1
|
Gao ZR, Yuan Z, Zhao CS, Zhao RG, Zhang Q. Better Predictive Value of Lymphocyte Count and Hemoglobin for CD4 Level of HIV Patients. Curr HIV Res 2023; 21:73-80. [PMID: 36567293 DOI: 10.2174/1570162x21666221222104349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 11/08/2022] [Accepted: 11/16/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE HIV patients are prone to infection and difficult to treat, which mainly manifests itself in decreased CD4+ T cells in the body. Therefore, the predictive value of lymphocyte count and hemoglobin for CD4+ levels in HIV patients was discussed in the prospective study. METHODS 125 HIV patients (aged >18 or < 80 years) were recruited. Pearson chi-square test was used to explore the correlation between CD4+ content and blood-related parameters in HIV patients. Univariate and multivariate logistic regression analyses were used to calculate ORs for each variable. In addition, receiver ROC curves were constructed to assess each factor's accuracy and sensitivity in diagnosing CD4+. RESULTS Lymphocyte count and hemoglobin were significantly correlated with CD4+. In terms of multivariate logistic regression level, there was a significant correlation between lymphocyte count (OR = 3.170, 95% CI: 1.442-6.969, P = 0.004), hemoglobin (OR = 2.545, 95% CI: 1.148- 5.646, P = 0.022) and CD4+ content in HIV patients. Based on the neural network model, the level of lymphocyte and hemoglobin might be the predictive indexes of CD4+ level. We find the high-risk warning indicator of CD4+ level: 3 < lymphocyte (109/L) < 3.6, and 150 < hemoglobin (g/L) < 200. CONCLUSION Better predictive value of lymphocyte count and hemoglobin for CD4+ level of HIV patients.
Collapse
Affiliation(s)
- Zheng-Rong Gao
- Department of Orthopaedics, Beijing Ditan Hospital, Capital Medical University, No. 8 Jingshun East Street, Chaoyang District, 100015, China
| | - Zheng Yuan
- Department of Orthopaedics, Beijing Ditan Hospital, Capital Medical University, No. 8 Jingshun East Street, Chaoyang District, 100015, China
| | - Chang-Song Zhao
- Department of Orthopaedics, Beijing Ditan Hospital, Capital Medical University, No. 8 Jingshun East Street, Chaoyang District, 100015, China
| | - Ru-Gang Zhao
- Department of Orthopaedics, Beijing Ditan Hospital, Capital Medical University, No. 8 Jingshun East Street, Chaoyang District, 100015, China
| | - Qiang Zhang
- Department of Orthopaedics, Beijing Ditan Hospital, Capital Medical University, No. 8 Jingshun East Street, Chaoyang District, 100015, China
| |
Collapse
|
2
|
Winichakoon P, Tongjai S. The Emerging of CRF01_AE: A Clinical Story and Future HIV/AIDS Situation in Thailand. Curr HIV Res 2021; 18:74-84. [PMID: 31995011 DOI: 10.2174/1570162x18666200129160723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 12/30/2019] [Accepted: 01/02/2020] [Indexed: 11/22/2022]
Abstract
The HIV epidemic in Thailand in the 1980's compromised the country's socio-economic development. The epidemic first became evident in the community of men with male sexual partners (MSM), and subsequently spread to intravenous drug users (IVDU), female commercial sex workers (CSW) and their male clients, and, ultimately, to their partners and children. The HIV epidemic has devastated the country's working-age population. The extensive negative impact and social stigma associated with the disease do not only have an impact on the victims of HIV but also on their descendants and relatives. An epicenter of the HIV epidemic has been in the northern provinces of Thailand. An HIV-1 subtype CRF01_AE, a complex chimeric virus composed of both A and E subtypes, is prevalent in Northern Thailand. The virus has quickly become a predominant viral strain circulating in Thailand, other neighboring Southeast Asian countries, and China as well as some other countries throughout the world. The epidemiology, evolution, and biology of CRF01_AE offer a unique model for further scientific investigations which would advance the knowledge of and curative strategies against HIV. In addition, Thailand has developed suitable national guidelines on HIV/AIDS treatment and prevention in order to control the epidemic. Effective antiretroviral drugs are, therefore, able to be made available to those who live with HIV. The national surveillance system has also been effective. The great efforts and resources which Thailand has dedicated to the fight against the epidemic have eventually paid off. In 2010, a plan was proposed to eliminate mother-to-child HIV transmission and Thailand has become the first country to be effective in this objective. Thailand therefore has become recognized as being the global leader in HIV prevention and treatment. The experience which Thailand has gained from the past and the current research and management strategies of the HIV epidemic has prepared the country for emerging strains of HIV-1 in the future.
Collapse
Affiliation(s)
- Poramed Winichakoon
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Tambon Sriphum, Amphoe Muang, Thailand
| | - Siripong Tongjai
- Department of Microbiology, Faculty of Medicine, Chiang Mai University, Tambon Sriphum, Amphoe Muang, Thailand
| |
Collapse
|
3
|
Francisco C, Lansang MA, Salvana EM, Leyritana K. Multidrug-resistant tuberculosis (MDR-TB) and multidrug-resistant HIV (MDR-HIV) syndemic: challenges in resource limited setting. BMJ Case Rep 2019; 12:e230628. [PMID: 31471363 PMCID: PMC6720699 DOI: 10.1136/bcr-2019-230628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2019] [Indexed: 11/03/2022] Open
Abstract
Tuberculosis (TB) is common among persons living with HIV. This public health concern is aggravated by infection with multidrug-resistant organisms and adverse effects of polypharmacy. There are few published cases of multidrug-resistant tuberculosis (MDR-TB) in multidrug-resistant HIV (MDR-HIV) infected patients. We report a case of a 29-year-old Filipino man with HIV on zidovudine (AZT)-containing antiretroviral therapy (ART) but was eventually shifted to tenofovir due to anaemia. He presented with left flank tenderness, which was found to be due to an MDR-TB psoas abscess, and for which second-line anti-TB treatment was started. HIV genotyping showed MDR-HIV infection susceptible only to AZT, protease inhibitors and integrase inhibitors. Subsequently, he developed neck abscess that grew Mycobacterium avium complex and was treated with ethambutol and azithromycin. ART regimen was revised to AZT plus lamivudine and lopinavir/ritonavir. Erythropoietin was administered for recurrent AZT-induced anaemia. Both abscesses resolved and no recurrence of anaemia was noted.
Collapse
Affiliation(s)
- Christian Francisco
- Section of Infectious Diseases, Department of Medicine, Philippine General Hospital, Manila, Philippines
| | - Mary Ann Lansang
- Section of Infectious Diseases, Department of Medicine, Philippine General Hospital, Manila, Philippines
| | - Edsel Maurice Salvana
- Section of Infectious Diseases, Department of Medicine, Philippine General Hospital, Manila, Philippines
| | - Katerina Leyritana
- Sustained Health Initiatives of the Philippines, Mandaluyong, Philippines
| |
Collapse
|
4
|
Song H, Ou W, Feng Y, Zhang J, Li F, Hu J, Peng H, Xing H, Ma L, Tan Q, Li D, Wang L, Wu B, Shao Y. Disparate impact on CD4 T cell count by two distinct HIV-1 phylogenetic clusters from the same clade. Proc Natl Acad Sci U S A 2019; 116:239-244. [PMID: 30559208 PMCID: PMC6320496 DOI: 10.1073/pnas.1814714116] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
HIV-1 evolved into various genetic subtypes and circulating recombinant forms (CRFs) in the global epidemic. The same subtype or CRF is usually considered to have similar phenotype. Being one of the world's major CRFs, CRF01_AE infection was reported to associate with higher prevalence of CXCR4 (X4) viruses and faster CD4 decline. However, the underlying mechanisms remain unclear. We identified eight phylogenetic clusters of CRF01_AE in China and hypothesized that they may have different phenotypes. In the National HIV Molecular Epidemiology Survey, we discovered that people infected by CRF01_AE cluster 4 had significantly lower CD4 counts (391 vs. 470, P < 0.0001) and higher prevalence of X4-using viruses (17.1% vs. 4.4%, P < 0.0001) compared with those infected by cluster 5. In an MSM cohort, X4-using viruses were only isolated from seroconvertors in cluster 4, which was associated with low a CD4 count within the first year of infection (141 vs. 440, P = 0.003). Using a coreceptor binding model, we identified unique V3 signatures in cluster 4 that favor CXCR4 use. We demonstrate that the HIV-1 phenotype and pathogenicity can be determined at the phylogenetic cluster level in the same subtype. Since its initial spread to humans from chimpanzees, estimated to be the first half of the 20th century, HIV-1 continues to undergo rapid evolution in larger and more diverse populations. The divergent phenotype evolution of two major CRF01_AE clusters highlights the importance of monitoring the genetic evolution and phenotypic shift of HIV-1 to provide early warning of the appearance of more pathogenic strains.
Collapse
Affiliation(s)
- Hongshuo Song
- State Key Laboratory for Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, 102206 Beijing, China
| | - Weidong Ou
- State Key Laboratory for Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, 102206 Beijing, China
| | - Yi Feng
- State Key Laboratory for Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, 102206 Beijing, China
| | - Junli Zhang
- State Key Laboratory for Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, 102206 Beijing, China
| | - Fan Li
- State Key Laboratory for Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, 102206 Beijing, China
| | - Jing Hu
- State Key Laboratory for Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, 102206 Beijing, China
| | - Hong Peng
- State Key Laboratory for Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, 102206 Beijing, China
| | - Hui Xing
- State Key Laboratory for Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, 102206 Beijing, China
| | - Liying Ma
- State Key Laboratory for Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, 102206 Beijing, China
| | - Qiuxiang Tan
- CAS Key Laboratory of Receptor Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, 201203 Shanghai, China
| | - Dongliang Li
- Chaoyang Center for Disease Control and Prevention, 100021 Beijing, China
| | - Lijuan Wang
- Chaoyang Center for Disease Control and Prevention, 100021 Beijing, China
| | - Beili Wu
- CAS Key Laboratory of Receptor Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, 201203 Shanghai, China
| | - Yiming Shao
- State Key Laboratory for Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, 102206 Beijing, China;
- Center of Infectious Diseases, Peking University, 100191 Beijing, China
- The First Affiliated Hospital, School of Medicine, Zhejiang University, 310003 Hangzhou, China
| |
Collapse
|
5
|
Shaukat SN, Khan S, Raza A, Khanani R, Ghayaz A, Kazmi SU. Prognostic markers in HIV mono-and co-infected individuals: A study from Karachi-Pakistan. J Infect Public Health 2017; 11:250-254. [PMID: 28844443 DOI: 10.1016/j.jiph.2017.07.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 07/19/2017] [Accepted: 07/31/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Multiple infections are the most common problem among HIV infected individuals. The prognostic impact of these co infections in HIV-population in resource-limited countries like Pakistan has not been fully elucidated. The aim of this study was to assess CD4 and hemoglobin (Hb) levels in patients with HIV mono infection and HIV co-infection with Hepatitis C (HCV), Hepatitis B (HBV) and Mycobacterium tuberculosis (MTB). METHODS A total of 207 HIV positive patients were assessed for CD4 cells count and hemoglobin levels after confirmation of HIV by rapid tests as well as PCR. CD4 counts were performed via flow cytometry whereas hemoglobin levels were performed by Sysmex K-4500 auto-analyzer. RESULTS Out of 207 patients, 22 patients were found to be HIV mono-infected, while 185 patients were HIV positive along with co-infections of MTB or HCV or HBV. We found significant positive correlation between HB levels and CD4 count across the studied group (r=0.30 in HIV mono-infected group, r=0.23 in HIV co-infected group, p<0.05) at baseline. However, majority of the low hemoglobin levels (<8g/dl) and low CD4 count (<200cells/ul) cases were observed particularly in HIV/TB co-infections. CONCLUSION This study documents the prognostic value of hemoglobin assessment in HIV patients. The results indicate that decreasing Hb levels correlate with decreasing CD4 counts. It is emphasizing that Hb measurement may be used as an inexpensive surrogate marker as compared to CD4 analysis for disease progression in HIV patients. In addition, low Hb levels may also indicate presence of under lying co-infections, particularly, with M. tuberculosis (MTB).
Collapse
Affiliation(s)
- Sobia N Shaukat
- Dadabhoy Institute of Higher Education, Karachi, Pakistan; Immunology and Infectious Diseases, Research Laboratory, Department of Microbiology, University of Karachi, Pakistan.
| | - Saeed Khan
- Dow University of Health Sciences, Karachi, Pakistan.
| | - Afsheen Raza
- Dadabhoy Institute of Higher Education, Karachi, Pakistan; Clinical Microbiology and Epidemiology, Dadabhoy Institute of Higher Education, Pakistan.
| | - Rafiq Khanani
- Dow University of Health Sciences, Karachi, Pakistan; Department of Pathology, Dow University of Health Sciences, Pakistan.
| | - Azra Ghayaz
- HIV/AIDS Treatment & Care Centre, Civil Hospital, Karachi, Pakistan
| | - Shahana U Kazmi
- Dadabhoy Institute of Higher Education, Karachi, Pakistan; Clinical Microbiology and Immunology-IIDRL And Rector, Dadabhoy Institute of Higher Education, Karachi, Pakistan.
| |
Collapse
|
6
|
Angira F, Akoth B, Omolo P, Opollo V, Bornheimer S, Judge K, Tilahun H, Lu B, Omana-Zapata I, Zeh C. Clinical Evaluation of the BD FACSPresto™ Near-Patient CD4 Counter in Kenya. PLoS One 2016; 11:e0157939. [PMID: 27483008 PMCID: PMC4970792 DOI: 10.1371/journal.pone.0157939] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 06/07/2016] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The BD FACSPresto™ Near-Patient CD4 Counter was developed to expand HIV/AIDS management in resource-limited settings. It measures absolute CD4 counts (AbsCD4), percent CD4 (%CD4), and hemoglobin (Hb) from a single drop of capillary or venous blood in approximately 23 minutes, with throughput of 10 samples per hour. We assessed the performance of the BD FACSPresto system, evaluating accuracy, stability, linearity, precision, and reference intervals using capillary and venous blood at KEMRI/CDC HIV-research laboratory, Kisumu, Kenya, and precision and linearity at BD Biosciences, California, USA. METHODS For accuracy, venous samples were tested using the BD FACSCalibur™ instrument with BD Tritest™ CD3/CD4/CD45 reagent, BD Trucount™ tubes, and BD Multiset™ software for AbsCD4 and %CD4, and the Sysmex™ KX-21N for Hb. Stability studies evaluated duration of staining (18-120-minute incubation), and effects of venous blood storage <6-24 hours post-draw. A normal cohort was tested for reference intervals. Precision covered multiple days, operators, and instruments. Linearity required mixing two pools of samples, to obtain evenly spaced concentrations for AbsCD4, total lymphocytes, and Hb. RESULTS AbsCD4 and %CD4 venous/capillary (N = 189/ N = 162) accuracy results gave Deming regression slopes within 0.97-1.03 and R2 ≥0.96. For Hb, Deming regression results were R2 ≥0.94 and slope ≥0.94 for both venous and capillary samples. Stability varied within 10% 2 hours after staining and for venous blood stored less than 24 hours. Reference intervals results showed that gender-but not age-differences were statistically significant (p<0.05). Precision results had <3.5% coefficient of variation for AbsCD4, %CD4, and Hb, except for low AbsCD4 samples (<6.8%). Linearity was 42-4,897 cells/μL for AbsCD4, 182-11,704 cells/μL for total lymphocytes, and 2-24 g/dL for Hb. CONCLUSIONS The BD FACSPresto system provides accurate, precise clinical results for capillary or venous blood samples and is suitable for near-patient CD4 testing. TRIAL REGISTRATION ClinicalTrials.gov NCT02396355.
Collapse
Affiliation(s)
- Francis Angira
- Kenya Medical Research Institute/US CDC Research and Public Health Collaboration, Kisumu, Kenya
| | - Benta Akoth
- Kenya Medical Research Institute/US CDC Research and Public Health Collaboration, Kisumu, Kenya
| | - Paul Omolo
- Kenya Medical Research Institute/US CDC Research and Public Health Collaboration, Kisumu, Kenya
| | - Valarie Opollo
- Kenya Medical Research Institute/US CDC Research and Public Health Collaboration, Kisumu, Kenya
| | - Scott Bornheimer
- BD Biosciences, 2350 Qume Drive, San Jose, California, United States of America
| | - Kevin Judge
- BD Biosciences, 2350 Qume Drive, San Jose, California, United States of America
| | - Henok Tilahun
- BD Biosciences, 2350 Qume Drive, San Jose, California, United States of America
| | - Beverly Lu
- BD Biosciences, 2350 Qume Drive, San Jose, California, United States of America
| | - Imelda Omana-Zapata
- BD Biosciences, 2350 Qume Drive, San Jose, California, United States of America
| | - Clement Zeh
- US Centers for Disease Control and Prevention (CDC-Kenya), Kisumu, Kenya
| |
Collapse
|
7
|
Chan LG, Ho MJ, Kaur P, Singh J, Ng OT, Lee CC, Leo YS, Carvalhal A. Differences in clinical and psychiatric outcomes between prevalent HIV-1 molecular subtypes in a multiethnic Southeast Asian sample. Gen Hosp Psychiatry 2016; 38:4-8. [PMID: 26380875 DOI: 10.1016/j.genhosppsych.2015.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 07/24/2015] [Accepted: 07/27/2015] [Indexed: 12/16/2022]
Abstract
OBJECTIVE In Southeast Asia, subtypes B and CRF01_AE are the prevalent human immunodeficiency virus-1 (HIV-1) subtypes. This study examines the intersubtype differences in clinical indicators and psychiatric symptoms in a multiethnic sample. METHODS The study site was a national HIV treatment center. Data were extracted from the Molecular Epidemiology Research study and the HIV-Psychiatry Integrated Mental Health Project, and analyzed according to groups defined by viral subtype. RESULTS Of 177 subjects, 54.8% were infected with subtype CRF01_AE; 42.9% screened positive on the Hospital Anxiety and Depression Scale (HADS). The CRF01_AE group was significantly older (mean 38.29 years vs. 34.62 years, P=.031) and had advanced immunosuppression (CD4 <200) just prior to HADS screening (33.0% vs. 13.5%, P=.003). By multivariate logistic regression, homosexual transmission [odds ratio (OR) 0.388, 95% confidence interval (CI) 0.158-0.951, P=.038], subtype CRF01_AE (OR 2.898, 95% CI 1.199-7.001, P=.018) and positive HADS screening (OR 2.859, 95% CI 1.261-8.484, P=.012) were associated with advanced immunosuppression; and only advanced immunosuppression was associated with screening positive on the HADS (OR 3.270, 95% CI 1.299-8.227, P=.012). CONCLUSION Subtype CRF01_AE is associated with advanced immunosuppression but not with symptoms of anxiety and depression. The results suggest that psychiatric symptoms are associated with advanced HIV disease regardless of subtype.
Collapse
Affiliation(s)
- Lai Gwen Chan
- Department of Psychological Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433.
| | - Mei Jing Ho
- Department of Psychological Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433.
| | - Palvinder Kaur
- Institute of Infectious Disease and Epidemiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433.
| | - Jaspal Singh
- Department of Psychological Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433; Psychological Wellness Program, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433.
| | - Oon Tek Ng
- Institute of Infectious Disease and Epidemiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433.
| | - Cheng Chuan Lee
- Institute of Infectious Disease and Epidemiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433; Yong Loo Lin School of Medicine, National University of Singapore, 11 Jalan Tan Tock Seng, Singapore, 308433.
| | - Yee Sin Leo
- Yong Loo Lin School of Medicine, National University of Singapore, 11 Jalan Tan Tock Seng, Singapore, 308433; Communicable Disease Centre, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433; Lee Kong Chian School of Medicine, Nanyang Technological University, 11 Jalan Tan Tock Seng, Singapore, 308433; Saw Swee Hock School of Public Health, National University of Singapore, 11 Jalan Tan Tock Seng, Singapore, 308433.
| | - Adriana Carvalhal
- Medical Psychiatry Consultation Service, Department of Psychiatry, St Michael's Hospital, 20 Bond Street, Toronto, ON, M5B 1W8, Canada; Department of Psychiatry, University of Toronto, 20 Bond Street, Toronto, ON, M5B 1W8, Canada; Li Kah Shing, St Michael's Hospital, 20 Bond Street, Toronto, ON, M5B 1W8, Canada.
| |
Collapse
|
8
|
Palm AA, Esbjörnsson J, Månsson F, Kvist A, Isberg PE, Biague A, da Silva ZJ, Jansson M, Norrgren H, Medstrand P. Faster progression to AIDS and AIDS-related death among seroincident individuals infected with recombinant HIV-1 A3/CRF02_AG compared with sub-subtype A3. J Infect Dis 2013; 209:721-8. [PMID: 23935204 DOI: 10.1093/infdis/jit416] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Human immunodeficiency virus type 1 (HIV-1) is divided into subtypes and circulating recombinant forms (CRFs) but the impact of subtype/CRF on disease progression is not fully understood. METHODS We determined the HIV-1 subtype/CRF of 152 seroincident individuals from Guinea-Bissau, based on the C2-V3 region of env. Disease progression was measured as time from estimated seroconversion to AIDS and AIDS-related death. Hazard ratios (HRs) were calculated using a Cox proportional hazard model, adjusting for gender and age at seroconversion. RESULTS The major subtypes/CRFs identified were CRF02_AG (53%), A3 (29%), and A3/02 (a recombinant of A3 and CRF02_AG) (13%). Infection with A3/02 was associated with a close to 3-fold increased risk of AIDS and AIDS-related death compared to A3 (HR = 2.6 [P = 0.011] and 2.9 [P = 0.032], respectively). The estimated time from seroconversion to AIDS and AIDS-related death was 5.0 and 8.0 years for A3/02, 6.2 and 9.0 years for CRF02_AG, and 7.2 and 11.3 years for A3. CONCLUSION Our results show that there are differences in disease progression between HIV-1 A-like subtypes/CRFs. Individuals infected with A3/02 have among the fastest progression rates to AIDS reported to date. Determining the HIV-1 subtype of infected individuals could be important in the management of HIV-1 infections.
Collapse
|
9
|
Byakwaga H, Petoumenos K, Ananworanich J, Zhang F, Boyd MA, Sirisanthana T, Li PCK, Lee C, Mean CV, Saphonn V, Omar SFS, Pujari S, Phanuphak P, Lim PL, Kumarasamy N, Chen YMA, Merati TP, Sungkanuparph S, Ditangco R, Oka S, Tau G, Zhou J, Law MG, Emery S. Predictors of clinical progression in HIV-1-infected adults initiating combination antiretroviral therapy with advanced disease in the Asia-Pacific region: results from the TREAT Asia HIV observational database. J Int Assoc Provid AIDS Care 2013; 12:270-7. [PMID: 23422741 DOI: 10.1177/1545109712469684] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The majority of HIV-infected patients in developing countries commences combination antiretroviral therapy (cART) with advanced disease. We examined predictors of disease progression in patients initiating cART with CD4 count ≤200 cells/mm(3) in the TREAT Asia HIV Observational Database. The main outcome measure was progression to either an AIDS-defining illness or death occurring 6 months after initiation of cART. We used survival analysis methods. A total of 1255 patients contributed 2696 person years of follow-up; 73 were diagnosed with AIDS and 9 died. The rate of progression to the combined end point was 3.0 per 100 person years. The factors significantly associated with a higher risk of disease progression were Indian ethnicity, infection through intravenous drug use, lower CD4 count, and hemoglobin ≤130 g/dL at 6 months. In conclusion, measurements of CD4 count and hemoglobin at month 6 may be useful for early identification of disease progression in resource-limited settings.
Collapse
Affiliation(s)
- H Byakwaga
- The Kirby Institute, University of New South Wales, Sydney, Australia.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Hemelaar J. Implications of HIV diversity for the HIV-1 pandemic. J Infect 2012; 66:391-400. [PMID: 23103289 DOI: 10.1016/j.jinf.2012.10.026] [Citation(s) in RCA: 99] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Accepted: 10/21/2012] [Indexed: 11/17/2022]
Abstract
HIV-1 genetic variability within individuals and populations plays a central role in the HIV pandemic. Multiple zoonotic transmissions of SIV to humans have resulted in distinct HIV lineages in humans which have further diversified within the population over time. High rates of mutation and recombination during HIV reverse transcription create a genetic diversity in the host which is subject to selection pressures by the immune response and antiretroviral treatment. The global distribution of HIV genetic variants and the impact of HIV diversity on pathogenesis, transmission and clinical management are reviewed. Finally, the key role of escape mutations in the immune response to HIV is discussed as well as the major challenge which HIV-1 diversity poses to HIV vaccine development.
Collapse
Affiliation(s)
- Joris Hemelaar
- Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Women's Centre, Level 3, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom.
| |
Collapse
|
11
|
Does genetic diversity of HIV-1 non-B subtypes differentially impact disease progression in treatment-naive HIV-1-infected individuals? A systematic review of evidence: 1996-2010. J Acquir Immune Defic Syndr 2012; 59:382-8. [PMID: 22269800 DOI: 10.1097/qai.0b013e31824a0628] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
With 88% of HIV-1-infected individuals living in areas of high prevalence of non-B subtypes and with expanded global access to antiretroviral treatment (ART), studying disease progression amongst non-B subtypes gains relevance. Optimized clinical management is a possibility with knowledge of non-B subtype profiles at baseline, which is currently not possible due to lack of subtype-specific point-of-care assays. In a systematic review, we synthesized global evidence on differential disease progression amongst non-B subtypes in ART-naive individuals. Due to lack of consistent effect measures, we avoided pooling data and inferred patterns with respect to disease progression outcomes (ie, AIDS, Death, CD4, viral load changes). Subtypes C and D were more aggressive, followed by G, AE, and AG, and A being the least aggressive of all HIV-1 subtypes. Evidence of greater rates of disease progression in globally prevalent C and D subtypes highlight the importance of expanding early HIV detection, and determining subtype profile at baseline with CD4 staging to optimize the quality of ART delivery and care in global settings.
Collapse
|
12
|
Abstract
BACKGROUND Reducing rates of partner change and increasing condom usage among gay men are obvious targets for potentially reducing syphilis transmission among gay men. METHODS We developed an agent-based stochastic model to examine syphilis transmission among a population of gay men, representative of gay men in Australia. This model was used to explore the potential impact of changes in sexual behavior over 1 month, 3 month, and indefinite time frames on syphilis epidemics. RESULTS Simulations of interventions showed that short-term reductions in rates of partner change and increased condom use would have negligible impact on the long-term trends of syphilis epidemics. If no interventions are introduced, then the model forecasts that the syphilis prevalence in the population could continue to rise, with an increase of 80% in the number of men infected with syphilis during the next decade. However, if changes in sexual behavior are maintained in the long-term, then syphilis epidemics can be mitigated. If condom use is sustained at 80% in partnerships that are HIV discordant or of unknown status, then the prevalence of syphilis is estimated to decrease by 9% over 10 years. Similarly, if partner acquisition rates decrease by 25%, then there will be a 22% reduction in syphilis prevalence. CONCLUSIONS Interventions promoting partner reduction or increased condom use would be ineffective in the short-term, and would have limited prospects for success in the long-term unless very large changes in behavior are sustained. Complementary social research indicates that such long-term changes in behavior are unlikely to be adopted, and therefore other intervention strategies need to be developed to reduce syphilis among gay men.
Collapse
|
13
|
Azzoni L, Foulkes AS, Firnhaber C, Yin X, Crowther NJ, Glencross D, Lawrie D, Stevens W, Papasavvas E, Sanne I, Montaner LJ. Metabolic and anthropometric parameters contribute to ART-mediated CD4+ T cell recovery in HIV-1-infected individuals: an observational study. J Int AIDS Soc 2011; 14:37. [PMID: 21801351 PMCID: PMC3163506 DOI: 10.1186/1758-2652-14-37] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2010] [Accepted: 07/29/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The degree of immune reconstitution achieved in response to suppressive ART is associated with baseline individual characteristics, such as pre-treatment CD4 count, levels of viral replication, cellular activation, choice of treatment regimen and gender. However, the combined effect of these variables on long-term CD4 recovery remains elusive, and no single variable predicts treatment response. We sought to determine if adiposity and molecules associated with lipid metabolism may affect the response to ART and the degree of subsequent immune reconstitution, and to assess their ability to predict CD4 recovery. METHODS We studied a cohort of 69 (48 females and 21 males) HIV-infected, treatment-naïve South African subjects initiating antiretroviral treatment (d4T, 3Tc and lopinavir/ritonavir). We collected information at baseline and six months after viral suppression, assessing anthropometric parameters, dual energy X-ray absorptiometry and magnetic resonance imaging scans, serum-based clinical laboratory tests and whole blood-based flow cytometry, and determined their role in predicting the increase in CD4 count in response to ART. RESULTS We present evidence that baseline CD4+ T cell count, viral load, CD8+ T cell activation (CD95 expression) and metabolic and anthropometric parameters linked to adiposity (LDL/HDL cholesterol ratio and waist/hip ratio) significantly contribute to variability in the extent of CD4 reconstitution (ΔCD4) after six months of continuous ART. CONCLUSIONS Our final model accounts for 44% of the variability in CD4+ T cell recovery in virally suppressed individuals, representing a workable predictive model of immune reconstitution.
Collapse
Affiliation(s)
- Livio Azzoni
- HIV-1 Immunopathogenesis Laboratory, the Wistar Institute, Philadelphia, PA, USA
| | - Andrea S Foulkes
- School of Public Health and Health Sciences, University of Massachusetts, Amherst, USA
| | - Cynthia Firnhaber
- Clinical HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Xiangfan Yin
- HIV-1 Immunopathogenesis Laboratory, the Wistar Institute, Philadelphia, PA, USA
| | - Nigel J Crowther
- Department of Chemical Pathology, National Health Laboratory Service and University of the Witwatersrand, Johannesburg, South Africa
| | - Deborah Glencross
- Department of Hematology and Molecular Medicine, National Health Laboratory Service and University of the Witwatersrand, Johannesburg, South Africa
| | - Denise Lawrie
- Department of Hematology and Molecular Medicine, National Health Laboratory Service and University of the Witwatersrand, Johannesburg, South Africa
| | - Wendy Stevens
- Department of Hematology and Molecular Medicine, National Health Laboratory Service and University of the Witwatersrand, Johannesburg, South Africa
| | - Emmanouil Papasavvas
- HIV-1 Immunopathogenesis Laboratory, the Wistar Institute, Philadelphia, PA, USA
| | - Ian Sanne
- Clinical HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Luis J Montaner
- HIV-1 Immunopathogenesis Laboratory, the Wistar Institute, Philadelphia, PA, USA
| |
Collapse
|
14
|
Sen S, Vyas A, Sanghi S, Shanmuganandan K, Gupta RM, Kapila BK, Praharaj AK, Kumar S, Batra RB. Correlation of CD4+ T cell Count with Total Lymphocyte Count, Haemoglobin and Erythrocyte Sedimentation Rate Levels in Human Immunodeficiency Virus Type-1 Disease. Med J Armed Forces India 2011; 67:15-20. [PMID: 27365755 DOI: 10.1016/s0377-1237(11)80005-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2010] [Accepted: 12/13/2010] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Studies in human immunodeficiency virus (HIV) infected adults have demonstrated association of total lymphocyte count (TLC) <1200/mm (3) and subsequent disease progression or mortality. The association of other surrogate makers such as haemoglobin (Hb), and erythrocyte sedimentation rate (ESR) with CD4 count and disease progression has also been suggested. This study was carried out to determine the relationship of CD4-positive T lymphocyte counts with TLC, Hb and ESR in HIV-infected individuals. METHODS The study population comprised of 215 antiretroviral treatment naïve HIV-1 infected adults. The CD4 positive T cell counts, TLC, Hb and ESR of study participants were measured. Spearman's rank order correlation and Receiver Operating Characteristic were used for statistical analyses. RESULT The sensitivity, specificity, positive and negative likelihood ratios for cut-off value of TLC <1200/mm (3) for predicting CD4 counts <200 cells/mm (3) and <350 cells/mm (3) were 9.4 %, 100 %, not measurable and 1.1, and 6.1 %, 98.8 %, 5.13 and 0.95, respectively. The association of Hb (<10,11,12 g/dl and <10,12,14 g/dl for CD4 counts <200 cells/mm (3) and <350 cells/mm (3) , respectively), and ESR (<10, 20 and 30 mm fall after 1 hour) with these two CD4 counts cut-off values were suboptimal. CONCLUSION This study reveals the poor association of TLC, Hb, and ESR with CD4 counts in HIV infected adults, thus highlighting the need to review the utility of these surrogate markers, for predicting CD4 counts in people living with HIV/AIDS.
Collapse
Affiliation(s)
- Sourav Sen
- Associate Professor, Department of Microbiology, AFMC, Pune-40
| | | | - Sunil Sanghi
- Classified Specialist (Dermatology), STI & HIV/AIDS, CH (SC), Pune-40
| | - K Shanmuganandan
- Senior Advisor (Med & Rheumat), Army Hospital (R&R), Delhi Cantt
| | - R M Gupta
- Senior Advisor (Pathology & Microbiology), CH (NC)
| | | | - A K Praharaj
- Professor & HOD, Department of Microbiology, AFMC, Pune-40
| | - Satish Kumar
- Associate Professor, Department of Microbiology, AFMC, Pune-40
| | - R B Batra
- Associate Professor, Department of Pathology, AFMC, Pune-40
| |
Collapse
|
15
|
CD4 cell eligibility thresholds: an analysis of the time to antiretroviral treatment in HIV-1 seroconverters. AIDS 2011; 25:819-23. [PMID: 21412060 DOI: 10.1097/qad.0b013e32834625d3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND WHO recommends initiating combination antiretroviral treatment at the minimal CD4 cell threshold of 350 cells/μl. In sub-Saharan Africa, the time for a recently infected patient to reach this threshold is unclear. METHOD We estimated the probability of reaching different CD4 cell thresholds over time in the ANRS 1220 cohort of HIV-1 seroconverters in Côte d'Ivoire. CD4 cell slopes were estimated using a mixed linear model. Probabilities of crossing the 350 and 500 cells/μl CD4 cell thresholds were estimated by the Kaplan-Meier method. RESULTS Between 1997 and 2009, 304 recent seroconverters have been enrolled in the Primo-CI cohort (62% men, median baseline age 29 years and median time since the estimated date of seroconversion 9 months). The probability of having a first CD4 cell count below 500 cells/μl was 0.57, 0.72, 0.79 and 0.84 at study entry, 2, 4 and 6 years, respectively. For a first CD4 cell count below 350 cells/μl, these figures were 0.29, 0.40, 0.55 and 0.67. The time for 75% of patients to reach the threshold was 3.0 years for 500 cells/μl and 7.0 years for 350 cells/μl.
Collapse
|
16
|
Abrogoua DP, Aulagner G, Kablan BJ, Petit C. [Study of meta-trajectories of CD4 cells count from taxonomy in the antiretroviral response of efavirenz-based regimen with naive symptomatic patients in Abidjan]. ANNALES PHARMACEUTIQUES FRANÇAISES 2010; 69:7-21. [PMID: 21296213 DOI: 10.1016/j.pharma.2010.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2010] [Revised: 06/23/2010] [Accepted: 09/08/2010] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Sub-Saharan Africa remains the most affected region in the global AIDS epidemic. Côte d'Ivoire is one of the most affected countries by this epidemic. The collective search for deleterious determinants of the evolution of immunological markers (CD4 cells count) may help to optimize the therapeutic efficiency in this resource-limited country. PATIENTS AND METHODS We are interested in studying the antiretroviral response of efavirenz-based regimen (treatment of choice in first line) by the nonhierarchical-descendant model by taxonomy of CD4 cells count trajectories. From 87 CD4 cells count trajectories of symptomatic naive patients, classes of similar profiles grouped by the model have formed typical profiles of evolution as meta-trajectories. The analysis of these meta-trajectories was used to study the determinants of CD4 cells count evolution by classes of patients. RESULTS Four classes have been determined for an optimal taxonomy with a partition score of 0.72: P1 (n=27), P2 (n=15), P3 (n=24), P4 (n=21). Our model showed a variation between groups of CD4 cells count trajectories linked to explanatory factors by highlighting the predictive role of certain characteristics on antiretroviral response in Côte d'Ivoire (CD4 cells count baseline [P<0.01], CD4 percentage baseline [P<0.05], adherence [P<0.05]). The multiple correspondence analysis revealed other characteristics that influence the immune response such as the presence of opportunistic infections, bloodless status and weight at the initiation of treatment. CONCLUSION The factors influencing the profile of meta-trajectories of CD4 cells count during efavirenz-based antiretroviral regimen should be considered at the initiation of treatment to optimize performance in the therapeutic monitoring of patients in Abidjan. The model of biomedical indicators meta-trajectories provides a therapeutic decision support provided prior to capitalize sufficient expertise for a better interpretation.
Collapse
Affiliation(s)
- D P Abrogoua
- Laboratoire de pharmacie clinique, pharmacologie et thérapeutique, UFR sciences pharmaceutiques et biologiques, université Cocody-Abidjan, 22 BP 1397 Abidjan 22, Côte d'Ivoire.
| | | | | | | |
Collapse
|
17
|
Johansson K, Robberstad B, Norheim O. Further benefits by early start of HIV treatment in low income countries: survival estimates of early versus deferred antiretroviral therapy. AIDS Res Ther 2010; 7:3. [PMID: 20180966 PMCID: PMC2836271 DOI: 10.1186/1742-6405-7-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2009] [Accepted: 01/16/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND International HIV guidelines have recently shifted from a medium-late to an early-start treatment strategy. As a consequence, more people will be eligible to Highly Active Antiretroviral Therapy (HAART). We estimate mean life years gained using different treatment indications in low income countries. METHODS We carried out a systematic search to identify relevant studies on the treatment effect of HAART. Outcome from identified observational studies were combined in a pooled-analyses and we apply these data in a Markov life cycle model based on a hypothetical Tanzanian HIV population. Survival for three different HIV populations with and without any treatment is estimated. The number of patients included in our pooled-analysis is 35,047. RESULTS Providing HAART early when CD4 is 200-350 cells/microl is likely to be the best outcome strategy with an expected net benefit of 14.5 life years per patient. The model predicts diminishing treatment benefits for patients starting treatment when CD4 counts are lower. Patients starting treatment at CD4 50-199 and <50 cells/microl have expected net health benefits of 7.6 and 7.3 life years. Without treatment, HIV patients with CD4 counts 200-350; 50-199 and < 50 cells/microl can expect to live 4.8; 2.0 and 0.7 life years respectively. CONCLUSIONS This study demonstrates that HIV patients live longer with early start strategies in low income countries. Since low income countries have many constraints to full coverage of HAART, this study provides input to a more transparent debate regarding where to draw explicit eligibility criteria during further scale up of HAART.
Collapse
|
18
|
Obirikorang C, Yeboah FA. Blood haemoglobin measurement as a predictive indicator for the progression of HIV/AIDS in resource-limited setting. J Biomed Sci 2009; 16:102. [PMID: 19922646 PMCID: PMC2783029 DOI: 10.1186/1423-0127-16-102] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2009] [Accepted: 11/18/2009] [Indexed: 11/10/2022] Open
Abstract
Background Anaemia is a frequent complication of infection with the human immunodeficiency virus (HIV) and may have multiple causes. The objective of this study was to find out if blood haemoglobin measurement could be used as an indicator for the progression of HIV/AIDS in resource-limited setting. Methods Two hundred and twenty-eight (228) consented People Living with HIV/AIDS (PLWHAs) who were placed in three groups according to their CD4 counts were used in the study. The three groups were those with CD4 counts (1) ≥ 500 mm-3; (2) 200-499 mm-3; and (3) <200 mm-3. One hundred (100) sex, age-matched and healthy HIV-seronegative individuals were used as control subjects. Blood haemoglobin, blood haematocrit, Red cell indices which included Mean Cell Volume, Mean Cell Haemoglobin Concentration and Mean Cell Haemoglobin and CD4 count were analysed in all subjects. Results The mean blood haemoglobin concentrations in those with CD4 counts <200 mm-3, 200-499 mm-3 and ≥ 500 mm-3 (8.83 ± 0.22 g/dl, 10.03 ± 0.31 g/dl and 11.3 ± 0.44 g/dl respectively) were significantly lower when compared with the control group (14.29 ± 0.77 g/dl) (p < 0.0001). The mean blood haematocrit levels in those with CD4 counts <200 mm-3, 200-499 mm-3 and ≥ 500 mm-3 (23.53 ± 0.85%, 28.28 ± 0.77% and 33.54 ± 1.35% respectively) were also significantly lower when compared with the control group (41.15 ± 2.15%) (p < 0.0001). The red cell indices were also lower in the subjects when compared with the control group. Using the Pearson's correlation, there was a significant and positive correlation between the blood haemoglobin level and their CD4 counts (r2 = 0.1755; p < 0.0001). Conclusion Anaemia in People Living with HIV/AIDS, if persistent, is associated with substantially decreased survival. From our analysis, there was a decrease in the blood haemoglobin, levels as the HIV infection progressed and our findings are consistent with those of other studies of anaemia as a prognostic factor in HIV infection. Haemoglobin levels could be measured easily where resources for more sophisticated laboratory markers such as viral load or even CD4 lymphocyte count are not available given that measurement of the CD4 lymphocyte count requires flow cytometry, an expensive technique unavailable in many developing countries. Regular measurements could help to determine which patients are at greatest risk of disease progression, allowing these patients to be identified for closer monitoring or therapeutic intervention.
Collapse
Affiliation(s)
- Christian Obirikorang
- Department of Molecular Medicine, School of Medical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana.
| | | |
Collapse
|
19
|
Wilson DP, Hoare A, Regan DG, Law MG. Importance of promoting HIV testing for preventing secondary transmissions: modelling the Australian HIV epidemic among men who have sex with men. Sex Health 2009; 6:19-33. [PMID: 19254488 DOI: 10.1071/sh08081] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2008] [Accepted: 12/11/2008] [Indexed: 01/05/2023]
Abstract
BACKGROUND We address the research questions: (i) what proportion of new HIV infections is transmitted from people who are (a) undiagnosed, (b) in primary HIV infection (PHI), (c) on antiretroviral therapy?; and (ii) what is the expected epidemiological impact of (a) increasing the proportion of newly acquired HIV infections receiving early treatment, and (b) increasing HIV testing rates? METHODS We used a mathematical model to simulate HIV transmission in the population of men who have sex with men (MSM) in Australia. We calibrated the model using established biological and clinical data and a wide range of Australian MSM epidemiological and behavioural data sources. RESULTS We estimate that ~19% of all new HIV infections are transmitted from the ~3% of Australian HIV-infected MSM who are in PHI; ~31% of new HIV infections are estimated to be transmitted from the ~9% of MSM with undiagnosed HIV. We estimate that the average number of infections caused per HIV-infected MSM through the duration of PHI is ~0.14-0.28. CONCLUSIONS The epidemiological impact of increasing treatment in PHI would be modest due to insufficient detection of newly-infected individuals. In contrast, increases in HIV testing rates could have substantial epidemiological consequences. The benefit of testing will also increase over time. Promoting increases in the coverage and frequency of testing for HIV could be a highly-effective public health intervention, but the population-level impact of interventions based on promoting early treatment of patients diagnosed in PHI is likely to be small. Treating PHI requires further evaluation of its long-term effects on HIV-infected individuals.
Collapse
Affiliation(s)
- David P Wilson
- National Centre in HIV Epidemiology and Clinical Research, The University of New South Wales, Sydney, NSW 2010, Australia.
| | | | | | | |
Collapse
|
20
|
Gurunathan S, Habib RE, Baglyos L, Meric C, Plotkin S, Dodet B, Corey L, Tartaglia J. Use of predictive markers of HIV disease progression in vaccine trials. Vaccine 2009; 27:1997-2015. [DOI: 10.1016/j.vaccine.2009.01.039] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2008] [Revised: 12/19/2008] [Accepted: 01/08/2009] [Indexed: 10/21/2022]
|
21
|
Wandel S, Egger M, Rangsin R, Nelson KE, Costello C, Lewden C, Lutalo T, Ndyanabo A, Todd J, Van der Paal L, Minga A, Zwahlen M. Duration from seroconversion to eligibility for antiretroviral therapy and from ART eligibility to death in adult HIV-infected patients from low and middle-income countries: collaborative analysis of prospective studies. Sex Transm Infect 2008; 84 Suppl 1:i31-i36. [PMID: 18647863 PMCID: PMC2569418 DOI: 10.1136/sti.2008.029793] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2008] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Estimation of the number of people in need of antiretroviral therapy (ART) in resource-limited settings requires information on the time from seroconversion to ART eligibility and from ART eligibility to death. OBJECTIVES To estimate duration from seroconversion to different ART eligibility criteria and from ART eligibility to death in HIV-infected adults in low-income and middle-income countries. METHODS Participants with documented seroconversion from five cohorts (two cohorts from Uganda, two from Thailand and one from Côte d'Ivoire) were analysed. We used Weibull survival models and Bayesian simulation methods to model true (unobserved) first time of treatment eligibility. We set a consistency constraint so that the mean duration from seroconversion to death was equal to the mean from seroconversion to ART eligibility plus the mean from eligibility to death. RESULTS We analysed data from 2072 participants, 16 157 person-years of follow-up and 794 deaths. For the criterion CD4 T-lymphocyte count <200 cells x10(6)/l, the median duration from seroconversion to ART eligibility was 6.1 years (95% credibility interval 3.3-10.4) for all studies and 7.6 years (95% credibility interval 3.4-15.2) for all but the Thai cohorts. Corresponding estimates for the time from CD4 T-lymphocyte count <200 cells x10(6)/l to death were 2.1 years (0.7-4.8) and 2.7 years (0.8-8.4). When including all cohorts, the mean time from serconversion to CD4 T-lymphocyte count <200 cells x10(6)/l and from CD4 T-lymphocyte count <200 cells x10(6)/l to death represented 66% (38-87%) and 34% (13-62%), respectively of the total survival time. CONCLUSIONS The duration of different ART eligibility criteria to death was longer than the estimates used in previous calculations of the number of people needing ART. However, uncertainty in estimates was considerable and heterogeneity across cohorts important.
Collapse
|
22
|
van Loggerenberg F, Mlisana K, Williamson C, Auld SC, Morris L, Gray CM, Abdool Karim Q, Grobler A, Barnabas N, Iriogbe I, Abdool Karim SS. Establishing a cohort at high risk of HIV infection in South Africa: challenges and experiences of the CAPRISA 002 acute infection study. PLoS One 2008; 3:e1954. [PMID: 18414658 PMCID: PMC2278382 DOI: 10.1371/journal.pone.0001954] [Citation(s) in RCA: 162] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2007] [Accepted: 02/27/2008] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To describe the baseline demographic data, clinical characteristics and HIV-incidence rates of a cohort at high risk for HIV infection in South Africa as well as the challenges experienced in establishing and maintaining the cohort. METHODOLOGY/PRINCIPLE FINDINGS Between August 2004 and May 2005 a cohort of HIV-uninfected women was established for the CAPRISA 002 Acute Infection Study, a natural history study of HIV-1 subtype C infection. Volunteers were identified through peer-outreach. The cohort was followed monthly to determine HIV infection rates and clinical presentation of early HIV infection. Risk reduction counselling and male and female condoms were provided. After screening 775 individuals, a cohort of 245 uninfected high-risk women was established. HIV-prevalence at screening was 59.6% (95% CI: 55.9% to 62.8%) posing a challenge in accruing HIV-uninfected women. The majority of women (78.8%) were self-identified as sex-workers with a median of 2 clients per day. Most women (95%) reported more than one casual sexual partner in the previous 3 months (excluding clients) and 58.8% reported condom use in their last sexual encounter. Based on laboratory testing, 62.0% had a sexually transmitted infection at baseline. During 390 person-years of follow-up, 28 infections occurred yielding seroincidence rate of 7.2 (95% CI: 4.5 to 9.8) per 100 person-years. Despite the high mobility of this sex worker cohort retention rate after 2 years was 86.1%. High co-morbidity created challenges for ancillary care provision, both in terms of human and financial resources. CONCLUSIONS/SIGNIFICANCE Challenges experienced were high baseline HIV-prevalence, lower than anticipated HIV-incidence and difficulties retaining participants. Despite challenges, we have successfully accrued this cohort of HIV-uninfected women with favourable retention, enabling us to study the natural history of HIV-1 during acute HIV-infection. Our experiences provide lessons for others establishing similar cohorts, which will be key for advancing the vaccine and prevention research agenda in resource-constrained settings.
Collapse
Affiliation(s)
- Francois van Loggerenberg
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Affiliation(s)
- Barbara S Taylor
- Department of Medicine and the Division of Infectious Diseases, Columbia University Medical Center, New York 10032, USA.
| | | | | | | |
Collapse
|
24
|
Liner KJ, Hall CD, Robertson KR. Impact of human immunodeficiency virus (HIV) subtypes on HIV-associated neurological disease. J Neurovirol 2007; 13:291-304. [PMID: 17849313 DOI: 10.1080/13550280701422383] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Among the many variables affecting transmission and pathogenesis of the human immunodeficiency virus type 1(HIV-1), the effects of HIV subtypes, or clades, on disease progression remain unclear. Although debated, some studies have found that the variable env and pol sequences of different subtypes of HIV-1 may endow some subtypes with greater degrees of cell tropism, virulence, and drug resistance, which may lead to differences in overall disease progression. HIV-associated dementia (HAD) appears to be associated with viral diversity and markers of immune activation. Africa has the highest prevalence of HIV, largest viral diversity, and is where clade recombination occurs most frequently. All of these factors would suggest that HAD would pose the largest threat in this region of the world. Although investigations into the effects of different subtypes on overall disease progression are well documented, few have looked into the effects of subtypes on neurological disease progression. This review highlights the need for more international research involving the neurological effects and especially the clinical presentation of dementia for the entire range of the group M HIV-1 subtypes.
Collapse
Affiliation(s)
- Kevin J Liner
- Department of Neurology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | | |
Collapse
|
25
|
Abstract
OBJECTIVES To estimate mortality directly attributable to HIV in HIV-infected adults in low and middle income countries and discuss appropriate methodology. DESIGN : Illustrative analysis of pooled data from six studies across sub-Saharan Africa and Thailand with data on individuals with known dates of seroconversion to HIV. METHODS Five of the studies also had data from HIV-negative subjects and one had verbal autopsies. Data for HIV-negative cohorts were weighted by the initial age and sex distribution of the seroconverters. Using the survival of the HIV-negative group to represent the background mortality, net survival from HIV was calculated for the seroconverters using competing risk methods. Mortality from all causes and 'net' mortality were modelled using piecewise exponential regression. Alternative approaches are explored in the dataset without information on mortality of uninfected individuals. RESULTS The overall effect of the net mortality adjustment was to increase survivorship proportionately by 2 to 5% at 6 years post-infection. The increase ranged from 2% at ages 15-24 to 22% in those 55 and over. Mortality rate ratios between sites were similar to corresponding ratios for all-cause mortality. CONCLUSION Differences between HIV mortality in different populations and age groups are not explained by differences in background mortality, although this does appear to contribute to the excess at older ages. In the absence of data from uninfected individuals in the same population, model life tables can be used to calculate background rates.
Collapse
|
26
|
Time from HIV seroconversion to death: a collaborative analysis of eight studies in six low and middle-income countries before highly active antiretroviral therapy. AIDS 2007; 21 Suppl 6:S55-63. [PMID: 18032940 DOI: 10.1097/01.aids.0000299411.75269.e8] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To estimate survival patterns after HIV infection in adults in low and middle-income countries. DESIGN An analysis of pooled data from eight different studies in six countries. METHODS HIV seroconverters were included from eight studies (three population-based, two occupational, and three clinic cohorts) if they were at least 15 years of age, and had no more than 4 years between the last HIV-negative and subsequent HIV-positive test. Four strata were defined: East African cohorts; South African miners cohort; Thai cohorts; Haitian clinic cohort. Kaplan-Meier functions were used to estimate survival patterns, and Weibull distributions were used to model and extend survival estimates. Analyses examined the effect of site, age, and sex on survival. RESULTS From 3823 eligible seroconverters, 1079 deaths were observed in 19 671 person-years of follow-up. Survival times varied by age and by study site. Adjusting to age 25-29 years at seroconversion, the median survival was longer in South African miners: 11.6 years [95% confidence interval (CI) 9.8-13.7] and East African cohorts: 11.1 years (95% CI 8.7-14.2) than in Haiti: 8.3 years (95% CI 3.2-21.4) and Thailand: 7.5 years (95% CI 5.4-10.4). Survival was similar for men and women, after adjustment for age at seroconversion and site. CONCLUSION Without antiretroviral therapy, overall survival after HIV infection in African cohorts was similar to survival in high-income countries, with a similar pattern of faster progression at older ages at seroconversion. Survival appears to be significantly worse in Thailand where other, unmeasured factors may affect progression.
Collapse
|
27
|
Sadeghi M, Süsal C, Daniel V, Naujokat C, Zimmermann R, Huth-Kühne A, Opelz G. Short communication: decreasing soluble CD30 and increasing IFN-gamma plasma levels are indicators of effective highly active antiretroviral therapy. AIDS Res Hum Retroviruses 2007; 23:886-90. [PMID: 17678471 DOI: 10.1089/aid.2006.0228] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
It was previously reported that without highly active antiretroviral therapy (HAART), secretion of Th1 cytokines and antiviral IFN-gamma in HIV-infected patients is decreased, whereas the production of Th2 cytokines, proinflammatory cytokines, and TNF-alpha is increased. We studied the effect of HAART on Th1-, Th2-, and monocyte-derived cytokines, and on the Th2-type immune response marker soluble (s)CD30 in HIV-1-infected hemophilia patients. Viral Load (VL), CD4+ lymphocyte counts, and plasma levels of sIL-1RA, IL-2, sIL-2R, IL-3, IL-4, IL-6, sIL-6R, IL-7, IL-10, TNF-alpha, TGF-beta2, IFN-gamma, and sCD30 were measured in 18 patients who received HAART. Nine patients were initially treatment-naive and were monitored after the initiation of HAART. sCD30 median levels were significantly higher in treatment-naive patients than in patients who were on HAART (77 vs. 30 U/ml, p = 0.005). A strong association was observed between sCD30 and VL (r = 0.85, p = 0.004). After the initiation of HAART, sCD30 levels decreased and remained low (at 1 year, 38; at 2 years, 41 U/ml; p = 0.012 and p = 0.021, respectively, as compared to baseline level) and this was accompanied by a decrease in VL and monocyte-derived IL-6 and an increase in CD4+ lymphocyte counts and Th1-derived IFN-gamma. One year after the initiation of HAART a strong inverse correlation was observed between IFN-gamma and VL (r = -0.83, p = 0.006). In contrast to sCD30 and IFN-gamma, CD4 counts and plasma IL-6 did not correlate with VL at any time. Our data suggest that decreasing sCD30 and increasing IFN-gamma plasma levels are indicators of effective HAART treatment and CD4 Th1 cell recovery in HIV-infected patients.
Collapse
Affiliation(s)
- Mahmoud Sadeghi
- Department of Transplantation Immunology, University of Heidelberg, Heidelberg, Germany.
| | | | | | | | | | | | | |
Collapse
|
28
|
Langford SE, Ananworanich J, Cooper DA. Predictors of disease progression in HIV infection: a review. AIDS Res Ther 2007; 4:11. [PMID: 17502001 PMCID: PMC1887539 DOI: 10.1186/1742-6405-4-11] [Citation(s) in RCA: 192] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2006] [Accepted: 05/14/2007] [Indexed: 01/18/2023] Open
Abstract
During the extended clinically latent period associated with Human Immunodeficiency Virus (HIV) infection the virus itself is far from latent. This phase of infection generally comes to an end with the development of symptomatic illness. Understanding the factors affecting disease progression can aid treatment commencement and therapeutic monitoring decisions. An example of this is the clear utility of CD4+ T-cell count and HIV-RNA for disease stage and progression assessment. Elements of the immune response such as the diversity of HIV-specific cytotoxic lymphocyte responses and cell-surface CD38 expression correlate significantly with the control of viral replication. However, the relationship between soluble markers of immune activation and disease progression remains inconclusive. In patients on treatment, sustained virological rebound to >10,000 copies/mL is associated with poor clinical outcome. However, the same is not true of transient elevations of HIV RNA (blips). Another virological factor, drug resistance, is becoming a growing problem around the globe and monitoring must play a part in the surveillance and control of the epidemic worldwide. The links between chemokine receptor tropism and rate of disease progression remain uncertain and the clinical utility of monitoring viral strain is yet to be determined. The large number of confounding factors has made investigation of the roles of race and viral subtype difficult, and further research is needed to elucidate their significance. Host factors such as age, HLA and CYP polymorphisms and psychosocial factors remain important, though often unalterable, predictors of disease progression. Although gender and mode of transmission have a lesser role in disease progression, they may impact other markers such as viral load. Finally, readily measurable markers of disease such as total lymphocyte count, haemoglobin, body mass index and delayed type hypersensitivity may come into favour as ART becomes increasingly available in resource-limited parts of the world. The influence of these, and other factors, on the clinical progression of HIV infection are reviewed in detail, both preceding and following treatment initiation.
Collapse
Affiliation(s)
- Simone E Langford
- Monash University, Melbourne, Australia
- The HIV Netherlands Australia Thailand Research Collaboration, Bangkok, Thailand
| | | | - David A Cooper
- The HIV Netherlands Australia Thailand Research Collaboration, Bangkok, Thailand
- The National Centre in HIV Epidemiology and Clinical Research, Sydney, Australia, University of New South Wales, Sydney, Australia
| |
Collapse
|
29
|
Quan VM, Vongchak T, Jittiwutikarn J, Kawichai S, Srirak N, Wiboonnatakul K, Razak MH, Suriyanon V, Celentano DD. Predictors of mortality among injecting and non-injecting HIV-negative drug users in northern Thailand. Addiction 2007; 102:441-6. [PMID: 17298652 DOI: 10.1111/j.1360-0443.2006.01709.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIMS To estimate mortality rates among HIV-negative injecting drug users (IDUs) and non-injecting drug users (non-IDUs), and to assess predictors for mortality among the IDUs. DESIGN Prospective cohort study in northern Thailand with 2-year follow-up. SETTING IDUs and non-IDUs who were admitted for detoxification treatment for opiate or amphetamine dependence in a regional drug treatment center were screened. After discharge, HIV-negative individuals were followed-up in the community. PARTICIPANTS A total of 821 HIV-negative drug users [346 IDUs (42%) and 475 non-IDUs, median age = 32; 51% were ethnic minorities]. MEASUREMENTS All-cause mortality. FINDINGS There were 33 deaths over 1360 person-years of follow-up. The all-cause mortality rate was 39 per 1000 person-years among IDUs [standardized mortality ratio (SMR) = 13.9], and was 14 per 1000 person-years among non-IDUs (SMR = 4.4). Among male IDUs, the hazards for all-cause deaths were ethnic minority status [adjusted hazard ratio (HR) = 2.9, 95% CI = 1.2-7.2], incident HIV infection (HR = 2.8, 95% CI = 1.1-7.7) and longer duration of drug injection (HR = 1.07, 95% CI = 1.01-1.14). CONCLUSIONS The mortality among IDUs is high. Being from an ethnic minority, recent HIV acquisition, and a greater number of years of drug injection are predictors of mortality among the IDUs in this region.
Collapse
Affiliation(s)
- Vu Minh Quan
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD 21205, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Abstract
PURPOSE OF REVIEW HIV knowledge is based on subtype B, common in resource-rich settings, whereas globally non-B subtypes predominate. Inter-subtype pol diversity encompasses multiple genotypic differences among HIV variants, the consequence of which is unknown. This review summarizes publications from the past year relevant to the impact of HIV diversity on drug resistance evolution and its potential clinical implications. RECENT FINDINGS The benefit of antiretroviral therapy in non-B infected patients is ongoing, though subtype heterogeneity in rates of disease progression is observed. Pol inter-subtype diversity is high, and known subtype B drug resistance mutations occur in non-B subtypes. New mutations and subtype-specific mutation rates are identified, however, unexplained drug susceptibilities are seen, and additional insight is offered on structural pathogenic mechanisms of resistance in non-B subtypes. These differences may affect genotypic interpretation and our ability to apply drug resistance to patient care. SUMMARY Current evidence suggests good treatment response and comparable drug resistance evolution in HIV-1 B and non-B infected patients, with increasingly emerging differences. Impact of inter-subtype diversity on drug susceptibility and on evolution of drug resistance should continue to be a major research focus to increase our understanding and ability to improve global patient care.
Collapse
Affiliation(s)
- Rami Kantor
- Division of Infectious Diseases, The Miriam Hospital, Providence, Rhode Island 02906, USA.
| |
Collapse
|
31
|
Abstract
PURPOSE OF REVIEW This review presents an update on the molecular epidemic patterns of HIV-1 infection and the effects of subtype-related genetic variability on transmission, disease progression, response to antiretroviral therapy and drug-resistance pathways. RECENT FINDINGS The molecular epidemiology of HIV-1 infection is complex and evolving. The emergence of new variants reflects HIV-1 prevalence, subtype epidemiology and risk-behaviour patterns in different geographical areas. Evidence indicates that certain subtypes may have a transmission advantage while others display higher replicative efficiency. The molecular mechanisms underlying these differences are being identified and include both virus- and host-related factors. Although drug susceptibility varies and clinical evidence remains limited, current antiretroviral regimens appear to have comparable efficacy in patients infected with B and non-B subtypes. Subtype-related variability influences resistance pathways. However, the major treatment-associated resistance mutations seen in subtype B also confer resistance in non-B subtypes and vice versa. SUMMARY Genetic differences among HIV-1 variants can influence the virus biological properties, susceptibility to existing and candidate antiretroviral drugs, and evolution of antiretroviral drug resistance. Further studies are required to define the impact of this variability on risk of transmission, disease outcomes, responses to antiretroviral therapy and resistance pathways. Meanwhile, plasma viral load and CD4 count remain the important predictors of disease outcome, regardless of the infecting subtype. Current antiretroviral regimens can be used reliably to treat patients with both B and non-B subtypes, and resistance interpretation algorithms provide adequate guidance. The limitations of current evidence should be acknowledged and instigate ongoing vigilance.
Collapse
Affiliation(s)
- Anna Maria Geretti
- Royal Free Hospital and Royal Free and University College Medical School, London, UK.
| |
Collapse
|
32
|
Egger M, Boulle A, Schechter M, Miotti P. Antiretroviral therapy in resource-poor settings: scaling up inequalities? Int J Epidemiol 2005; 34:509-12. [PMID: 15941732 DOI: 10.1093/ije/dyi110] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
33
|
Miller V. Commentary: Sifting through the maze of viral and host diversity and HIV/AIDS clinical progression. Int J Epidemiol 2005; 34:584-5. [PMID: 15851391 DOI: 10.1093/ije/dyi090] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Veronica Miller
- Forum for Collaborative HIV Research, Department of Prevention and Community Health, The George Washingon University, 2175 K Street NW, Suite 700, Washington DC 20037, USA.
| |
Collapse
|