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Virological efficacy and immunological recovery among Ethiopian HIV-1 infected adults and children
© Mulu et al.; licensee BioMed Central Ltd. 2014
Received: 9 July 2013
Accepted: 10 January 2014
Published: 14 January 2014
Introduction of antiretroviral therapy (ART) in sub-Saharan Africa was a hot debate due to many concerns about adherence, logistics and resistance. Currently, it has been significantly scaled up. However as the WHO clinico-immunological approaches for initiation and monitoring of ART in the region lacks viral load determination and drug resistance monitoring, HIV infected adults and children may be at risk for “unrecognized” virologic failure and the subsequent development of antiretroviral drug resistance. This study evaluates the virological efficacy and immunological recovery of HIV/AIDS patients under ART.
Consecutive HIV-1 infected adults (N = 100) and children (N = 100) who have been receiving ART for up to 6 years at Gondar University Hospital, Ethiopia were enrolled following the WHO protocol for assessment of acquired drug resistance. Magnitude of viral suppression, genotypic drug resistance mutations and patterns of CD4+ T cell recovery were determined using standard virological and immunological methods.
Virological suppression (HIV RNA < 40 copies/ml) was observed in 82 and 87% of adults and children on a median time of 24 months on ART, respectively. Mutation K103N conferring resistance to non nucleoside reverse transcriptase inhibitors and thymidine analogue mutations (M41L, L210W) were found only in one adult and child patient, respectively. Median CD4+ T cell count has increased from baseline 124 to 266 (IQR: 203–306) and 345 (IQR: 17–1435) to 998 (IQR: 678–2205) cells/mm3 in adults and children respectively after 12 months of ART. Nevertheless, small but significant number of clinically asymptomatic adults (16%) and children (13%) had low level viraemia (HIV-1 RNA 41–1000 copies/ml).
Majority of both adults (82%) and children (87%) who received ART showed high viral suppression and immunological recovery. This indicates that despite limited resources in the setting virological efficacy can be sustained for a substantial length of time and also enhance immunological recovery irrespective of age. However, the presence of drug resistance mutations and low level viraemia among clinically asymptomatic patients highlights the need for virological monitoring.
The provision of antiretroviral therapy (ART) has reduced mortality of people living with HIV-infection [1, 2]. Conceivably, the use of ART especially in low in-come countries with sub optimal medication and patient’s follow-up may favour the emergence and transmission of drug resistant HIV-1 mutations. Particularly long term use of ART can lead to drug resistance especially among those individuals with previous mono- or dual-therapy or when temporary discontinuation in therapy has occurred . This poses the risk that HIV with definite resistance profiles may be transmitted to uninfected people and thus will impair the success of ART programs. Moreover, introducing ART particularly to sub-Saharan Africa was debated controversially because of concerns about adherence and subsequent development of drug resistance, poor infrastructure, logistic and human capacity, and cost-effectiveness . However, the World Health Organization (WHO) pilot ART feasibility study catalysed global efforts and ART has been significantly scaled up . Nevertheless, long term challenges of providing ART will become increasingly evident, including late drug toxicities, treatment failure and emergence of drug resistance [3, 6]. Good levels of adherence to ART in the first year of treatment [7, 8] and a short-term virological efficacy comparable to industrialized countries  have been documented from some African countries. But, it has been shown that 10% of patients who commence ART develop some form of genotypic drug resistance after two years, and almost 30% of patients develop viral failure within six years after starting ART , thereby representing a threat to the control of transmitted multi drug resistance . Studies from sub-Saharan Africa countries revealed a level of drug resistance as high as 50% [12–15]. Moreover, African patients with very low CD4+ T cell counts have a high risk of mortality both before and during the initial months of ART [16, 17] and advanced pre-treatment immunodeficiency is also reported to be associated with reduced capacity for restoration of CD4+ T cell counts and its functional responses during ART [18–20]. This raises the concern that many patients entering ART programmes in sub-Saharan Africa may have limited potential for immune recovery. Despite the rapid scaling up of ART and its positive outcomes in adults, as of 2012 only 30% of HIV infected children (≤14 years) eligible for ART were receiving it. Moreover, the limited access of paediatric regimens, the challenges of paediatric ART adherence and the likelihood of HIV drug resistance development raise great public health concern about drug resistance in children receiving ART .
In Ethiopia HIV prevalence is estimated to be 1.5% among the general population with an estimate of about 800, 000 people living with HIV (78% adults and 22% children <14 years). By the end of 2012, there were 249,174 adults and 16,000 children on treatment, of whom 135 children and 865 adults were receiving second line drugs. However, in some regions 40% of patients who were enrolled to ART dropped out from treatment. The over all current ART coverage for adult populations is high (86% of estimated eligible). Conversely, the coverage of ART for children is low (only 20% of estimated eligible) (http://www.etharc.org/). Access to optimal laboratory monitoring with viral load testing is not available. Hence, ART initiation and monitoring is based on the WHO clinico-immunological approach. However, as this approach lacks viral load determination and drug resistance monitoring by sequencing of reverse transcriptase gene segments HIV infected adults and children may be at risk for “unrecognized” virologic failure and the subsequent development of antiretroviral drug resistance. The aim of this study was to evaluate the virological efficacy and CD4+ T cell recovery among HIV/AIDS adults and children patients who were on ART for up to 6 years.
Patients and ART
Baseline characteristics of adult HIV/AIDS patients on ART at GUH
Number of patients
WHO clinical stage
Anaemia status (%)a
CD4 cell count (cells/mm3)b
Total duration on ART (months)
1a: 3TC + d4T + NVP
1b: 3TC + d4T + EFV
1c: 3TC + AZT** + NVP
1d: 3TC + AZT + EFV***
Study design and selection procedure
This longitudinal study follows the WHO protocol for assessment of acquired drug resistance for adults . Consecutive HIV-infected adult (N = 100) and children (N = 100) who had received first-line ART for more than 12 months and visiting Gondar Hospital from June to November 2008 were included in the study. Patients who had interrupted treatment or patients transferred from another ART clinic or pregnant women or those with known chronic illness were excluded.
Clinical and laboratory assessment
Minimal socio-demographic data and relevant clinical features of the patients were retrieved from medical records. About 10 ml venous blood was collected in a tube containing ethylene diamine tetra-acetic acid (EDTA). After centrifugation (956 rcf for 5 minutes) plasma was separated and stored at -40°C until further used. CD4+ T cell count was done at baseline and at 6 months interval using the FACSCount flow cytometer (Becton Dickinson, San Jose, CA, USA) following the manufacturer’s protocol. The laboratory is accredited by the American Society of Clinical Pathologists and participated in external quality control and assurance program.
RNA extraction and plasma viral load determination
RNA was extracted from 0.6 ml of plasma with the Abbott m2000sp automated sample preparation system (Abbott Molecular, Des Plaines, IL, USA) according to manufacturer’s instructions. Plasma viral load was measured using Quantitative RealTime HIV-1 assay by the Abbott m2000rt instrument with a lower detection limit of 40 copies/ml.
Sequence determination of HIV-1 pol gene
Viral RNA was reverse transcribed using AMV reverse transcriptase (Promega Corporation, WI, USA) and the outer primer HIVrt (5′TGTTTTACATCATTAGTGTG 3′). The entire protease (PR) and partial (76%) reverse transcriptase (RT) regions of the pol gene were amplified using an in house assay. In brief, Phusion Hot Start High-Fidelity DNA polymerase (Finnzymes, Espoo, Finland) was used in nested PCR with the outer primers HIVpcrFor1 (5′TGATGACAGCATGTCAGGGAGTGG3′) and HIVpcrRev1 (5′GGCTCTTGATAAATTTGATATGTCCATTG3′) yielding a 1757 bp amplicon, and subsequently by the inner primers HIVpcrFor2 (5′AGCCAACAGCCCCACCAG3′) and HIVpcrRev2 (5′CTGTATTTCTGCTATTAAGTCTTTTG 3′) yielding a 1389 bp amplicon. Initial denaturation was done at 98°C for 2 minutes followed by 40 cycles consisting of 10 seconds of denaturation at 98°C and 25 seconds of annealing at 64°C for the first round outer primers (HIVpcrFor1 and HIVpcrRev1) PCR and at 53°C for the nested inner primers (HIVpcrFor2 and HIVpcrRev2) PCR with a 40 seconds extension at 72°C for both and final extension for 5 min at 72°C. Purified PCR products were subjected to direct sequencing of both the sense and antisense strands using Big Dye Terminator Cycle Sequencing Ready Reaction kit (Applied Biosystems, Foster City, CA, USA). For each sample, six separate sequencing reactions were done using the two inner PCR primers and four additional internal primers: HIVseq1 (5′GTTAAACAATGGCCATTGACAGA3′), HIVseq2 (5′TGGAAAGGATCACCAGCAATATT3′), HIVseq3 (5′GGGCCATCCATTCCTGGCT3′) and HIVseq4 (5′2CCATCCCTGTGGAAGCACATT3′) which allowed a double coverage of the pol region. All primers positions are matched to HIV-1HXB2 (GenBank accession number K03455). Both forward and reverse overlapping sequences were manually edited with the Geneious Basic software version 5.4 . Genotypic drug resistance was defined according to The Stanford University HIV Drug-Resistance Database (http://hivdb.stanford.edu/).
The main outcomes of interest were virological suppression (HIV RNA < 40 copies/ml), drug resistance mutation/s and immunological recovery. Virological suppression was defined as HIV viral load <40 copies/ml. Immunological recovery was evaluated based on CD4+ T cell response: patients who failed to achieve an absolute increase in CD4+ T cell count from baseline by at least 50 cell/mm3 at 12 months were defined as immunological non responders. Those patients who achieved an absolute CD4+ T cell count of 200 cells/mm3 at the 12 months visit were defined as immunological responders. Absolute response in CD4+ T cell count was calculated at every 6 months intervals and categorized into 2 phases: Phase I from base line to 12 months, Phase II from 13–48 months. Duration of ART was rounded to the nearest half or full year. Univariate analysis was performed for sex, age, WHO clinical stages, ART regimen at baseline, duration of ART, haematocrit value and CD4+ T cell count. Logistic regression was used to study associations between baseline characteristics and outcomes. A p-value of less than 0.05 was considered statistically significant. The statistical analyses were carried out using SPSS statistical software version 17.
The work meets relevant ethical guidelines. Institutional ethical clearance was obtained from the University of Gondar Ethics Review Committee. Written and/or verbal informed consent was also obtained from study subjects and/or families and/or guardians.
Baseline patient’s characteristics
A total of 200 HIV-infected patients (100 adults and 100 children) were included in the present study with the mean ± standard deviation age of 34.2 ± 8.4 and 5.3 ± 1.2 years, respectively. At baseline the median CD4+ T cell count for adults and children was 144 cells/mm3 (Inter quartile range (IQR) 91.25-181.75) and 345 (IQR 17–1435). The median duration with ART was 24 months (IQR: 18.00-29.25) for both adults and children. The proportions of patients with CD4+ T cell strata, WHO clinical stages, the duration of time on ART, the main therapeutic regimen are summarized in Table 1. A standard first-line ART regimen as defined by national ART guidelines was initiated: 3TC + d4T + NVP for 39% of adults and children; 3TC + AZT + NVP for 12 and 57% of adults and children (Table 1). All the children except two were born from HIV infected mothers without exposure to single dose nevirapine (sdNVP) and combined ART for prevention of mother to child transmission (PMTCT) prophylaxis.
Virological response to ART
Genotyping drug resistance mutations in patients with ART failure a
Time on ART
M36I, H69K, T74S, L89M
M36I, H69K, T74S, L89M
M36I, H69K, L89M
M36I, H69K, L89M
M36I, H69K, L89M
Similar to the adults, high virological suppression rate (87%) was observed in children in a median time of 24 months on ART. One HIV-1 subtype C isolate with thymidine analogue mutations (M41L, L210W) was detected. Low level viraemia (HIV-1 RNA in the range of 41–1000 copies/ml) was observed in a single sample of 13 clinically asymptomatic children.
CD4+T cell response to ART
In a similar trend, the median absolute CD4+ T cell count of children has increased from 345 (IQR 17 to1435) to 998 (IQR 678–2205) in a median time of 12 months on ART. The CD4+ T cell counts after a median time of 24 months on ART were similar between viraemic (n = 13) and aviraemic (n = 87) children (median (IQR) 996 (730–1524) versus 946 (472–1102) (P = 0.10) cell/mm3.
Effect of baseline CD4+ T cell count and ART regimens on rates of CD4+T cell increase
Logistic regression models predicting overall change in CD4 + T cell count of adults during ART
aRisk of non-response
bRisk of failure to attain >200 CD4 cell
OR (95% CI)
OR (95% CI)
WHO Clinical Stage I
3TC + d4T + NVP
3TC + d4T + EFV
3TC + AZT + NVP
3TC + AZT + EFV
CD4+ T cell count
0.578 0.99 (0.00-)
0.060 0.99 (0.00-)
0.451 0.99 (0.00-)
The 82% suppression rates and the low level of HIV drug resistance in adults with a median time of 24 months on first line ART in the present study from Ethiopia demonstrates a high level of effectiveness of the antiretroviral agents in the setting. The result is in agreement with data from Europe and North America  and with a more recent report from Tanzania  where 88% viral suppression (defined as viral load below 400 copies/ml) with a median follow up time of 23 months has been described. A good short term virological efficacy rates have been reported and a systematic review on virological outcomes after 12 months ART from low-to-middle-income countries where 83-86% of virological efficacy on treatment was reported . The high virological suppression rate of 87% with low-level drug resistance among the paediatric age groups of this study is somewhat unexpected too but is similar to a recent study from Mozambique . On the other hand, the detection of low level viraemia (13%) and thymidine analogue mutation (1%) in children documented to receive PMTCT prophylaxis is expected. The viral suppression rates in both adult and children for up to four years after starting first line ART in a setting where nearly half of the population living under poverty line are affected by various co-morbid infectious diseases and where access to ART is largely restricted to two drug classes is encouraging. The results exceeded the WHO suggested target of ≥70%  and are similar to reports from other settings [19, 20, 26–28].
The high rate of virological suppression may have an impact on HIV prevention and reducing the overall risk of transmission at a population level. It has been suggested that scaling up of ART results in a level of virological suppression at the population level that will reduce HIV transmission [29–32]. To reach this goal ART should be extended to WHO groups I and II. However, the transient viraemia observed in this study among both adults and children of clinically asymptomatic conditions could be an early warning indicator for early virological failure as some may suppress and others may develop virological failure if tested in future. It does not appear to affect CD4+ or CD8+ T-cell counts or the risk of subsequent virological failure. Natural variation, assay effects and adherence might all have a role.
The sustained virological efficacy on 6 years ART in the present study might be attributed to free provision of ART and care for HIV infected patients as it has been previously shown to improve treatment efficacy  and the pre and post ART provision readiness and adherence counselling . Moreover, it might have been related to the strong collaboration between the nurses and the community based workers that ensured a follow up of patients and their network at village and home level. In addition, because traditional medicine is culturally entrenched, accessible, and affordable, up to 80% of the Ethiopian population relies on traditional remedies (herbs) as a primary source of health care . This is also the case for treatment of AIDS, but its contribution to treatment success has not been evaluated and certainly not been demonstrated yet. Nevertheless, it is claimed that certain medicinal plant remedies improve the quality of life of patients with AIDS by reducing the viral load .
It has been documented in European patients that, after the initiation of ART, peripheral CD4+ T cell count starts rising and continues so for at least 3–5 years . Our data indicate a rapid initial increase in CD4+ T cell count in the first 6 months and in the following 7–12 months by 12.2 cells/mm3/month and 9.6 cell/mm3/month, respectively, followed by almost linear rise in the subsequent two years. This is in agreement with a report that shows the rapid initial increase in CD4+ T cell count in the first 6 months  which relies on a reduction in T-cell activation and primarily consists of a release of memory CD4+ T cells trapped in the lymphoid tissue. However, the relative slow increase rate of CD4+ T cell after 12 months of ART (13–24 months: mean = 6.3 cells/mm3/month; 25–48 months: mean = 3 cells/mm3/month) and the gradual annual changes in CD4+ T cell count thereafter suggests that the number of CD4+ T cell may reach a plateau level sometime in the future. In this case the naïve CD4+ T-lymphocytes from the thymus, as well as memory CD4+ T-lymphocytes, contribute to the reconstitution of the immune system . The data also shows that those patients with baseline CD4+ T cell count of <50 cells/mm3 had similar rate of increase in the first 6 months and the consecutive months compared with higher baseline CD4+ T cell count. In most HIV-1 infected individuals treated with ART, CD4+ T cell recover to levels above 500 cells/mm3, at which HIV-1 related clinical complications are rare . None of the patients in this study reached this threshold in 48 months of ART which could be associated with the naturally lower CD4+ T cell counts in adult Ethiopians irrespective of HIV infection [38, 39] and lower immune recovery of Africans . The relative high CD4+ T cell counts and optimal CD4+ T cell recovery among children in the current study is parallel with the data that shows the predominance of naive CD4+ T cell phenotype at birth which is comparable to Caucasians .
After a median time of 24 months on ART, high viral suppression rates in adults (82%) and children (87%) were observed in Gondar hospital, Northwest Ethiopia where patients usually present late in the course of infection. This suggests that antiretroviral drugs in the setting can sustain virological efficacy for a substantial length of time and enhance immunological recovery irrespective of age. However, the presence of drug resistance mutations and low level viraemia among clinically asymptomatic patients highlights the need for regular virological monitoring in order to optimise treatment success and preserve future treatment options.
The authors would like to thank all study participants. Expert technical assistance by Sandra Bergs and Janka Rätzke is gratefully acknowledged. This work was supported by German Academic Exchange Service (DAAD), Association of Sponsors and Friends of Leipzig University, and HIV/AIDS Prevention and Control Office of Amhara Regional State, Ethiopia. The funders had no any role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
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