Hormonal levels among HIV-1-seropositive women compared with high-risk HIV-seronegative women during the menstrual cycle. Women's Health Study (WHS) 001 and WHS 001a Study Team

The Endocannabinoid System as a Potential Therapeutic Target for HIV-1-Associated Neurocognitive Disorder

Background: Despite the successful introduction of combined antiretroviral therapy, the prevalence of mild to moderate forms of HIV-associated neurocognitive disorders (HAND) remains high. It has been demonstrated that neuronal injury caused by HIV is excitotoxic and inflammatory, and it correlates with neurocognitive decline in HAND. Endocannabinoid system (ECS) protects the body from excitotoxicity and neuroinflammation on demand and presents a promising therapeutic target for treating HAND. Here, we firstly discuss the potential pathogenesis of HAND. We secondly discuss the structural and functional changes in the ECS that are currently known among HAND patients. We thirdly discuss current clinical and preclinical findings concerning the neuroprotective and anti-inflammatory properties of the ECS among HAND patients. Fourth, we will discuss the interactions between the ECS and neuroendocrine systems, including the hypothalamic-pituitary-adrenocortical (HPA) and hypothalamic-pituitary-gonadal (HPG) axes under the HAND conditions. Materials and Methods: We have carried out a review of the literature using PubMed to summarize the current state of knowledge on the association between ECS and HAND. Results: The ECS may be ideally suited for modulation of HAND pathophysiology. Direct activation of presynaptic cannabinoid receptor 1 or reduction of cannabinoid metabolism attenuates HAND excitotoxicity. Chronic neuroinflammation associated with HAND can be reduced by activating cannabinoid receptor 2 on immune cells. The sensitivity of the ECS to HIV may be enhanced by increased cannabinoid receptor expression in HAND. In addition, indirect regulation of the ECS through modulation of hormone-related receptors may be a potential strategy to influence the ECS and also alleviate the progression of HAND due to the reciprocal inhibition of the ECS by the HPA and HPG axes. Conclusions: Taken together, targeting the ECS may be a promising strategy to alleviate the inflammation and neurodegeneration caused by HIV-1 infection. Further studies are required to clarify the role of endocannabinoid signaling in HIV neurotoxicity. Strategies promoting endocannabinoid signaling may slow down cognitive decline of HAND are proposed.

The Association Between HIV Status, Estradiol, and Sex Hormone Binding Globulin Among Premenopausal Women in the Women's Interagency HIV Study

Background: Characterizing estradiol among women with HIV may have implications for breast cancer and cardiovascular disease risk but has not been adequately explored. We quantified differences in total (E2), free (FE2) estradiol, and sex hormone binding globulin (SHBG) by HIV and viral suppression status. Methods: Women from a substudy (2003-2006) within the Women's Interagency HIV Study (IRB approved at each participating site) were included if they reported: a period in the last six months, were not pregnant/breastfeeding, no oophorectomy, and no exogenous hormone use in the prior year. Serum was collected on days 2-4 of the menstrual cycle. We assessed differences in biomarkers at 25th, 50th, and 75th percentiles by HIV and viral suppression status using weighted quantile regression. Results: Among 643 women (68% with HIV) median age was 37 years. All E2 percentiles were significantly (p < 0.05) lower in women with suppressed viral load versus women without HIV (4-10 pg/mL). The 25th and 50th percentile of E2 were 4-5 pg/mL lower in women with unsuppressed viral load compared to women without HIV (p < 0.05). The 25th and 50th percentile of SHBG was significantly higher in women with unsuppressed viral load compared to women without HIV (10 and 12 nmol/L, respectively). There were no consistent differences in estradiol or SHBG by suppression status. Conclusions: There were no differences in FE2 but significantly lower E2 and higher SHBG among women with HIV versus without HIV. Further research is merited in a large contemporary sample to clarify the clinical implications of these findings.

Sex-based differences in HIV type 1 pathogenesis

Human immunodeficiency virus (HIV) remains a global infectious diseases threat that disproportionally affects women. Beyond social and political factors, biological and genetic differences have been identified that lead to differential disease courses and outcomes in men and women. Following HIV type 1 (HIV-1) seroconversion, women have up to 40% lower HIV loads and higher CD4(+) T-cell counts than men. However, at the same level of viremia, progression to AIDS is faster in women. After adjustment for viral load, HIV-positive women also display increased levels of generalized immune activation and experience the consequences of elevated inflammatory activity more frequently than men. Part of these observations are linked to sex-based differences in innate immunity, in which the differential ability of plasmacytoid dendritic cells to produce interferon α following stimulation of Toll-like receptor 7 and upregulation of interferon-stimulated genes play a central role. Here, we review the current knowledge and remaining gaps therein regarding sex-based differences in HIV-1 pathogenesis.

Effects of progesterone on the content of CCR5 and CXCR4 coreceptors in PBMCs of seropositive and exposed but uninfected Mexican women to HIV-1

CCR5 and CXCR4 play an important role in the establishment of HIV infection and disease progression. Caucasian people exposed to HIV but uninfected (EU) present a deletion of 32bp in CCR5 that has not been reported in EU Hispanics from Latin America. Therefore, other factors besides mutations should be involved in this phenomenon. Studies in healthy women have shown that sex hormones such as progesterone (P) can modulate CCR5/CXCR4 expression through an unknown mechanism. The aim of this paper was to determine the role of P in the regulation of CCR5 and CXCR4 in peripheral blood mononuclear cells (PBMCs) of HIV-1 infected and EU women. We analyzed HIV-1-infected women with stable highly active antiretroviral therapy (HAART) with CD4+ cell counts <400/mm(3) or diminution of 20%, EU and HIV-1 seronegative healthy controls. 5×10(6) PBMCs, from HIV-1 infected women, EU women and HIV-1 seronegative healthy controls were cultured and incubated with P (10 or 100 nM), RU486 (P antagonist, 1 μM) or P (100 nM)+RU486 (1 μM). CCR5/CXCR4 content was determined by Western blot. Densitometry data were analyzed using Mann-Whitney test. We found that CCR5 content was reduced by P in all groups. In contrast, CXCR4 content was increased by P in healthy controls and in HIV-1 infected women. Interestingly, CXCR4 content was reduced by P in EU. RU486 did not block P effects in any group. These findings suggest that P should participate in the acquisition and progression of HIV-1 infection by modulating CCR5 and CXCR4 expression. P could contribute to the resistance acquisition of HIV by EU through the down-regulation of both coreceptors.

Gynecologic issues in the HIV-infected woman

In this article, gynecologic conditions of increased importance in the HIV-infected woman are discussed. Women living with HIV may have an increase in menstrual disorders, lower genital tract neoplasias, gynecologic surgery, and sexually transmitted infections. The literature relevant to choosing a method of contraception for HIV-positive women is also discussed. With the advent of HAART, seropositive women are now facing issues around longevity, such as menopause and disorders of bone mineral density, as well as those associated with fertility.

Estradiol and progesterone regulate HIV type 1 replication in peripheral blood cells

Endogenous levels of estradiol and progesterone fluctuate in the peripheral blood of premenopausal women during the reproductive cycle. We studied the effects of these sex hormones on HIV-1 replication in peripheral blood mononuclear cells (PBMCs). We compared HIV-1 replication in PBMCs infected in the presence of mid-secretory (high concentrations) and mid-proliferative (low concentrations) or in the absence of sex hormones. With PBMCs from men, we used concentrations of estradiol and progesterone that are normally present in their plasma. Our findings demonstrate that mid-proliferative phase conditions increased, and mid-secretory phase conditions decreased, HIV-1 replication. To determine if sex hormones affect specific stages of the viral life cycle we performed real-time PCR assays and found decreased levels of HIV-1 integration in the mid-secretory phase and increased levels viral transcription in the mid-proliferative phase. No significant effects on HIV-1 reverse transcription or on CCR5 expression were found. In addition, we assessed hormonal regulation of the HIV-1 LTR in the absence of the viral regulatory protein Tat. We observed that mid-proliferative hormone levels enhanced, whereas mid-secretory hormone concentrations reduced, the activity of the LTR. These findings demonstrate that in HIV-1-infected cells, estradiol and progesterone regulate HIV-1 replication most likely by directly altering HIV-1 transcriptional activation. An additional indirect mechanism of sex hormone regulation of cytokine and chemokine secretion cannot be excluded.

HIV and menopause: a review

The use of highly active antiretroviral therapy (HAART) has resulted in dramatic reductions in morbidity and mortality of HIV infected individuals. With increasing life expectancy, a growing population of women will experience menopausal transitions while infected with HIV. Changes associated with menopause may affect HIV disease progression, and HIV-infected women may experience menopause in a different way from that of uninfected women. Age at natural menopause among non-HIV-infected white and Hispanic women is on the average 51 years, and that of African American women is 49 years. Several studies have shown that the mean age of menopause in HIV-infected women is 47-48 years. This is likely due to factors other than HIV infection that predict early menopause, such as drug use, smoking, and low socioeconomic status. It may be difficult to separate out HIV symptoms from menopausal symptoms. The additive effects of menopause, HIV infection, and HAART on changes involving bone, lipid, and glucose metabolism need further investigation. Likewise, there is a need for a better understanding of the prevalence and manifestations of depression among these women.

Assisted reproduction for HIV-infected couples

Many HIV-infected individuals are in relationships with HIV-uninfected partners and desire to have children. This review focuses on the issue of reproductive choices for these couples, in particular assisted reproductive technologies, and summarises the published outcome data currently available. The results thus far from assisted reproductive technologies in optimising pregnancy outcomes and reducing heterosexual and perinatal HIV transmission are promising. In the future, it is essential that there is ongoing reporting of outcome data, publication of methodology and follow-up, and reporting of adverse outcomes.

Ovarian response to stimulation of HIV-positive patients during IVF treatment: a matched, controlled study

BACKGROUND

Our aim was to compare the ovarian response of HIV-positive and -negative patients during IVF.

METHODS

Setting - HIV and IVF reference university hospital. Twenty-seven HIV-infected patients who had undergone IVF between March 2000 and March 2005 were matched with 77 HIV-negative patients for age, aetiology of infertility, whether it was primary or secondary infertility, duration of infertility, history of pelvic surgery and type of pituitary inhibition. Outcome - poor responders were defined using one of the following criteria: a cancelled cycle (for insufficient ovarian response), less than four mature follicles (> or = 16 mm), peak serum levels of E2 lower than 1000 pg/ml.

RESULTS

There were no differences between the two groups of patients for the matched criteria. The proportion of African women and of women with a history of pelvic inflammatory disease was significantly higher among HIV patients than among the control group. With the exception of a lower number of transferred embryos among HIV-positive patients versus HIV-negative ones (1.3 versus 1.9; P = 0.035), there was no significant difference between the two groups of patients regarding ovarian response parameters.

CONCLUSION

HIV-infected patients who are in good general condition and who are matched to a control group present a similar ovarian response to stimulation, suggesting the existence of a similar ovarian reserve.

Symptom exacerbation and adherence to antiretroviral therapy during the menstrual cycle: a pilot study

Our objective is to investigate the relationship between drug and menstrual cycle symptoms in HIV+ women receiving antiretroviral therapy (HAART). Interviews were done for 12 weeks with 54 HIV+ women receiving HAART. Patients were asked if they experienced any of 28 symptoms associated with HAART and the menstrual cycle and about HAART adherence. Weeks were divided into menstrual weeks (MWs), premenstrual weeks (PWs), and other weeks. Women reported more bloating (P = .02) and cramps (P = .001) during MWs. Skin problems (P = .08) and breast tenderness (P = .03) were experienced during PWs. Feeling tired/loss of energy (P = .05), joint pain (P = .02), and chills (P = .03) were higher in non-MW/PWs. Women were slightly less adherent during the MWs (89%) than PWs (94%) and other weeks (93%). Feeling sad or depressed (P = .01) was associated with nonadherence. Experiencing certain symptoms associated with both the menstrual cycle and HAART drugs was related with nonadherence.

Outcome of ICSI in HIV-1-infected women

BACKGROUND

Since 2001, French law has permitted the use of assisted reproductive technology in human immunodeficiency virus (HIV)-1 infected women under strict conditions. This report describes a preliminary series of seropositive women who underwent assisted reproduction treatment at our facility. To minimize contamination of culture media, equipment, and therefore of male gametes and embryos, we chose to perform ICSI in all cases. The outcome of ICSI was compared with the outcome in an age-matched group of non-HIV-1-infected women. Since several previous reports have indicated that HIV infection may be associated with a decrease in spontaneous fertility, our goal was also to assess the fertility status of the HIV-1-infected women entering our ICSI programme.

METHODS

The French law governing the use of assisted reproduction protocols in HIV-1-infected women was strictly applied. The inclusion criteria were absence of ongoing disease, CD4((+)) count >200 cells/mm(3), and stable HIV-1 RNA level. Since mean age at the time of ICSI was higher in HIV-1-infected women than in the overall group of non-HIV-infected women, we compared outcome data in HIV-1-infected women (group I) to a group of non-HIV-1-infected women matched with regard to age and follicle retrieval period (group II) as well as to the overall group of women who underwent ICSI at our institution (group III).

RESULTS

A total of 66 ovarian stimulations was performed in 29 HIV-1-infected-infected women. The percentage of cancelled cycles was higher in infected women than in matched controls (15.2 versus 4.9%, P < 0.05). The duration of ovarian stimulation (13.3 versus 11.7 days, P < 0.05) and amount of recombinant FSH injected (2898 versus 2429 IU, P < 0.001) were also higher in infected women. The number of retrieved oocytes, mature oocytes, and embryos obtained as well as embryo quality was similar in all groups. The fertilization rate was higher in infected women than in matched controls (67 versus 60%, P < 0.01). The pregnancy rate was not significantly different between groups I and II (16.1 versus 19.6%) in spite of the fact that the number of embryos transferred was purposefully restricted in the HIV-1-infected group to minimize multiple pregnancy (2.0 versus 2.4, not significant).

CONCLUSION

The results of this preliminary series of ICSI cycles in HIV-1-infected women indicate that optimal ovarian stimulation is slightly more difficult to achieve than in matched seronegative women. However, when criteria for oocyte retrieval were fulfilled, ICSI results were similar to those of age-matched controls.

Gynecologic issues in the HIV-infected woman

Science has made great strides in understanding the management of the many gynecologic conditions that affect HIV-positive women with an increased frequency. As HIV-infected women's life expectancy continues to lengthen, new treatments are necessary for recurring conditions, such as lower genital tract neoplasias. The medical field has much to learn about the interaction between sex steroids, HIV-infection, and the immune system. As knowledge grows, clinicians will be better equipped to counsel women about contraceptive issues, pregnancy, and menopause.