Viral suppression and immune recovery after antiretroviral therapy initiation in a Moroccan human immunodeficiency virus type 1-infected cohort: A retrospective analysis

Abstract

Introduction: Morocco has made substantial progress in expanding human immunodeficiency virus (HIV) testing and treatment, yet longitudinal data on immuno-virologic outcomes remain limited.

Objective: We sought to define the clinical profile at presentation and analyze long-term immuno-virologic outcomes under expanding integrase inhibitor-based treatment.

Methods: We performed a retrospective analysis of patients with confirmed HIV-1 infection who initiated antiretroviral therapy at the Center of Virology, Infectious, and Tropical Diseases at the Military Training Hospital between 2017 and 2025. Demographic, clinical, immunological, and virological data were collected at baseline and throughout follow-up. Statistical analyses were conducted using the Statistical Package for Social Sciences software.

Results: Late presentation was common: 35.7% presented with Centers for Disease Control and Prevention stage C, and 41.5% had CD4 < 200 cells/μL. Women had higher baseline cluster of differentiation 4 (CD4) counts than men (416 vs. 250 cells/μL; p= 0.001), whereas men displayed higher viral loads (1.19 × 10⁵ vs. 5.51 × 10⁴copies/mL; p= 0.005). Opportunistic infections remained substantial, including cytomegalovirus (16.5%), tuberculosis (12.5%), and toxoplasmosis (5.8%). First-line therapy was initially non-nucleoside reverse transcriptase inhibitor-based in half of the patients, but rapid national adoption of updated guidelines led to 93.8% receiving dolutegravir plus two nucleoside reverse transcriptase inhibitors at the last follow-up. Viral loads declined sharply within the first month, with most patients achieving and maintaining suppression from months 6-12 onward. CD4 counts rose from a median of 279 cells/μL at baseline to 560 at year 3, peaking at 610 at year 5 before stabilizing.

Conclusion: Morocco’s transition to dolutegravir-based antiretroviral therapy has produced durable virologic control and robust immune recovery. Persistent late diagnosis, sex-based disparities, and limited access to genotyping remain major obstacles. Strengthening early testing, expanding molecular monitoring, and enhancing differentiated care services will be essential to sustain national progress.

Keywords

Human immunodeficiency virus type 1 / Epidemiology / Immuno-virologic surveillance / Clinical characteristics / Antiretroviral therapy / Morocco

References

[1] UNAIDS. Fact Sheet 2024. Geneva, Switzerland: UNAIDS; 2024. Accessed July 27, 2025. https://www.unaids.org/sites/default/files/media_asset/UNAIDS_FactSheet_en.pdf

[2] World Health Organization. HIV Data and Statistics. World Health Organization. Accessed July 27, 2025. https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/hiv/strategic-information/hiv-data-and-statistics

[3] Sáez-Cirión A, Mamez AC, Avettand-Fenoel V, et al. Sustained HIV remission after allogeneic hematopoietic stem cell transplantation with wild-type CCR5 donor cells. Nat Med. 2024; 30(12):3544-3554. doi: 10.1038/s41591-024-03277-z

[4] Yang X, Su B, Zhang X, Liu Y, Wu H, Zhang T. Incomplete immune reconstitution in HIV/AIDS patients on antiretroviral therapy: Challenges of immunological non‐responders. J Leukoc Biol. 2020; 107(4):597-612. doi: 10.1002/jlb.4mr1019-189r

[5] Ministry of Health and Social Protection. Rapport National SIDA 2024 Maroc [Morocco National AIDS Report 2024]. Rabat, Morocco: Ministry of Health and Social Protection; 2024. Accessed April 1, 2025. https://www.sante.gov.ma/Documents/2024/11/Rapport%20SIDA%202024%20VF%20.pdf

[6] UNAIDS. Maroc [Morocco]. UNAIDS. Accessed December 30, 2024. https://www.unaids.org/fr/regionscountries/countries/morocco

[7] Association de Lutte Contre le Sida (ALCS). Rapport d’Activité ALCS 2023 [ALCS 2023 Activity Report]. Casablanca, Morocco: Association de Lutte Contre le Sida; 2024. Accessed May 8, 2026. https://alcs.ma/wp-content/uploads/2024/07/Rapport-dactivite-ALCS-2023-version-def.pdf

[8] Ministry of Health and Social Protection. Guide National de Prise en Charge de la Co-infection TB-VIH [National Guide for the Management of TB-HIV Co-infection]. Rabat, Morocco: Ministry of Health and Social Protection; 2024. Accessed November 25, 2025. https://www.sante.gov.ma/Documents/2024/04/Guide%20national%20de%20p.e.c%20de%20la%20co-infection%20TB%20-VIH%20VF.pdf

[9] Gökengin D, Doroudi F, Tohme J, Collins B, Madani N. HIV/AIDS: trends in the Middle East and North Africa region. Int J Infect Dis. 2016; 44:66-73. doi: 10.1016/j.ijid.2015.11.008

[10] European Centre for Disease Prevention and Control, WHO Regional Office for Europe. HIV/AIDS Surveillance in Europe 2024: 2023 Data. Stockholm, Sweden: European Centre for Disease Prevention and Control; 2024. Accessed July 27, 2025. https://www.ecdc.europa.eu/en/publications-data/hiv-aids-surveillance-europe-2024-2023-data

[11] Roomaney RA, van Wyk B, Pillay-van Wyk V. Aging with HIV: Increased Risk of HIV Comorbidities in Older Adults. Int J Environ Res Public Health. 2022; 19(4):2359. doi: 10.3390/ijerph19042359

[12] Annaz HE, Recordon-Pinson P, Tagajdid R, et al. Drug resistance mutations in HIV type 1 isolates from patients failing antiretroviral therapy in Morocco. AIDS Res Hum Retroviruses. 2012; 28(8):944-948. doi: 10.1089/aid.2011.0278

[13] Annaz HE, Recordon-Pinson P, Baba N, Sedrati O, Mrani S, Fleury H. Presence of Drug Resistance Mutations Among Drug-Naive Patients in Morocco. AIDS Res Hum Retroviruses. 2011; 27(8):917-920. doi: 10.1089/aid.2010.0284

[14] Karbasi A, Fordjuoh J, Abbas M, et al. An Evolving HIV Epidemic in the Middle East and North Africa (MENA) Region: A Scoping Review. Int J Environ Res Public Health. 2023; 20(5):3844. doi: 10.3390/ijerph20053844

[15] Sallam M, Al-Khatib AO, Sabra T, et al. Challenges in Elucidating HIV-1 Genetic Diversity in the Middle East and North Africa: A Review Based on a Systematic Search. Viruses. 2025; 17(3):336. doi: 10.3390/v17030336

[16] Antar AA, Jenike KM, Jang S, et al. Longitudinal study reveals HIV-1-infected CD4+ T cell dynamics during long-term antiretroviral therapy. J Clin Invest. 2020; 130(7):3543-3559. doi: 10.1172/jci135953

[17] Calmy A, Balestre E, Bonnet F, et al. Mean CD4 cell count changes in patients failing a first-line antiretroviral therapy in resource-limited settings. BMC Infect Dis. 2012; 12(1). doi: 10.1186/1471-2334-12-147

[18] Stirrup OT, Sabin CA, Phillips AN, et al. Associations between baseline characteristics, CD4 cell count response and virological failure on first-line efavirenz + tenofovir + emtricitabine for HIV. J Virus Erad. 2019; 5(4):204-211.doi: 10.1016/s2055-6640(20)30037-6

[19] Neesgaard B, Mocroft A, Greenberg L, et al. How to RESPOND to Modern Challenges for People Living with HIV: A Profile for a New Cohort Consortium. Microorganisms. 2020; 8(8):1164. doi: 10.3390/microorganisms8081164

[20] Hsu RK, Fusco JS, Henegar CE, et al. Heavily treatment-experienced people living with HIV in the OPERA® cohort: population characteristics and clinical outcomes. BMC Infect Dis. 2023; 23(1). doi: 10.1186/s12879-023-08038-w

[21] World Health Organization. Consolidated Guidelines on HIV Prevention, Testing, Treatment, Service Delivery and Monitoring: Recommendations for a Public Health Approach. Geneva, Switzerland: World Health Organization; 2021. Accessed April 13, 2025. https://www.who.int/publications/i/item/9789240031593

[22] World Health Organization. Update on the Transition to Dolutegravir-Based Antiretroviral Therapy: Report of a WHO Meeting, 29-30 March 2022. Geneva, Switzerland: World Health Organization; 2022. Accessed April 13, 2025. https://www.who.int/publications/i/item/9789240053335

[23] European AIDS Clinical Society. EACS Guidelines 2024. Brussels, Belgium: European AIDS Clinical Society; 2024. Accessed September 5, 2025. https://eacs.sanfordguide.com

[24] World Health Organization. HIV Drug Resistance - Brief Report 2024. Geneva, Switzerland: World Health Organization; 2024. Accessed September 5, 2025. https://www.who.int/publications/i/item/9789240086319

[25] Khodadad N, Hashempour A, Nazar MMKA, Ghasabi F. Evaluating HIV drug resistance in the middle East and North Africa and its associated factors: a systematic review. Virol J. 2025; 22(1). doi: 10.1186/s12985-025-02740-8

[26] Eisinger RW, Dieffenbach CW, Fauci AS. HIV Viral Load and Transmissibility of HIV Infection: Undetectable Equals Untransmittable. JAMA. 2019; 321(5):451-452. doi: 10.1001/jama.2018.21167

[27] World Health Organization. The Role of HIV Viral Suppression in Improving Individual Health and Reducing Transmission. Geneva, Switzerland: World Health Organization; 2023. Accessed September 5, 2025. https://www.who.int/publications/i/item/9789240055179

[28] Zhong M, Li M, et al. A retrospective clinical study of dolutegravir- versus efavirenz-based regimen in treatment-naïve patients with advanced HIV infection in Nanjing, China. Front Immunol. 2023; 13:1033098. doi: 10.3389/fimmu.2022.1033098

[29] Gandla S, Nakka R, Khan RA, Bose E, Ghebremichael M. Biological and Social Predictors of HIV-1 RNA Viral Suppression in ART Treated PWLH in Sub-Saharan Africa. Trop Med Infect Dis. 2025; 10(1):24. doi: 10.3390/tropicalmed10010024

[30] Hayashi R, Hara A, Iwasa Y. Viral rebound occurrence immediately after drug discontinuation involving neither drug resistance nor latent reservoir. J Theor Biol. 2024; 582:111767. doi: 10.1016/j.jtbi.2024.111767

[31] Rathore G, Singh RP. Transforming disease management: The clinical benefits of long-acting injectable drug delivery systems. Intelligent Hospital. 2025; 1(1):100001. doi: 10.1016/j.inhs.2025.100001

[32] Alaoui N, El Alaoui MA, El Annaz H, et al. HIV-1 Integrase Resistance among Highly Antiretroviral Experienced Patients from Morocco. Intervirology. 2019; 62(2):65-71. doi: 10.1159/000501016

[33] Bakhouch K, Oulad-Lahcen A, Bensghir R, et al. The prevalence of resistance-associated mutations to protease and reverse transcriptase inhibitors in treatment-naïve HIV1-infected individuals in Casablanca, Morocco. J Infect Dev Ctries. 2009; 3(5). doi: 10.3855/jidc.247

[34] Floridia M, Giuliano M, Palmisano L, Vella S. Gender differences in the treatment of HIV infection. Pharmacol Res. 2008; 58(3-4):173-182. doi: 10.1016/j.phrs.2008.07.007

[35] Addo MM, Altfeld M. Sex-Based Differences in HIV Type 1 Pathogenesis. J Infect Dis. 2014; 209(suppl 3):S86-S92. doi: 10.1093/infdis/jiu175

[36] World Health Organization. Guideline on When to Start Antiretroviral Therapy and on Pre-exposure Prophylaxis for HIV. Geneva, Switzerland: World Health Organization; 2015. Accessed May 12, 2026. https://www.who.int/publications/i/item/9789241509565

[37] Sokoya T, Steel HC, Nieuwoudt M, Rossouw TM. HIV as a Cause of Immune Activation and Immunosenescence. Mediators Inflamm. 2017; 2017:1-16. doi: 10.1155/2017/6825493

[38] Mukumbang FC, Ndlovu S, van Wyk B. Comparing Patients’ Experiences in Three Differentiated Service Delivery Models for HIV Treatment in South Africa. Qual Health Res. 2021; 32(2):238-254. doi: 10.1177/10497323211050371

[39] Odhiambo F, Mando RO, Lewis-Kulzer J, et al. Effectiveness and experiences with differentiated service delivery of HIV care in Kisumu County, Kenya: A mixed methods study, 2014-2021. PLOS Glob Public Health. 2025; 5(8):e0004481. doi: 10.1371/journal.pgph.0004481