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Bull M, Mitchell C, Soria J, Styrchak S, Williams C, Dragavon J, Ryan KJ, Acosta E, Onchiri F, Coombs RW, La Rosa A, Ticona E, Frenkel LM. Genital Shedding of Human Immunodeficiency Virus Type-1 (HIV) When Antiretroviral Therapy Suppresses HIV Replication in the Plasma. J Infect Dis 2021; 222:777-786. [PMID: 32274499 DOI: 10.1093/infdis/jiaa169] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 04/08/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND During antiretroviral treatment (ART) with plasma HIV RNA below the limit of quantification, HIV RNA can be detected in genital or rectal secretions, termed discordant shedding (DS). We hypothesized that proliferating cells produce virions without HIV replication. METHODS ART-naive Peruvians initiating ART were observed for DS over 2 years. HIV env and pol genomes were amplified from DS. Antiretrovirals and cytokines/chemokines concentrations were compared at DS and control time points. RESULTS Eighty-two participants had ART suppression. DS was detected in 24/82 (29%) participants: 13/253 (5%) cervicovaginal lavages, 20/322 (6%) seminal plasmas, and 6/85 (7%) rectal secretions. HIV RNA in DS specimens was near the limit of quantification and not reproducible. HIV DNA was detected in 6/13 (46%) DS cervicovaginal lavages at low levels. Following DNase treatment, 5/39 DS specimens yielded HIV sequences, all without increased genetic distances. Women with and without DS had similar plasma antiretroviral levels and DS in 1 woman was associated with inflammation. CONCLUSIONS HIV RNA and DNA sequences and therapeutic antiretroviral plasma levels did not support HIV replication as the cause of DS from the genital tract. Rather, our findings infer that HIV RNA is shed due to proliferation of infected cells with virion production.
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Affiliation(s)
- Marta Bull
- Seattle Children's Research Institute, Seattle, Washington, USA.,Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Caroline Mitchell
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, USA
| | - Jaime Soria
- Infectious Diseases Department, Hospital Nacional Dos de Mayo, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Sheila Styrchak
- Seattle Children's Research Institute, Seattle, Washington, USA
| | - Corey Williams
- Seattle Children's Research Institute, Seattle, Washington, USA
| | - Joan Dragavon
- Department of Laboratory Medicine, University of Washington, Seattle, Washington, USA
| | - Kevin J Ryan
- School of Medicine, University of Alabama, Birmingham, Alabama, USA
| | - Edward Acosta
- School of Medicine, University of Alabama, Birmingham, Alabama, USA
| | - Frankline Onchiri
- Core for Biomedical Statistics, Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Robert W Coombs
- Department of Laboratory Medicine, University of Washington, Seattle, Washington, USA.,Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Alberto La Rosa
- Asociaciòn Civil Impacta Salud y Educación, Lima, Peru, and.,Merck Sharp & Dohme, Lima, Peru
| | - Eduardo Ticona
- Infectious Diseases Department, Hospital Nacional Dos de Mayo, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Lisa M Frenkel
- Seattle Children's Research Institute, Seattle, Washington, USA.,Department of Pediatrics, University of Washington, Seattle, Washington, USA
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McNicholl JM, Leelawiwat W, Whitehead S, Hanson DL, Evans-Strickfaden T, Cheng CY, Chonwattana W, Mueanpai F, Kittinunvorakoon C, Markowitz L, Dunne EF. Self-collected genital swabs compared with cervicovaginal lavage for measuring HIV-1 and HSV-2 and the effect of acyclovir on viral shedding. Int J STD AIDS 2016; 28:372-379. [PMID: 27179350 PMCID: PMC5315198 DOI: 10.1177/0956462416650123] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
HIV-1 and HSV-2 are frequent genital co-infections in women. To determine how self-collected genital swabs compare to provider-collected cervicovaginal lavage, paired self-collected genital swabs and cervicovaginal lavage from women co-infected with HIV-1 and HSV-2 were evaluated. Women were in an acyclovir clinical trial and their samples were tested for HIV-1 RNA (361 samples) and HSV-2 DNA (378 samples). Virus shedding, quantity and acyclovir effect were compared. HIV-1 and HSV-2 were more frequently detected in self-collected genital swabs: 74.5% of self-collected genital swabs and 63.6% of cervicovaginal lavage had detectable HIV-1 (p ≤ 0.001, Fisher's exact test) and 29.7% of self-collected genital swabs and 19.3% of cervicovaginal lavage had detectable HSV-2 (p ≤ 0.001) in the placebo month. Cervicovaginal lavage and self-collected genital swabs virus levels were correlated (Spearman's rho, 0.68 for HIV; 0.61 for HSV-2) and self-collected genital swabs levels were generally higher. In multivariate modeling, self-collected genital swabs and cervicovaginal lavage could equally detect the virus-suppressive effect of acyclovir: for HIV-1, proportional odds ratios were 0.42 and 0.47 and for HSV-2, they were 0.10 and 0.03 for self-collected genital swabs and cervicovaginal lavage, respectively. Self-collected genital swabs should be considered for detection and measurement of HIV-1 and HSV-2 in clinical trials and other studies as they are a sensitive method to detect virus and can be collected in the home with frequent sampling.
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Affiliation(s)
- Janet M McNicholl
- 1 Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, GA, USA.,2 The Thai Ministry of Public Health, U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Wanna Leelawiwat
- 2 The Thai Ministry of Public Health, U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Sara Whitehead
- 1 Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, GA, USA.,2 The Thai Ministry of Public Health, U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Debra L Hanson
- 1 Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, GA, USA
| | | | - Chen Y Cheng
- 3 Division of STD Prevention, Centers for Disease Control and Prevention, GA, USA
| | - Wannee Chonwattana
- 2 The Thai Ministry of Public Health, U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Famui Mueanpai
- 2 The Thai Ministry of Public Health, U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Chonticha Kittinunvorakoon
- 2 The Thai Ministry of Public Health, U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Lauri Markowitz
- 3 Division of STD Prevention, Centers for Disease Control and Prevention, GA, USA
| | - Eileen F Dunne
- 3 Division of STD Prevention, Centers for Disease Control and Prevention, GA, USA
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Tobian AAR, Kigozi G, Manucci J, Grabowski MK, Serwadda D, Musoke R, Redd AD, Nalugoda F, Reynolds SJ, Kighoma N, Laeyendecker O, Lessler J, Gray RH, Quinn TC, Wawer MJ. HIV shedding from male circumcision wounds in HIV-infected men: a prospective cohort study. PLoS Med 2015; 12:e1001820. [PMID: 25919012 PMCID: PMC4412625 DOI: 10.1371/journal.pmed.1001820] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 03/17/2015] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND A randomized trial of voluntary medical male circumcision (MC) of HIV-infected men reported increased HIV transmission to female partners among men who resumed sexual intercourse prior to wound healing. We conducted a prospective observational study to assess penile HIV shedding after MC. METHODS AND FINDINGS HIV shedding was evaluated among 223 HIV-infected men (183 self-reported not receiving antiretroviral therapy [ART], 11 self-reported receiving ART and had a detectable plasma viral load [VL], and 29 self-reported receiving ART and had an undetectable plasma VL [<400 copies/ml]) in Rakai, Uganda, between June 2009 and April 2012. Preoperative and weekly penile lavages collected for 6 wk and then at 12 wk were tested for HIV shedding and VL using a real-time quantitative PCR assay. Unadjusted prevalence risk ratios (PRRs) and adjusted PRRs (adjPRRs) of HIV shedding were estimated using modified Poisson regression with robust variance. HIV shedding was detected in 9.3% (17/183) of men not on ART prior to surgery and 39.3% (72/183) of these men during the entire study. Relative to baseline, the proportion shedding was significantly increased after MC at 1 wk (PRR = 1.87, 95% CI = 1.12-3.14, p = 0.012), 2 wk (PRR = 3.16, 95% CI = 1.94-5.13, p < 0.001), and 3 wk (PRR = 1.98, 95% CI = 1.19-3.28, p = 0.008) after MC. However, compared to baseline, HIV shedding was decreased by 6 wk after MC (PRR = 0.27, 95% CI = 0.09-0.83, p = 0.023) and remained suppressed at 12 wk after MC (PRR = 0.19, 95% CI = 0.06-0.64, p = 0.008). Detectable HIV shedding from MC wounds occurred in more study visits among men with an HIV plasma VL > 50,000 copies/ml than among those with an HIV plasma VL < 400 copies/ml (adjPRR = 10.3, 95% CI = 4.25-24.90, p < 0.001). Detectable HIV shedding was less common in visits from men with healed MC wounds compared to visits from men without healed wounds (adjPRR = 0.12, 95% CI = 0.07-0.23, p < 0.001) and in visits from men on ART with undetectable plasma VL compared to men not on ART (PRR = 0.15, 95% CI = 0.05-0.43, p = 0.001). Among men with detectable penile HIV shedding, the median log10 HIV copies/milliliter of lavage fluid was significantly lower in men with ART-induced undetectable plasma VL (1.93, interquartile range [IQR] = 1.83-2.14) than in men not on ART (2.63, IQR = 2.28-3.22, p < 0.001). Limitations of this observational study include significant differences in baseline covariates, lack of confirmed receipt of ART for individuals who reported ART use, and lack of information on potential ART initiation during follow-up for those who were not on ART at enrollment. CONCLUSION Penile HIV shedding is significantly reduced after healing of MC wounds. Lower plasma VL is associated with decreased frequency and quantity of HIV shedding from MC wounds. Starting ART prior to MC should be considered to reduce male-to-female HIV transmission risk. Research is needed to assess the time on ART required to decrease shedding, and the acceptability and feasibility of initiating ART at the time of MC.
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Affiliation(s)
- Aaron A. R. Tobian
- Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Rakai Health Sciences Program, Entebbe, Uganda
- * E-mail:
| | | | - Jordyn Manucci
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Mary K. Grabowski
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - David Serwadda
- Rakai Health Sciences Program, Entebbe, Uganda
- Institute of Public Health, Makerere University, Kampala, Uganda
| | | | - Andrew D. Redd
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | | | - Steven J. Reynolds
- Rakai Health Sciences Program, Entebbe, Uganda
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | | | - Oliver Laeyendecker
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Justin Lessler
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Ronald H. Gray
- Rakai Health Sciences Program, Entebbe, Uganda
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Thomas C. Quinn
- Rakai Health Sciences Program, Entebbe, Uganda
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Maria J. Wawer
- Rakai Health Sciences Program, Entebbe, Uganda
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
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Changes in plasma viral load and penile viral shedding after circumcision among HIV-positive men in Kisumu, Kenya. J Acquir Immune Defic Syndr 2014; 64:511-7. [PMID: 23933768 DOI: 10.1097/qai.0b013e3182a7ef05] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND We conducted a prospective cohort study of HIV-positive men aged 18-35 years in Kisumu, Kenya to determine if medical circumcision of ART-naive HIV-positive men leads to increased viral load and penile viral shedding. METHODS From 108 HIV-positive men circumcised by forceps-guided method and followed up weekly for 6 weeks, 29 men were evaluated for penile viral shedding. HIV-1 RNA was measured in plasma from 19 men and in penile lavage samples from 29 men. Samples were collected before circumcision and at weekly intervals for 6 weeks or until the circumcision wound was healed. CD4 T-cell counts from 102 HIV-positive men were determined at baseline and at 2 weeks thereafter. Wounds with healthy scar, no scab or opening, and no suture tracks were deemed healed. RESULTS Among 65 ART-naive men, mean CD4 T-cell count increased from 417 cells per cubic millimeter at baseline to 456 cells per cubic millimeter after 2 weeks (P = 0.04), but did not change in the 37 men on ART (P = 0.81). There was no change in HIV plasma viral load (P = 0.36), but penile viral shedding rose significantly within 1 week after circumcision then declined to undetectable levels by 6 weeks (multivariate analysis of variance; P < 0.001). In 28 of 29 men (96.6%), there was no detectable viral shedding after certification of wound healing. CONCLUSIONS Medical circumcision among ART-naive HIV-infected men results in a transitory rise in penile viral shedding before complete wound healing, which should pose no additional risk of HIV transmission if men adhere to 6 weeks postcircumcision sexual abstinence and use condoms consistently.
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