Simiyu Melap LynnetJacob Stanley IramiotRebecca NekakaPatrick OkwareMary Abwola OlwedoJoshua EpuitaiPaul ObothHerbert ItabangiLydia V. N. SsenyongaJulius NteziyaremyeDavid Okia2026-06-102026-06-102026Lynnet, S. M., Iramiot, J. S., Nekaka, R., Okware, P., Olwedo, M. A., Epuitai, J., ... & Okia, D. (2026). Second-line virologic failure and elevated bilirubin as a potential surrogate marker of ART adherence among people living with HIV in Eastern Uganda. AIDS Research and Therapy.https://doi.org/10.1186/s12981-026-00861-whttps://ir.sun.ac.ug/handle/123456789/157Ethical clearance was obtained from the Mbale Regional Referral Hospital Research Ethics Committee (MRRH-2022-204). Permission to collect data was sought from the administration of MRRH and Tororo Hospital. Written informed consent was obtained from all participants who completed the questionnaires individually to ensure privacy, confidentiality, and anonymity. Participation was voluntary, and participants could withdraw from the study at any time without penaltySecond-line antiretroviral therapy (ART) failure remains a challenge in HIV Programs. We conducted a cross sectional study among people living with HIV on second-line ART in Eastern Uganda to determine the prevalence and associated factors of virological failure and to assess elevated serum bilirubin as a surrogate marker of adherence. The prevalence of virological failure was 7.5%. Elevated bilirubin showed poor sensitivity and specificity for predicting adherence or virological failure. The findings highlight the need for routine viral load monitoring, as bilirubin is not a reliable surrogate marker of treatment adherence or virological failure. Keywords Second-line virological failure, Elevated bilirubin, And adherenceenArticle