32 This should produce an accelerated response after three months of commencement of ART. Any result outside these values will amount to therapeutic failure

which could manifest as mTOR inhibitor immunological failure, virological failure or both.38 Virological failure occurs when the viral load is still detectable after 3 to 6 months of antiretroviral therapy while immunological failure is said to occur if the CD4+ cell counts fail to increase by, at least, 50 to 100 cells/mm3 after 6 months to one year of antiretroviral therapy.38 Our findings revealed a statistically significant association between drug adherence and good therapeutic outcome. For a quarter of the patients who were assessed to have adhered adequately and still had therapeutic failure, drug resistance could be responsible GSK2656157 order for this. There is, therefore, a need to undertake

resistance studies in these patients since such a high level of resistance in patients on ART should ring alarm bells globally. A similar result was obtained in a study performed in Brazil in which some patients had therapeutic failure despite adequate adherence to ART regimen.38 As a result, the choice of subsequent therapies proved to be difficult, since such failure generally resulted in the emergence of resistant mutations that could even cause cross-resistance between several ARV drugs of the same class. In this scenario, several studies have assessed the benefit of genotyping tests as a tool for assisting in the therapeutic rescue of patients with treatment failure.39 These studies

have shown that, among patients with treatment failure, the use of genotyping tests led to a greater effectiveness regarding medication change, in comparison with the empirical choices that were habitually made.39 The fact that out patients may not truly disclose the number of doses of ARV drugs they have missed may also account for the therapeutic failure in this study since adherence was assessed through recall. As for those who adhered poorly, the complexity of ART regimens, whether due to pill number, dosing frequency, meal restrictions or other issues along with adverse drug events such as lip dystrophy, dyslipidemia, insulin resistance and a host of others may create intentional non-adherence and may have contributed to this problem.39 Cough (13.3%) was the most frequently reported adverse event associated with the use of ARV drugs. Except for maraviroc, an HIV entry inhibitor, cough has not been reported as a common adverse event of ARV drugs 40 and in this study none of the patients was on maraviroc because it was not among the 23 different regimens prescribed. The cough was unlikely due to tuberculosis as patients with this comorbidity were excluded. Cough could also be a symptom of advanced HIV infection rather than being an adverse event of ARV drugs. An evidence supporting this is found in a study carried out in India in which cough (72.1%) was the second most common presenting symptom after weight loss (74.

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