Determinants of cognitive health in Indonesian HIV patients beginning antiretroviral therapy

Effect of atorvastatin on subclinical atherosclerosis in virally-suppressed HIV-infected patients with CMV seropositivity: a randomized double-blind placebo-controlled trial

Background: Persistent immune activation and inflammation in HIV-infection are linked to excess cardiovascular risk and other non-communicable diseases. Periodic asymptomatic CMV-reactivity in HIV infected patients over a lifetime may contribute to non-AIDS defining morbidity. Despite undetectable levels of HIV and CMV, these patients continue to have increased levels of biomarkers and immune activations. Statin administration is thought to reduce subclinical atherosclerosis by decreasing LDL-C levels. It may also add beneficial effects against CMV infection. Methods: We are conducting a double-blind placebo-controlled trial in which patients are randomized to receive either atorvastatin or placebo with a ratio of 1:1. This trial aims to study the effect of atorvastatin in statin-naive virally-suppressed HIV-infected patients with stable ART and CMV seropositivity on carotid intima media thickness (CIMT), tool that evaluates subclinical atherosclerosis. The study recruits 80 patients at HIV integrated care unit of Cipto Mangunkusumo hospital. All eligible subjects have CIMT evaluation as primary outcome, along with flow mediated vasodilatation (FMD), liver fibrosis and steatosis evaluation, fasting lipid, neurocognitive test, community periodontal index (CPI), and residual immune activation as secondary outcomes in 48 weeks. Ethics and dissemination: This study has received an ethical approval from Health Research Ethics Commitee-Universitas Indonesia and Cipto Mangunkusumo Hospital. Before joining the study, all participants fill in an informed consent form. At the end of study analysis, the trial results will be published and disseminated in peer-reviewed journals. Discussion: The main purpose of our study is to evaluate the effect of atorvastatin administration on CIMT changes in statin naïve virally suppressed HIV-infected patients with stable ART and CMV seropositivity Registration: ClinicalTrials.gov ID NCT04101136; registered on 24 September 2019.

Effect of atorvastatin on subclinical atherosclerosis in virally-suppressed HIV-infected patients with CMV seropositivity: a randomized double-blind placebo-controlled trial

Background: Persistent immune activation and inflammation in HIV-infection are linked to excess cardiovascular risk and other non-communicable diseases. Periodic asymptomatic CMV-reactivity in HIV infected patients over a lifetime may contribute to non-AIDS defining morbidity. Despite undetectable levels of HIV and CMV, these patients continue to have increased levels of biomarkers and immune activations. Statin administration is thought to reduce subclinical atherosclerosis by decreasing LDL-C levels. It may also add beneficial effects against CMV infection. Methods: We are conducting a double-blind placebo-controlled trial in which patients are randomized to receive either atorvastatin or placebo with a ratio of 1:1. This trial aims to study the effect of atorvastatin in statin-naive virally-suppressed HIV-infected patients with stable ART and CMV seropositivity on carotid intima media thickness (CIMT), tool that evaluates subclinical atherosclerosis. The study recruits 80 patients at HIV integrated care unit of Cipto Mangunkusumo hospital. All eligible subjects have CIMT evaluation as primary outcome, along with flow mediated vasodilatation (FMD), liver fibrosis and steatosis evaluation, fasting lipid, neurocognitive test, community periodontal index (CPI), and residual immune activation as secondary outcomes in 48 weeks. Ethics and dissemination: This study has received an ethical approval from Health Research Ethics Commitee-Universitas Indonesia and Cipto Mangunkusumo Hospital. Before joining the study, all participants fill in an informed consent form. At the end of study analysis, the trial results will be published and disseminated in peer-reviewed journals. Discussion: The main purpose of our study is to evaluate the effect of atorvastatin administration on CIMT changes in statin naïve virally suppressed HIV-infected patients with stable ART and CMV seropositivity Registration: ClinicalTrials.gov ID NCT04101136; registered on 24 September 2019.

γδ T Cell Subpopulations Associate with Recovery of Memory Function in Indonesian HIV Patients Starting Antiretroviral Therapy

Cognitive impairment may persist in HIV patients despite effective antiretroviral therapy (ART). However, recovery is influenced by the neurocognitive domain tested, the severity of HIV disease, and by education. In young adult patients commencing ART in Jakarta, Indonesia, we described improvements in all cognitive domains except memory after 6-12 months on ART. In this study, we address relationships between cytomegalovirus (CMV), γδ T cell profiles and neurocognitive assessments with a focus on memory. The JakCCANDO (Jakarta CMV Cardiovascular ART Neurology Dentistry Ophthalmology) project recruited patients (aged 18-48 years) beginning ART with <200 CD4⁺ T cells/μL. Cognitive assessments used validated tests of five domains. Flow cytometry was used to assess proportions of Vδ2^- and Vδ2⁺ γδ T cells, and their activation (HLA-DR) and terminal differentiation (CD27^-/CD45RA⁺). All patients carried high levels of antibodies reactive with CMV, so the detection of CMV DNA before ART was used to stratify participants into subgroups with a moderate/high or an extremely high burden of CMV. Patients had higher proportions of Vδ2^- γδ T cells and fewer Vδ2⁺ γδ T cells than healthy controls before ART and at 6 months. Z-scores for memory function correlated with proportions of Vδ2⁺ γδ T cells at both time points. Linear regression analyses confirmed this association. When the detection of CMV DNA was used to stratify the cohort, the association between memory Z-scores and Vδ2⁺ γδ T cells or CMV antibodies was only discernible in patients with a lower CMV burden. Hence, CMV and Vδ2⁺ γδ T cells warrant further consideration as factors that may contribute to the poor recovery of memory on ART.

Sequencing of the Viral UL111a Gene Directly from Clinical Specimens Reveals Variants of HCMV-Encoded IL-10 That Are Associated with Altered Immune Responses to HCMV

Human cytomegalovirus (HCMV) is a beta-herpesvirus carried by ~80% of adults worldwide. Acute infections are often asymptomatic in healthy individuals but generate diverse syndromes in neonates, renal transplant recipients (RTR), and people with HIV (PWH). The HCMV gene UL111a encodes a homolog of human interleukin-10 (IL-10) that interacts with the human IL-10 receptor. Deep sequencing technologies were used to sequence UL111a directly from 59 clinical samples from Indonesian PWH and Australian RTR, healthy adults, and neonates. Overall, 93% of samples contained more than one variant of HCMV, as defined by at least one nonsynonymous variation. Carriage of these variants differed between neonates and adults, Australians and Indonesians, and between saliva and blood leukocytes. The variant alleles of N41D and S71Y occurred together in Australian RTR and were associated with higher T-cell responses to HCMV pp65. The variant P122S was associated with lower levels of antibodies reactive with a lysate of HCMV-infected fibroblasts. L174F was associated with increased levels of antibodies reactive with HCMV lysate, immediate-early 1 (IE-1), and glycoprotein B (gB) in Australian RTR and Indonesians PWH, suggesting a higher viral burden. We conclude that variants of UL111a are common in all populations and may influence systemic responses to HCMV.

Brief Report: Polymorphisms in CAMKK2 may Influence Domain-Specific Neurocognitive Function in HIV+ Indonesians Receiving ART

BACKGROUND

Despite effective antiretroviral therapy (ART), milder forms of HIV-associated neurocognitive disorders remain prevalent and are characterized by neuroinflammation, synaptic dysfunction, and neuronal loss.

METHODS

We explore associations between neurocognitive impairment in HIV+ Indonesians and 17 polymorphisms in adjacent genes involved in inflammation and neuronal growth/repair pathways, P2X4R and CAMKK2. HIV+ Indonesians (n = 59) who had received ART for 12 months were assessed to derive Z-scores for the attention, fluency, memory, executive, and motor speed domains relative to local control subjects. These were used to determine total cognitive scores.

RESULTS

No alleles of P2X4R displayed significant associations with neurocognition in bivariate or multivariable analyses. In CAMKK2, rs2686344 influenced total cognitive scores in bivariate analyses (P = 0.04). Multivariable linear regression modeling independently associated rs2686344 with higher executive function Z-scores (P = 0.05) after adjusting for CD4 T-cell counts (adjusted R2 = 0.103, model P = 0.034), whereas rs1653588 associated with lower and rs1718120 (P = 0.05) with higher fluency Z-scores (P = 0.05) after adjusting for education and log10 HIV RNA copies/mL (adjusted R2 = 0.268, model P = 0.001).

CONCLUSIONS

Polymorphisms in CAMKK2 may influence neurocognitive outcomes in specific domains in HIV+ Indonesians receiving ART for 12 months.

Challenging the Conventional Interpretation of HCMV Seronegativity

The majority of adults in the world (around 83%) carry antibodies reactive with HCMV and are thought to retain inactive or latent infections lifelong. The virus is transmitted via saliva, so infection events are likely to be common. Indeed, it is hard to imagine a life without exposure to HCMV. From 45 seronegative individuals (13 renal transplant recipients, 32 healthy adults), we present seven cases who had detectable HCMV DNA in their blood and/or saliva, or a CMV-encoded homologue of IL-10 (vIL-10) in their plasma. One case displayed NK cells characteristic of CMV infection before her HCMV DNA became undetectable. In other cases, the infection may persist with seroconversion blocked by vIL-10. Future research should seek mechanisms that can prevent an individual from seroconverting despite a persistent HCMV infection, as HCMV vaccines may not work well in such people.

Sequencing Directly from Clinical Specimens Reveals Genetic Variations in HCMV-Encoded Chemokine Receptor US28 That May Influence Antibody Levels and Interactions with Human Chemokines

Human cytomegalovirus (HCMV) is a beta-herpesvirus carried by ∼80% of the world’s population. Acute infections are asymptomatic in healthy individuals but generate diverse syndromes in neonates, solid organ transplant recipients, and HIV-infected individuals. The HCMV gene US28 encodes a homolog of a human chemokine receptor that is able to bind several chemokines and HIV gp120. Deep sequencing technologies were used to sequence US28 directly from 60 clinical samples from Indonesian HIV patients and Australian renal transplant recipients, healthy adults, and neonates. Molecular modeling approaches were used to predict whether nine nonsynonymous mutations in US28 may alter protein binding to a panel of six chemokines and two variants of HIV gp120. Ninety-two percent of samples contained more than one variant of HCMV, as defined by at least one nonsynonymous mutation. Carriage of these variants differed between neonates and adults, Australian and Indonesian samples, and saliva samples and blood leukocytes. Two nonsynonymous mutations (N170D and R267K) were associated with increased levels of immediate early protein 1 (IE-1) and glycoprotein B (gB) HCMV-reactive antibodies, suggesting a higher viral burden. Seven of the nine mutations were predicted to alter binding of at least one ligand. Overall, HCMV variants are common in all populations and have the potential to affect US28 interactions with human chemokines and/or gp120 and alter responses to the virus. The findings relied on deep sequencing technologies applied directly to clinical samples, so the variants exist in vivo.

IMPORTANCE Human cytomegalovirus (HCMV) is a common viral pathogen of solid organ transplant recipients, neonates, and HIV-infected individuals. HCMV encodes homologs of several host genes with the potential to influence viral persistence and/or pathogenesis. Here, we present deep sequencing of an HCMV chemokine receptor homolog, US28, acquired directly from clinical specimens. Carriage of these variants differed between patient groups and was associated with different levels of circulating HCMV-reactive antibodies. These features are consistent with a role for US28 in HCMV persistence and pathogenesis. This was supported by in silico analyses of the variant sequences demonstrating altered ligand-binding profiles. The data delineate a novel approach to understanding the pathogenesis of HCMV and may impact the development of an effective vaccine.

Neurocognitive outcomes in indonesians living with HIV are influenced by polymorphisms in the gene encoding purinergic P2X receptor 7

The advent of effective antiretroviral therapy (ART) has decreased the prevalence and severity of HIV-associated neurocognitive disorders (HAND), but milder forms of HAND remain despite optimal treatment. Neuronal injury and loss due to inflammation may mediate HAND. P2X7R encodes purinergic P2X receptor 7 which influences neuroinflammatory pathways and carries polymorphisms associated with sensory neuropathy in HIV patients. We assessed associations between P2X7R polymorphisms and neurocognitive outcomes in Indonesian patients (n ​= ​59) as they commenced ART and after 3, 6 and 12 months. Z-scores were calculated over 5 domains using local controls and evaluated as continuous variables. Optimal linear regression models identified polymorphisms influencing attention, memory, executive function, motor speed and total cognitive function at each time point. rs504677 was associated with lower executive and motor speed Z-scores at 0, 3, 6, and 12 months, and with memory at 0 and 12 months. Memory was positively influenced by carriage of the rs208296 minor allele at 0, 3 and 6 months and by carriage of the rs208307 minor allele at 0 and 12 months. Higher attention Z-scores associated with carriage of minor alleles of rs1653598 after 0 and 12 months. These also positively influenced executive function and motor speed after 0–6 months. This study identifies polymorphisms in P2X7R which influence domain-specific neurocognitive outcomes in HIV+ ​Indonesians prior to and shortly after commencing ART. This implicates purinergic P2X receptor 7 in the pathogenesis of HAND.

•

Neurocognitive outcomes in HIV+ ​Indonesians were assessed over one year on ART.

•

Overall scores were influenced by age, education and CD4 T-cell counts.

•

Five intronic polymorphisms in P2X7R affected scores of selected domains.

•

The influence of P2X7R polymorphisms varied over time on ART.

•

P2X7R may influence neurocognitive changes on ART.

Effects of Playing Angklung and Practicing Silence on Emotion, Cognition and Oxytocin Levels in Children: A Preliminary Study

Background

Playing angklung, an Indonesian traditional musical instrument and practicing silence have been shown to exert beneficial effects on emotion and cognition; the mechanism of such an effect possibly involve oxytocin. To date, only a few clinical and biomolecular studies have investigated the effects of playing angklung and practicing silence. This study aimed to examine the effects of playing angklung and practicing silence on human emotion and cognition and on oxytocin levels.

Methods

This experimental study involved 61 Fourth Grade students from Surabaya, East Java, Indonesia. The participants were divided into two groups: the angklung intervention group and silence intervention group. The two interventions were performed for 15 min before the morning classes for 2 months. The control group attended their classes as usual. Clinical parameters, namely, emotion and cognition, as well as the saliva oxytocin levels were measured.

Results

No significant differences were observed among the three groups in terms of concentration and cognitive flexibility. However, changes in oxytocin levels significantly differed among the three groups (P < 0.001) and the oxytocin levels were highest in the silence intervention group.

Conclusion

Practicing silence significantly increased the oxytocin levels, but it did not elicit changes in cognitive function and emotion of the students.

Periodontitis and Cytomegalovirus Associate With Atherosclerosis Among HIV Patients After 5 Years on ART

OBJECTIVES

Atherosclerosis has been linked with periodontitis in the general population and with persistent immune activation and a high burden of cytomegalovirus (CMV) in HIV patients responding to antiretroviral therapy (ART). Here, we assess risk factors for cardiovascular changes in younger HIV patients representative of patient populations in Asia.

STUDY DESIGN

HIV-infected adults (n = 82) with <200 CD4 T-cells/μl were examined as they began ART at Cipto Mangunkusumo Hospital, Jakarta, and after 3 months. 32 patients were re-assessed after 5 years, alongside 32 age-matched healthy controls.

METHODS

We assessed the community periodontal index of treatment needs, carotid -thickness (cIMT), plasma markers of immune activation (using commercial enzyme-linked immunosorbent assay) and CMV antibodies by in-house enzyme-linked immunosorbent assay.

RESULTS

Periodontitis persisted in 16/32 patients after 5 years and was potentiated by greater age (P = 0.03) and poor oral hygiene (P = 0.05), with no effect of smoking, pulmonary tuberculosis, oral candidiasis, or low CD4 T-cell counts (P > 0.05). After 5 years on ART, right and left cIMT were greater in HIV patients with periodontitis (P = 0.02, 0.006, respectively). Moreover, cIMT values were higher in patients with periodontitis (P = 0.05-0.01) than in equivalent controls. Simple linear regressions showed that patients with periodontitis had greater right (P = 0.01) and left (P = 0.004) cIMT than those without periodontitis. Multiple linear regressions showed that periodontitis and CMV antibody levels optimally predicted poor right and left cIMT (Adjusted R = 0.36, P = 0.0013; Adjusted R = 0.40, P = 0.001, respectively).

CONCLUSIONS

Our data identify periodontitis and CMV as independent predictors of atherosclerosis in young adult HIV patients.

Frailty among HIV-1 Infected Adults under Antiretroviral Therapy in Indonesia

BACKGROUND

Increasing age of HIV-1 infected population brought about the risk of frailty as comorbidity, whose prevalence is higher in low and middle-income countries (LMICs). Indonesia as an LMIC also bears a major burden of HIV-1 epidemic with a similarly aging population, but the prevalence of frailty and its predictors are unknown.

OBJECTIVES

To identify the prevalence of frailty and analyze its associated factors, among HIV-1 infected adults under antiretroviral therapy in Indonesia.

METHODS

A cross-sectional study was conducted among HIV-infected individuals with inclusion criteria of age ≥30 years old and underwent ART for at least 6 months. The main assessment was done using Fried's frailty phenotype score, which categorizes subjects into non-frail, pre-frail, or frail. Factors associated with frailty were characterized and multiple logistic regression analysis was performed.

RESULTS

A total of 164 subjects were recruited; male subjects were 118 (72%), the median age was 40.5 years old, and the median CD4 nadir was 53 cells/μl. Frailty was identified among 90 (54.9%) subjects with 84 (51.2%) identified as pre-frail and 6 (3.7%) as frail, with dominant frailty phenotype was weakness in grip strength. The multivariate model showed that depression was the only factor significantly correlated with pre-frailty and frailty (OR 2.14; 95% CI 1.04-4.43, p=0.036).

CONCLUSION

Frailty is a common occurrence among HIV-infected patients under ART, with depression as an independent predictive factor.