
| | - Paola Milini
- Infectious Diseases Unit, Macerata Hospital, Macerata, Italy
| | - Paola Meraviglia
- 1st Division of Infectious Diseases, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Laura Monno
- Department of Biomedical Sciences and Human Oncology, Clinic of Infectious Diseases, University of Bari Medical School, Bari, Italy
| | - Annalisa Saracino
- Department of Biomedical Sciences and Human Oncology, Clinic of Infectious Diseases, University of Bari Medical School, Bari, Italy
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Geretti AM, Abdullahi A, Mafotsing Fopoussi O, Bonnett L, Fokom Defo V, Moudourou S, Fokam J, Kouanfack C, Torimiro J. An apparent paradox: resistance mutations in HIV-1 DNA predict improved virological responses to antiretroviral therapy. J Antimicrob Chemother 2019; 74:3011-3015. [PMID: 31299067 DOI: 10.1093/jac/dkz264] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/21/2019] [Accepted: 05/28/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND In sub-Saharan Africa, detecting resistance-associated mutations (RAMs) at failure of first-line ART with two NRTIs plus an NNRTI predicts improved virological responses to second-line therapy with two NRTIs plus a ritonavir-boosted PI (PI/r). This indicates residual NRTI activity in the presence of RAMs, although additional factors may contribute to the effect. OBJECTIVES The aim of this study was to investigate the influence of pre-existing RAMs on the outcomes of maintenance monotherapy with ritonavir-boosted darunavir within a randomized trial in Cameroon. METHODS RAMs were detected in HIV-1 DNA using PBMCs collected at initiation of darunavir/ritonavir monotherapy. Adherence was assessed by pill count and visual analogue scale (VAS). Predictors of virological failure (confirmed or last available viral load >400 copies/mL) were explored by logistic regression analysis. Trial name = MANET (NCT02155101). RESULTS After NNRTI-based therapy, participants (n = 81) had received PI/r-based therapy for a median of 3.2 years and had a confirmed viral load <60 copies/mL and a median CD4 count of 466 cells/mm3. NRTI and NNRTI RAMs were detected in 39/60 (65.0%) and 41/60 (68.3%) HIV-1 DNA sequences, respectively. Over 48 weeks of monotherapy, 16/81 (19.8%) patients experienced virological failure. After adjusting for age, HIV-1 DNA load, adherence by VAS and RAM status, virological failure was less likely with higher VAS-measured adherence (adjusted OR 0.04, 95% CI 0.01-0.37; P = 0.004) and detectable HIV-1 DNA RAMs (adjusted OR 0.15, 95% CI 0.03-0.82; P = 0.028). CONCLUSIONS Pre-existing NRTI and NNRTI RAMs are associated with improved virological responses to NRTI-sparing ART in sub-Saharan Africa, indicating a predictive effect that is independent of residual NRTI activity.
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Affiliation(s)
- Anna Maria Geretti
- Institute of Infection & Global Health, University of Liverpool, Liverpool, UK
| | - Adam Abdullahi
- Institute of Infection & Global Health, University of Liverpool, Liverpool, UK
| | - Olga Mafotsing Fopoussi
- Institute of Infection & Global Health, University of Liverpool, Liverpool, UK
- Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention & Management (CIRCB), Yaoundé, Cameroon
| | - Laura Bonnett
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Victoire Fokom Defo
- Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention & Management (CIRCB), Yaoundé, Cameroon
- Hôpital Central Yaoundé, Ministry of Public Health, Yaoundé, Cameroon
| | - Sylvie Moudourou
- Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention & Management (CIRCB), Yaoundé, Cameroon
| | - Joseph Fokam
- Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention & Management (CIRCB), Yaoundé, Cameroon
| | - Charles Kouanfack
- Hôpital Central Yaoundé, Ministry of Public Health, Yaoundé, Cameroon
| | - Judith Torimiro
- Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention & Management (CIRCB), Yaoundé, Cameroon
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