The majority of patients with advanced ovarian germ cell cancer are treated by cisplatin-based chemotherapy. Despite adequate first-line treatment, nearly one third of patients relapse and almost half develop cisplatin-resistant disease, which is often fatal. The treatment of cisplatin-resistant disease is challenging and prognosis remains poor. There are limited data on the efficacy of specific chemotherapeutic regimens, high-dose chemotherapy with autologous progenitor cell support and targeted therapies. The inclusion of patients in clinical trials is strongly recommended, especially in clinical trials on the most frequent male germ cell tumors, to offer wider therapeutic opportunities. Here, we provide an overview of current and potential new treatment options including combination chemotherapy, high-dose chemotherapy and molecular targeted therapies, for patients with cisplatin-resistant ovarian germ cell tumors. The European age-standardized incidence rate for female germ cell tumors (GCTs) is 0.4 per 100,000 persons per year . GCTs deMalignant ovarian GCTs (MOGCTs) are subdivided into dysgerminomatous tumors (the most frequent type) and non-dysgerminomatous tumors. The World Health Organization (WHO) classification of MOGCT is shown in Non-dysgerminoma tumors have multiple histological subtypes that resemble the differentiation occurring during human development. In particular, hallmarks of embryonic differentiation occur in embryonal carcinoma (EC) and teratoma (both mature and immature), while features of extraembryonic differentiations are present in yolk sac tumors and choriocarcinomas . ECs, chIn general, non-dysgerminomas are cisplatin (CDDP)-sensitive and are treated by a combination of surgery and chemotherapy, whereas teratomas are relatively chemo-resistant. In the majority of patients, GCTs consist of a mixture of non-dysgerminomatous histologic components, although a combination of dysgerminoma and non-dysgerminoma components is also possible. Tumor markers may thus vary between histotypes.Dysgerminomas are most likely to be localized in the ovaries at diagnosis and are often early-stage tumors . HoweverPatients with de novo advanced disease require a surgical approach, and a careful balance is needed between achieving optimal cytoreduction and preventing delays in postoperative chemotherapy . The majIn the present review we provide an overview of current options and future prospects for the management of female patients with advanced GCTs, focusing on those who are not cured after first-line chemotherapy and are thus candidates for salvage treatment.Prognostic factors are an important element in the management of MOGCT because they can help to identify the patients who need more intensive therapeutic strategies. Despite the common origin of GCTs from primordial germ cells, prognostic factors for MOGCT differ from those of TGCTs. There is a well known prognostic classification system for male GCTs incorporating stage, histology and serum biomarkers , whereasA modified version of the male International Germ Cell Cancer Collaboration Group (IGCCCG) risk classification revealed that patients classified as poor risk on the basis of pre-operative and pre-chemotherapy markers had poorer progression-free (PFS) and overall survival (OS) rates . HoweverTherefore, as shown above, currently there is not a validated prognostic classification that could help physicians in their clinical practice and further studies are requested . A prognWhen indicated, CDDP-based chemotherapy can cure the majority of patients with GCTs. Conversely, CDDP-refractoriness is associated with aggressive disease and extremely poor prognosis. The molecular basis for this sensitivity or resistance, probably multifactorial, is still poorly understood. CDDP sensitivity appears to correlate with the frequent presence of wild-type TP53, low levels of p53 and the p53 negative feedback regulator, MDM2 (mouse double minute 2 homolog). Moreover, high levels of Oct4 and low levels of cytoplasmatic p21 contribute to the high sensitivity of GCTs to CDDP-based chemotherapy. Thus, the development of CDDP resistance is mediated through altered levels of various key factors . Other mCDDP sensitivity in GCTs is largely related to the role of p53 and to DNA damage response. In numerous tumor types, CDDP resistance correlates with p53 inactivation at the genetic or protein level given that tumor protein p53 (TP53) is one of the most widely mutated genes in human cancer. Surprisingly, CDDP resistance has been directly linked to TP53 mutations in only a subset of refractory TGCTs, . Thus, mRASSF1A and HIC1 genes are associated with CDDP resistance, while a high incidence of MGMT and RARB promoter hypermethylation may play a role in the sensitivity of GCTs to CDDP [More undifferentiated GCTs such as seminomas, which show higher sensitivity to CDDP, are hypomethylated, whereas non-seminomas have more highly methylated DNA . Further to CDDP . A numbe to CDDP ,49,50,51Deregulation of the PDGFRb/PI3K/p-AKT pathway plays a key role in CDDP resistance ,52,53 anECs represent an undifferentiated type of tumor that shares expression of pluripotency factors with normal embryonic stem cells. Yolk-sac tumors, choriocarcinomas and teratomas are believed to be derived from more highly differentiated cells . The ind2 was reached; ifosfamide 1500 mg/m2 was administered by infusion over 60 min on days 2 to 5; and CDDP 25 mg/m2 was infused over 30 min on days 2 to 5. All patients received prophylactic granulocyte colony-stimulating factor (G-CSF). Thirty-two (70%) of the 46 patients obtained a CR and 29 (63%) were disease-free at a median follow-up of 69 months. The 2-year progression-free survival rate was 65%. Fourteen CR patients showed a late relapse and seven achieved a CR to chemotherapy followed by surgery. All seven were disease-free at a median follow-up of 51 months. A British Medical Research Council multicenter phase II trial evaluated the use of second-line TIP based on four courses of paclitaxel 175 mg/m2 on day 1 followed by ifosfamide 1 g/m2 and CDDP 20 mg/m2 on days 1–5 at 3-weekly intervals [2 plus ifosfamide 5 g/m2 infused over 24 h and CDDP 75 mg/m2 every 3 weeks [Recurrent OGCT is typically detected by an increase in serum tumor markers  or by the appearance of new lesions at routine surveillance imaging. Patients who progress after first-line chemotherapy are commonly treated with ifosfamide and CDDP-based regimens, a strategy also used in men with relapsed GCTs ,61. For ntervals . Thus, lCDDP-resistant female GCT is so rare that no prospective studies have ever been conducted in this patient population. The only phase II study performed to date focused on patients with recurrent or advanced dysgerminoma who were CDDP-sensitive and treated with the PVB  regimen. However, the trial was closed early because of poor accrual . A retro2 and etoposide 750 mg/m2 daily for 3 days, followed by PBPC infusion [2 daily for 3 days, followed by PBPC infusion [High-dose chemotherapy (HDC) with peripheral blood progenitor cell (PBPC) support is considered an option for salvage treatment in male patients with relapsed GCT ,70. Multinfusion . The MSKinfusion . For patinfusion . A few sinfusion . Of the infusion . Ammakkainfusion .p = 0.12) [Over the last decade several targeted therapies for male GCTs have been evaluated but proven ineffective . Such da = 0.12) .In GCT tumorigenesis, aberrations of the retinoblastoma (RB) pathway are a central event , especiaThe role of immune check-point inhibitors should also be analyzed in these rare tumors. High PD-L1 expression has been reported in TGCTs, indicating that patients could potentially benefit from immunotherapy approaches with programmed death 1 (PD-1) or PD-ligand 1 (PD-L1) inhibition . FurtherFurther studies based on patient selection and specific biomarkers are needed, including, where possible, female GCTs . The maiAlthough female GCTs represent an extremely rare disease, the majority of patients can be cured with surgery or CDDP-based treatment. For this reason, the goal of treatments must also be to preserve fertility and reduce the risk of late adverse effects to guarantee good quality of life. Salvage therapy for MOGCT remains an unmet need, with current treatments based mainly on the results of retrospective studies. Several new drugs for this setting have been investigated in recent years, but with disappointing effects.The present review suggests that HDC is a valid therapeutic option for CDDP-resistant female GCT. However, it is clear that more effective treatments are needed in this subset of patients. In two prospective clinical trials and in major consecutive series in GCTs accepting both genders, female GCT patients represented 3–7% of the overall recruited population ,87. In tOn the basis of the rarity of the disease, new clinical trials on GCTs should include both male and female patients to provide prospective data on intensified therapeutic strategies such as HDC and/or new drugs, in particular molecular targeted therapies, for female GCTs. In this respect, the role of cooperative groups at national and international level will be crucial. Moreover, collaborative studies could be performed to validate prognostic classification systems to identify patients who are more likely to benefit from salvage HDC than from other SDC regimens. For the moment, patients with CDDP-resistant MOGCTs should undergo HDC or should be included in clinical trials, when possible. Referral of patients to centers with high expertise in this field is essential.


In-hospital stay was also longer in the NSTEMI group . ECABG for UA and NSTEMI patients showed comparable outcomes, but hs-cTnI elevation at the ED may be associated with immediate postoperative complications.High-sensitivity cardiac troponin I (hs-cTnI) is a widely used biomarker to identify ischemic chest pain in the Emergency Department (ED), but the clinical impact on emergency coronary artery bypass grafting (eCABG) remains undetermined. We aimed to evaluate the clinical impact of hs-cTnI measured at the ED by comparing outcomes of eCABG in patients with non–ST-segment–elevation acute coronary syndrome (NSTE-ACS) which comprises unstable angina (UA) and non–ST-segment–elevation myocardial infarction (NSTEMI). From January 2012 to March 2016, 242 patients undergoing eCABG were grouped according to serum hs-cTnI level in the ED. The primary endpoint was major cardiovascular cerebral event (MACCE) defined as a composite of all-cause death, myocardial infarction, repeat revascularization, and stroke. The incidence of each MACCE composite, in addition to postoperative complications such as acute kidney injury, reoperation, atrial fibrillation, and hospital stay duration were also compared. Patients were divided into two groups: UA  and NSTEMI . The incidence of MACCE did not differ between the two groups. Postoperative acute kidney injury was more frequent in the NSTEMI group after adjusting for confounding factors (6.9% vs. 23.6%; odds ratio, 2.76; 95% confidence interval, 1.09–6.99;  Serial testing of cardiac biomarkers has shown excellent diagnostic performance, and the development of high-sensitivity cardiac troponin assay has led to reclassification of NSTE-ACS2. That is, the patients with resting chest pain who were originally thought to have UA could be reclassified as having an NSTEMI1. On previous studies, the clinical significance of high-sensitivity cardiac troponin was validated among acute coronary syndrome (ACS) patients in the ED setting, and the subgroups of NSTE-ACS, classified by high-sensitivity cardiac troponin, have also shown different clinical outcomes during medical or placebo therapy4. However, current guidelines lack details on surgical coronary revascularization8.Stratifying patients with ischemic cardiac symptoms in the Emergency Department (ED) is critical but challenging. Especially, the subgroups of non–ST-segment–elevation acute coronary syndrome (NSTE-ACS) which comprises unstable angina (UA), and non–ST-segment–elevation myocardial infarction (NSTEMI) present indistinguishable clinical and electrocardiographic features, but the clinical impact of emergency coronary artery bypass grafting (eCABG) on these subgroups remains uncertain10, eCABG for ACS patients represent challenging subgroup given their high risk characteristics11. The current guidelines suggest a limited role of eCABG in the acute phase of ST-segment–elevation myocardial infarction (STEMI)8. So, understanding the clinical impact of high-sensitivity cardiac troponin on eCABG may be helpful in determining treatment strategy for NSTE-ACS patients in the ED. Therefore, we aimed to compare the postoperative outcome of eCABG among the subgroups of NSTE-ACS, classified by high-sensitivity cardiac troponin I (hs-cTnI) measured at the ED.Although the overall outcome of coronary artery bypass grafting (CABG) has significantly improved over time with well-established benefits in multi-vessel disease with complex lesionsp-value < 0.001).Among the 1,792 patients who underwent CABG from January 2012 to March 2016, 266 patients underwent eCABG, and 242 patients met inclusion criteria for analysis. The flowchart of patients is shown in Fig. p-value < 0.001), but preoperatively measured ejection fraction and hemoglobin level were significantly lower in the NSTEMI group  , but the use of aortic modulation was higher  . After adjustment, the incidence of MACCE during the overall follow-up period was not significantly different . The incidence of MACCE during one year, 30-day, or in-hospital follow-ups did not differ between the two groups. Non-inferiority test showed that mean difference of MACCE between UA and NSTEMI was –2.6% (95% CI −10.2% to 5.01%). At 5.2% of non-inferiority margin, p-value was 0.022. Survival curves for MACCE are presented in Fig. Clinical outcomes are presented in Table p-value = 0.032). Postoperative inotropic use was more frequently needed in the NSTEMI group based on univariate analysis, but it was not significant after adjustment. The durations of inotropic use, intensive care, and in-hospital stay were also longer in the NSTEMI group . Rates of other postoperative complications such as newly-developed atrial fibrillation, reoperation, or wound complications did not significantly differ between the two groups.The risk of postoperative AKI was significantly higher in the NSTEMI group  compared to the UA group, the NSTEMI group showed a higher incidence of postoperative AKI and longer durations of inotropic use, intensive care, and hospital stay after eCABG, 2) the incidence of MACCE and other complications were not significantly different between the groups. These results suggest that, in NSTE-ACS patients, hs-cTnI measured at the ED may be associated with the postoperative complications of eCABG, but the incidence of complications during long-term follow-up might not be different.st century, UA was included as a subgroup of ACS, along with NSTEMI and STEMI. UA and NSTEMI exhibit the same clinical features and have been usually considered together as NSTE-ACS, but differentiating the subgroups of NSTE-ACS has shown clinical importance in many previous studies13. Advances in the sensitivity of cardiac troponin assays resulted in reduction of URL, and led to high sensitivity but low specificity for detecting MI14. A currently available assay, with the URL reduced to 0.04 ng/ml, has not only shown clinical significance, but has also been validated in the ED setting15. Combined with clinical assessment, serial hs-cTnI testing was initially used for early exclusion of ACS in the ED17, and adopted in the accelerated diagnostic protocol for ED triage with satisfying results among patients with possible ACS19. However, guidelines for surgical coronary revascularization still lack detail.By the beginning of the 216. On the other hand, CABG in NSTE-ACS is justified in patients with extended ischemia, acute presentation of symptoms, and the ability to achieve full revascularization. Subgroups that require eCABG represent challenging and high-risk characteristics8. Modalities of revascularization in NSTE-ACS have never been directly compared in a randomized trial, but the recent American and European guidelines both suggest that, when hemodynamically stable, the modality can be chosen as if the patient had stable ischemic heart disease7. However, current guidelines do not provide an optimal timing of CABG for NSTEMI. Previous studies report that CABG is performed in 5 to 10% of patients with NSTE-ACS, and especially in NSTEMI patients one-third undergo CABG within 48 hours after hospital admission20. Although it is recommended to delay CABG for NSTEMI, recent studies report that outcomes of eCABG offer comparable results to those of staged CABG after adjusting for higher risk factors that are more likely to be shown in the patients who require eCABG21. So, up to the present it is reasonable to individualize the timing of CABG based on various factors8, and understanding the clinical impact of hs-cTnI at the ED on eCABG might be helpful. In this study, we used a current-generation assay, and performed serial testing combined with clinical assessments in accordance with current protocols19 and showed that the clinical outcome of eCABG in NSTE-ACS was not different according to the presence of myocardial ischemia. Further studies on optimal timing of CABG or modalities for coronary revascularization in NSTE-ACS patients are needed.In patients with STEMI, eCABG is strictly reserved for those with ongoing ischemia after successful or failed PCI, coronary anatomy suitable for CABG, mechanical complications of MI, or hemodynamic instability22. Our results partly correlate with previous studies showing that hs-cTnI in the ED predicts early discharge19. However, contrary to previous studies on long-term outcomes, AKI did not change the incidence of MACCE23. This may share an explanation with one showing reduced incidence of postoperative AKI by using the off-pump technique in CABG but without evidence of better preserved kidney function or improved clinical outcomes24. In our study, the off-pump technique was more frequently used in the UA group; however, it was adjusted in the multivariate model and showed no interaction in subgroup analysis. Another explanation may be the magnitude of AKI. A reduction in the inflammatory response to change long-term outcomes might have been done for too few patients in this study, because the most frequent postoperative AKI was stage 1. Also, the difference in postoperative inotropic requirements suggests that lowered cardiac output may have caused a transient creatinine elevation. Although sustainment of AKI can be differentiated by optimized postoperative care, most previous studies did not refer to it23. Also, NSTEMI group showed higher incidence of ongoing ischemic symptoms as an indication for eCABG. This is reasonable because prolonged ischemia leads to myocardial infarction even despite the absence of evidence for coronary obstruction defined as type 2 myocardial infarction25. This may also be related to not only AKI but also more inotropic use and longer duration intensive care and hospital stays in the NSTEMI group. However, the incidence of MACCE did not differ despite higher incidence of preoperative ongoing ischemic symptoms. So, our results suggest that eCABG could be performed in these patients with more caution and optimized postoperative care.The results of this study showed that the immediate complications in the NSTEMI group, in terms of AKI, were more frequent compared to patients with UA, and it resulted in prolonged duration of inotropic use, intensive care, and hospital stay. Postoperative AKI is known to be caused by hemodynamic, inflammatory, and nephrotoxic factors, and independently associated with clinical outcomes26, renal dysfunction itself can also cause hs-cTnI elevation without a coronary cause27. In addition, despite the long-term survival benefit of early CABG, even in high-risk patients, cardiac troponin level alone cannot diagnose cardiac conditions28. So, a subgroup analysis was performed to evaluate hidden interactions with AKI risk factors, and revealed no interaction with any factor.Although a significant rise or fall in serial testing of hs-cTnI maintains the high diagnostic accuracy of myocardial infarctionThe results of this study should be interpreted considering the following limitations. First, this study was not randomized; therefore, potential confounding factors might have significantly biased the results. Second, although our practice followed institutional protocol based on current guidelines, details of surgical indications for eCABG may have not been always consistent. The main indication for emergency operation was summarized based on medical record, but measurable parameters for our indications are absent. And also, conditions other than pathology such as patient consent or the schedule of operating theaters may have also been involved. In addition, patients might have undergone different treatments in the ED, and details of treatment in the ED and postoperative care may have also been updated during the study period. Third, this study does not provide any evidence for supporting eCABG in NSTE-ACS patients, and is rather focused on the effect of myocardial ischemia on eCABG. Moreover, non-inferiority of our analysis showed low statistical power because of small study population. Therefore, a following investigation is needed to change details of daily practice. Despite these limitations, this is the first study to compare outcomes of eCABG among the subgroups of NSTE-ACS classified by hs-cTnI in the ED.In eCABG for the patients presenting ongoing pain of a potential cardiac ischemia without ST elevation, UA and NSTEMI patients showed comparable outcomes, but hs-cTnI elevation at the ED was associated with immediate postoperative complications. A further study is needed to investigate optimized postoperative care.This study was a single-center study approved by the Institutional Review Board at Samsung Medical Center. From January 2012 to March 2016, 1,792 consecutive patients who underwent CABG at our institution were initially enrolled. Inclusion criteria were 1) patients who visited the ED for chest pain, 2) patients with hs-cTnI measured in the ED, and 3) patients who underwent eCABG. We excluded one patient younger than 18 years of age considering the different reference limit for hs-cTnI in pediatric patients. To exclude hs-cTnI elevation from direct manipulation of the heart, we also excluded 23 patients who underwent percutaneous coronary intervention (PCI) or cardiac massage from presentation at the ED to eCABG. Enrolled patients were grouped according to serum hs-cTnI level measured in the ED . In patients with multiple measurements, the peak level was used for stratification. The need for individual consent was waived by the Institutional Review Board, as this was a retrospective study involving medical record review. All medical data were collected by a standardized protocol, and analyzed anonymously after deidentification.Hs-cTnI is routinely used at our institution, and is measured using a highly sensitive immunoassay by an automated analyzer . All patients who presented to the ED with possible ACS underwent serial testing of hs-cTnI according to our institutional protocol. The lower limit of detection was 0.006 ng/mL, and the upper reference limit (URL), according to the 99th percentile reference, was 0.04 ng/mL. Reference limits were all provided by the manufacturer.The patients for eCABG were selected at the discretion of a surgeon and cardiologist on duty based on the current guidelines. The major indications of eCABG included 1) ongoing chest pain, (2) coronary anatomy unsuitable for PCI, and (3) ongoing or recurrent ischemia. The ongoing chest pain was defined as intractable or worsening pain. Coronary anatomy was determined as unsuitable either by cardiologists based on coronary angiogram or when PCI was attempted but failed. Ischemia was regarded as ongoing when ischemic symptoms such as pain, dyspnea or shortness of breath were accompanied by cardiac enzyme elevation, EKG change, cardiac enzyme elevation, fatal arrhythmia, heart failure or vital instability. Other indications for eCABG were other pathologic condition of the patient or schedule of operating theater. The indications of eCABG are summarized in Supplemental Table  ongoing 29. After cannulating the radial artery for real-time blood pressure monitoring during induction of general anesthesia, all patients were induced and maintained either with propofol and remifentanil or etomidate and isoflurane inhalation. The femoral artery and internal jugular vein were cannulated for direct hemodynamic monitoring. Mechanical ventilation using a mixture of medical air and oxygen was set at a tidal volume of 8–10 ml/kg, and the respiratory rate was adjusted to maintain normocapnea. Crystalloids and colloids were infused in response to hemodynamic changes.Details of anesthetic techniques have been previously described elsewhere25. Stroke was defined as a new ischemic or hemorrhagic lesion causing a neurological deficit lasting longer than 24 hours. The secondary outcomes included MACCE, postoperative acute kidney injury (AKI), newly-developed atrial fibrillation, reoperation, postoperative inotropic treatment, and wound complications during the hospital stay. The durations of inotropic use, intensive care, and hospital stay were also compared. Postoperative AKI was defined based on the Kidney Disease Improving Global Outcomes criteria using creatinine level. An absolute increase more than 0.3 mg/dl or a relative increase more than 50% from preoperative baseline level was definitive for AKI30.ECABG was defined as a procedure performed within 48 hours after presentation at the ED. The primary outcome was major adverse cardiovascular and cerebral events (MACCE), which was defined as a composite of all-cause mortality, myocardial infarction (MI), repeat revascularization, and stroke. MI was defined according to the third universal definition of clinically relevant MIPast medical history was organized by reviewing the electronic medical records. Hypertension was self-reported or prescription of anti-hypertensives or systolic blood pressure >140 mm Hg at rest. Diabetes mellitus was defined as a history of treatment such as medication and lifestyle intervention or diagnosis of type 1 or type 2 diabetes mellitus. The history of stroke was defined as a history of neurological function loss caused by an ischemic or hemorrhagic event with residual symptoms at least 24 h after onset. Chronic kidney disease was defined as any condition with gradual loss of kidney function with serum creatinine level consistently over 2.0 mg/dl or being on dialysis. Anemia was defined as a hemoglobin level less than 13 g/dL in men and less than 12 g/dL in women.p-value < 0.15 were used in the multivariable model. We performed multiple Cox (MACCE) or logistic regression  analysis and hazard ratios (HR) or odds ratios (OR) are reported with 95% confidence intervals (CI). For Cox regression analysis, the time-to-event period was calculated as months. The power of an equivalence test for the difference between the groups was calculated using the non-inferiority margin . To further adjust the difference between the two groups, we performed subgroup analysis to reveal hidden interactions between postoperative AKI and variables such as male, chronic kidney disease, previous PCI, ejection fraction <40%, aortic modulation, off-pump technique, preoperative anemia.For continuous variables, the Student’s t-test or Mann-Whitney test was used, and the results were presented as mean ± standard deviation (SD). Chi-square or Fisher’s exact test was used to compare categorical data. Kaplan-Meier estimates were used to generate survival curves which were compared with the log-rank test. Covariates with a All statistical analyses were performed using SPSS 20.0 . All tests were two-tailed and p-values < 0.05 were considered statistically significant.Supplemental Table 1


HIV and TB programs have rapidly scaled-up over the past decade in Sub-Saharan Africa and uninterrupted supplies of those medicines are critical to their success. However, estimates of stock-outs are largely unknown. This survey aimed to estimate the extent of stock-outs of antiretroviral and TB medicines in public health facilities across South Africa, which has the world’s largest antiretroviral treatment (ART) program and a rising multidrug-resistant TB epidemic.We conducted a cross-sectional telephonic survey (October—December 2015) of public health facilities. Facilities were asked about the prevalence of stock-outs on the day of the survey and in the preceding three months, their duration and impact.Nationwide, of 3547 eligible health facilities, 79% (2804) could be reached telephonically. 88% (2463) participated and 4% (93) were excluded as they did not provide ART or TB treatment. Of the 2370 included facilities, 20% (485) reported a stock-out of at least 1 ARV and/or TB-related medicine on the day of contact and 36% (864) during the three months prior to contact, ranging from 74% (163/220) of health facilities in Mpumalanga to 12% (32/261) in the Western Cape province. These 864 facilities reported 1475 individual stock-outs, with one to fourteen different medicines out of stock per facility. Information on impact was provided in 98% (1449/1475) of stock-outs: 25% (366) resulted in a high impact outcome, where patients left the facility without medicine or were provided with an incomplete regimen. Of the 757 stock-outs that were resolved 70% (527) lasted longer than one month.There was a high prevalence of stock-outs nationwide. Large interprovincial differences in stock-out occurrence, duration, and impact suggest differences in provincial ability to prevent, mitigate and cope within the same framework. End-user monitoring of the supply chain by patients and civil society has the potential to increase transparency and complement public sector monitoring systems. In recent years, health programs in Sub-Saharan Africa rapidly scaled up access to HIV and tuberculosis (TB) treatment. South Africa has the highest number of people living with HIV, the highest incidence of TB worldwide, a rising epidemic of multidrug resistant (MDR) TB and the world’s largest antiretroviral treatment (ART) program . ExpansiStock-outs are defined by the WHO as the complete absence of a required medicine for at least one day at a storage or delivery point . A stockIn South Africa, stock-outs have been reported throughout the years –19. The st and December 11th 2015. At each facility, one staff member was invited to respond in the following order of preference: pharmacist, pharmacy assistant, person who orders the medicine, nurse-in-charge or nurse. Participants provided verbal informed consent. Risk to participants was minimized by anonymizing participant and facility name, and aggregating results to the provincial and national levels.We conducted a cross-sectional telephonic survey of all health facilities in the South African public sector, identified from the national District Health Information Database (DHIS 2), between October 1Data was collected through a previously piloted standard questionnaire by trained research assistants and recorded in an electronic database. Participants were asked to provide the name of each ARV and TB-related medicine that was out of stock on the day of contact and any additional stock-out experienced by the facility in the three-month period prior to contact. Respondents were asked to report (i) the duration of stock-outs, (ii) the resulting action of the facility and (iii) the quantity of medicines the patient received as compared to standard of care. Responses were subsequently categorized . DuratioA “stock-out” was defined as the complete absence of a specific formulation and/or dosage of medicine at a given facility. Stock-outs “on the day of contact” were defined as occurring on the day the facility responded. Those “occurring in the three-month period prior to contact” were defined as occurring on the day of contact or the ninety days prior. Each stock-out was classified as having a high, medium or low impact on patients based on the action of the facility and the supply given to the patient . A site We conducted a validation sub-study to determine the reliability of the measures in a random sample of facilities (n = 159). These facilities were surveyed twice on the same day, with two different participants providing answers to the same questions. Specifically, both participants were asked “Today do you have an ARV or TB medicine unavailable?” When it was not possible to reach a second participant on the same day, the second participant was surveyed on the following day.Statistical analyses were performed using Stata 13.0. Means and medians were calculated using respondents for the question of interest as the denominator. We conducted standard descriptive statistics to compare across strata of interest. We used t-tests to compare continuous variables, and either chi-square or Fisher’s exact tests to compare categorical variables. We assessed ordinal variables using Wilcoxon Rank-Sum test. For the purpose of validating our measures we used the kappa coefficient as a measure of agreement between the responses by the first and second participant from validation sites.Ethical approval was granted from the Human Research Ethics Committee of the University of Cape Town (624/2015) and the Ethics Review Board of Médecins Sans Frontières (1548). As this was a telephonic study, no written consent was obtained. Facility representatives were asked to provide oral informed consent to participate as a respondent before answering the survey questionnaire which was manually recorded in the electronic database. The verbal consent procedure was approved by both ethical boards.A total of 3547 facilities were identified as eligible for inclusion; 79% 2804) could be reached telephonically, of which 88% (2463) participated in the study; 4% (93) did not provide ARV or TB treatment and are not included in this analysis Figs  and 2. 9804 couldNationwide, 20% (485/2370) of facilities reported a stock-out on the day of contact and 36% (864/2370) reported at least 1 ARV and/or TB-related medicines stock-out during the three months prior to contact, ranging from 74% (163/220) in Mpumalanga province to 12% (32/261) in the Western Cape province .In the three months prior to contact, there was a stock-out of at least one: adult first-line ARV in 11% (264/2370), adult second-line ARV in 15% (353/2370), less commonly used ARV in 11% (267/2370), pediatric ARV in 9% (209/2370), TB-related medicines in 4% (84/2370) and nevirapine syrup in 1% (25/2370) of facilities .A total of 1475 single medicine stock-outs were reported  across 3Of 1082 stock-outs of adult ARVs, 29% (315) were first-line ARVs, 41% (449) second-line ARVs and 29% (315) were less commonly used ARVs. The main driver of second-line ARV stock-outs was a national shortage of adult LPV/r making up 77% (348/449) of second-line adult ARV stock-outs and accounting for 24% (348/1475) of stock-outs overall. Stock-outs of adult abacavir (ABC) were reported in 19% (278) of instances. ABC could have been used to substitute for LPV/r in some cases during shortages, and contributed to stock-outs of less commonly used ARVs.Respondents reported that of 757 stock-outs that had been resolved, 8% (63) lasted less than a week, 22% (167) between one and four weeks and 70% (527) longer than one month . There wInformation on impact of the stock-out was provided in 98% (1449/1475) of stock-outs. In 25% (366/1449) of cases, patients left the facility without any treatment or were provided with an incomplete treatment regimen (high impact); 39% (561/1449) had a medium impact and 36% (522/1449) had a low impact .Of 2370 facilities nationwide, 10% (242) reported at least 1 high impact, 15% (366) at least 1 medium impact and 16% (374) at least one low impact stock-out.Of the 159/2463 (7%) facilities randomly selected for the validation study, 90% (143/159) responded. Validation participants provided the same answer as the primary participant 94% of the time, suggesting near perfect agreement between the results reported by the different participants (Kappa coefficient = 0.84)This is, to our knowledge, the first national stock-out survey conducted in a resource-limited setting. Results show that stock-outs of HIV and TB medicines were widespread in South Africa. Nationally, more than one third of health facilities had a stock-out of ARV and/or TB medicines in the three months preceding the survey; a quarter of these stock-outs had a high impact on patients, who left the facility without or with an insufficient quantity of medicines. One fifth of facilities had a stock-out on the day they were contacted.A national stock-out of adult LPV/r caused one quarter of facility stock-outs, particularly contributing to stock-outs in the provinces of Gauteng and Free State. Supply fragility due to a single international supplier contributed to this specific stock-out. All other HIV and TB-related medicines reported out of stock were available in-country, indicating downstream deficiencies.Regardless of the cause, large interprovincial differences remained in stock-out occurrence, duration and impact, suggesting differences in provincial ability to prevent, mitigate and cope within the same national framework. The long duration of existing stock-outs indicates the lack of end-level visibility and mitigation mechanisms to alert and solve stock-outs when they occur. A national telephonic survey can be used as an inexpensive tool to rapidly assess supply in facilities or audit existing monitoring systems.Consequences of ART and TB stock-outs are ultimately borne by patients, putting them at risk of treatment interruption or discontinuation, catastrophic expenditure ,15, treaStock-outs of adult ARVs were most common (74%), fueled by stock-outs of LPV/r and ARVs used for its substitution. Only 4% of stock-outs were of the fixed-dose combination (FDC) of TDF/3TC/EFV used as first line ART for the majority of patients on HIV treatment. Stock-outs were more frequent of alternative ARVs used for a smaller group of more vulnerable patients, such as those with contraindications or drug resistance.Stock-outs are reported to be widespread in other countries in sub-Saharan Africa, with proportion of months with ART stock-outs higher in Africa than other continents. Data from WHO show that in 1703 clinics in 35 countries, 35.7% had an ART stock-out over a one-year period between 2005 and 2014 . ClinicsThis study has several strengths and limitations. Only 79% of South African public health facilities were contactable. Poorly functioning facilities may be less likely to be contactable and more likely to have stock-outs leading to underestimation of stock-outs. A strength of the survey was the high response rate of contactable facilities. While pharmacists were the preferred respondent, there was a high proportion of nurses-in-charge and nurses, who might be less aware of stock-outs. In turn, non-clinicians like pharmacists might be less aware than clinicians of prescriptions changes in response to stock-outs. Respondents may also be less likely to recall stock-outs which happened in the more distant past than those which are current. These limitations might lead to underestimation of the number of stock-outs. Similarly, individual recall of duration of stock-outs is prone to error and should be treated with caution. Finally, this survey is not able to provide the number of patients leaving facilities without medication.In May 2016, WHO member states passed a resolution at the World Health Assembly to address medicine shortages with specific requests to the Director General to assess the magnitude and nature of the problem, recognizing the urgency of the situation . This stWhile South Africa has made great strides to extend access to ART as well as increase the quality of the services it provides patients, stock-outs hamper these efforts. The introduction of universal test and treat for HIV means that an increasing number of people need uninterrupted supplies of chronic medication. Differentiated models of care through the dispensing and distribution of medical supplies outside health facilities reduce congestion while also providing patients with more options for prescription refills closer to their homes . HoweverTransparency is essential in a publicly funded supply chain and civilians or their representatives should hold the system accountable and report challenges , 32. SupS1 Appendix(PDF)Click here for additional data file.S1 Dataset(XLSX)Click here for additional data file.S1 TableHIV Medicines: 3TC–Lamivudine; ABC–Abacavir; AZT–Zidovudine; ATV–Atazanavir; ddI–Didanosine; DRV–Darunavir; d4T –Stavudine; EFV–Efavirenz; FTC–Emtricitabine; FDC–Fixed-Dose Combination of TDF, FTC and EFV; LPV–Lopinavir; NVP– Nevirapine; RTV or /r–Ritonavir; TDF–Tenofovir. TB Related Medicines: IPT–Isoniazid Preventive Therapy; R/H–Rifampicin/Isoniazid; RHZE–Rifampicin/Isoniazid /Pyrazinamide/Ethambutol; E–Ethambutol; ETO–Ethionamide; INH–Isoniazid (for preventive therapy); Km–Kanamycin; Lvx–Levofloxacin; R–Rifampicin; Z–Pyrazinamide; Vit B6 –Vitamin B6 or pyridoxine. * Medicines prescribed as first-choice treatment for the large majority of the patient cohort with no demonstrated resistance to ARVs, were classified as “first-line ARVs.” ** ARVs prescribed for the majority of patients who demonstrated resistance to first-line ARVs were classified as “second-line ARVs”. *** ARVs used for patients who experienced side-effects or resistance to the most frequently used first- and second-line treatment were classified as “ARVs for exceptional cases”. **** All medicines for which the formulation and/or dosage has been adapted for administration to children were classified as paediatric ARVs. These adaptions allow for the variation in children’s weights and ability to swallow pills. ***** For this analysis, only NVP solution for children was classified as an ARV for PMTCT, as it is primarily used in infants of HIV-positive mothers.(DOCX)Click here for additional data file.


Cardiovascular disease is an important cause of morbidity and mortality in people living with HIV (PLWH), who commonly experience lipid disturbances. The aim of this study was to determine whether the plasma lipidomic profile differs between PLWH receiving a darunavir-based ART and those receiving integrase inhibitor-based ART. This was a cross-sectional study of unselected patients for whom metabolomic analysis was performed using ultra-high-performance liquid chromatography coupled to mass spectrometry. Data for the two subgroups were compared by calculating the log2 of the fold change for each metabolite and then grouping these into the main lipid families. Sixty-two PLWH aged 49.3 ± 8.6 years (82% men) were included: 12 patients (19.4%) had hypertension, 8 (12.9%) had type 2 diabetes, 25 (41.0%) had dyslipidaemia and 9 (14.5%) were taking statins, without significant differences in all these variables between the two groups. Twenty-five (40.3%) received darunavir-based ART and 37 (59.7%) integrase inhibitor-based ART. Although the differences were not statistically significant, patients treated with darunavir-based ART had higher concentrations of total cholesterol (211 mg/dL vs 194 mg/dL), LDL-cholesterol (132 mg/dL vs 117 mg/dL) and triglycerides (155 mg/dL vs 122 mg/dL), and lower HDL-cholesterol concentration (50 mg/dL vs 52 mg/dL). The main lipid families and metabolites differed slightly between groups : ceramides , phosphatidylinositols , diacylglycerols , phosphatidylethanolamines , triacylglycerols  and lysophosphatidylethanolamines . In the integrase inhibitor-based group, the use of tenofovir alafenamide fumarate significantly increases the majority of lipid fractions, when compared with tenofovir disoproxil fumarate. The lipidomic profile did not differ between PLWH treated with darunavir-based or integrase inhibitor-based ART. This was especially true for ceramides, which are involved in cardiovascular disease. Further studies are needed to study the impact of ART in lipidomic profile. ART-induced dyslipidaemia is characterized by a reduction in HDL-cholesterol and an increase in LDL-cholesterol, total cholesterol and triglyceride concentrations4. These parameters are incorporated in most of the equations used to estimate CV risk, even though these scores can underestimate the risk in PLWH5.Dyslipidaemia is associated with increased risk of CV diseases in PLWH7. Ceramides have also been implicated in cell senescence and apoptosis8. PLWH exhibit several differences in the plasma lipid profile compared with healthy people not infected with HIV. These include increase levels of some metabolites such as diacylglycerols and reduced level of others such as sphingomyelin. However, little is known about the effects of ART on plasma lipidomic profile9.Some molecular lipid species, especially ceramides, are involved in many central processes involved in the development of atherosclerosis and are significant predictors of CV death in HIV-uninfected patients with and without established CV diseases10. The aim of this study was to determine whether the plasma lipidomic profiles differ between PLWH receiving a darunavir-based ART and those receiving an integrase inhibitor-based ART.Classically, protease inhibitors were associated with a worse lipid profile than are integrase inhibitors, as measured by the differences in the concentrations of cholesterol and triglycerides. However, these differences are smaller with modern protease inhibitors such as darunavir, especially when boosted with cobicistat instead of ritonavir11. It was reviewed and approved by the Regional Ethics Committee of Galicia (register code 2016/423). All participants provided written informed consent. A database was created, and all data were anonymized before analysis.The research protocol was conducted in accordance with the Declaration of Helsinki and the STROBE StatementThis was a cross-sectional study of consecutive PLWH who attended a mono-centric HIV unit. In this unit, approximately 1380 PLWH with stable ART are followed. Of them, 29% received a darunavir-based regimen and 43% an integrase inhibitor-based ART. Participants were included if they were being treated with a darunavir-based or an integrase inhibitor-based ART, for at least six months, were older than 18 years old, and signed the informed consent. The exclusion criteria were: pregnant women and people with an active AIDS-defining condition or an active cancer.Demographic data, CV risk factors and HIV characteristics  were collected. Blood samples were obtained under fasting conditions of at least 8 hours, processed and frozen at −80 °C. Participants were included in the study between January and March 2017.11. Briefly, two separate UHPLC-time of flight-MS-based platforms to analyse the methanol and chloroform–methanol serum extracts were used. A specific metabolite extraction procedure was performed for each platform. Identified ion features in the methanol-extraction platform included fatty acids, bile acids, monoacylglycerol phospholipids, monoether glycerol phospholipids, and free sphingoid bases. The chloroform–methanol extraction platform provided coverage over glycerolipids, cholesterol esters, sphingolipids, diacylglycerophospholipids, and acyl-ether-glycerophospholipids. The lipid nomenclature and classification follow the LIPID MAPS convention (www.lipidmaps.org). Metabolite extraction procedures, chromatographic separation conditions and mass spectrometric detection conditions have been detailed previously12. Metabolomics data were pre-processed using the TargetLynx application manager . Intra-batch  and inter-batch  data normalization was performed as described by Martínez-Arranz13.Serum metabolic profiles were semi-quantified using ultra-high-performance liquid chromatography coupled to mass spectrometry (UHPLC-MS) as described previouslyP-values obtained using Student’s t test. All calculations were performed using R statistical software package .Univariate analyses were performed on metabolomic-normalized data. For each metabolite, differences between subgroups were calculated as the base 2 logarithm of the fold-change. The bootstrapping method involving 1000 repetitions, each with 80% of the samples for each study group, was used to obtain a relatively unbiased estimate of fold changes and 95% confidence intervals. These values were accompanied by a significance level based on P-value = 0.90). The main characteristics of the study population are shown in Table A total of 62 PLWH were included in the study: 25 (40.3%) were receiving a darunavir-based ART  and 37 (59.7%) an integrase inhibitor-based ART. The number of patients included in each group represents in both cases just over 6% of the total of patients taking that ART. The average duration of the current therapy was 5 ± 3 years in the darunavir-based group and 4 ± 3 years in the integrase inhibitor-based : ceramides , phosphatidylinositols , diacylglycerols , phosphatidylethanolamines , triacylglycerols  and lysophosphatidylethanolamines . To compare the results visually, log2-fold changes and significance levels were used to create detailed heatmaps. Supplementary Table All lipid panels were compared between patients receiving darunavir-based therapy vs integrase inhibitor-based ART. The main lipid families and metabolites differed slightly between groups  in asymptomatic PLWH; this finding is consistent with data from studies is in HIV-uninfected people9. These data suggest a potential use of plasma ceramides as markers of CV risk. Measurement of ceramide level may be of particular interest in PLWH, whose CV risk scores based on traditional markers underestimate their risk.HIV infection causes substantial inflammatory dysregulation that affects lipid metabolism and causes both qualitative and quantitative changes in several metabolites. Ceramides are associated with lipoprotein aggregation, inflammation, reactive oxygen species production and apoptosis, and seem to be an intermediate link between over-nutrition and some abnormalities related to CV risk such as insulin resistance and metabolic syndrome18. In this study, we found no differences in the levels of ceramides or other families that can affect CV risk, such as phosphatidylethanolamines, phosphatidylinositols, cholesteryl esters or diacylglycerols. In the study by Wong et al., all of these lipid families were associated with future CV events in PLWH (ORs 3 to 6)9. Recently, an interesting study has analysed the role of ceramides in the progression of the carotid artery atherosclerosis in PLWH. Zhao et al. communicated a good correlation between plasma levels of C16:0 and C24:1 ceramides and immune activation and inflammation. In their data, elevated ceramide levels were associated with antiretroviral therapy use, particularly with the PIs use. We do not find differences in ceramides between the darunavir/cobicistat-based and the integrase inhibitor-based groups. Probably, in the study of Zhao, there were patients taking PIs older than darunavir/cobicistat, which are already known to have a worse lipid profile17.Elevated cholesterol and triglyceride levels play an unquestionable role in CV disease. However, even after controlling these levels, there remains a residual risk that other mediators cannot change. Most of the ARTs currently used in developed countries have a minor effect on cholesterol fractions and triglycerides, but further data are needed on the entire plasma lipidomic profile to provide complete information. Darunavir/cobicistat increases cholesterol and triglyceride levels in both treatment-naive and pretreated PLWH above those observed with an integrase inhibitor-based regimen; these differences are usually statistically significant but clinically have little relevanceTenofovir disoproxil fumarate has some lipid-lowering properties, which are lost when tenofovir alafenamide fumarate is used; this has been shown by measuring fractions of cholesterol and triglycerides. In our data, despite the limitation of the sample size, patients taking tenofovir alafenamide fumarate  had a worse lipid profile, when compared with tenofovir disoproxil fumarate and quantitatively worse than those who take a darunavir-based treatment, in the mail lipid metabolites. We hypothesized that, perhaps in the future, the backbone therapy is as important (or more) than the third agent, in the development of metabolic disturbances. Further studies must focus in this issue.20. Dietary interventions, specifically the Mediterranean diet, are effective in mitigating the deleterious effects of ceramides on CV risk, as shown by a recent report from the PREDIMED Trial7. In our study, few patients were taking statins (14.5%), despite the higher prevalence of dyslipidaemia (41%). This under-treatment of dyslipidaemia in these PLWH has been noted previously and seems to be explained by the low prescription rate and low adherence to lipid-lowering drugs21. Some investigators have hypothesized that statins are beneficial in PLWH with elevated CV risk regardless of their cholesterol levels. More studies of the levels of ceramides and other proatherogenic metabolites in PLWH will help to answer this question. The role of dietary interventions is especially interesting in PLWH and should be examined in future studies.Lipid-lowering therapies seem to have a beneficial effect on the global lipid composition, although few studies have reported this findingThere are some limitations to this study. First, the small sample size limited the statistical power and did not allow us to analyse the interactions of different variables, especially the role of the different backbone therapies. Even though the groups were homogeneous, some bias was possible. This study has been designed as a proof of concept, so a sample size calculation has not been performed. The low proportion of women (<20%) limits the validity of our findings for women, and further studies are required. It was not possible to analyse specifically the role of lipid-lowering therapies in PLWH, and dietary data were not collected. The inclusion of a HIV-uninfected group as a control could potentially have helped to analyse the specific role of HIV infection in lipid disturbances. We did not include patients taking tenofovir alafenamide fumarate in the darunavir/cobicistat group, which would be desirable for a better analysis of the impact of tenofovir alafenamide fumarate on lipid disturbances.In conclusion, we found no differences in the lipidomic profile, especially for ceramides, between patients treated with darunavir-based and those treated with an integrase inhibitor-based ART. To understand CV disease better in PLWH, especially the role of dyslipidaemia, further studies are needed to clarify the importance of multiple factors such as genetics, modifiable risk factors, diet, inflammation and senescence in addition to the role of ART exposure.Supplementary Table S1 and S2


Previous literatures revealed that homeostasis model assessment-estimated insulin resistance (HOMA-IR) was one of the cardio-metabolic risk factors. This study was conducted to access the association between HOMA-IR and frailty in the United States of America (U.S.) middle-aged and elderly high-risk insulin-resistant population. In the National Health and Nutrition Examination Survey (NHANES III) from 1988 to 1994, the study included 3,893 participants. In order to exam the association between HOMA-IR and frailty in the middle-aged and elderly population through the regression model adjusted for multiple covariates, we divided the participants into middle aged group (Age <65 years) and elderly group (Age > = 65 years) in this study. Each group was then divided into tertiles depending on their HOMA-IR levels. Higher level of HOMA-IR was significantly associated with frailty in the elderly group, but this association was not seen in the middle-aged population. These results demonstrated that the HOMA-IR level can be a novel risk assessment of frailty in elderly high-risk insulin-resistant individuals (Age > = 65 years). The prevalence of frailty is getting higher in the aging society5. Among individuals with diabetes and other chronic comorbidities, frailty is even more widespread. Due to its serious consequences, numerous studies aiming to identify biological markers for preventing the onset of frailty had been conducted and several human biomarkers, such as C-reactive protein (CRP), interleukin (IL)-6, tumor necrosis factor-alpha (TNF-α), transferrin, fibrinogen, serum total bilirubin levels, serum uric acid concentrations, serum 25(OH)D concentrations, serum triglycerides levels, etc., had been identified to be associated with frailty11.Frailty, a preventable geriatric syndrome, is a state of decline in physical function and decreased ability to deal with acute stress, which will lead to major adverse health events, including falls, disability, hospitalization, and deathet al.9 found that frailty syndrome was positively associated with IR, but the difference between middle-aged and elderly subgroup was still unknown. To further explore these questions, we enrolled high-risk insulin-resistant population and then divided the participants into middle-aged (age <65 years) and elderly groups (age >=65 years) and investigated the relationship between HOMA-IR and frailty from the third National Health and Nutrition Evaluation Survey (NHANES III) data in the United States of America (U.S.).Homeostasis model assessment-estimated insulin resistance (HOMA-IR) is a more convenient quantification tool for insulin resistance, compared with the gold standard hyperinsulinemic euglycemic clamp method. Several previous researches also used this tool to estimate the occurrence of frailty. Barzilay, J.I., A total of 3,893 adults in the NHANES III database were included in this study. Table Among the elderly population (Age >=65 years), age, BMI, serum high-density lipoprotein (HDL) levels, serum total protein levels, serum insulin and HOMA-IR levels were significantly greater in the frailty group. However, diastolic blood pressure, serum total bilirubin levels were lower in the frailty group. There were fewer non-Hispanic white, fewer smoker, fewer physical activities, but more stroke, and diabetes mellitus in the frailty group.Positive associations between HOMA-IR tertiles and the risk of frailty were observed in elderly adults (Age > = 65 years) as shown in Table However, the association between HOMA-IR tertiles and the risk of frailty in the middle-aged (Age <65 years) group all showed statistically insignificant. The p-values for the trend among middle-aged group were 0.081 in model 1 and 0.296, 0.332, 0.304 in model 2, model 3, and model 4, respectively.With regard to frailty components associated with HOMA-IR tertiles Table , there wIn the non-institutionalized U.S. high-risk insulin-resistant population, we investigated the relationship between HOMA-IR level and frailty. No previous study had comprehensively evaluated the link between HOMA-IR level and frailty in US middle-aged and elderly participants. The most remarkable finding was a positive correlation between HOMA-IR level and frailty in elderly adults. However, we did not find such association among the middle-aged group.12. One previous study showed the predictive value of HOMA-IR on habitual gait speed, one of the domains of frailty13. Furthermore, Joshua I. Barzilay et al.9 also reported that frailty syndrome was positively associated with IR, but the difference between middle-aged and elderly population was not analyzed.Frailty is a dynamic state affecting an individual who experiences accelerated decline in several domains of homeostatic mechanisms et al. found that frailty adults had higher plasma concentrations in inflammatory markers such as transferrin, fibrinogen, and IL-611. A meta-analysis also demonstrated that in frail participants dwelling in the community, the CRP and IL-6 levels were significantly higher than the non-frail population14. Chronic inflammation leads to increased IR and muscle dysfunction, subsequently results in frailty syndrome in elderly adults15.The physiopathology of frailty syndrome is multifactorial and includes nutritional, physical and hormonal elements. The first possible mechanism is that chronic low-grade inflammation, and oxidative status has an effect on frailty syndrome. Darvin, K. 18. Lower muscle mass also results in poorer blood glucose control through lower peripheral glucose uptake by skeletal muscle and this will cause hyperinsulinemia status and insulin resistance16. The crosstalk interaction increases frailty incidence.Another possible mechanism is that the decline in insulin sensitivity causes a defect in muscle mass catabolism and muscle quality, resulting in sarcopenia and loss of strength19. The increase of IR causes loss of muscle mass, resulting in the defect of myokines. Accordingly, the virtuous cycle of IR and sarcopenia may subsequently result in impaired body energy regulation and performance, and increase the frailty incidence. Other studies21 had also highlighted that three major circulating hormones were decreased in ageing body, including insulin-like growth factor-1(IGF-1), sex hormone, dehydroepiandrosterone and dehydroepiandrosterone sulfate production. IGH-1 can improve insulin sensitivity mediated through skeletal muscle and the deficiency of the IGF-1 actions cause to insulin resistance23. These hormones changes are considered to cause frailty in elderly people.The alternative explanation may be the endocrine theory. Muscle mass is thought to be a metabolic tissue and endocrine organ, and several endocrines are released from muscle mass, called myokines. These myokines can increase insulin sensitivity, elevate mitochondrial activity and modulate body composition, such as playing an anabolic effect on skeletal muscle, and decreasing muscle protein degradation24. The elderly people may have poorer nutritional status than younger population and poor nutrition can also be a mediating factor to frailty3. Furthermore, anemia is more frequently observed in aging population and the etiologies are often associated with the presence of chronic diseases through several pathway25. Anemia can contribute to functional decline by means of the restriction of oxygen delivery to muscle, and some vital organ, such as brain. Anemia can be a risk factor to the frailty syndrome and even be an independent risk factor in community-dwelling elderly women28. The elderly people who have overlapping comorbidities are more frequent than middle-aged and the contribution of subclinical diseases may be associated to increase the incidence of frailty29.A cross-sectional study researched the relationship between cumulative physiological dysfunction in six different systems and frailty , which reported three or more systems dysfunction were able to predict frailty, independent of age and comorbidity31 independent of coronary artery disease32. In advanced stage of heart failure, the cardiomyocytes are reversed to fetal form and the use of glucose as a fuel is increased instead of free fatty acids33. Impairment in glucose use and higher fasting insulin level during insulin resistance status will result in heart failure due to energy starvation. Several evidence also implicated that insulin resistance accompanied with hyperinsulinemia was a predictor of cancers35. Insulin has effects on cell proliferation, and may promote cancer through this mechanism36. In addition, loss of lean muscle mass and alteration in body adipose tissue are frequently found in cancer cachexia. The cachexia associated metabolic derangements will promote pro-inflammatory status and insulin resistance37. Further evidence also showed that insulin resistance was an independent and significant risk factor for ischemic stroke through enhancing platelet aggregation and atherosclerosis change40. In our study, we had excluded the participants who had congestive heart failure, cancer, and asthma, because these diseases may directly contribute to frailty, instead of owing to insulin resistance pathway.Several cross interactions between insulin resistance, certain systemic diseases, and frailty deserve to be mentioned. Insulin resistance is positively associated with the development of heart failure41. Emerging evidence supported the anti-inflammatory and antioxidant effects of serum total bilirubin43 and reported that serum total bilirubin was inversely associated with likelihood of functional dependence in elderly adults44. Functional impairment and frailty are closely associated with lower HDL level45. In contrast to previous evidence, the HDL level was higher in our frailty group of elderly population. The possible explanation was the benefits of higher HDL level may be overtaken by other comorbidities in our frailty group of elderly population.Some characteristic differences between non-frailty and frailty group in the elderly population showed statistically significant in our study. The lower total bilirubin level and higher HDL level in the frailty group of elderly population were worthy of being discussed. The pathophysiology of frailty is a complex interaction involved oxidative stress and inflammationThis study had several potential limitations. Firstly, the sample size of middle aged individuals was relatively smaller to elderly group, which may have caused some biases. We will continue to expand the sample size of middle aged individuals to study the relationship of HOMA-IR and frailty. Secondly, the study using NHANES III database was a cross-sectional study, that cannot determine the causality between HOMA-IR level and increased risk of frailty. Only prospective study can overcome this limitation. Thirdly, there may be some comorbidities in participants that limited their human functions and some drugs which can contribute to frailty and insulin resistance we didn’t adjust. Although we had adjusted multiple potential confounding variables, it’s difficult to adjust comprehensively due to limited by data available in the NHANES. Fourthly, recall bias is the inherited limitation of cross-sectional studies, and may not represent real conditions among the participants.In conclusion, this study demonstrated that in the U.S. high-risk insulin-resistant population, HOMA-IR level can have good predictive ability of frailty in elderly population.The data were obtained from NHANES III of the U.S. non-institutionalized population, from 1988 to 1994, who underwent comprehensive household interview and health examination performed at a mobile examination center. A total of 3,893 participants with aged 40–90 years were enrolled in this cross-sectional study. The examined data in NHANES III included several contents: demographic data, extensive household interview , physical examination, blood sampling, anthropometric measurement, and body-composition assessment. Written informed consents of all participants were obtained before beginning.46. We separated all participants into two groups based on age: age <65 years (middle-aged group), age >=65 years (elderly group). Each group was then categorized into three tertiles according to their HOMA-IR level. The tertiles were as follows: T1 (0.34–1.75), T2 (1.76–3.09), T3 (3.10–16.17) in the middle-aged group and T1 (0.30–1.80), T2 (1.81–3.08), T3 (3.09–16.23) in the elderly group.HOMA-IR index was estimated using the following formula: HOMA-IR = [fasting serum insulin (mU/L) × fasting plasma glucose (mmol/L)]/22.5et al.3. We followed the definition and modified the criteria for application to NHANES III data. The main modifications of frailty were that the nutritional status was based on low BMI instead of weight loss in the preceding months, and weakness/ Low physical activity were self-reported, not measured by direct assessment of grip strength and physical activity.Frailty was defined based on the previously validated frailty criteria originally reported by Fried 2 was defined as low body weight.The five modified domains of frailty criteria were as follows: (a) slow walking was defined as in the 8 foot walking speed test, participants within the worst quintile adjusted for sex; (b) weakness, defined as present if participants were asked the question “How much difficulty you have while lifting or carrying something as heavy as 10 pounds“, they responded this question as some difficulty, much difficulty, or unable to do it; (c) exhaustion, defined as present if participants had the answer as some difficulty, much difficulty, or unable to do it to the question “How much difficulty you have while walking from one room to the other on the same level?”; (d) low physical activity, defined as present if participants answered less active to the question “When compared to most men/women of your age, would you say that you are more active, less active or about the same?”; (e) BMI less than 18 kg/mParticipants who met 3 or more of 5 domains were considered as frailty. We dichotomized all participants into “frailty group” (3 or more frailty criteria) and “non-frailty group” (0–2 frailty criteria) for the purposes of our analyses.Questionnaire information that may act as potential confounders independently to the outcome included age, sex, race/ethnicity, medical conditions , smoking status, and physical activity. Self-reported race/ethnicity was separated into non-Hispanic white and others. Smoking status was obtained during the interview and was categorized into smokers and non-smokers. Chronic disease, such as stroke was ascertained from self-reports. Diabetes mellitus was defined if they had been diagnosed by a doctor, or using anti-diabetic drugs , or random serum glucose level ≥200 mg/dL, or the fasting glucose level was ≥126 mg/dL.Systolic and diastolic blood pressure were measured three times at 1–2 min intervals and to get the average of these readings after the participant seated for 5 min using a mercury sphygmomanometer with an appropriate sized cuff. Weight and height were measured in standardized conditions, and were used to calculate BMI as weight in kilogram divided by squared height in meters. The serum biochemical profiles analyses were performed in standard protocols and the documented accuracy was approved by the Centre for Disease Control and Prevention (CDC). All detailed information about standardized protocols was available on the NHANES website.The following physical activity questionnaires were collected: which and how frequently they got involved in leisure time physical activities during the past month. The physical activities included riding a bicycle, swimming, jogging or running ≥1 mile), weight training and yard work. Metabolic equivalent tasks (METs), the ratio of the metabolic rate during the activity to the basal metabolic rate were used as a means of expressing the energy cost of physical activities among persons of different weight. We measured the energy expenditure in physical activity using the summary of METs and participants were further classified as ideal and non-ideal group in Table  mile, weStatistical Product and Service Solutions (SPSS) version 18  were used for all data management. Characteristics of the study population were calculated according to the survey design. Continuous variables were presented as mean value and standard deviations (SD), and qualitative variables were presented as numbers with percentages. Differences in continuous data were compared by the independent t-test, and comparisons of categorical variables were conducted by Chi-square test. Multivariable logistic regression models were used to calculate the odds ratios of frailty based on the tertiles of HOMA-IR in middle aged and elderly population. The significance tests were two-sided and p-values < 0.05 were considered to indicate statistical significance. We used the HOMA-IR level as a continuous variable to examine the associations between an increase of HOMA-IR level and frailty, and p-values for the trend were analyzed. The model-adjusted method was used to adjust the potential confounding effects of covariates: in model 1, there were no variables adjusted; Model 2 was further adjusted for age, sex, race/ethnicity, BMI, systolic blood pressure; Model 3 consisted of Model 2 and was additionally adjusted for serum fasting glucose, serum uric acid, serum C-reactive protein. Model 4 was additionally adjusted for history of stroke, smoking, physical activity.The National Center for Health Statistics Institutional Review Board (IRB) approved the NHANES study protocol before beginning. Before data collection procedures and NHANES health examinations, informed consents had been obtained from all participants. All methods in this study were performed in the light of the relevant guidelines and regulations.


Adherence clubs, where groups of 25–30 patients who are virally suppressed on antiretroviral therapy (ART) meet for counseling and medication pickup, represent an innovative model to retain patients in care and facilitate task-shifting. This intervention replaces traditional clinical care encounters with a 1-hour group session every 2–3 months, and can be organized at a clinic or a community venue. We performed a pragmatic randomized controlled trial to compare loss from club-based care between community- and clinic-based adherence clubs.3. Overall, 47% (95% CI 44%–51%) experienced the primary outcome of loss from club-based care. Among community-based club participants, the cumulative proportion lost from club-based care was 52% (95% CI 47%–57%), compared to 43%  among clinic-based club participants. The risk of loss to club-based care was higher among participants assigned to community-based clubs than among those assigned to clinic-based clubs , after accounting for sex, age, nationality, time on ART, baseline CD4 count, and employment status. Among those who were lost from club-based care (n = 367), the most common reason was missing a club visit and the associated ART medication pickup entirely , and was similar by arm (p = 0.086). Development of an excluding comorbidity occurred in 3% overall of those lost from club-based care, and was not different by arm (p = 0.816); no deaths occurred in either arm during club-based care. Viral rebound occurred in 13% of those lost from community club-based care and 21% of those lost from clinic-based care (p = 0.051). In post hoc secondary analysis, among those referred to standard care, 72% (95% CI 68%–77%) reengaged in clinic-based care within 90 days of their club-based care discontinuation date. The main limitations of the trial are the lack of a comparison group receiving routine clinic-based standard care and the potential limited generalizability due to the single-clinic setting.Patients on ART with undetectable viral load at Witkoppen Health and Welfare Centre in Johannesburg, South Africa, were randomized 1:1 to a clinic- or community-based adherence club. Clubs were held every other month. All participants received annual viral load monitoring and medical exam at the clinic. Participants were referred back to clinic-based standard care if they missed a club visit and did not pick up ART medications within 5 days, had 2 consecutive late ART medication pickups, developed a disqualifying (excluding) comorbidity, or had viral rebound. From February 12, 2014, to May 31, 2015, we randomized 775 eligible adults into 12 pairs of clubs—376 (49%) into clinic-based clubs and 399 (51%) into community-based clubs. Characteristics were similar by arm: 65% female, median age 38 years, and median CD4 count 506 cells/mmThese findings demonstrate that overall loss from an adherence club intervention was high in this setting and that, importantly, it was worse in community-based adherence clubs compared to those based at the clinic. We urge caution in assuming that the effectiveness of clinic-based interventions will carry over to community settings, without a better understanding of patient-level factors associated with successful retention in care.PACTR201602001460157).Pan African Clinical Trials Registry  and decongest busy clinics in high-burden settings.In adherence clubs, groups of 20–30 patients meet every other month for a 1-hour counseling and medication pickup session in a clinic or community setting.There is currently no evidence base to support whether clinic- or community-based adherence clubs are a preferable implementation strategy—community-based clubs may offer closer proximity to patients’ homes, while clinic-based clubs may offer easy access to additional healthcare services, and either model may impact HIV-related stigma perceived or experienced by patients.We randomized stable ART patients at a clinic in Johannesburg, South Africa, to receive either a clinic- or community-based adherence club intervention, and followed participants for 24 months to determine which type of adherence club led to fewer individuals being lost from care in the intervention.Participants in clinic-based clubs had lower levels of loss from the club intervention than those in community-based clubs.Overall loss from either type of adherence club-based care was high, with approximately half of individuals dropping out.In this study, we found that community-based adherence clubs did not work as well as clinic-based clubs at retaining patients within the club intervention; however, with half of the individuals dropping out of the clubs overall, neither intervention may be a good choice for implementation.It is important to understand the mechanism by which individuals are lost from differentiated care interventions such as adherence clubs so that their implementation can be optimized. World Health Organization (WHO) recommendations for universal antiretroviral therapy (ART) for all people living with HIV regardless of level of immunosuppression have been recently implemented across many high-HIV-burden countries ,2. AlthoAdherence clubs have been implemented within the community setting, where clubs are held at venues such as churches, libraries, or community centers –8, as weWe conducted a pragmatic, open-label, parallel randomized controlled trial comparing community- versus clinic-based adherence clubs for stable ART patients in Johannesburg, South Africa. Eligible patients were randomized 1:1 to receive assignment to either a community- or clinic-based adherence club, stratified by area of residence.This trial was set at Witkoppen Health and Welfare Centre, a primary care clinic that provides services to approximately 2,000 patients on ART per month, in northern Johannesburg, South Africa. Participants were recruited from patients receiving ART at the clinic. The medical files of those on ART were prescreened daily by a lay HIV counselor in order to identify potentially eligible participants residing in the clinic catchment areas of Diepsloot, Fourways, Kya Sands, Cosmo City, and Msawawa . These iInclusion criteria were the following: (a) age ≥ 18 years, (b) on the same ART regimen for ≥12 months , and (c) virally suppressed for at least 12 months . Exclusion criteria were the following: (a) currently on a stavudine-containing regimen, (b) currently pregnant or intending to become pregnant within 6 months of club start, (c) current comorbidity or chronic illness that requires routine, frequent, or complex clinical management , (d) hypertensive and requiring treatment with more than 1 antihypertensive agent, and (e) attending ART care with an HIV-positive child.Study recruitment was conducted on a monthly rolling basis, and 1 pair of clubs (1 clinic-based and 1 community-based) was launched with newly recruited participants per month. For each month of recruitment, a geographic target area of residence was predetermined. Eligible patients residing within the target area were approached for study enrollment. Those living outside the monthly target area were entered into a database and contacted for recruitment in an upcoming month in which their area of residence was scheduled to be targeted. Patients who agreed to participate and provided informed consent had a baseline blood draw to confirm viral load suppression prior to participation in the first adherence club visit. Individuals who had a baseline viral load of >200 copies/ml were excluded from the study as screening failures.The adherence club intervention followed the model proposed by Luque-Fernandez et al. . Each clParticipants could have a “buddy” pick up their medication at a club visit. The buddy was preselected by the participant and documented upon enrollment. The counselor in charge of the club verified the buddy identification. Participants who were unable to attend a club visit were allowed to pick up their medication at the clinic within 5 days of the club visit on a limited basis (see below).Clinic-based clubs were held at an onsite meeting space separate from where clinical exam rooms were located. Community-based clubs were held at community venues within the preselected area of residence, including community-based nongovernmental organization facilities, churches, and community centers. These venues were typically 3–5 kilometers closer to the community than the Witkoppen clinic, with the exception of the venue in the Fourways community, which was located a similar distance from the community as the clinic see . The firReasons for referral from club-based care to standard care (at the clinic) included the following: voluntary return, 2 consecutive buddy pickups in a row, 2 consecutive late pickups (at the clinic instead of at the scheduled club visit), 3 late pickups in 12 months, missing a medication pickup entirely , becoming pregnant, TB diagnosis, requiring treatment with more than 1 antihypertensive agent, identification of an excluding comorbid or chronic condition , ART regimen change for any reason, and viral rebound . Participants who were referred back to standard care were contacted in order to book a clinic appointment. Those who could not be contacted were referred for defaulter tracing according to the clinic standard of care (3 attempts to contact during different days/times of day).Participants requiring clinical follow-up  were referred to a dedicated nurse at the clinic, who also managed club-based blood draws, ART re-scripting, and annual medical visits. The annual medical visit included review of blood results  and measurement of weight, blood pressure, hemoglobin, and urine glucose, as well as a routine clinical exam and Pap smear for female participants.The primary outcome was loss from club-based care, defined as referral to clinic-based standard care for any of the above specified reasons. Participants were assessed for the outcome at each club visit, each annual medical visit and any interim clinical visit made between medical visits. The primary outcome was assessed through review of the club register and review of the participants’ clinical files and electronic medical records.Key prespecified secondary outcomes were the proportion of patients who voluntarily chose to return to clinic-based standard care, the proportion of patients with medical contraindication for continuation of club-based care , and all-cause mortality. Participants were followed for outcomes for 24 months following the initial treatment assignment, and outcomes were compared by arm.A post hoc secondary outcome was the proportion of participants who were referred to clinic-based standard care who reengaged in care by 90 days following referral. We also explored the proportion lost to any ART (inclusive of both club-based care and clinic-based standard care). Engagement in care was assessed using review of routine clinical files and electronic medical records.We assumed 90% power and a 2-sided α of 0.05. With equal sample size in the 2 arms, using a difference of proportions, we calculated that we would be able to observe a difference in the primary outcome of at least 10% with a sample size of at least 600 individuals (300 per arm), which corresponded to enrolling 12 clubs, each with a minimum of 25 participants per club . Each sheet was sealed in an opaque envelope, and the envelopes were thoroughly mixed and stored in a locked cabinet in a locked room to which only study staff had access. After consenting, in the presence of a research assistant, each participant chose an envelope and was assigned to the arm indicated inside. The research assistant documented the assignment.We used standard descriptive statistics to characterize the cohort. We used a multivariable Cox proportional hazards model clustered by club to compare participants by arm on our primary outcome of loss from club-based care, adjusting for differences in baseline covariates as well as the prespecified variables age, sex, nationality, and time on ART. We constructed Kaplan–Meier curves of the cumulative proportion retained in club-based care by arm and compared them using the log-rank test. We used differences in proportions to compare reasons for return to clinic-based standard care by arm. We used multivariable linear regression clustered by club to estimate a post hoc secondary outcome of adjusted risk difference. We used a univariate and multivariable Cox proportional hazards model clustered by club, and as well as Kaplan–Meier curves, to compare participants by arm on our post hoc secondary outcome of loss from any ART care. All statistical analyses were conducted using Stata 13. The significance level was set at 0.05.This trial was approved by the Human Research Ethics Committee at the University of the Witwatersrand in South Africa (Clearance number M131121) and the Institutional Review Board at the University of North Carolina . The Institutional Review Board at the Johns Hopkins Bloomberg School of Public Health provided authorization to rely on the Human Research Ethics Committee at the University of the Witwatersrand for review and continuing oversight of this trial. All participants provided informed written consent. The trial was registered with the Pan African Clinical Trials Registry (PACTR201602001460157) after the end of participant enrollment  as the authors were not aware of the requirements for registration of behavioral intervention trials. The full protocol for this trial can be accessed in n = 434/846, 51%) or a clinic-based club . After baseline HIV viral load testing, an additional 71 individuals were identified as ineligible because they were not virally suppressed, representing 8% of those randomized to a community-based club (35/434) and 9% of those randomized to a clinic-based club (36/412). After exclusion of these individuals, there were a total of 775 participants in the study, 399 (51%) in community-based clubs and 376 (49%) in clinic-based clubs, all of whom are included in this analysis.Between February 12, 2014, and May 31, 2015, clinicians screened 1,309 ART patients for study eligibility see . Among t3 (IQR 342–665) among those assigned to community-based clubs and 527 cells/mm3 (IQR 377–690) among those assigned to clinic-based clubs.Twelve pairs of clubs (1 community-based and 1 clinic-based club in each pair) were started based on residential area, with more clubs started in areas with a greater density of potential participants. Seven pairs were started for Diepsloot, 3 for Cosmo City, 1 for Kya Sands/Msawawa, and 1 for Fourways. The majority (65%) of club participants were female . At basep = 0.002) among clinic-based club participants (see p = 0.012). In the primary analysis, after adjusting for sex, age, nationality, time on ART, employment status, and baseline CD4 count, the risk of loss to club-based care was 38% higher among participants assigned to community-based clubs than among those assigned to clinic-based clubs . In a secondary analysis, a univariate Cox proportional hazards model, this estimate remained similar . In a post hoc analysis, after adjusting for sex, age, nationality, time on ART, employment status, and baseline CD4 count, the adjusted risk difference in the cumulative proportion lost from club-based care (community-based club arm minus clinic-based club arm) was 9% .Over 24 months of follow-up (until 31 May 2017), 5,878 person-months were accumulated by those assigned to community-based clubs, and 6,323 by those assigned to clinic-based clubs. A total of 367  participants experienced the primary outcome of loss from club-based care. The intraclass correlation coefficient with respect to clustering of outcomes by study arm was 0.04 (95% CI 0.00–0.75). Among community-based club participants, the cumulative proportion lost from club-based care by 2 years was 52% (95% CI 47%–57%), compared to 43% , the most common reason was missing a club visit and the associated ART pickup entirely  (see p = 0.086). Documented viral rebound was higher, again not significantly so, among participants assigned to clinic-based clubs  than among those assigned to community-based clubs . Voluntary return to clinic-based standard care was uncommon , and was similar between treatment arms (p = 0.429). No participants in either treatment arm died during club-based care.Among those who were lost from club-based care (59%) see . This prp = 0.993).Among the 367 participants lost to club-based care, 266  reengaged in clinic-based care within 90 days of their club-based care discontinuation date. This proportion was similar by treatment arm  among clinic-based club participants (see p = 0.018). In a univariate Cox proportional hazards model, the risk of loss to any ART care was non-significantly increased among participants assigned to community-based clubs as compared with those assigned to clinic-based clubs . In a sensitivity analysis, after adjusting for baseline differences in sex, age, nationality, time on ART, employment status, and baseline CD4 count, this estimate was similar .We also examined a secondary outcome of loss from any ART care (either club-based care or clinic-based standard care following discontinuation from club-based care). Overall, 77  participants were lost from ART care during follow-up. Among community-based club participants, the proportion lost from any ART care was 12% (95% CI 9%–16%), compared to 7%  compared to those in clubs based within the clinic (43%). Although the majority (72%) of adherence club participants who were referred back to clinic-based standard care reengaged in care within 90 days, the disparity between participants in community- versus clinic-based clubs persisted when considering the outcome of 24-month loss from any kind of ART care. Such poor adherence club retention, where nearly half of those receiving the intervention were referred back into routine clinic-based care, cannot be considered a success, particularly given that decongesting busy clinics and streamlining patient care are the primary goals of adherence clubs.These findings are in contrast to those from 2 published studies examining the effectiveness of adherence clubs from Cape Town, South Africa, in which retention in ART care for adherence club participants was excellent , scheduling logistics , and concerns around stigma or confidentiality. For some participants in this study, the perceived cost of receiving ART care through adherence clubs may outweigh the perceived value, resulting in disengagement from care . For exaThis study has several limitations. Follow-up was limited to 24 months as a proxy for what is intended to be a lifelong intervention, and thus estimates of loss from club-based care may underestimate that which occurs over a longer span of time. Those dropping out of care at the study clinic may have sought care at other clinics despite not being transferred out, and thus we may have overestimated loss from any ART care. Treatment assignment was unblinded for practical reasons, but could have led to differential loss from club-based care between treatment arms. Aside from death, we did not collect specific data on other potential adverse events , although data on comorbidities were routinely collected. Finally, this study was conducted at a single clinic in a high-burden, middle-income setting in urban South Africa, and thus its findings may not be generalizable to settings where a lower HIV burden, fewer resources, or more rural geography may introduce additional implementation challenges that may not make the intervention feasible in such settings.In summary, in the present study, our findings demonstrate that losses from clinic-based adherence clubs were lower compared to those from community-based adherence clubs. We urge caution in assuming that the effectiveness of clinic-based interventions will carry over to the community setting, without a better understanding of patient-level factors associated with loss from care. Examining the outcome of loss from club-based care rather than just loss from ART care is essential to understanding the value of these and future interventions designed to provide differentiated care to people living with HIV. Differentiated care models for ART will undoubtedly evolve going forward, and it will be necessary to understand differences in patient preferences and perspectives in order to maximize beneficial outcomes for all patients. As ART availability increases globally, it will be important to efficiently deliver reliable and effective methods of treatment in order to meet ambitious global targets of viral suppression in 90% of those initiated on ART .S1 Data(CSV)Click here for additional data file.S1 Text(PDF)Click here for additional data file.S2 Text(DOC)Click here for additional data file.