As with most ART studies, we found adherence to be a significant factor in the successful suppression see more of HIV-1 RNA. Early mortality upon initiation of first-line ART has been well described in resource-limited settings [15–18] and predictors for mortality have consistently included
low BMI, low CD4 cell count and anaemia [15–19]. Low BMI and low CD4 cell counts were similarly associated with early HIV-associated illnesses and mortality in our cohort of patients initiating second-line ART and in a study of second-line ART patients treated in Médecins Sans Frontières (MSF) programmes . Additionally, the mortality prior to initiation of second-line ART mirrors mortality before initiation of first-line treatment [21–23]. The striking similarity of severe events occurring around initiation of first- and second-line ART in resource-limited settings suggests that the advanced stage of HIV disease of patients in both situations is the underlying cause. The primary reason why our ART failure BKM120 nmr patients were in such advanced stages of disease is likely to be the reliance on clinical and, less consistently, immunological monitoring for identification of ART failure in the Malawi ART programme. The results from our second-line programme may improve over time if clinicians become more experienced in identifying ART failure, and if second-line ART
becomes more widely available outside tertiary centres, avoiding lengthy referral procedures. We Progesterone have previously demonstrated a complex array of mutation patterns in this patient cohort such that 17% of patients would be expected to have no active NRTI in the second-line regimen and an additional 68% would have reduced susceptibility to the NRTI combination . Despite the degree of baseline resistance, among our survivors, there was a high rate of virological suppression and immunological recovery, comparable to findings in other studies in both resource-rich and resource-poor settings [20,24]. While our study was not powered to detect differences in suppression rates according to varying degrees of resistance, we found the presence
of more complex resistance genotypes was actually associated with more successful suppression on univariate analysis. The presence of the wild type or only low genetic barrier resistance mutations (M184V or NNRTI mutations) may suggest recent nonadherence as the aetiology of failure for both first- and second-line regimens, whereas more highly adherent patients, paradoxically, may have accumulated more mutations in response to their failing first-line combination. Alternatively, if patients were recently nonadherent, we may have failed to detect minority variants that would suggest high resistance. LPV/r has been shown to be an effective monotherapy regimen in ART-naïve patients in both the short and longer term [11,12].