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Gurunathan S, Habib RE, Baglyos L, Meric C, Plotkin S, Dodet B, Corey L, Tartaglia J. Use of predictive markers of HIV disease progression in vaccine trials. Vaccine 2009; 27:1997-2015. [DOI: 10.1016/j.vaccine.2009.01.039] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2008] [Revised: 12/19/2008] [Accepted: 01/08/2009] [Indexed: 10/21/2022]
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102
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103
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Blish CA, Dogan OC, Derby NR, Nguyen MA, Chohan B, Richardson BA, Overbaugh J. Human immunodeficiency virus type 1 superinfection occurs despite relatively robust neutralizing antibody responses. J Virol 2008; 82:12094-103. [PMID: 18842728 PMCID: PMC2593335 DOI: 10.1128/jvi.01730-08] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2008] [Accepted: 09/29/2008] [Indexed: 11/20/2022] Open
Abstract
Superinfection by a second human immunodeficiency virus type 1 (HIV-1) strain indicates that gaps in protective immunity occur during natural infection. To define the role of HIV-1-specific neutralizing antibodies (NAbs) in this setting, we examined NAb responses in 6 women who became superinfected between approximately 1 to 5 years following initial infection compared to 18 women with similar risk factors who did not. Although superinfected individuals had less NAb breadth than matched controls at approximately 1 year postinfection, no significant differences in the breadth or potency of NAb responses were observed just prior to the second infection. In fact, four of the six subjects had relatively broad and potent NAb responses prior to infection by the second strain. To more specifically examine the specificity of the NAbs against the superinfecting virus, these variants were cloned from five of the six individuals. The superinfecting variants did not appear to be inherently neutralization resistant, as measured against a pool of plasma from unrelated HIV-infected individuals. Moreover, the superinfected individuals were able to mount autologous NAb responses to these variants following reinfection. In addition, most superinfected individuals had NAbs that could neutralize their second viral strains prior to their reinfection, suggesting that the level of NAbs elicited during natural infection was not sufficient to block infection. These data indicate that preventing infection by vaccination will likely require broader and more potent NAb responses than those found in HIV-1-infected individuals.
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Affiliation(s)
- Catherine A Blish
- Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, WA 98109-1024, USA
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104
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Impact of small reductions in plasma HIV RNA levels on the risk of heterosexual transmission and disease progression. AIDS 2008; 22:2179-85. [PMID: 18832881 DOI: 10.1097/qad.0b013e328312c756] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To estimate the impact of small changes in plasma levels of HIV-1 RNA on the risk of heterosexual transmission or disease progression to an AIDS-defining event or death. DESIGN AND METHODS We systematically reviewed the published literature for studies that evaluated small viral load changes among antiretroviral-therapy-naive, adult populations. We modeled relative risk estimates for viral transmission and disease progression according to 0.3, 0.5, and 1.0 log10 increments of HIV load. RESULTS We calculated that the likelihood of transmitting HIV by heterosexual contact increased, on average, by 20% and that the annual risk of progression to an AIDS-defining illness or related death increased by 25% with every 0.3 log10 increment in HIV RNA. A 0.5 log10 increment in HIV RNA was associated with 40% greater risk of heterosexual transmission and 44% increased risk of progression to AIDS or death. A 1.0 log10 increment in HIV RNA was associated with 100% greater risk of heterosexual transmission and 113% increased risk of progression to AIDS or death. CONCLUSION Antiretroviral therapy continues to be unavailable or not-yet-indicated for 72% of the world's HIV-infected persons. Mounting evidence that treatment of coinfections may reduce HIV viral load, even modestly, suggests the priority of improved adjunctive care for HIV-infected persons even without antiretroviral therapy, both to slow disease progression and to reduce infectiousness.
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Abstract
The majority of the 15.4 million human immunodeficiency virus (HIV)-infected women worldwide are of child-bearing age and need access to contraception. Hormonal methods of contraception are safe, acceptable, and effective in preventing unwanted pregnancies. Many published studies have examined the impact of hormonal contraception on HIV disease acquisition and transmissibility. Far fewer have investigated the relationship between hormonal contraception and HIV disease progression. This review examines available data on this relationship from clinical, animal, and immunological studies. Several clinical studies suggest an overall effect but are not definitive, and the mechanisms behind HIV disease progression are unclear. Animal and immunological data suggest that immunomodulation by hormonal contraceptive methods may affect the immune response to HIV infection. Additional work is needed in this area to elucidate the possible relationship between hormonal methods for birth control and progression to acquired immunodeficiency syndrome in HIV-infected women.
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Affiliation(s)
- Elizabeth Stringer
- Department of Obstetrics and Gynecology, Division of International Women's Health, University of Alabama at Birmingham, USA.
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106
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Piantadosi A, Ngayo MO, Chohan B, Overbaugh J. Examination of a second region of the HIV type 1 genome reveals additional cases of superinfection. AIDS Res Hum Retroviruses 2008; 24:1221. [PMID: 18729772 DOI: 10.1089/aid.2008.0100] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
HIV-1 superinfection may occur at a rate similar to that of initial infection, raising concerns for HIV-1 vaccine strategies predicated on eliciting immune responses similar to those in natural infection. Because of the high rate of recombination during HIV-1 replication, studies examining only one region of the HIV-1 genome are likely to miss cases of HIV-1 superinfection. We examined HIV-1 gag sequences from 14 high-risk Kenyan women in whom superinfection was not detected in a previous study of env sequences. We detected two additional cases of HIV-1 superinfection: one intersubtype superinfection that occurred between 1046 and 1487 days postinfection (DPI) and one intrasubtype superinfection that occurred between 341 and 440 DPI. Our results suggest that studies that examine only small genome regions may lead to underestimates of the risk of superinfection, highlighting the need for more extensive studies examining multiple regions of the HIV-1 genome.
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Affiliation(s)
- Anne Piantadosi
- Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington 98109
- Department of Pathobiology, University of Washington, Seattle, Washington 98109
| | - Musa Otieno Ngayo
- Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington 98109
| | - Bhavna Chohan
- Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington 98109
| | - Julie Overbaugh
- Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington 98109
- Department of Pathobiology, University of Washington, Seattle, Washington 98109
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107
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Kumwenda JJ, Makanani B, Taulo F, Nkhoma C, Kafulafula G, Li Q, Kumwenda N, Taha TE. Natural history and risk factors associated with early and established HIV type 1 infection among reproductive-age women in Malawi. Clin Infect Dis 2008; 46:1913-20. [PMID: 18462100 DOI: 10.1086/588478] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Data evaluating the biological events and determinants of early human immunodeficiency virus type 1 (HIV-1) infection are limited in sub-Saharan Africa. We examined plasma viral levels and trends during early and established HIV-1 infection among reproductive-age women who participated in a randomized trial to treat genital tract infection in Malawi. We also assessed the association of injectable hormonal contraceptive use with HIV-1 infection. METHODS We studied 3 groups of women who were infected or uninfected with HIV-1: seroconverters, seroprevalent women, and seronegative women. Questionnaires and blood samples were collected at baseline and every 3 months for 1 year. The virus set point in seroconverters and levels and trends of viral load over time were determined. The associations of injectable hormonal contraceptive use with HIV-1 infection and viral load were assessed using conditional logistic regression and mixed-effect models, respectively. RESULTS In the original clinical trial, 844 women infected with HIV-1 and 842 women not infected with HIV-1 were enrolled. Of 31 women who experienced seroconversion during 12 months, 27 were matched with 54 seroprevalent and 54 seronegative women. The estimated median plasma virus set point was 4.45 log(10) copies/mL (interquartile range, 4.32-5.14 log(10) copies/mL). Injectable hormonal contraceptive use was significantly associated with HIV-1 seroconversion (adjusted odds ratio, 10.42; P = .03) but not with established HIV-1 infection. Among the seroconverters, a statistically significant interaction was found between the linear association of viral load and time of injectable hormonal contraceptive use (regression coefficient, -0.14; P = .02). CONCLUSION Knowledge of virus set point and trends of viral load in HIV-1 seroincident and seroprevalent asymptomatic women could assist in antiretroviral treatment management.
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108
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Peters PJ, Zulu I, Kancheya NG, Lakhi S, Chomba E, Vwalika C, Kim DJ, Brill I, Meinzen-Derr J, Tichacek A, Allen SA. Modified Kigali combined staging predicts risk of mortality in HIV-infected adults in Lusaka, Zambia. AIDS Res Hum Retroviruses 2008; 24:919-24. [PMID: 18593343 DOI: 10.1089/aid.2007.0297] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We assessed the utility of the modified Kigali combined (MKC) staging system for predicting survival in HIV-infected Zambian adults in a prospective, longitudinal, open cohort. From 1995 to 2004, HIV-discordant couples (one HIV-infected partner and one HIV-negative partner) were recruited from couples' voluntary counseling and testing centers in Lusaka, Zambia and followed at 3-month intervals. MKC stage, which incorporates clinical stage with erythrocyte sedimentation rate (ESR), hematocrit, and body mass index (BMI), was determined at enrollment. Kaplan-Meier survival and Cox proportional hazard methods were used to calculate median survival and relative hazards. We enrolled 1479 HIV-discordant couples with a combined 7305 person-years of follow-up. Among HIV-infected participants over the 9-year study period, there were 333 confirmed deaths. The time to 50% mortality was 8.5 years with MKC stage 1 and 2 disease compared to 3.7 years with MKC stage 4 disease at enrollment. Survival rates at 3 years were 85% with MKC stage 1 and 2 disease, 74% with MKC stage 3 disease, and 51% with MKC stage 4 disease. A total of 275 HIV-negative partners seroconverted during follow-up. In comparison, survival rates at 3 years were 94% for HIV-negative participants and 92% for participants who seroconverted during follow-up. In multivariate analysis, MKC stage 4 disease (HR = 3.7, 95% CI = 2.7-5.0) remained a strong predictor of mortality. Incorporating ESR, hematocrit, and BMI with clinical staging is a powerful, low-cost tool to identify HIV-infected adults at high risk for mortality.
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Affiliation(s)
- Philip J. Peters
- Emory University, Division of Infectious Diseases, Atlanta, Georgia 30030
| | - Isaac Zulu
- University Teaching Hospital, Lusaka, Zambia
| | | | | | | | | | - Dhong-Jin Kim
- University of Alabama at Birmingham, Birmingham, Alabama 35294
| | - Ilene Brill
- University of Alabama at Birmingham, Birmingham, Alabama 35294
| | - Jareen Meinzen-Derr
- Children's Hospital Medical Center, Center for Epidemiology and Biostatistics, Cincinnati, Ohio 45229
| | - Amanda Tichacek
- Emory University, Rollins School of Public Health, Department of Global Health, Atlanta, Georgia 30030
| | - Susan A. Allen
- Emory University, Rollins School of Public Health, Department of Global Health, Atlanta, Georgia 30030
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109
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Duh D, Saksida A, Petrovec M, Ahmeti S, Dedushaj I, Panning M, Drosten C, Avsic-Zupanc T. Viral load as predictor of Crimean-Congo hemorrhagic fever outcome. Emerg Infect Dis 2008; 13:1769-72. [PMID: 18217568 PMCID: PMC3375790 DOI: 10.3201/eid1311.070222] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
We used quantitative real-time reverse transcription-PCR to measure viral load in serum from 24 patients in Kosovo who had acute Crimean-Congo hemorrhagic fever. Viral load correlated with clinical disease and antibodies and could be used as a predictor of disease outcome.
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Affiliation(s)
- Darja Duh
- Institute of Microbiology and Immunology, Ljubljana, Slovenia
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110
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Richardson BA, Nduati R, Mbori-Ngacha D, Overbaugh J, John-Stewart GC. Acute HIV infection among Kenyan infants. Clin Infect Dis 2008; 46:289-95. [PMID: 18171265 DOI: 10.1086/524748] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Clinical signs and symptoms of acute human immunodeficiency virus (HIV) infection in infants are not well characterized. METHODS Serial clinical assessments and HIV PCR assays were conducted in a cohort of children born to HIV-seropositive mothers from birth to 2 years of age. Acute HIV infection visits were defined as those up to 3 months prior to and including the visit at which HIV DNA was first detected. Noninfection visits included all visits at which the child had test results negative for HIV, including the last visit at which a test result negative for HIV DNA was obtained in children who later acquired HIV infection. Differences in the prevalence of symptoms at acute infection versus noninfection visits were determined overall and were stratified by age at infection (<2 months vs. >or=2 months). HIV RNA was measured serially in infected infants and was compared between infants with and infants without symptoms of acute HIV infection. RESULTS There were 125 acute infection visits (among 56 infants) and 3491 noninfection visits (among 306 infants). Acute HIV infection was associated with rash (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.1-2.8), failure to thrive (OR, 1.9; 95% CI, 1.0-3.5), and lymphadenopathy (OR, 2.5; 95% CI, 1.4-4.8). Acute HIV infection was associated with lymphadenopathy (OR, 2.6; 95% CI, 1.3-5.0) in infants <2 months of age and with pneumonia (OR, 3.2; 95% CI, 1.1-9.3) and dehydration (OR, 6.0; 95% CI, 1.9-18.5) in infants >or=2 months of age. Infant peak viral load and mortality were not associated with symptoms of acute HIV infection. However, infants with symptoms had higher viral levels later in the course of infection than did those without symptoms (P=.05). CONCLUSIONS Infants may manifest symptoms early during the course of HIV infection, and symptoms of acute HIV infection may correlate with poor viral control. Rash, failure to thrive, lymphadenopathy, pneumonia, and dehydration may signify acute HIV infection in infants.
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Affiliation(s)
- Barbra A Richardson
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
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111
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Secor WE, Sundstrom JB. Below the belt: new insights into potential complications of HIV-1/schistosome coinfections. Curr Opin Infect Dis 2007; 20:519-23. [PMID: 17762787 DOI: 10.1097/qco.0b013e3282e9ac03] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW Areas of the world with high endemnicity for helminth parasites overlap with those regions that have a seemingly disproportionate prevalence of HIV/AIDS. This has fueled speculation that potential pathological interactions between these infectious agents may accelerate disease progression. The proximity of many helminth infections to gastrointestinal mucosal sites combined with the recent discovery that acute HIV-1 infection causes early and massive depletion of CD4+ T cells in the gut furthers the potential pathological significance of co-infection. In this review, the 'gut wrenching' consequences of schistosome infection on HIV disease progression that may ensue during coinfection are considered. RECENT FINDINGS Massive depletion of CD4+ T cells in the gut during acute HIV-1 infection suggests that in addition to the administration of highly active antiretroviral therapy, limiting viral infection of susceptible cells in the gut after initial exposure may offer the best opportunity for slowing disease progression. In addition to memory T cells, mast cells, which are present in the intestinal lamina propria and upregulated in the gut during schistosome infection, have been recently described as an inducible reservoir of persistent HIV-1 infection. SUMMARY Schistosome infections create immune environments that may accelerate HIV disease progression. Their impact on highly active antiretroviral therapy should be considered.
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Affiliation(s)
- W Evan Secor
- Division of Parasitic Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia 30341-3724, USA.
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112
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Piantadosi A, Chohan B, Chohan V, McClelland RS, Overbaugh J. Chronic HIV-1 infection frequently fails to protect against superinfection. PLoS Pathog 2007; 3:e177. [PMID: 18020705 PMCID: PMC2077901 DOI: 10.1371/journal.ppat.0030177] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2007] [Accepted: 10/03/2007] [Indexed: 11/18/2022] Open
Abstract
Reports of HIV-1 superinfection (re-infection) have demonstrated that the immune response generated against one strain of HIV-1 does not always protect against other strains. However, studies to determine the incidence of HIV-1 superinfection have yielded conflicting results. Furthermore, few studies have attempted to identify superinfection cases occurring more than a year after initial infection, a time when HIV-1-specific immune responses would be most likely to have developed. We screened a cohort of high-risk Kenyan women for HIV-1 superinfection by comparing partial gag and envelope sequences over a 5-y period beginning at primary infection. Among 36 individuals, we detected seven cases of superinfection, including cases in which both viruses belonged to the same HIV-1 subtype, subtype A. In five of these cases, the superinfecting strain was detected in only one of the two genome regions examined, suggesting that recombination frequently occurs following HIV-1 superinfection. In addition, we found that superinfection occurred throughout the course of the first infection: during acute infection in two cases, between 1-2 y after infection in three cases, and as late as 5 y after infection in two cases. Our results indicate that superinfection commonly occurs after the immune response against the initial infection has had time to develop and mature. Implications from HIV-1 superinfection cases, in which natural re-exposure leads to re-infection, will need to be considered in developing strategies for eliciting protective immunity to HIV-1.
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Affiliation(s)
- Anne Piantadosi
- Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
- Department of Pathobiology, University of Washington, Seattle, Washington, United States of America
| | - Bhavna Chohan
- Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
- Department of Pathobiology, University of Washington, Seattle, Washington, United States of America
| | - Vrasha Chohan
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | - R. Scott McClelland
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Julie Overbaugh
- Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
- Department of Pathobiology, University of Washington, Seattle, Washington, United States of America
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113
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Time from HIV seroconversion to death: a collaborative analysis of eight studies in six low and middle-income countries before highly active antiretroviral therapy. AIDS 2007; 21 Suppl 6:S55-63. [PMID: 18032940 DOI: 10.1097/01.aids.0000299411.75269.e8] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To estimate survival patterns after HIV infection in adults in low and middle-income countries. DESIGN An analysis of pooled data from eight different studies in six countries. METHODS HIV seroconverters were included from eight studies (three population-based, two occupational, and three clinic cohorts) if they were at least 15 years of age, and had no more than 4 years between the last HIV-negative and subsequent HIV-positive test. Four strata were defined: East African cohorts; South African miners cohort; Thai cohorts; Haitian clinic cohort. Kaplan-Meier functions were used to estimate survival patterns, and Weibull distributions were used to model and extend survival estimates. Analyses examined the effect of site, age, and sex on survival. RESULTS From 3823 eligible seroconverters, 1079 deaths were observed in 19 671 person-years of follow-up. Survival times varied by age and by study site. Adjusting to age 25-29 years at seroconversion, the median survival was longer in South African miners: 11.6 years [95% confidence interval (CI) 9.8-13.7] and East African cohorts: 11.1 years (95% CI 8.7-14.2) than in Haiti: 8.3 years (95% CI 3.2-21.4) and Thailand: 7.5 years (95% CI 5.4-10.4). Survival was similar for men and women, after adjustment for age at seroconversion and site. CONCLUSION Without antiretroviral therapy, overall survival after HIV infection in African cohorts was similar to survival in high-income countries, with a similar pattern of faster progression at older ages at seroconversion. Survival appears to be significantly worse in Thailand where other, unmeasured factors may affect progression.
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114
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HIV-1 disease progression and mortality before the introduction of highly active antiretroviral therapy in rural Uganda. AIDS 2007; 21 Suppl 6:S21-9. [PMID: 18032935 DOI: 10.1097/01.aids.0000299407.52399.05] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To provide estimates of survival and progression to different HIV disease endpoints after HIV infection among adults in a rural Ugandan setting. DESIGN A prospective population-based cohort study. METHODS Eligible individuals at least 15 years of age with documented HIV seroconversion were recruited from a general population cohort in rural Uganda, along with a randomly selected proportion of HIV-prevalent and HIV-negative individuals. All participants were followed up every 3 months, and CD4 cell counts taken every 6 months in HIV-positive participants. Life tables and Kaplan-Meier functions were used to estimate survival patterns for all endpoints [death, time to World Health Organization (WHO) stage 2, 3, AIDS and CD4 cell count < 200 cells/mul]. Analysis of follow-up time was truncated when antiretroviral therapy (ART) became available in the area in January 2004. RESULTS We recruited 240 HIV incident cases, 108 prevalent cases and 257 HIV-negative controls. Crude mortality rates were 70.0 per 1000 person-years in HIV-positive, and 12.1 per 1000 person-years in HIV-negative individuals. The median time from seroconversion to death was 9.0 years (N = 240) and 6.2 years to a CD4 cell count less than 200 cells/mul or WHO stage 4 (N = 229). The median time from ART eligibility (CD4 cell count < 200 cells/mul, < 350 cells/mul and WHO stage 3, or WHO stage 4) to death was 34.7 months. Older age at seroconversion was a risk factor for faster progression to death and ART eligibility. CONCLUSION HIV progression in this African cohort is similar to that reported in industrialized countries before the widespread introduction of ART.
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115
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Lieve VDP, Shafer LA, Mayanja BN, Whitworth JAG, Grosskurth H. Effect of pregnancy on HIV disease progression and survival among women in rural Uganda. Trop Med Int Health 2007; 12:920-8. [PMID: 17697086 DOI: 10.1111/j.1365-3156.2007.001873.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To investigate the effect of pregnancy on HIV disease progression and survival among HIV-infected women in rural Uganda, prior to the introduction of anti-retroviral therapy (ART). METHODS From a clinical cohort established in 1990, we selected records from HIV-infected women of reproductive age. We conducted two analyses: (1) all HIV-infected cases contributing to analysis of CD4 decline, using a linear regression model with random intercepts and slopes; (b) incident cases with known date of seroconversion contributed to analyses of median time to CD4 <200 cells/microl, AIDS and death. RESULTS A total of 139 women were included in the analysis of CD4 decline. Women who subsequently became pregnant had higher CD4 counts at enrolment and had a slower CD4 decline than those who did not become pregnant. In women who became pregnant, CD4 decline was faster after pregnancy than before (P < 0.0001). The survival analyses showed no significant differences between women who became pregnant and those who did not with respect to median time to CD4 count <200, AIDS or death. CONCLUSIONS The initial comparative immunological advantage possessed by fertile women before they become pregnant is subsequently lost as a result of their pregnancy. Women should be informed about the potential negative effect of pregnancy on their immunological status and should be offered contraception. In resource-limited settings, women determined to become pregnant should be given priority for ART if eligible.
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116
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Variation in HIV-1 set-point viral load: epidemiological analysis and an evolutionary hypothesis. Proc Natl Acad Sci U S A 2007; 104:17441-6. [PMID: 17954909 DOI: 10.1073/pnas.0708559104] [Citation(s) in RCA: 301] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The natural course of HIV-1 infection is characterized by a high degree of heterogeneity in viral load, not just within patients over time, but also between patients, especially during the asymptomatic stage of infection. Asymptomatic, or set-point, viral load has been shown to correlate with both decreased time to AIDS and increased infectiousness. The aim of this study is to characterize the epidemiological impact of heterogeneity in set-point viral load. By analyzing two cohorts of untreated patients, we quantify the relationships between both viral load and infectiousness and the duration of the asymptomatic infectious period. We find that, because both the duration of infection and infectiousness determine the opportunities for the virus to be transmitted, this suggests a trade-off between these contributions to the overall transmission potential. Some public health implications of variation in set-point viral load are discussed. We observe that set-point viral loads are clustered around those that maximize the transmission potential, and this leads us to hypothesize that HIV-1 could have evolved to optimize its transmissibility, a form of adaptation to the human host population. We discuss how this evolutionary hypothesis can be tested, review the evidence available to date, and highlight directions for future research.
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117
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Graham SM, Baeten JM, Richardson BA, Wener MH, Lavreys L, Mandaliya K, Ndinya-Achola JO, Overbaugh J, McClelland RS. A decrease in albumin in early HIV type 1 infection predicts subsequent disease progression. AIDS Res Hum Retroviruses 2007; 23:1197-200. [PMID: 17961104 DOI: 10.1089/aid.2007.0065] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We investigated the association between albumin levels and HIV-1 disease progression among 78 Kenyan women followed from before infection through a median of 70 months. With HIV-1 acquisition, median albumin decreased from 38.5 g/liter to 36.8 g/liter (p = 0.07) and the prevalence of hypoalbuminemia increased from 16% to 32% (p = 0.02). Each 1 g/liter decrease in albumin with HIV-1 acquisition was associated with a 13% increase (p = 0.01) in the risk of progressing to a CD4 count <200 cells/mul, after adjustment for set point plasma viral load. A decrease in albumin of over 10% was associated with a 3.5-fold increase in the risk of progressing to a CD4 count <200 cells/mul (95% CI 1.4-9.0, p = 0.008). Trends for an increased risk of mortality were also seen. A greater decrease in albumin levels accompanying HIV-1 acquisition may be a marker for changes in early infection associated with more rapid disease progression.
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Affiliation(s)
- Susan M. Graham
- Department of Medicine, University of Washington, Seattle, Washington 98104
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | - Jared M. Baeten
- Department of Medicine, University of Washington, Seattle, Washington 98104
| | - Barbra A. Richardson
- Departments of Biostatistics, University of Washington, Seattle, Washington 98104
| | - Mark H. Wener
- Laboratory Medicine, University of Washington, Seattle, Washington 98104
| | - Ludo Lavreys
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
- Epidemiology, University of Washington, Seattle, Washington 98104
| | | | | | - Julie Overbaugh
- Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - R. Scott McClelland
- Department of Medicine, University of Washington, Seattle, Washington 98104
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
- Epidemiology, University of Washington, Seattle, Washington 98104
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Abstract
HIV infection starts as an acute, systemic infection, followed by a chronic period of clinical latency, usually lasting 3 to 10 years, which precedes the eventual collapse of the immune system. It is increasingly recognized that events occurring during acute HIV infection may determine the natural course of the disease. The very dynamic events of acute HIV infection provide multiple opportunities for biologic interventions, such as anti-retroviral or immune-based therapies. Similarly, the implementation of public health measures during acute HIV infection could help control epidemics or outbreaks. Many of the dramatic possibilities for intervention in acute HIV infection remain unproved, not the least because of traditional difficulty of diagnosing patients during this early period. This article reviews the natural history, pathogenesis and clinical presentation of acute HIV infection, and suggests a diagnostic and therapeutic approach to guide clinicians dealing with patients with suspected or confirmed acute HIV infection.
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Affiliation(s)
- Nicola M Zetola
- Division of Infectious Diseases, University of California-San Francisco, San Francisco, CA 94103, USA
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119
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Kelley CF, Barbour JD, Hecht FM. The Relation Between Symptoms, Viral Load, and Viral Load Set Point in Primary HIV Infection. J Acquir Immune Defic Syndr 2007; 45:445-8. [PMID: 17514014 DOI: 10.1097/qai.0b013e318074ef6e] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To examine the relation between symptoms, initial viral load, and viral load set point in primary HIV infection (PHI). DESIGN Prospective cohort of patients with preseroconversion or recent seroconversion HIV infection (typically <60 days) in San Francisco. METHODS Subjects were questioned about 21 potential PHI symptoms at enrollment and were subsequently followed with viral load measures. RESULTS The analysis included 57 subjects with preseroconversion HIV infection and 120 with recent seroconversion. In univariate analysis, most symptoms and the total number of symptoms were each associated with a significantly higher initial viral load. In stepwise multiple linear regression, however, only the number of symptoms was independently associated with a higher initial viral load, with an increase in the initial viral load of 0.08 log10 per additional symptom (P < 0.001). In univariate analysis, more PHI symptoms were associated with a higher viral load set point, but in a multivariable mixed-effects model, this association was accounted for by the initial viral load, which was strongly correlated with viral load set point (R = 0.44, P < 0.001). CONCLUSIONS A high initial viral load was associated with more symptoms during PHI. The strong correlation between initial HIV-1 RNA viral load levels and viral load set point suggests that early interactions between the HIV-1 virus and a new host, even before fully developed adaptive immune responses, are important in establishing viral load set point.
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Affiliation(s)
- Colleen F Kelley
- Department of Medicine, San Francisco General Hospital, University of California at San Francisco, 995 Potrero Avenue, San Francisco, CA 94110, USA
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120
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Graham SM, Baeten JM, Richardson BA, Bankson DD, Lavreys L, Ndinya-Achola JO, Mandaliya K, Overbaugh J, McClelland RS. Higher pre-infection vitamin E levels are associated with higher mortality in HIV-1-infected Kenyan women: a prospective study. BMC Infect Dis 2007; 7:63. [PMID: 17594484 PMCID: PMC1914075 DOI: 10.1186/1471-2334-7-63] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2007] [Accepted: 06/26/2007] [Indexed: 11/25/2022] Open
Abstract
Background Low vitamin E levels are often found in HIV-1 infection, and studies have suggested that higher levels may decrease the risk of disease progression. However, vitamin E supplementation has also been reported to increase CCR5 expression, which could increase HIV-1 replication. We hypothesized that vitamin E levels at HIV-1 acquisition may influence disease progression. Methods Vitamin E status was measured in stored samples from the last pre-infection visit for 67 Kenyan women with reliably estimated dates of HIV-1 acquisition. Regression analyses were used to estimate associations between pre-infection vitamin E and plasma viral load, time to CD4 count <200 cells/μL, and mortality. Results After controlling for potential confounding factors, each 1 mg/L increase in pre-infection vitamin E was associated with 0.08 log10 copies/mL (95% CI -0.01 to +0.17) higher set point viral load and 1.58-fold higher risk of mortality (95% CI 1.15–2.16). The association between higher pre-infection vitamin E and mortality persisted after adjustment for set point viral load (HR 1.55, 95% CI 1.13–2.13). Conclusion Higher pre-infection vitamin E levels were associated with increased mortality. Further research is needed to elucidate the role vitamin E plays in HIV-1 pathogenesis.
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Affiliation(s)
- Susan M Graham
- Department of Medicine, Box 356420, University of Washington, Seattle, Washington 98195, USA
- Department of Medical Microbiology, University of Nairobi, P.O. Box 30197-00100, Nairobi, Kenya
| | - Jared M Baeten
- Department of Medicine, Box 356420, University of Washington, Seattle, Washington 98195, USA
| | - Barbra A Richardson
- Department of Biostatistics, Box 357232, University of Washington, Seattle, Washington 98195, USA
| | - Daniel D Bankson
- Department of Laboratory Medicine, Box 357110, University of Washington, Seattle, Washington 98195, USA
- Department of Pathology and Laboratory Medicine Service, Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way, Seattle, Washington 98108, USA
| | - Ludo Lavreys
- Department of Epidemiology, Box 357236, University of Washington, Seattle, Washington 98195, USA
- Department of Medical Microbiology, University of Nairobi, P.O. Box 30197-00100, Nairobi, Kenya
| | | | | | - Julie Overbaugh
- Division of Human Biology, Fred Hutchinson Cancer Research Center, P.O. Box 19024, Seattle, Washington 98109, USA
| | - R Scott McClelland
- Department of Medicine, Box 356420, University of Washington, Seattle, Washington 98195, USA
- Department of Epidemiology, Box 357236, University of Washington, Seattle, Washington 98195, USA
- Department of Medical Microbiology, University of Nairobi, P.O. Box 30197-00100, Nairobi, Kenya
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Baeten JM, Lavreys L, Overbaugh J. The influence of hormonal contraceptive use on HIV-1 transmission and disease progression. Clin Infect Dis 2007; 45:360-9. [PMID: 17599316 DOI: 10.1086/519432] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2007] [Accepted: 04/04/2007] [Indexed: 11/03/2022] Open
Abstract
Women account for nearly one-half of new human immunodeficiency virus type 1 (HIV-1) infections worldwide, including the majority of infections in Africa. Biological and epidemiological studies suggest that hormonal contraceptive use could influence susceptibility to HIV-1, as well as infectivity and disease progression for those who become infected. However, not all studies have shown this relationship, and many questions remain. Safe and effective contraceptive choices are essential for women with and at risk for HIV-1 infection. Thus, understanding the effect, if any, of hormonal contraception on HIV-1 disease among women is a public health priority.
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Affiliation(s)
- Jared M Baeten
- Department of Medicine, University of Washington, Seattle, WA, USA.
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Glynn JR, Sonnenberg P, Nelson G, Bester A, Shearer S, Murray J. Survival from HIV-1 seroconversion in Southern Africa: a retrospective cohort study in nearly 2000 gold-miners over 10 years of follow-up. AIDS 2007; 21:625-32. [PMID: 17314525 DOI: 10.1097/qad.0b013e328017f857] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To obtain robust estimates of survival with HIV in individuals with known dates of seroconversion in Africa in the pre-antiretroviral era. DESIGN AND METHODS Mortality rates were estimated in men from four South African gold mines in a retrospective cohort study with 10-year follow-up. HIV testing was carried out with counselling and consent, in random surveys in the early 1990s and in clinics. A total of 1950 HIV-positive men with seroconversion intervals < 3 years were compared with 6164 HIV-negative men with no subsequent evidence of HIV. Unique industry numbers were used to link medical records to demographic and occupational information. Follow-up after leaving the mine was conducted through employment offices across southern Africa, and using South African death registration data. RESULTS Follow-up was complete for 85% of those who seroconverted. Median survival was 10.5 years overall: 11.5 years for those aged 15-24 at seroconversion, 10.5 years for those aged 25-34, 9.5 years for those aged 35-44, and 6.3 years for those aged 45+ years. The relative mortality rate in comparison with HIV-uninfected miners increased quickly, reaching 13 for those HIV-infected for at least 9 years, and did not vary by age group. Excess mortality increased with age and duration of infection to > 10% per year. Adjusted to age 25-29 years at seroconversion, 5-year survival was 89% and 10-year 62%. DISCUSSION This study reports by far the largest cohort of individuals with known dates of seroconversion available in Africa. After adjusting for age, the survival pattern was similar to that seen in the West before antiretroviral therapy was available.
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Affiliation(s)
- Judith R Glynn
- Department of Epidemiology and Population Sciences, London School of Hygiene and Tropical Medicine, UK.
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