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Godwe C, Goni OH, San JE, Sonela N, Tchakoute M, Nanfack A, Koro FK, Butel C, Vidal N, Duerr R, Martin DP, de Oliveira T, Peeters M, Altfeld M, Ayouba A, Ndung’u T, Tongo M. Phylogenetic evidence of extensive spatial mixing of diverse HIV-1 group M lineages within Cameroon but not between its neighbours. Virus Evol 2024; 10:veae070. [PMID: 39386075 PMCID: PMC11463025 DOI: 10.1093/ve/veae070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 07/12/2024] [Accepted: 08/28/2024] [Indexed: 10/12/2024] Open
Abstract
From the perspective of developing relevant interventions for treating HIV and controlling its spread, it is particularly important to comprehensively understand the underlying diversity of the virus, especially in countries where the virus has been present and evolving since the cross-species transmission event that triggered the global pandemic. Here, we generate and phylogenetically analyse sequences derived from the gag-protease (2010 bp; n = 115), partial integrase (345 bp; n = 36), and nef (719 bp; n = 321) genes of HIV-1 group M (HIV-1M) isolates sampled between 2000 and 2022 from two cosmopolitan cities and 40 remote villages of Cameroon. While 52.4% of all sequenced viruses belonged to circulating recombinant form (CRF) 02_AG (CRF02_AG), the remainder were highly diverse, collectively representing seven subtypes and sub-subtypes, eight CRFs, and 36 highly divergent lineages that fall outside the established HIV-1M classification. Additionally, in 77 samples for which at least two genes were typed, 31% of the studied viruses apparently had fragments from viruses belonging to different clades. Furthermore, we found that the distribution of HIV-1M populations is similar between different regions of Cameroon. In contrast, HIV-1M demographics in Cameroon differ significantly from those in its neighbouring countries in the Congo Basin (CB). In phylogenetic trees, viral sequences cluster according to the countries where they were sampled, suggesting that while there are minimal geographical or social barriers to viral dissemination throughout Cameroon, there is strongly impeded dispersal of HIV-1M lineages between Cameroon and other locations of the CB. This suggests that the apparent stability of highly diverse Cameroonian HIV-1M populations may be attributable to the extensive mixing of human populations within the country and the concomitant trans-national movements of major lineages with very similar degrees of fitness; coupled with the relatively infrequent inter-national transmission of these lineages from neighbouring countries in the CB.
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Affiliation(s)
- Célestin Godwe
- Center of Research for Emerging and Re-Emerging Diseases (CREMER), Institute of Medical Research and Study of Medicinal Plants (IMPM), Yaoundé, PO Box. 906 Yaoundé, Cameroon
- Department of Biochemistry, University of Douala, Douala, PO Box. 24157 Douala, Cameroon
| | - Oumarou H Goni
- Center of Research for Emerging and Re-Emerging Diseases (CREMER), Institute of Medical Research and Study of Medicinal Plants (IMPM), Yaoundé, PO Box. 906 Yaoundé, Cameroon
- Department of Microbiology, Faculty of Sciences, University of Yaoundé 1, Yaoundé, PO Box. 812 Yaoundé, Cameroon
| | - James E San
- KwaZulu-Natal Research Innovation and Sequencing Platform, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban 4001, South Africa
- Duke Human Vaccine Institute, Duke University, Durham, NC 27710, United States
| | - Nelson Sonela
- Center of Research for Emerging and Re-Emerging Diseases (CREMER), Institute of Medical Research and Study of Medicinal Plants (IMPM), Yaoundé, PO Box. 906 Yaoundé, Cameroon
- Chantal BIYA International Reference Centre for Research on HIV/AIDS prevention and management (CIRCB), Yaoundé PO Box. 3077 Yaoundé, Cameroon
- Weill Cornell Medical College, Department of Medicine, Cornell University, New York, NY 10021, United States
| | - Mérimé Tchakoute
- Programmes de Santé et développement au sein du Groupement de la Filière Bois du Cameroun, PO Box 495, Yaoundé, Cameroon
| | - Aubin Nanfack
- Chantal BIYA International Reference Centre for Research on HIV/AIDS prevention and management (CIRCB), Yaoundé PO Box. 3077 Yaoundé, Cameroon
| | - Francioli K Koro
- Department of Biochemistry, University of Douala, Douala, PO Box. 24157 Douala, Cameroon
| | - Christelle Butel
- TransVIHMI, Université de Montpellier, IRD, INSERM, 911 Avenue Agropolis, Montpellier, Montpellier cedex 34394, France
| | - Nicole Vidal
- TransVIHMI, Université de Montpellier, IRD, INSERM, 911 Avenue Agropolis, Montpellier, Montpellier cedex 34394, France
| | - Ralf Duerr
- Department of Medicine, Division of Infectious Diseases and Immunology, NYU Grossman School of Medicine, New York, NY 10016, United States
- Vaccine Center, NYU Grossman School of Medicine, New York, NY 10016, United States
- Department of Microbiology, NYU Grossman School of Medicine, New York, NY 10016, United States
| | - Darren P Martin
- Department of Integrative Biomedical Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, Cape Town 7700, South Africa
| | - Tulio de Oliveira
- KwaZulu-Natal Research Innovation and Sequencing Platform, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban 4001, South Africa
- Centre for Epidemic Response and Innovation (CERI), School of Data Science and Computational Thinking, Stellenbosch University, Stellenbosch 7600, South Africa
| | - Martine Peeters
- TransVIHMI, Université de Montpellier, IRD, INSERM, 911 Avenue Agropolis, Montpellier, Montpellier cedex 34394, France
| | - Marcus Altfeld
- Universitätsklinikum Hamburg-Eppendorf, Hamburg, Hamburg 20251, Germany
| | - Ahidjo Ayouba
- Center of Research for Emerging and Re-Emerging Diseases (CREMER), Institute of Medical Research and Study of Medicinal Plants (IMPM), Yaoundé, PO Box. 906 Yaoundé, Cameroon
- TransVIHMI, Université de Montpellier, IRD, INSERM, 911 Avenue Agropolis, Montpellier, Montpellier cedex 34394, France
| | - Thumbi Ndung’u
- HIV Pathogenesis Programme, The Doris Duke Medical Research Institute, University of KwaZulu Natal, Durban 4013, South Africa
- Africa Health Research Institute (AHRI), Durban 4001, South Africa
- Ragon Institute of MGH, MIT and Harvard University, Cambridge MA 02139, United States
- Division of Infection and Immunity, University College London, London WC1E 6BT, United Kingdom
| | - Marcel Tongo
- Center of Research for Emerging and Re-Emerging Diseases (CREMER), Institute of Medical Research and Study of Medicinal Plants (IMPM), Yaoundé, PO Box. 906 Yaoundé, Cameroon
- HIV Pathogenesis Programme, The Doris Duke Medical Research Institute, University of KwaZulu Natal, Durban 4013, South Africa
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Junqueira DM, Wilkinson E, Vallari A, Deng X, Achari A, Yu G, McArthur C, Kaptue L, Mbanya D, Chiu C, Cloherty GA, de Oliveira T, Rodgers MA. New Genomes from the Congo Basin Expand History of CRF01_AE Origin and Dissemination. AIDS Res Hum Retroviruses 2020; 36:574-582. [PMID: 32281388 PMCID: PMC7398440 DOI: 10.1089/aid.2020.0031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Although the first HIV circulating recombinant form (CRF01_AE) is the predominant strain in many Asian countries, it is uncommonly found in the Congo Basin from where it first originated. To fill the gap in the evolutionary history of this important strain, we sequenced near complete genomes from HIV samples with subgenomic CRF01_AE regions collected in Cameroon and the Democratic Republic of the Congo from 2001 to 2006. HIV genomes were generated from N = 13 plasma specimens by next-generation sequencing of metagenomic libraries prepared with spiked primers targeting HIV, followed by Sanger gap-filling. Genome sequences were aligned to reference strains, including Asian and African CRF01_AE sequences, and evaluated by phylogenetic and recombinant analysis to identify four CRF01_AE strains from Cameroon. We also identified two CRF02, one CRF27, and six unique recombinant form genomes (01|A1|G, 01|02|F|U, F|G|01, A1|D|01, F|G|01, and A1|G|01). Phylogenetic analysis, including the four new African CRF01_AE genomes, placed these samples as a bridge between basal Central African Republic CRF01_AE strains and all Asian, European, and American CRF01_AE strains. Molecular dating confirmed previous estimates indicating that the most recent common CRF01_AE ancestor emerged in the early 1970s (1968–1970) and spread beyond Africa around 1980 to Asia. The new sequences and analysis presented in this study expand the molecular history of the CRF01_AE clade, and are illustrated in an interactive Next Strain phylogenetic tree, map, and timeline at (https://nextstrain.org/community/EduanWilkinson/hiv-1_crf01).
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Affiliation(s)
- Dennis Maletich Junqueira
- Centro Universitário Ritter dos Reis-UniRitter, Porto Alegre, Brazil
- KwaZulu-Natal Research Innovation Sequencing Platform (KRISP), University of KwaZulu-Natal, Durban, Republic of South Africa
- School of Laboratory Medicine and Medical Science, College of Health Sciences, University of KwaZulu-Natal, Durban, Republic of South Africa
| | - Eduan Wilkinson
- KwaZulu-Natal Research Innovation Sequencing Platform (KRISP), University of KwaZulu-Natal, Durban, Republic of South Africa
- School of Laboratory Medicine and Medical Science, College of Health Sciences, University of KwaZulu-Natal, Durban, Republic of South Africa
| | - Ana Vallari
- Abbott Diagnostics, Infectious Disease Research, Abbott Park, Illinois, USA
| | - Xianding Deng
- Department of Laboratory Medicine, University of California, San Francisco, California, USA
- UCSF-Abbott Viral Diagnostics and Discovery Center, San Francisco, California, USA
| | - Asmeeta Achari
- Department of Laboratory Medicine, University of California, San Francisco, California, USA
- UCSF-Abbott Viral Diagnostics and Discovery Center, San Francisco, California, USA
| | - Guixia Yu
- Department of Laboratory Medicine, University of California, San Francisco, California, USA
- UCSF-Abbott Viral Diagnostics and Discovery Center, San Francisco, California, USA
| | - Carole McArthur
- School of Dentistry and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | | | - Dora Mbanya
- Université de Yaoundé I, Yaoundé, Cameroon
- University of Bamenda, Bamenda, Cameroon
| | - Charles Chiu
- Department of Laboratory Medicine, University of California, San Francisco, California, USA
- UCSF-Abbott Viral Diagnostics and Discovery Center, San Francisco, California, USA
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, California, USA
| | - Gavin A. Cloherty
- Abbott Diagnostics, Infectious Disease Research, Abbott Park, Illinois, USA
| | - Tulio de Oliveira
- KwaZulu-Natal Research Innovation Sequencing Platform (KRISP), University of KwaZulu-Natal, Durban, Republic of South Africa
- School of Laboratory Medicine and Medical Science, College of Health Sciences, University of KwaZulu-Natal, Durban, Republic of South Africa
- Research Department of Infection, University College London, London, United Kingdom
| | - Mary A. Rodgers
- Abbott Diagnostics, Infectious Disease Research, Abbott Park, Illinois, USA
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Tongo M, Harkins GW, Dorfman JR, Billings E, Tovanabutra S, de Oliveira T, Martin DP. Unravelling the complicated evolutionary and dissemination history of HIV-1M subtype A lineages. Virus Evol 2018; 4:vey003. [PMID: 29484203 PMCID: PMC5819727 DOI: 10.1093/ve/vey003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Subtype A is one of the rare HIV-1 group M (HIV-1M) lineages that is both widely distributed throughout the world and persists at high frequencies in the Congo Basin (CB), the site where HIV-1M likely originated. This, together with its high degree of diversity suggests that subtype A is amongst the fittest HIV-1M lineages. Here we use a comprehensive set of published near full-length subtype A sequences and A-derived genome fragments from both circulating and unique recombinant forms (CRFs/URFs) to obtain some insights into how frequently these lineages have independently seeded HIV-1M sub-epidemics in different parts of the world. We do this by inferring when and where the major subtype A lineages and subtype A-derived CRFs originated. Following its origin in the CB during the 1940s, we track the diversification and recombination history of subtype A sequences before and during its dissemination throughout much of the world between the 1950s and 1970s. Collectively, the timings and numbers of detectable subtype A recombination and dissemination events, the present broad global distribution of the sub-epidemics that were seeded by these events, and the high prevalence of subtype A sequences within the regions where these sub-epidemics occurred, suggest that ancestral subtype A viruses (and particularly sub-subtype A1 ancestral viruses) may have been genetically predisposed to become major components of the present epidemic.
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Affiliation(s)
- Marcel Tongo
- KwaZulu-Natal Research Innovation and Sequencing Platform (Krisp), School of Laboratory Medicine and Medical Sciences, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban 4041, South Africa
- Division of Computational Biology, Department of Integrative Biomedical Sciences and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town 7925, South Africa
- Center of Research for Emerging and Re-Emerging Diseases (CREMER), Institute of Medical Research and Study of Medicinal Plants (IMPM), Yaoundé, Cameroon
| | - Gordon W Harkins
- South African MRC Bioinformatics Unit, South African National Bioinformatics Institute, University of the Western Cape, Bellville 7535, South Africa
| | - Jeffrey R Dorfman
- Division of Immunology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town 7925, South Africa
- Division of Immunology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa
| | - Erik Billings
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD 20910–7500, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., Bethesda, MD 20910–7500, USA
| | - Sodsai Tovanabutra
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD 20910–7500, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., Bethesda, MD 20910–7500, USA
| | - Tulio de Oliveira
- KwaZulu-Natal Research Innovation and Sequencing Platform (Krisp), School of Laboratory Medicine and Medical Sciences, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban 4041, South Africa
| | - Darren P Martin
- Division of Computational Biology, Department of Integrative Biomedical Sciences and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town 7925, South Africa
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Rife BD, Mavian C, Chen X, Ciccozzi M, Salemi M, Min J, Prosperi MCF. Phylodynamic applications in 21 st century global infectious disease research. Glob Health Res Policy 2017; 2:13. [PMID: 29202081 PMCID: PMC5683535 DOI: 10.1186/s41256-017-0034-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 03/31/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Phylodynamics, the study of the interaction between epidemiological and pathogen evolutionary processes within and among populations, was originally defined in the context of rapidly evolving viruses and used to characterize transmission dynamics. The concept of phylodynamics has evolved since the early 21st century, extending its reach to slower-evolving pathogens, including bacteria and fungi, and to the identification of influential factors in disease spread and pathogen population dynamics. RESULTS The phylodynamic approach has now become a fundamental building block for the development of comparative phylogenetic tools capable of incorporating epidemiological surveillance data with molecular sequences into a single statistical framework. These innovative tools have greatly enhanced scientific investigations of the temporal and geographical origins, evolutionary history, and ecological risk factors associated with the growth and spread of viruses such as human immunodeficiency virus (HIV), Zika, and dengue and bacteria such as Methicillin-resistant Staphylococcus aureus. CONCLUSIONS Capitalizing on an extensive review of the literature, we discuss the evolution of the field of infectious disease epidemiology and recent accomplishments, highlighting the advancements in phylodynamics, as well as the challenges and limitations currently facing researchers studying emerging pathogen epidemics across the globe.
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Affiliation(s)
- Brittany D Rife
- Emerging Pathogens Institute and Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, FL USA
| | - Carla Mavian
- Emerging Pathogens Institute and Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, FL USA
| | - Xinguang Chen
- Department of Epidemiology, University of Florida, Gainesville, FL USA
| | - Massimo Ciccozzi
- Department of Infectious, Parasitic and Immune-Mediated Diseases, Istituto Superiore di Sanità, Rome, Italy
- Unit of Clinical Pathology and Microbiology, University Campus Biomedico of Rome, Rome, Italy
| | - Marco Salemi
- Emerging Pathogens Institute and Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, FL USA
| | - Jae Min
- Department of Epidemiology, University of Florida, Gainesville, FL USA
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Delatorre E, Bello G. Time-scale of minor HIV-1 complex circulating recombinant forms from Central and West Africa. BMC Evol Biol 2016; 16:249. [PMID: 27852214 PMCID: PMC5112642 DOI: 10.1186/s12862-016-0824-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 11/08/2016] [Indexed: 11/29/2022] Open
Abstract
Background Several HIV-1 circulating recombinant forms with a complex mosaic structure (CRFs_cpx) circulate in central and western African regions. Here we reconstruct the evolutionary history of some of these complex CRFs (09_cpx, 11_cpx, 13_cpx and 45_cpx) and further investigate the dissemination dynamic of the CRF11_cpx clade by using a Bayesian coalescent-based method. Results The analysis of two HIV-1 datasets comprising 181 pol (36 CRF09_cpx, 116 CRF11_cpx, 20 CRF13_cpx and 9 CRF45_cpx) and 125 env (12 CRF09_cpx, 67 CRF11_cpx, 17 CRF13_cpx and 29 CRF45_cpx) sequences pointed to quite consistent onset dates for CRF09_cpx (~1966: 1958–1979), CRF11_cpx (~1957: 1950–1966) and CRF13_cpx (~1965: 1958–1973) clades; while some divergence was found for the estimated date of origin of CRF45_cpx clade [pol = 1970 (1964–1976); env = 1960 (1952–1969)]. Phylogeographic reconstructions indicate that the HIV-1 CRF11_cpx clade most probably emerged in Cameroon and from there it was first disseminated to the Central Africa Republic and Chad in the early 1970s and to other central and western African countries from the early 1980s onwards. Demographic reconstructions suggest that the CRF11_cpx epidemic grew between 1960 and 1990 with a median exponential growth rate of 0.27 year−1, and stabilized after. Conclusions These results reveal that HIV-1 CRFs_cpx clades have been circulating in Central Africa for a period comparable to other much more prevalent HIV-1 group M lineages. Cameroon was probably the epicenter of dissemination of the CRF11_cpx clade that seems to have experienced a long epidemic growth phase before stabilization. The epidemic growth of the CRF11_cpx clade was roughly comparable to other HIV-1 group M lineages circulating in Central Africa. Electronic supplementary material The online version of this article (doi:10.1186/s12862-016-0824-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Edson Delatorre
- Laboratório de AIDS e Imunologia Molecular, Instituto Oswaldo Cruz - FIOCRUZ, Av. Brasil 4365, 21040-360, Rio de Janeiro, RJ, Brazil.
| | - Gonzalo Bello
- Laboratório de AIDS e Imunologia Molecular, Instituto Oswaldo Cruz - FIOCRUZ, Av. Brasil 4365, 21040-360, Rio de Janeiro, RJ, Brazil
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Abdellaziz A, Papuchon J, Khaled S, Ouerdane D, Fleury H, Recordon-Pinson P. Predominance of CRF06_cpx and Transmitted HIV Resistance in Algeria: Update 2013-2014. AIDS Res Hum Retroviruses 2016; 32:370-2. [PMID: 26529365 DOI: 10.1089/aid.2015.0292] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Since 2008, no data on HIV diversity or the transmission rate of HIV resistance mutations in naive patients have been presented for Algeria, a country of MENA region. Between 2013 and 2014, we studied 152 samples including 89 naive patients. The current study describes the change in HIV diversity in Algeria with the predominance of CRF06_cpx and the huge increase of transmitted HIV resistance, which now reaches 15%.
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Affiliation(s)
- Akila Abdellaziz
- Université des Sciences et de la Technologie Houari Boumediene, Alger, Algérie
- Hopital Spécialisé en Maladies Infectieuses El Hadi Flici, Alger, Algérie
| | - Jennifer Papuchon
- Université Bordeaux, Laboratoire MFP UMR 5234, Bordeaux, France
- Centre Hospitalier Universitaire de Bordeaux, Laboratoire de Virologie, Bordeaux, France
| | - Safia Khaled
- Hopital Spécialisé en Maladies Infectieuses El Hadi Flici, Alger, Algérie
| | - Dalila Ouerdane
- Hopital Spécialisé en Maladies Infectieuses El Hadi Flici, Alger, Algérie
| | - Hervé Fleury
- Université Bordeaux, Laboratoire MFP UMR 5234, Bordeaux, France
- Centre Hospitalier Universitaire de Bordeaux, Laboratoire de Virologie, Bordeaux, France
| | - Patricia Recordon-Pinson
- Université Bordeaux, Laboratoire MFP UMR 5234, Bordeaux, France
- Centre Hospitalier Universitaire de Bordeaux, Laboratoire de Virologie, Bordeaux, France
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Delatorre E, Mir D, Bello G. Spatiotemporal dynamics of the HIV-1 subtype G epidemic in West and Central Africa. PLoS One 2014; 9:e98908. [PMID: 24918930 PMCID: PMC4053352 DOI: 10.1371/journal.pone.0098908] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 05/03/2014] [Indexed: 01/25/2023] Open
Abstract
The human immunodeficiency virus type 1 (HIV-1) subtype G is the second most prevalent HIV-1 clade in West Africa, accounting for nearly 30% of infections in the region. There is no information about the spatiotemporal dynamics of dissemination of this HIV-1 clade in Africa. To this end, we analyzed a total of 305 HIV-1 subtype G pol sequences isolated from 11 different countries from West and Central Africa over a period of 20 years (1992 to 2011). Evolutionary, phylogeographic and demographic parameters were jointly estimated from sequence data using a Bayesian coalescent-based method. Our analyses indicate that subtype G most probably emerged in Central Africa in 1968 (1956–1976). From Central Africa, the virus was disseminated to West and West Central Africa at multiple times from the middle 1970s onwards. Two subtype G strains probably introduced into Nigeria and Togo between the middle and the late 1970s were disseminated locally and to neighboring countries, leading to the origin of two major western African clades (GWA-I and GWA-II). Subtype G clades circulating in western and central African regions displayed an initial phase of exponential growth followed by a decline in growth rate since the early/middle 1990s; but the mean epidemic growth rate of GWA-I (0.75 year−1) and GWA-II (0.95 year−1) clades was about two times higher than that estimated for central African lineages (0.47 year−1). Notably, the overall evolutionary and demographic history of GWA-I and GWA-II clades was very similar to that estimated for the CRF06_cpx clade circulating in the same region. These results support the notion that the spatiotemporal dissemination dynamics of major HIV-1 clades circulating in western Africa have probably been shaped by the same ecological factors.
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Affiliation(s)
- Edson Delatorre
- Laboratório de AIDS & Imunologia Molecular, Instituto Oswaldo Cruz, FIOCRUZ, Rio de Janeiro, Brazil
| | - Daiana Mir
- Laboratório de AIDS & Imunologia Molecular, Instituto Oswaldo Cruz, FIOCRUZ, Rio de Janeiro, Brazil
| | - Gonzalo Bello
- Laboratório de AIDS & Imunologia Molecular, Instituto Oswaldo Cruz, FIOCRUZ, Rio de Janeiro, Brazil
- * E-mail:
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David PM. Towards the embodiment of biosocial resistance? How to account for the unexpected effects of antiretroviral scale-up in the Central African Republic. Glob Public Health 2014; 9:144-59. [PMID: 24499050 DOI: 10.1080/17441692.2014.881521] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
At the fringes of the unprecedented medication scale-up in the treatment of HIV, many African countries have experienced dramatic antiretroviral drug stock-outs. Usually considered the result of irrational decisions on behalf of local politicians, programme managers and even patients (who are stigmatised as immoral), these problems seem not to be so exceptional. However, ethnographic attention to the social consequences of the presence and absence of antiretroviral drugs in the Central African Republic (CAR) suggests that these stock-outs entail far more than logistical failures. In 2010 and 2011 in the CAR, major antiretroviral treatment (ARV) stock-outs resulted in the renewal of 'therapeutic' social ties and also significant social resistance and defiance. While this paper explores reasons for the shortage, its focus is on subsequent popular reactions to it, particularly among people who are HIV-positive and dependent on ARVs. The exceptional and ambiguous consequences of these drug stock-outs raise new concerns relevant to the politics of global public health.
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Affiliation(s)
- Pierre-Marie David
- a Department of Medication and Population Health, Faculty of Pharmacy , Université de Montréal , Montreal , Canada
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Abstract
Previous studies have shown that the HIV-1 epidemic in Cuba displayed a complex molecular epidemiologic profile with circulation of several subtypes and circulating recombinant forms (CRF); but the evolutionary and population history of those viral variants remains unknown. HIV-1 pol sequences of the most prevalent Cuban lineages (subtypes B, C and G, CRF18_cpx, CRF19_cpx, and CRFs20/23/24_BG) isolated between 1999 and 2011 were analyzed. Maximum-likelihood analyses revealed multiple introductions of subtype B (n≥66), subtype C (n≥10), subtype G (n≥8) and CRF18_cpx (n≥2) viruses in Cuba. The bulk of HIV-1 infections in this country, however, was caused by dissemination of a few founder strains probably introduced from North America/Europe (clades BCU-I and BCU-II), east Africa (clade CCU-I) and central Africa (clades GCU, CRF18CU and CRF19CU), or locally generated (clades CRFs20/23/24_BG). Bayesian-coalescent analyses show that the major HIV-1 founder strains were introduced into Cuba during 1985–1995; whereas the CRFs_BG strains emerged in the second half of the 1990s. Most HIV-1 Cuban clades appear to have experienced an initial period of fast exponential spread during the 1990s and early 2000s, followed by a more recent decline in growth rate. The median initial growth rate of HIV-1 Cuban clades ranged from 0.4 year−1 to 1.6 year−1. Thus, the HIV-1 epidemic in Cuba has been a result of the successful introduction of a few viral strains that began to circulate at a rather late time of the AIDS pandemic, but then were rapidly disseminated through local transmission networks.
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Affiliation(s)
- Edson Delatorre
- Laboratório de AIDS e Imunologia Molecular, Instituto Oswaldo Cruz, FIOCRUZ, Rio de Janeiro, Brazil
| | - Gonzalo Bello
- Laboratório de AIDS e Imunologia Molecular, Instituto Oswaldo Cruz, FIOCRUZ, Rio de Janeiro, Brazil
- * E-mail:
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Péré H, Charpentier C, Mbelesso P, Dandy M, Matta M, Moussa S, De Dieu Longo J, Grésenguet G, Abraham B, Bélec L. Virological response and resistance profiles after 24 months of first-line antiretroviral treatment in adults living in Bangui, Central African Republic. AIDS Res Hum Retroviruses 2012; 28:315-23. [PMID: 21942692 DOI: 10.1089/aid.2011.0127] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The rate of virological failure was assessed in 386 adult patients attending the Centre National Hospitalier Universitaire of Bangui, the capital city of the Central African Republic (CAR), receiving their first-line antiretroviral (ARV) drug regimen for 24 months, according to the World Health Organization (WHO) recommendations. In addition, genotypic resistance testing was carried out in 45 of 145 randomly selected patients whose plasma HIV-1 RNA load was detectable. Overall, 28.5% of ARV-treated patients were in virological failure (e.g., HIV-1 RNA >3.7 log(10) copies/ml). Twenty-four percent of patients in virological failure showed wild-type viruses, likely indicating poor adherence. Even after excluding the M184V mutation, all 76% of patients in virological failure displayed viruses harboring at least one major drug resistance mutation to nucleoside reverse transcriptase inhibitors (NRTI), non-NRTI, or protease inhibitors. Whereas the second-line regimen proposed by the 2010 WHO recommendations, including zidovudine, tenofovir, lopinavir, and atazanavir, could be effective in more than 90% of patients in virological failure with resistant viruses, the remaining patients showed genotypic profiles highly predictive of resistance to the usual WHO second-line regimen, including complex genotypic profiles diagnosed only by genotypic resistance tests in some patients. In conclusion, our observations highlight the high frequency of therapeutic failure in ARV-treated adults in this study, as well as the urgent and absolute need for improving viral load assessment in the CAR to prevent and/or, from now on, to monitor therapeutic failure.
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Affiliation(s)
- Hélène Péré
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Laboratoire de Virologie, France
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11
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Faria NR, Suchard MA, Abecasis A, Sousa JD, Ndembi N, Bonfim I, Camacho RJ, Vandamme AM, Lemey P. Phylodynamics of the HIV-1 CRF02_AG clade in Cameroon. INFECTION, GENETICS AND EVOLUTION : JOURNAL OF MOLECULAR EPIDEMIOLOGY AND EVOLUTIONARY GENETICS IN INFECTIOUS DISEASES 2012; 12:453-60. [PMID: 21565285 PMCID: PMC4677783 DOI: 10.1016/j.meegid.2011.04.028] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Revised: 04/19/2011] [Accepted: 04/22/2011] [Indexed: 12/18/2022]
Abstract
Evolutionary analyses have revealed an origin of pandemic HIV-1 group M in the Congo River basin in the first part of the XX century, but the patterns of historical viral spread in or around its epicentre remain largely unexplored. Here, we combine epidemiologic and molecular sequence data to investigate the spatiotemporal patterns of the CRF02_AG clade. By explicitly integrating prevalence counts and genetic population size estimates we date the epidemic emergence of CRF02_AG at 1973.1 (1972.1, 1975.3, 95% CI). To infer the phylogeographic signature of this clade at a regional scale, we analyze pol and env time-stamped sequence data from 10 countries using a Bayesian phylogeographic approach based on an asymmetric discretized diffusion model. Our data confirms a spatial origin of CRF02_AG in the Democratic Republic of Congo (DRC) and suggests that viral dissemination to Cameroon occurred at an early stage of the evolutionary history of CRF02_AG. We find considerable support for epidemiological linkage between neighbour countries. Compilation of ethnographic data suggested that well-supported viral migration did not reflect sustained human migratory flows. Finally, using sequence data from 15 locations in Cameroon, we use relaxed random walk models to explore the spatiotemporal dynamics of CRF02_AG at a finer geographical detail. Phylogeographic dispersal in continuous space reveals that at least two distinct CRF02_AG lineages are circulating in overlapping regions that are evolving at different evolutionary and diffusion rates. In conclusion, by combining molecular and epidemiological data, our results provide a time scale for CRF02_AG, early 70s, place its spatial root in the DRC within the putative root of group-M diversity and propose a scenario of chance-exportation events for the spatiotemporal patterns of a successful HIV-1 lineage both at a regional and country-scale.
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Affiliation(s)
- Nuno R Faria
- Rega Institute for Medical Research, Katholieke Universiteit Leuven, Leuven, Belgium.
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12
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Moussa S, Pinson P, Pelembi P, Gody JC, Mbitikon O, Fikouma V, Mbay P, Fleury HJ. First data on HIV-1 resistance mutations to antiretroviral drugs in Central African Republic. AIDS Res Hum Retroviruses 2010; 26:1247-8. [PMID: 20939688 DOI: 10.1089/aid.2010.0091] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
In a background of high genomic HIV-1 variability with a predominance of CRF11_cpx and CRF22_01A1, we have studied the emergence of resistance mutations in isolates from Central African patients at failure of d4T-AZT/3TC/NVP-EFV plus two at failure of a PI-including regimen; the resistance mutations observed are those which are expected on HIV-1 subtype B.
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Affiliation(s)
- Sandrine Moussa
- Unité des Rétrovirus et des Virus Oncogènes, Institut Pasteur de Bangui, Bangui, Central African Republic
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13
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Chan PA, Kantor R. Transmitted drug resistance in nonsubtype B HIV-1 infection. ACTA ACUST UNITED AC 2009; 3:447-465. [PMID: 20161523 DOI: 10.2217/hiv.09.30] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
HIV-1 nonsubtype B variants account for the majority of HIV infections worldwide. Drug resistance in individuals who have never undergone antiretroviral therapy can lead to early failure and limited treatment options and, therefore, is an important concern. Evaluation of reported transmitted drug resistance (TDR) is challenging owing to varying definitions and study designs, and is further complicated by HIV-1 subtype diversity. In this article, we discuss the importance of various mutation lists for TDR definition, summarize TDR in nonsubtype B HIV-1 and highlight TDR reporting and interpreting challenges in the context of HIV-1 diversity. When examined carefully, TDR in HIV-1 non-B protease and reverse transcriptase is still relatively low in most regions. Whether it will increase with time and therapy access, as observed in subtype-B-predominant regions, remains to be determined.
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14
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Yamaguchi J, Ndembi N, Ngansop C, Mbanya D, Kaptué L, Gürtler LG, Devare SG, Brennan CA. HIV type 1 group M subtype G in Cameroon: five genome sequences. AIDS Res Hum Retroviruses 2009; 25:469-73. [PMID: 19361281 DOI: 10.1089/aid.2008.0296] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Near full-length viral genome sequences were obtained for five putative subtype G candidates identified in HIV-infected Cameroonian blood donors, based on partial genome sequences for the gag, pol, and env regions. Phylogenetic analysis of the genome sequences shows that all five strains are pure subtype G with no indication of intersubtype recombination. The Cameroon subtype G sequences did not form a geographically based subcluster and were intermixed within the subtype G branch with isolates from several different countries. HIV-1 group M subtype G accounts for only 4.5% of HIV infections in Cameroon. However, genome segments of subtype G are present in 67% of all infections and 80% of infections due to intersubtype recombinant strains in Cameroon. The addition of five subtype G genome sequences to the HIV database may contribute to a better understanding of the origins and classification of HIV-1 subtypes and CRFs.
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Affiliation(s)
| | | | | | | | - Lazare Kaptué
- University of Yaoundé I, Yaoundé, Cameroon
- Université des Montagnes, Bangangté, Cameroon
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15
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Mintsa-Ndong A, Caron M, Plantier JC, Makuwa M, Le Hello S, Courgnaud V, Roques P, Kazanji M. High HIV Type 1 prevalence and wide genetic diversity with dominance of recombinant strains but low level of antiretroviral drug-resistance mutations in untreated patients in northeast Gabon, Central Africa. AIDS Res Hum Retroviruses 2009; 25:411-8. [PMID: 19320567 DOI: 10.1089/aid.2008.0223] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
The northeast of Gabon, central Africa is characterized by high population density and a high rate of immigration from the surrounding countries. To determine the prevalence, circulating subtypes, and antiretroviral resistance mutations of HIV-1, 810 blood samples were collected from the general population of the two main cities (Oyem and Makokou) of this region. Of these, 61 (7.5%) were found to be positive for HIV-1. Analysis of the env (gp120), pol, and gag (p24) sequences as well as phylogenetic analyses showed at least eight different viral lineages. The most prevalent strains were CRF02 recombinants, followed by subtypes A, D, and C. The remaining strains were found to be F, J, G, and also, for the first time in Gabon, the recombinant form CRF11cpx. Analysis of antiretroviral drug-resistance mutations in protease and reverse transcriptase from this untreated population showed a low level of specific mutations. These mutations were associated with subtype polymorphism rather than with resistance to antiretroviral drugs. The wide diversity and the emergence of recombinant strains are in accordance with the rapid spread of new HIV strains in the population and, thus, the dynamic evolution of the epidemic.
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Affiliation(s)
- Armel Mintsa-Ndong
- Unité de Rétrovirologie, Centre International de Recherches Médicales de Franceville, Franceville, Gabon
| | - Melanie Caron
- Unité de Rétrovirologie, Centre International de Recherches Médicales de Franceville, Franceville, Gabon
- Service de Coopération et d'Action Culturelle, French Embassy, Libreville, Gabon
| | | | - Maria Makuwa
- Unité de Rétrovirologie, Centre International de Recherches Médicales de Franceville, Franceville, Gabon
| | - Simon Le Hello
- Unité de Rétrovirologie, Centre International de Recherches Médicales de Franceville, Franceville, Gabon
| | - Valerie Courgnaud
- Institut de Génétique Moléculaire CNRS Unité Mixte de Recherches 5535, Université Montpellier II, Montpellier, France
| | - Pierre Roques
- Unité de Rétrovirologie, Centre International de Recherches Médicales de Franceville, Franceville, Gabon
- Service de Coopération et d'Action Culturelle, French Embassy, Libreville, Gabon
- Service d'Immuno-virologie, Unité Mixte de Recherches E1, Pais XI, Centre d'Etudes Nucleaires, Fontenay aux Roses, France
| | - Mirdad Kazanji
- Unité de Rétrovirologie, Centre International de Recherches Médicales de Franceville, Franceville, Gabon
- Service de Coopération et d'Action Culturelle, French Embassy, Libreville, Gabon
- Réseau International des Instituts Pasteur, Institut Pasteur, Paris, France
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16
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Yamaguchi J, Badreddine S, Swanson P, Bodelle P, Devare SG, Brennan CA. Identification of new CRF43_02G and CRF25_cpx in Saudi Arabia based on full genome sequence analysis of six HIV type 1 isolates. AIDS Res Hum Retroviruses 2008; 24:1327-35. [PMID: 18844465 DOI: 10.1089/aid.2008.0101] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Recently, we reported a high level of HIV-1 strain diversity in patients at the King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia. Based on phylogenetic analysis of gag p24, pol integrase, and env gp41 sequences, subtypes A, B, C, D, and G, and CRF02_AG, as well as unique recombinant forms were identified. Subtype G accounted for 25% of the infections in the Saudi population and this high prevalence was unexpected. Although subtype G is found in west central Africa, pure subtype G strains are uncommon. To further characterize the subtype G infections in Saudi Arabia, six strains that appeared to be pure subtype G were selected for full genome sequencing. Near full-length genomes were obtained using RT-PCR amplification to generate overlapping fragments from viral RNA extracted from plasma. The six strains are not subtype G throughout their entire genome. Four isolates have a recombinant structure composed of CRF02_AG and subtype G and share three identical breakpoints. This recombinant form defines a new CRF designated CRF43_02G. The remaining two isolates are CRF25_cpx, a circulating recombinant form identified in Cameroon composed of subtypes A and G and unclassified segments. Reanalysis of the previously reported Saudi HIV-1 partial genome sequences revealed additional isolates classified as CRF43_02G and CRF25_cpx and one isolate was reclassified to CRF22_01A. Identification of CRF43_02G in Saudi Arabia could indicate a transmission network within the country. Alternatively, the new CRF could have been introduced from an external source where this CRF is not yet recognized.
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Affiliation(s)
| | - Samar Badreddine
- King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
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17
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Caron M, Makuwa M, Souquière S, Descamps D, Brun-Vézinet F, Kazanji M. Human immunodeficiency virus type 1 seroprevalence and antiretroviral drug resistance-associated mutations in miners in Gabon, central Africa. AIDS Res Hum Retroviruses 2008; 24:1225-8. [PMID: 18788914 DOI: 10.1089/aid.2008.0097] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Miners in sub-Saharan African are known to have an extremely high prevalence of HIV-1 infection. We therefore evaluated the prevalence of HIV-1 infection among manganese miners in Gabon, central Africa and examined the diversity of HIV-1 strains by characterizing the polymorphism of the pol gene in order to observe drug resistance-associated mutations. In 857 samples tested, the HIV-1 prevalence was 2.9%. By pol sequence analysis, we showed that all the HIV-1 strains belonged to group M, with a majority of CRF02_AG (57%) followed by subtype A (9%) and CRF01_AE or subtype B (4%). The remaining HIV-1 strains demonstrated discordant genomic results and exhibited a mosaic pol genome (30%). Most of the mutations detected in pol coding regions corresponded to the subtype polymorphism, with no specific antiretroviral drug resistance. To avoid the rapid emergence of resistant viruses in this part of central Africa, continuous surveillance of the circulation of drug-resistant viruses must be maintained to guide treatment strategies.
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Affiliation(s)
- Mélanie Caron
- Unité de Rétrovirologie, Centre International de Recherches Médicales, Franceville,Gabon
| | - Maria Makuwa
- Unité de Rétrovirologie, Centre International de Recherches Médicales, Franceville,Gabon
| | - Sandrine Souquière
- Unité de Rétrovirologie, Centre International de Recherches Médicales, Franceville,Gabon
| | - Diane Descamps
- Service de Virologie, Centre Hospitalier Bichat-Claude Bernard, Paris, France
| | | | - Mirdad Kazanji
- Unité de Rétrovirologie, Centre International de Recherches Médicales, Franceville,Gabon
- Service de Coopération et d'Action Culturelle, French Embassy, Libreville, Gabon
- Réseau International des Instituts Pasteur, Institut Pasteur, 75015 Paris, France
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18
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Lahuerta M, Aparicio E, Bardaji A, Marco S, Sacarlal J, Mandomando I, Alonso P, Martinez MA, Menendez C, Naniche D. Rapid spread and genetic diversification of HIV type 1 subtype C in a rural area of southern Mozambique. AIDS Res Hum Retroviruses 2008; 24:327-35. [PMID: 18271719 DOI: 10.1089/aid.2007.0134] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In this study, we analyzed the human immunodeficiency type 1 (HIV-1) viruses circulating between 1999 and 2004 in antiretroviral-naive women from a rural area of southern Mozambique. Nucleotide sequencing of the HIV-1 long terminal repeat (LTR) U3, envelope (env) C2V3C3, and protease (pr) genomic regions was performed from women sera samples collected in 1999 and 2004. Phylogenetic analysis revealed that all amplified sequences belonged to subtype C. Although env sequences were predominantly CCR5-tropic (R5), CXCR4-tropic (X4) variants were also identified (13%). Both 1999 and 2004 sequences were widely dispersed across multiple clusters and were related to different reference sequences from neighboring countries. Sequences from 2004 showed significantly more nucleotide genetic diversity than sequences from 1999. Importantly, genetic diversification was also observed at the pr and env amino acid level, suggesting that positive selection forces were implicated in the viral diversification. These results indicate the rapid spread and diversification of subtype C virus in Mozambique where HIV-1 prevalence in the Manhiça antenatal clinic reached 23% in 2004.
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Affiliation(s)
- Maria Lahuerta
- Barcelona Center for International Health Research (CRESIB), Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universtitat de Barcelona, Barcelona, Spain
| | - Ester Aparicio
- Fundació irsiCaixa, Hospital Universitari Germans Trias i Pujol, Universitat Autonoma de Barcelona, 08916 Badalona, Spain
| | - Azucena Bardaji
- Barcelona Center for International Health Research (CRESIB), Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universtitat de Barcelona, Barcelona, Spain
- The Manhiça Health Research Center (CISM), Manhiça, Mozambique
| | - Sandra Marco
- Fundació irsiCaixa, Hospital Universitari Germans Trias i Pujol, Universitat Autonoma de Barcelona, 08916 Badalona, Spain
| | - Jahit Sacarlal
- The Manhiça Health Research Center (CISM), Manhiça, Mozambique
- Faculdade de Medicina da Universidade Eduardo Mondlane, Maputo, Mozambique
| | | | - Pedro Alonso
- Barcelona Center for International Health Research (CRESIB), Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universtitat de Barcelona, Barcelona, Spain
- The Manhiça Health Research Center (CISM), Manhiça, Mozambique
| | - Miguel Angel Martinez
- Fundació irsiCaixa, Hospital Universitari Germans Trias i Pujol, Universitat Autonoma de Barcelona, 08916 Badalona, Spain
| | - Clara Menendez
- Barcelona Center for International Health Research (CRESIB), Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universtitat de Barcelona, Barcelona, Spain
- The Manhiça Health Research Center (CISM), Manhiça, Mozambique
| | - Denise Naniche
- Barcelona Center for International Health Research (CRESIB), Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universtitat de Barcelona, Barcelona, Spain
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