Plasma HHV‐8 viral load in HHV‐8‐related lymphoproliferative disorders associated with HIV infection

This is a mono‐institutional analysis of the clinical features, immunological and virological findings, and prognostic factors of patients with HIV infection and HHV‐8‐lymphoproliferative disorders. Patients with Multicentric Castleman Disease and HHV‐8‐related lymphoma diagnosed and treated from April 1987 to June 2004 were included in the study. HHV‐8 and HIV plasma viral load, CD4+ count, hematologic parameters, and general wellbeing (performance status) were assessed at the onset of the diseases and analyzed in order to identify possible prognostic factors. Nine patients with Multicentric Castleman disease, and 16 with HHV‐8‐related lymphomas (13 primary effusion lymphomas and 3 solid lymphomas), were diagnosed and treated out of 327 HIV‐related non‐Hodgkin's lymphomas. Four patients with Multicentric Castleman disease received only antiretroviral drugs; 5 HAART plus oral etoposide. Nine patients with primary effusion lymphoma were treated with a CHOP‐like regimen (Cyclophosphamide, Prednisone anthracyclines, Vinca alkaloids, Bleomycin, Etoposide) and HAART; 1 with etoposide and HAART, 1 with HAART alone. The patients with solid lymphoma underwent CHOP‐like chemotherapy. Patients with Multicentric Castleman disease showed lower median values of HHV‐8 viral load and longer overall survival compared with HHV‐8‐related lymphomas. Patients with viral load of HHV‐8, >40,000 cp/ml had a significant shorter overall survival. In the univariate analysis, HHV‐8‐related lymphoma, HHV‐8 viral load >40,000 cp/ml and performance status >2 were associated with an increased risk of death. Multivariate analysis confirmed the diagnosis of lymphoma as an independent predictor of shorter survival. J. Med. Virol. 81:888–896, 2009. © 2009 Wiley‐Liss, Inc.     

Occult hepatitis B infection in patients infected with HIV: Report of two cases of hepatitis B reactivation and prevalence in a hospital cohort

Patients co‐infected with human immunodeficiency virus (HIV) and hepatitis B virus (HBV) are particularly at risk of hepatitis B reactivation. Two cases of patients infected with HIV with isolated anti‐HBc antibodies who had experienced an HBV reactivation are described. In the two cases HBV reactivation occurred after withdrawal of anti‐retroviral treatment with anti‐HBV activity from the patients' highly active antiretroviral therapy (HAART), in accordance with HIV genotypic resistance profiles. Consequently, plasma samples from 383 patients infected with HIV were tested to assess the prevalence of occult HBV infection in the Infectious Diseases Department Unit of Nancy Hospital by investigating serological patterns and HBV replication. Forty‐five percent (172/383) of patients had had previous contact with HBV. Isolated anti‐HBc antibodies were observed in 48 patients (48/383, 12%) and, among these, 2 were HBV‐DNA positive. Since 75% (288/383) of the patients were treated with HAART, including at least one drug active against HBV, occult HBV infection was perhaps unrecognized. In cases of HIV infection, all patients should be screened for HBV infection and the knowledge of HBV status as well as the monitoring of HBV viral load are essential in preventing HBV reactivation. Consideration should be given to the continuation of drugs with anti‐HBV activity in co‐infected patients receiving HAART, as cessation of therapy is associated with a risk of HBV reactivation. At least, close monitoring of the HBV viral load is warranted in such situations. J. Med. Virol. 82:206–212, 2010. © 2009 Wiley‐Liss, Inc.     

Neurologic disease in HIV‐infected children and the impact of combination antiretroviral therapy

The prevalence of HIV‐associated neurocognitive impairment in perinatally HIV‐infected children has declined since the introduction of combination antiretroviral therapy (cART). Early initiation of cART in infancy has been shown to positively impact neurodevelopment; however, children continue to be diagnosed with HIV outside of the early infancy period and can experience subtle to severe neurocognitive deficits despite cART. The causes of these neurocognitive deficits despite effective cART are multifactorial and likely include continued viral replication in the CNS, ongoing neuroinflammation, irreversible CNS injury prior to cART initiation, neurotoxic effects of cART, and socioeconomic and psychosocial effects. Many aspects of our understanding of HIV‐associated neurocognitive disorders have emerged from research in adult patients, but perinatally HIV‐infected children represent a very different population. These children were exposed to HIV during a period of rapid brain development and have lifelong infection and potential lifelong cART exposure. HIV is no longer a rapidly fatal disease, and most HIV‐infected children in resource‐rich countries are living into adulthood. It is therefore critical to optimize neurocognitive outcomes of these youth. This review summarizes current understanding of the pathogenesis of HIV‐associated CNS infection and the impact of cART on neurocognitive function in children and adolescents and discusses important areas for future research. Copyright © 2014 John Wiley & Sons, Ltd.     

Detection of infectious HIV in circulating monocytes from patients on prolonged highly active antiretroviral therapy

The existence of a reservoir of resting CD4+ T cells harboring latent replication-competent HIV has been demonstrated in patients on prolonged highly active antiretroviral therapy (HAART). Latently infected tissue macrophages may constitute a second HIV reservoir. The pool of these cells may be maintained by incoming infected monocytes from blood and/or by in situ viral replication. In this study, the presence of infectious HIV was investigated in highly purified monocytes from 5 patients receiving HAART with undetectable plasma viral load for up to 16 months. HIV was detected in freshly isolated monocytes and recovered following Staphylococcus aureus Cowan strain 1 (SAC) or lipopolysaccharide (LPS) activation. No new drug resistance-associated mutation was found in monocyte-associated HIV. These results demonstrate the long-term persistence of infectious virus in cells of the monocyte-macrophage lineage in patients receiving HAART. These cells are capable of releasing infectious virus under appropriate stimulations.     

Changes in thymus volume in adult HIV-infected patients under HAART: correlation with the T-cell repopulation

An important thymus role has been suggested in T‐cell repopulation after HAART in adult HIV‐1 infected patients. Thymus volume increase after treatment has been described in HIV‐1 infected children but not in adult patients. The objective of this work was to evaluate the effect of HAART on the thymic volume of adult HIV‐1 infected patients and its relation with the T‐cell repopulation. Twenty‐one adult patients following 24 weeks under HAART were included in the study. All patients underwent a thoracic computed tomography (CT) evaluation for the measurement of thymic volumes at weeks 0, 12 and 24. Baseline thymus volume showed a significant correlation with the patient's age. Thymic volume significantly increased after 24 weeks of HAART. Besides, a significant correlation between changes in the thymus volume and changes in both total and naïve CD4+ cell counts was found. Only patients with increases ≥100 CD4+ cell counts after treatment significantly increased the thymic volume. These data show the first evidence of an early change in thymic volume of adult HIV‐1 infected patients under HAART. This increase was related to the rise of both total and naïve CD4+ cell counts suggesting a functional role of thymic volume increase.     

Prevalence of human papillomaviruses in urine samples of male patients infected with HIV‐1 in Sao Paulo,Brazil

Human papillomavirus is a DNA virus that includes 118 genotypes. HPV16 is responsible for 80% of cervical cancer in women. Men are important reservoirs and major transmitters of HPV to their partners. The aim of this study was to detect HPV DNA and to determine the prevalence of HPV types 6, 11, 16, and 18 in urine samples of men infected with HIV‐1. This study included 223 patients infected with HIV‐1 from the Center of Reference on HIV/AIDS (CRT‐SP) and an outpatient clinic of HIV. Urine samples were collected and after DNA extraction real‐time PCR was performed for detection of HPV DNA. Positive samples were then tested by conventional PCR using type‐specific primers for the four HPV types. A total of 223 men infected with HIV‐1 were tested, 81% of whom were on HAART. Four (5.8%) were positive for HPV6, 18 (26.1%) were positive for HPV11, 22 (31.9%) were positive for HPV16 and five (7.2%) were positive for HPV18 by conventional PCR. Twenty (29%) patients had other HPV types and five patients (1.5%) had multiple types. The mean T CD4+cells count was 517 and 441 cells/mm³ (P = 0.30), in HPV negative and positive men, respectively. The HIV viral load was higher in the HPV negative group than for in the men with HPV (P = 0.0002). A 30.9% prevalence of HPV was found in asymptomatic urine samples of men infected with HIV‐1. This study suggests that urine may be a useful specimen for HPV screening. J. Med. Virol. 81:2007–2011, 2009. © 2009 Wiley‐Liss, Inc.     

Reconstitution of NK cell activity in HIV-1 infected individuals receiving antiretroviral therapy

We studied natural immunity mediated by natural killer (NK) cells in 62 HIV-1 infected individuals, 54 HIV-1 infected individuals receiving highly active antiretroviral therapy (HAART) for more than one year and 8 HIV-1 infected individuals without antiretroviral therapy. 22 individuals had a complete suppression of viral replication characterized by viral load values <50 copies/ml, whereas 32 individuals presented with persistent viral replication. The 8 untreated patients had an indication to start antiretroviral treatment. Lytic activity of NK cells was measured in a 51chromium release assay. In patients with persistent viral replication under HAART NK cell activity was significantly decreased compared to patients with effective control of HIV viremia. Patients with complete suppression of HIV replication displayed a similar NK activity to healthy control persons. Differences in antibody-dependent cellular cytotoxicity (ADCC) were not observed. Further studies will investigate whether decreased NK cell activity is a reason for or the consequence of persistent viral replication.     

The relationship between genotypic sensitivity score and treatment outcomes in late stage HIV disease after supervised HAART

This study investigated the effect of resistance testing quantified through a genotypic sensitivity score (GSS) on virologic, immunologic, and clinical responses among patients with late stage HIV‐1 disease receiving supervised highly active antiretroviral therapy (HAART). Newly admitted patients received drug resistance testing (n = 198) and then HAART supervised by residential health‐care facilities nurses. After initiating a resistance testing‐informed HAART regimen, patients were followed for HIV‐1 RNA suppression (<50 copies/ml), mean change in CD4⁺ T‐cells, new AIDS defining category C opportunistic conditions and death. GSS was constructed using the HAART regimen prescribed after resistance testing and data derived from IAS‐USA consensus mutations table with modification. Regressions with generalized estimating equations for robust estimation of standard errors and Cox proportional hazards regression estimated independent associations between GSS and treatment responses. After adjusting for adherence, initial log₁₀ HIV‐1 RNA levels, and other covariates, patients with a GSS ≥3 had significantly greater HIV‐1 RNA suppression (adjusted odds ratio (AOR) 2.32; 95% CI 1.14, 4.75). HIV‐1 RNA levels were lower among patients with ≥95% adherence, but the effect of GSS on viral suppression was not modified by adherence. Self‐rated health status, and baseline CD4⁺ T‐cell counts independently predicted HIV‐1 RNA suppression. GSS did not predict mean change in CD4⁺ cells/mm³ (236 vs. 233, P = 0.92), occurrence of new AIDS defining category C conditions or death. These data support resistance testing‐guided therapy as an independent predictive factor to improve virologic responses in treatment‐experienced patients. J. Med. Virol. 81:1323–1335, 2009. © 2009 Wiley‐Liss, Inc.     

Plasma levels of intact and cleaved urokinase receptor decrease in HIV-1-infected patients initiating highly active antiretroviral therapy

Elevated blood levels of soluble urokinase receptor (suPAR) measured by ELISA decrease in human immunodeficiency virus‐1 (HIV‐1)‐infected patients initiating highly active antiretroviral therapy (HAART). As the suPAR ELISA measures both three‐ and two‐domain suPAR [suPAR(I–III), suPAR(II–III)] and suPAR(I–III)–ligand complexes, the amount by which the individual suPAR forms (suPAR(I–III), suPAR(II–III) and one‐domain suPAR [suPAR(I)]) decrease in plasma in HIV‐1‐infected patients initiating HAART is unknown. Consequently, the objective of this study was to investigate HAART‐induced changes in the individual plasma suPAR forms in HIV‐1‐infected patients. Plasma suPAR was measured by three time‐resolved fluorescence immunoassays detecting suPAR(I–III), suPAR(I–III) + suPAR(II–III) and suPAR(I) in 29 treatment‐naïve HIV‐1‐infected patients followed annually for 5 years after initiation of HAART and in 20 age‐ and gender‐matched healthy individuals. In addition, plasma levels of the following inflammatory markers were also investigated: soluble tumour necrosis factor receptor (sTNFr)‐II, TNF‐α, interleukins (IL)‐10, IL‐6, IL‐4, IL‐2 and interferon (IFN)‐γ. In HIV‐1‐infected patients, plasma suPAR(I–III), suPAR(II–III) and suPAR(I) decreased within the first treatment year (all P < 0.05) and suPAR(I–III) and suPAR(II–III) remained above normal throughout follow‐up (both P < 0.05). Plasma sTNFrII, IL‐6, IFN‐γ and IL‐10 also decreased during HAART (all P < 0.05). In HIV‐1‐infected patients, sTNFrII correlated with all suPAR forms before (all P < 0.01) and after 5 years HAART (all P < 0.001), whereas sTNFrII and suPAR did not correlate in healthy individuals. Intact and cleaved plasma suPAR decreased in HIV‐1‐infected patients initiating HAART but remained above normal. The positive correlation with sTNFrII suggests that the individual plasma suPAR forms are linked to immune activation in HIV‐1 infection.     

Viral load and physical status of human papillomavirus (HPV) 18 in cervical samples from female sex workers infected with HPV 18 in Burkina Faso

Viral DNA load and physical status might be predictive of either high‐grade cervical lesions or disease progression among women infected by human papillomavirus (HPV) 16, but these virological markers have rarely been studied in HPV 18 infections. The relationships between HPV 18 DNA load, viral genome physical status and cervical squamous intraepithelial lesions were analyzed among female sex workers infected with HPV18 in Burkina Faso. HPV 18 E2 and E6 genes were quantitated by real‐time PCR. Among 21 women infected with HPV 18, 67% of whom were HIV‐1‐seropositive, 11 (52.4%) had a normal cytology, 8 (38.1%) had low‐grade squamous intraepithelial lesions, and 2 (9.5%) had high‐grade squamous intraepithelial lesions. Total viral load and integrated viral load were higher in women with squamous intraepithelial lesions than in women with normal cytology (P = 0.01 for both parameters). Total viral load and integrated viral load were higher in HIV‐1‐seropositive women than in those who were not infected with HIV (P = 0.01, and P, 0.01, respectively). Total viral load or integrated viral load >1,000 copies/ng of DNA were more frequent in women with squamous intraepithelial lesions than in women with normal cytology (7/10 vs. 1/11; P = 0.007) and in HIV‐1‐seropositive women (8/14 vs. 0/7 in HIV‐uninfected women; P = 0.02). Both HPV 18 DNA and integrated DNA loads might represent markers of cervical lesions. Prospective evaluations are needed to establish the value of these parameters to predict high‐grade lesion or lesion progression. J. Med. Virol. 81:1786–1791, 2009. © 2009 Wiley‐Liss, Inc.     

Sublingual allergen immunotherapy in HIV‐positive patients

HIV infection is a relative contraindication for allergic immunotherapy (AIT). In the last decade, highly active antiretroviral therapy (HAART) has improved the immune function and life expectancy in HIV‐infected patients whose respiratory allergic incidence is similar to the general population. We evaluated the safety and clinical effectiveness of sublingual immunotherapy in a group of grass pollen‐allergic HAART‐treated HIV‐positive patients. Thirteen patients received sublingual immunotherapy (SLIT) tablet (Oralair, Stallergenes©) and symptomatic therapy and were compared with nine patients receiving symptomatic therapy alone. Clinical benefits were evaluated by the analysis of total combined score (TCS), sum of symptom–medication score, and a quality of life (QoL) questionnaire. HIV viral load and peripheral TCD4 lymphocytes were analyzed at the beginning and at the end of the study. Clinical efficacy data showed a significant improvement in SLIT‐treated patients compared to controls (TCS: P = 0.0001; QoL: P = 0.03). We did not observe any significant alteration of TCD4 cell counts and viral load (VL) in both groups. Our preliminary data showed that SLIT therapy in viro‐immunological controlled HAART treated HIV positive patients was efficacious, safe and well tolerated.     

Assessing the efficacy of highly active antiretroviral therapy in the brain

The devastating effects of HIV infection have been documented for the last 2 decades. Since the 1980s over 60 million people have been infected and at present 40 million people globally are living with HIV. HIV infects the central nervous system (CNS) early in the disease process. Indeed, numerous studies document the presence of HIV within the cerebrospinal fluid (CSF). Direct infection of the brain by HIV ultimately results in HIV associated dementia (HAD), which (prior to the advent of antiretroviral therapy) affected 20% of patients. An increasing number of drugs have been developed to treat this infection and delay the development of AIDS. Current treatment is aimed at inhibiting viral replication, and thus, lowering the viral load. However a subsequent increase in viral load can occur as patients become resistant to drug therapy. In the era of HAART, the incidence of HAD has been reduced, whereas the prevalence rate is increasing as people with HIV survive longer. However, in a study of initial AIDS defining illnesses, the proportion with HIV related dementia did not decline following introduction of HAART. In a separate study, no decrease was found in the incidence of dementia per se, although there was a decrease in the incidence of all AIDS-defining illnesses during this time period. It is evident from most studies that since the introduction of HAART, its effect on HAD is not entirely clear, although the majority of findings indicate that it is beneficial. Here we will outline the issues relevant to preventing HAD by HAART.     

Comprehensive analysis of HIV Gag‐specific IFN‐γ response in HIV‐1‐ and HIV‐2‐infected asymptomatic patients from a clinical cohort in The Gambia

Majority of HIV‐2‐infected individuals meet the criteria of long‐term non‐progressors. This has been linked to superior qualitative HIV‐2‐specific cellular immune responses that correlate with viral control. However, it is unknown whether this is due to frequent targeting of immunodominant Gag epitopes in HIV‐2 than HIV‐1 infection. We describe a comprehensive comparison of the magnitude, breadth and frequency of Gag responses and the degree of cross‐recognition of frequently targeted, immunodominant Gag peptides in a cross‐sectional study of asymptomatic HIV‐1‐ and HIV‐2‐infected individuals. Fresh PBMC from 20 HIV‐1‐ and 20 HIV‐2‐infected patients with similar CD4⁺ T‐cell counts (p=0.36) were stimulated with pools of HIV‐1 and/or HIV‐2 Gag peptides in an IFN‐γ ELISPOT assay. We found no difference in the cumulative magnitude of IFN‐γ responses (p=0.75) despite significantly lower plasma viral loads in HIV‐2‐infected people (p<0.0001). However, Gag211–290 was targeted with significantly higher magnitude in HIV‐2‐infected subjects (p=0.03) although this did not correlate with viral control. There was no difference in frequently targeted Gag peptides, the breadth, immunodominance or cross‐recognition of Gag peptide pools between the two infections. This suggests that other factors may control viral replication in HIV‐2 infection.     

Occult hepatitis B in persons infected with HIV is associated with low CD4 counts and resolves during antiretroviral therapy

Occult hepatitis B virus (HBV) is defined by the presence of plasma HBV DNA in individuals with HBV core antibodies (anti‐HBc), but without HBV surface antigen (HBsAg). The prevalence of occult HBV in HIV‐infected patients remains controversial, and the risk factors, clinical significance and effect of highly active antiretroviral therapy (HAART) are unknown. The aim of this study was to determine prevalence, risk factors, and clinical significance of occult HBV in HIV‐infected patients and to evaluate the effect of HAART. Plasma HBV DNA levels were determined in 191 HIV positive, antiretroviral naïve patients, who were anti‐HBc positive and HBsAg negative. Quantitative HBV DNA was determined using a Taqman real‐time nested PCR. Additionally, plasma HIV RNA levels, CD4 cell counts, anti‐HBs‐antibodies, anti‐HCV‐antibodies, ALT, AST, and γGT were determined. Occult HBV (a plasma HBV DNA level >50 copies/ml) was detected in 9/191 (4.7%) of the patients. Among 45 anti‐HBs‐negative patients (isolated anti‐HBc positive), the prevalence was 11.1%. Patients with occult HBV had significantly lower CD4 count compared to anti‐HBc‐positive/HBsAg negative/HBV DNA‐negative patients (105 ± 157 (median ± SD) vs. 323 ± 299 cells/mm³, P = 0.019). When HAART (including lamivudine) was initiated in the patients with occult HBV, HBV DNA was no longer detectable in any of the patients during 3 years of follow‐up. In conclusion, occult HBV was associated with low CD4 counts and may be viewed as opportunistic reactivation of HBV that resolves as a consequence of HAART induced immune reconstitution and/or the effect of lamivudine. J. Med. Virol. 81:441–445, 2009. © 2009 Wiley‐Liss, Inc.     

Low‐level plasma HIVs in patients on prolonged suppressive highly active antiretroviral therapy are produced mostly by cells other than CD4 T‐cells

The cellular source(s) and the clinical significance of persistent low‐level viremia, below 50 HIV RNA copies per ml of plasma, achieved in many patients with high adherence to highly active antiretroviral therapy (HAART) remain unclear. Also, it is not clear if residual plasma HIVs during HAART can become predominant populations in the rebounding plasma viral loads after therapy interruption. Since, different HIV quasispecies tend to compartmentalize in various cell types and tissue locations in patients during chronic infection, the phylogenetic relationships between HIV sequences amplified from residual plasma viruses and CD4 T cells of five patients on long‐term suppressive therapy were examined. Three of these patients stopped therapy voluntarily for 3 weeks, but only one of them demonstrated viral load rebound in plasma. In phylogenetic analyses, the residual plasma viruses were found to be distinct genetically from the majority of CD4 T cell‐associated virus populations in four of five patients. The compartmental analyses revealed that in all patients, plasma‐ and CD4 T cell‐derived viral sequences were compartmentalized separately. Interestingly, the plasma sequences obtained before and after HAART‐off in two patients were produced apparently from the same compartment, which was different from the circulating CD4 T cell‐compartment. These results suggest the possibility that residual plasma viruses in patients on long‐term suppressive HAART may be produced persistently from a cellular source yet to be identified, and are capable of spreading quickly in vivo, accounting for the rapid rebound of viral loads in plasma after therapy interruption. J. Med. Virol. 81:9–15, 2009. © 2008 Wiley‐Liss, Inc.     

Reservoirs of HIV-1 in vivo: implications for antiretroviral therapy

The eradication of HIV-1 from infected individuals remains the ultimate goal of all anti-HIV therapeutics. Although highly active antiretroviral therapy (HAART) has led to a profound decrease in morbidity and mortality in infected people by suppressing HIV replication, the virus continues to evolve slowly during therapy even when patients achieve below detectable levels of HIV in plasma. HIV-1 persists in latently infected memory CD4+ T cells and there is minimal decay of HIV in this compartment despite prolonged HAART. Various other reservoirs and sanctuary sites harboring HIV are also established in vivo during antiretroviral therapy. Collectively these sites represent a major impediment to the eradication of HIV-1. This review presents a detailed overview of various reservoir sites in vivo, and discusses their impact on the success and failure of HAART for HIV patients. In addition, it addresses the effect of sub-optimal drug concentrations on reservoir establishment and outlines future therapeutic strategies to counteract these reservoirs and sanctuaries.     

Could differential virological characteristics account for ongoing viral replication and insidious damage of the brain during HIV 1 infection of the central nervous system?

Neurocognitive disorders due to human immunodeficiency virus type 1 (HIV-1) infection have been reported in 25–60% of cases,1, 2, 3 despite a sustained viral response in peripheral blood while on highly active anti-retroviral therapy (HAART). A possible reason may be that the central nervous system (CNS) is less accessible for anti-retroviral agents, therefore this sanctuary site can provide a reservoir for ongoing HIV-1 replication. Mutations conferring resistance to anti-retroviral drugs may predominate in compartments where drug levels are suboptimal. This review provides an overview on the literature regarding the development of resistance mutations and the sensitivity for co-receptors in CNS.Mutations caused by the anti-retroviral drugs with the lowest intracerebral penetration would be expected to be found in higher percentages in the CNS than in the periphery of the human body. However, few studies have been performed that can confirm or reject this claim. Zidovudine, the anti-retroviral drug with the best intracerebral penetration, has been studied to some extent. This drug indeed induces resistance mutations in blood as well as the CNS.HAART induces a switch from HIV that uses co-receptor CRR5 to HIV that uses co-receptor CXCR4. This switch may appear later in the CNS compartment compared to the periphery. However, current literature shows conflicting evidence.In conclusion, the current understanding of HIV-strain evolution under drug pressure in sanctuary sites like CNS is incomplete. Therefore, more research is needed in order to establish the role of these sites in the development of drug resistant mutants under adequate HAART.