HAART's first decade: success brings further challenges

Epidemiology, prevalence, and associated factors of oral candidiasis in HIV patients from southwest Iran in post-highly active antiretroviral therapy era

Background

Oral candidiasis (OC) is one of the most common opportunistic fungal infections among people living with HIV/AIDS (PLWHA). The prevalence of OC and Candida profiles among HIV-infected patients might be changing in the era of Highly Active Antiretroviral Therapy (HAART). This study aimed to identify Candida spp., determine OC prevalence and associated risk factors for PLWHA.

Materials and methods

Oral candidiasis prevalence was explored in oral swabs of 276 patients who referred for consultation at Behavioral Diseases Counseling Center (BDCC). Clinical symptoms, culture and molecular assays were used for OC detection. In statistical analysis, we assessed socio-demographic characteristics, clinical information and treatment history of some infections.

Results

The overall prevalence of OC was 41%. Candida albicans (64.6%) was the most common species, followed by C. glabrata (26.5%) and C. dubliniensis (19.5%). Candida famata, C. africana, and C. stellatoidea as the first fungi isolated from OC in PLWHA from southwest Iran. In 36.3% of patients, mixed cultures of more than one species were observed. Body mass index (BMI) (OR = 0.947; CI = 0.89–0.99; p = 0.045) and CD4 count ≤ 200 cells/mm3 (OR = 4.365; CI = 1.73–10.98; p = 0.002) were the predictors of OC in the final model of multiple logistic regression analysis. Education level, addiction status, sexual behaviors, chest X-ray, other infections and WHO clinical stage were other important risk factors for OC.

Conclusion

Oral candidiasis remains a significant opportunistic infection in post-HAART era among PLWHA. Despite the increasing prevalence of NAC species, C. albicans (64.6%) was still the predominant species. Our results showed that low BMI with OC indicates treatment failure (i.e., failure to increase CD4 count or suppress viral load). Also, low CD4 counts (≤200 cells/mm3) in HIV patients show an impaired immune status, and our findings emphasize that OC can be a clinical indicator of HIV infection in individuals who do not know their HIV status or have failed treatment.

A study of the top-cited studies on drug therapy for HIV

Background Research on drug therapy for HIV remained major hot-spots, but relevant data were not satisfactory. We aimed to assess the status and trends of the most cited studies on drug therapy for HIV by using bibliometric methods.

Methods The Web of Science Core Collection database was searched for the drug therapy for HIV studies. The period for retrieval was from the beginning of the database to July 26, 2022. The 100 top cited studies were selected. These general information and bibliometric data were collected and analyzed. VOS viewer software was used for visualization analysis.

Results The number of citations for the 100 top cited studies ranged from 451 to 5597 and were published from 1987 to 2017. These studies were published in 29 journals. The top 3 journals in terms of the number of studies were the New England Journal of Medicine (n = 22), Lancet (n = 15), and JAMA (n = 13). The most frequently nominated author was Matthias Eiger from the University of Bern, who has contributed 5 studies. United States, Switzerland, and England contributed most of the highly cited studies. Research hot spots reflected clinical trials, treatment adverse events, basic research, and clinical adherence.

Conclusion The majority of 100 top-cited studies have been published in the United States, and primarily focused on treatment adverse events, basic research, and clinical adherence. They provide a basic list of the most important and influential academic contributions to literature of HIV drug treatment for researchers.

Treatment outcome of HAART-treated patients in a resource-limited setting: the Belgrade Cohort Study

INTRODUCTION

We evaluated the effects of highly-active-antiretroviral-therapy (HAART) in a resource-limited settings.

METHODS

A cross-sectional study was performed in patients who had initiated HAART at the HIV/AIDS-Center, Belgrade, Serbia. Treatment response was considered favorable in case of the achievement of undetectable HIVRNA plasma-viral-load (pVL<50 copies/μL), and with the CD4+ T-cell counts increased above 350cells/μL. The treatment failure was defined as pVL over 1.7 log10 copies/mL, regardless of immunological improvement.

RESULTS

Eight hundred and forty HIV infected patients were followed-up for 8.2±3.4years. Out of 697 patients available for follow-up, 113 (16.2%) patients died, 44 (6.3%) experienced treatment failure, while 540 (77.5%) had sustained undetectable viremia. In 419 (60.1%) favorable treatment response was achieved, while the dissociation between immunological and virological responses to HAART occurred in 121 (14.4%). A baseline CD4+ T-cell counts above 200 cells/μL was the single independent predictor of a favorable treatment response (HR=2, 95%CI=1.69-2.61, P=0.001), while pre-treatment with ART, HCV co-infection and AIDS at the time of treatment initiation, were all factors preventing a favorable response (HR=0.27, 95%CI=0.19-0.36, P=0.001; HR=0.75, 95%CI=0.56-0.95, P=0.02; HR=0.73, 95%CI=0.17-0.95, P=0.018, respectively). A sustained viral suppression was an independent predictor of survival (HR=0.2, 95% CI 0.07-0.61, P=0.004). HAART treated HIV-infected patients who reach and maintain undetectable viremia, have an 80% probability of a 14-years survival (P=0.08, log-rank).

CONCLUSION

If patient with advanced HIV-related immunodeficiency reach and maintain optimal viral suppression during HAART, regardless of the level of immune recovery, and if they continue to maintain this, their prognosis may be fairly good even in the resource-limited settings.

The Changing Epidemiology of Oropharyngeal Candidiasis in Patients with HIV/AIDS in the Era of Antiretroviral Therapy

The impact of antiretroviral therapy (ART) on opportunistic conditions in HIV patients continues to evolve. We specifically studied the changing epidemiology of oropharyngeal candidiasis (OPC) in 215 HIV/AIDS patients. Status of yeast colonization was assessed from oral rinse samples, and preliminary yeast identification was made using CHROMagar Candida and confirmed with standard microbiological techniques and/or molecular sequencing. Susceptibility to fluconazole was determined by CHROMagar Candida agar dilution screening and CLSI broth microdilution. 176 (82%) patients were colonized and 59 (27%) patients had symptomatic OPC. Candida albicans was the most prevalent species, though C. glabrata and C. dubliniensis were detected in 29% of isolates. Decreased fluconazole susceptibility occurred in 10% of isolates. Previous ART reduced the risk of OPC, while smoking increased the risk of colonization. Oral yeast colonization and symptomatic infection remain common even with advances in HIV therapy. C. albicans is the most common species, but other yeasts are prevalent and may have decreased susceptibility to fluconazole.

Late Presentation of HIV-Infected Individuals

Late presentation remains a major concern despite the dramatically improved prognosis realized by ART. We define a first presentation for HIV care during the course of HIV infection as ‘late’ if an AIDS-defining opportunistic disease is apparent, or if CD4+ T-cells are <200/μl. In the Western world, approximately 10 and 30% of HIV-infected individuals still present with CD4+ T-cells <50 and <200/μl, respectively; estimates are substantially higher for developing countries. Diagnosis and treatment of opportunistic diseases and intense supportive in-hospital care take precedence over ART. Benefits of starting ART without delay, that is, when opportunistic diseases are still active, include faster resolution of opportunistic diseases and a decreased risk of recurrence. The downside of starting ART without delay could include toxicity, drug interactions and immune reconstitution inflammatory syndrome (IRIS). Among asymptomatic or oligosymptomatic individuals presenting late, where ART and primary prophylaxis are initiated, ∼10–20% will become symptomatic from drug toxicity or undiagnosed opportunistic complications, including IRIS, which require appropriate therapies. In this review we describe late presentation to HIV care, the scale of the problem, the evaluation of a late-presenting patient and challenges associated with initiation of potent anti-retroviral therapy (ART) in the setting of acute opportunistic infections and other comorbidities.

Construction of a novel SHIV having an HIV-1-derived protease gene and its infection to rhesus macaques: a useful tool for in vivo efficacy tests of protease inhibitors

We generated a novel SHIV (termed SHIV-pr) that possesses the HIV-1-derived protease (PR) gene in the corresponding position in the SIVmac genome. SHIV-pr is replication-competent in human and monkey CD4(+) T lymphoid cell lines as well as rhesus macaque PBMCs. The viral growth of SHIV-pr was completely blocked in the presence of a peptide-analog PR inhibitor at the tissue culture level. When SHIV-pr was intravenously inoculated into two rhesus macaques, it resulted in a weak but long-lasting persistent infection in one monkey, whereas the infection of another was only temporary. To enhance the viral growth competence by adaptation, we then passaged the virus in vivo from a monkey up to the fourth generation. The initial peak values of plasma viral loads as well as the setpoint values increased generation by generation and reached those of a parental virus SIVmac. When a medication using the content of Kaletra capsule (a mixture of two PR inhibitors, lopinavir and ritonavir) was orally given to three SHIV-pr-infected monkeys for 4 weeks, plasma viral loads dropped to near or below the detection limit and quickly rebounded after the cessation of medication. The results suggest that SHIV-pr can be used to evaluate PR inhibitors using monkeys.