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Masaba RO, Woelk G, Herrera N, Siamba S, Simiyu R, Ochanda B, Okomo G, Odionyi J, Audo M, Mwangi E. Standardized enhanced adherence counseling for improved HIV viral suppression among children and adolescents in Homa Bay and Turkana Counties, Kenya. Medicine (Baltimore) 2022; 101:e30624. [PMID: 36221325 PMCID: PMC9542655 DOI: 10.1097/md.0000000000030624] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Viral suppression is suboptimal among children and adolescents on antiretroviral therapy (ART) in Kenya. We implemented and evaluated a standardized enhanced adherence counseling (SEAC) package to improve viral suppression in children and adolescents with suspected treatment failure in Homa Bay and Turkana. The SEAC package, implemented from February 2019 to September 2020, included: standard procedures operationalizing the enhanced adherence counseling (EAC) process; provider training on psychosocial support and communication skills for children living with HIV and their caregivers; mentorship to providers and peer educators on EAC processes; and individualized case management. We enrolled children and adolescents aged 0 to 19 years with suspected treatment failure (viral load [VL] >1000 copies/mL) who received EAC before standardization as well as those who received SEAC in a pre-post evaluation of the SEAC package conducted in 6 high-volume facilities. Pre-post standardization comparisons were performed using Wilcoxon-Mann-Whitney and Pearson's chi-square tests at a 5% level of significance. Multivariate logistic regression was performed to identify factors associated with viral resuppression. The study enrolled 741 participants, 595 pre- and 146 post-SEAC implementation. All post-SEAC participants attended at least 1 EAC session, while 17% (n = 98) of pre-SEAC clients had no record of EAC attendance. Time to EAC following the detection of high VL was reduced by a median of 8 days, from 49 (interquartile range [IQR]: 23.0-102.5) to 41 (IQR: 20.0-67.0) days pre- versus post-SEAC (P = .006). Time to completion of at least 3 sessions was reduced by a median of 12 days, from 59.0 (IQR: 36.0-91.0) to 47.5 (IQR: 33.0-63.0) days pre- versus post-SEAC (P = .002). A greater percentage of clients completed the recommended minimum 3 EAC sessions at post-SEAC, 88.4% (n = 129) versus 61.1% (n = 363) pre-SEAC, P < .001. Among participants with a repeat VL within 3 months following the high VL, SEAC increased viral suppression from 34.6% (n = 76) to 52.5% (n = 45), P = .004. Implementation of the SEAC package significantly reduced the time to initiate EAC and time to completion of at least 3 EAC sessions, and was significantly associated with viral suppression in children and adolescents with suspected treatment failure.
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Affiliation(s)
- Rose Otieno Masaba
- Elizabeth Glaser Pediatric AIDS Foundation, Nairobi, Kenya
- *Correspondence: Rose Otieno Masaba, Elizabeth Glaser Pediatric AIDS Foundation, Nairobi, Kenya (e-mail: )
| | - Godfrey Woelk
- Elizabeth Glaser Pediatric AIDS Foundation, WA, DC, USA
| | | | - Stephen Siamba
- Elizabeth Glaser Pediatric AIDS Foundation, Nairobi, Kenya
| | - Rogers Simiyu
- Elizabeth Glaser Pediatric AIDS Foundation, Nairobi, Kenya
| | - Boniface Ochanda
- US Centers for Disease Control and Prevention, Center for Global Health, Division of Global HIV & TB, Kisumu, Kenya
| | | | | | - Michael Audo
- Elizabeth Glaser Pediatric AIDS Foundation, Nairobi, Kenya
| | - Eliud Mwangi
- Elizabeth Glaser Pediatric AIDS Foundation, Nairobi, Kenya
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Rashed Ul Islam SM, Jahan M, Nessa A, Tabassum S. Response to First-Line Antiretroviral Therapy Among PLHIV from a High-Risk, Low-Prevalence Setting. J Int Assoc Provid AIDS Care 2020; 18:2325958219867329. [PMID: 31392926 PMCID: PMC6900579 DOI: 10.1177/2325958219867329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The study reports the response of first-line antiretroviral therapy (ART) by assessing
CD4 and CD8 T-lymphocyte and viral load (VL) among Bangladeshi people living with HIV
(PLHIV). This observational approach was conducted on 100 PLHIVs, grouped into therapy
naive (n = 33), therapy initiators with CD4 T-cell count of <350 cells/µL (n = 33), and
therapy receivers for >1 year prior to the study period (n = 34). Therapy initiators
who continued the study (n = 20) were followed up after 12 and 24 weeks of therapy
initiation. The CD4 and CD8 T-lymphocyte count estimation and (VL) were quantified. The
mean CD4 T-lymphocyte count was significantly reduced among the therapy initiators in
comparison to therapy naive and therapy receivers. Similar findings were observed for CD8
T-lymphocyte count among the study groups. The mean HIV-1 RNA VL among therapy initiators
showed a significant decrease after 12 and 24 weeks, and 85% patients in this group
obtained undetectable VL status indicating the good therapeutic outcome.
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Affiliation(s)
| | - Munira Jahan
- 1 Department of Virology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh
| | - Afzalun Nessa
- 1 Department of Virology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh
| | - Shahina Tabassum
- 1 Department of Virology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh
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Edessa D, Sisay M, Asefa F. Second-line HIV treatment failure in sub-Saharan Africa: A systematic review and meta-analysis. PLoS One 2019; 14:e0220159. [PMID: 31356613 PMCID: PMC6663009 DOI: 10.1371/journal.pone.0220159] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Increased second-line antiretroviral therapy (ART) failure rate narrows future options for HIV/AIDS treatment. It has critical implications in resource-limited settings; including sub-Saharan Africa (SSA) where the burden of HIV-infection is immense. Hence, pooled estimate for second-line HIV treatment failure is relevant to suggest valid recommendations that optimize ART outcomes in SSA. METHODS We retrieved literature systematically from PUBMED/MEDLINE, EMBASE, CINAHL, Google Scholar, and AJOL. The retrieved studies were screened and assessed for eligibility. We also assessed the eligible studies for their methodological quality using the Joanna Briggs Institute's appraisal checklist. The pooled estimates for second-line HIV treatment failure and its associated factors were determined using STATA, version 15.0 and MEDCALC, version 18.11.3, respectively. We assessed publication bias using Comprehensive Meta-analysis software, version 3. Detailed study protocol for this review/meta-analysis is registered and found on PROSPERO (ID: CRD42018118959). RESULTS A total of 33 studies with the overall 18,550 participants and 19,988.45 person-years (PYs) of follow-up were included in the review. The pooled second-line HIV treatment failure rate was 15.0 per 100 PYs (95% CI: 13.0-18.0). It was slightly higher at 12-18 months of follow-up (19.0/100 PYs; 95% CI: 15.0-22.0), in children (19.0/100 PYs; 95% CI: 14.0-23.0) and in southern SSA (18.0/100 PYs; 95% CI: 14.0-23.0). Baseline values (high viral load (OR: 5.67; 95% CI: 13.40-9.45); advanced clinical stage (OR: 3.27; 95% CI: 2.07-5.19); and low CD4 counts (OR: 2.80; 95% CI: 1.83-4.29)) and suboptimal adherence to therapy (OR: 1.92; 95% CI: 1.28-2.86) were the factors associated with increased failure rates. CONCLUSION Second-line HIV treatment failure has become highly prevalent in SSA with alarming rates during the 12-18 month period of treatment start; in children; and southern SSA. Therefore, the second-line HIV treatment approach in SSA should critically consider excellent adherence to therapy, aggressive viral load suppression, and rapid immune recovery.
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Affiliation(s)
- Dumessa Edessa
- Department of Clinical Pharmacy, School of Pharmacy, College of Health and Medical Sciences, Haramaya University, Harar, Oromia, Ethiopia
- * E-mail:
| | - Mekonnen Sisay
- Department of Pharmacology and Toxicology, School of Pharmacy, College of Health and Medical Sciences, Haramaya University, Harar, Oromia, Ethiopia
| | - Fekede Asefa
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Oromia, Ethiopia
- Center for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, NSW, Australia
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Sarmati L, D'Ettorre G, Parisi SG, Andreoni M. HIV Replication at Low Copy Number and its Correlation with the HIV Reservoir: A Clinical Perspective. Curr HIV Res 2016; 13:250-7. [PMID: 25845389 PMCID: PMC4460281 DOI: 10.2174/1570162x13666150407142539] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 01/27/2015] [Accepted: 04/02/2015] [Indexed: 01/01/2023]
Abstract
The efficacy of combination therapy (antiretroviral therapy - ARV) is demonstrated by the high rates of viral suppression achieved in most treated HIV patients. Whereas contemporary
treatments may continuously suppress HIV replication, they do not eliminate the latent reservoir, which can reactivate HIV infection if ARV is discontinued. The persistence of HIV proviral DNA and
infectious viruses in CD4+ T cells and others cells has long been considered a major obstacle in eradicating the HIV virus in treated patients. Moreover, recent studies have demonstrated the
persistence of HIV replication at low copies in most patients on suppressive ARV. The source of this ‘residual viraemia’ and whether it declines over years of therapy remain unknown. Similarly, little is known regarding the biological
relationships between the HIV reservoir and viral replication at low copies. The question of whether this ‘residual viraemia’ represents active replication or the release of non-productive virus from the reservoir has not been adequately
resolved. From a clinical perspective, both the quantification of the HIV reservoir and the detection of low levels of replication in full-responder patients on prolonged ARV may provide important information regarding the effectiveness of treatment
and the eradication of HIV. To date, the monitoring of these two parameters has been conducted only for research purposes; the routine use of standardised tests procedure is lacking.
This review aims to assess the current data regarding the correlation between HIV replication at low copies and the HIV reservoir and to provide useful information for clinicians.
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Affiliation(s)
- Loredana Sarmati
- Clinical Infectious Diseases, Tor Vergata University, V. Montpellier 1, 00133, Roma, Italy.
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Chao C, Tang B, Hurley L, Silverberg MJ, Towner W, Preciado M, Horberg M. Risk factors for short-term virologic outcomes among HIV-infected patients undergoing regimen switch of combination antiretroviral therapy. AIDS Res Hum Retroviruses 2012; 28:1630-6. [PMID: 22475276 DOI: 10.1089/aid.2012.0005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
We investigated risk factors for unfavorable virologic responses among HIV-infected patients who recently switched antiretroviral regimens. We identified HIV-infected patients who switched antiretroviral regimens (defined as adding ≥2 new medications) between 2001 and 2008 at Kaiser Permanente California. Virological response, measured after 6 months on the new regimen, was classified as (1) maximal viral suppression (HIV RNA <75/ml), (2) low-level viremia (LLV; 75-5000/ml), or (3) advanced virologic failure (>5000/ml). Potential risk factors examined included (1) HIV disease factors, e.g., prior AIDS, CD4 cell count; (2) history of antiretroviral use, e.g., therapy classes of the newly switched regimen, medication adherence, and virologic failure at previous regimens; and (3) novel patient-level factors including comorbidities and healthcare utilization. Adjusted odds ratios (aOR) for LLV and advanced virologic failure were obtained from multivariable nominal logistic regression models. A total of 3447 patients were included; 2608 (76%) achieved maximal viral suppression, 420 (12%) had LLV, and 419 (12%) developed advanced virologic failure. Factors positively associated with LLV and advanced virologic failure included number of regimens prior to switch [aOR(per regimen)=1.38 (1.17-1.62) and 1.77 (1.50-2.08), respectively], nucleotide reverse transcriptase inhibitor-only regimens (vs. protease inhibitor-based) [aOR=2.78 (1.28-6.04) and 5.10 (2.38-10.90), respectively], and virologic failure at previous regimens [aOR=3.15 (2.17-4.57) and 4.71 (2.84-7.81), respectively]. Older age, higher CD4 cell count, and medication adherence were protective for unfavorable virologic outcomes. Antiretroviral regimen-level factors and immunodeficiency were significantly associated with virologic failure after a recent therapy switch and should be considered when making treatment change decisions.
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Affiliation(s)
- Chun Chao
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Beth Tang
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Leo Hurley
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Michael J Silverberg
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - William Towner
- Los Angeles Medical Center, Kaiser Permanente Southern California, Los Angeles, California
| | - Melissa Preciado
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Michael Horberg
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic, Rockville, Maryland
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Johnston V, Fielding KL, Charalambous S, Churchyard G, Phillips A, Grant AD. Outcomes following virological failure and predictors of switching to second-line antiretroviral therapy in a South African treatment program. J Acquir Immune Defic Syndr 2012; 61:370-80. [PMID: 22820803 PMCID: PMC3840925 DOI: 10.1097/qai.0b013e318266ee3f] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Without resistance tests, deciding which patients with virological failure should switch to second-line antiretroviral therapy (ART) is difficult. The factors influencing this decision are poorly understood. We assess predictors of switching regimens after virological failure. DESIGN Retrospective cohort study using clinical data from a South African ART program with 6-monthly viral load (VL) monitoring. METHODS We constructed a dataset of patient visits occurring following first-line virological failure, and used random effects logistic regression (accounting for individual-level and clinic-level clustering) to assess predictors of switching at each visit. RESULTS One thousand six hundred sixty-eight patients with virological failure (73% male, mean age 41 years, median CD4 184 cells/mm, mean log10 VL 4.3) contributed 1922 person-years of viremia. 12 months after failure, the cumulative incidence of switching regimen, viral resuppression, or death was 16.9%, 13.2%, and 4.6%, respectively. In adjusted analysis, switching was more likely at the third or subsequent visit after failure; in visits occurring in 2008 versus 2003 to 2007; and in patients with ART experience pre-programme, current high VL or low CD4 count. Switching was less likely in patients with no clinic contact for 4 months, or declining VL. Switching rates varied between clinics with clinic-level clustering evident in the final model (P <0.001). CONCLUSIONS Despite 6-monthly virological monitoring and recommendations to switch after adherence interventions and confirmed viremia, patients experienced delayed switching. Individual-level covariates influenced switching but did not account for variable switching rates between clinics, suggesting differences in guideline implementation. In certain circumstances delays may be warranted; however understanding barriers to guideline implementation will limit unnecessary delays.
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Affiliation(s)
- Victoria Johnston
- London School of Hygiene and Tropical Medicine, Keppel Street, London, United Kingdom.
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Calmy A, Balestre E, Bonnet F, Boulle A, Sprinz E, Wood R, Delaporte E, Messou E, McIntyre J, El Filali KM, Schechter M, Kumarasamy N, Bangsberg D, McPhail P, Van Der Borght S, Zala C, Egger M, Thiébaut R, Dabis F. Mean CD4 cell count changes in patients failing a first-line antiretroviral therapy in resource-limited settings. BMC Infect Dis 2012; 12:147. [PMID: 22742573 PMCID: PMC3573925 DOI: 10.1186/1471-2334-12-147] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Accepted: 04/26/2012] [Indexed: 11/10/2022] Open
Abstract
Background Changes in CD4 cell counts are poorly documented in individuals with low or moderate-level viremia while on antiretroviral treatment (ART) in resource-limited settings. We assessed the impact of on-going HIV-RNA replication on CD4 cell count slopes in patients treated with a first-line combination ART. Method Naïve patients on a first-line ART regimen with at least two measures of HIV-RNA available after ART initiation were included in the study. The relationships between mean CD4 cell count change and HIV-RNA at 6 and 12 months after ART initiation (M6 and M12) were assessed by linear mixed models adjusted for gender, age, clinical stage and year of starting ART. Results 3,338 patients were included (14 cohorts, 64% female) and the group had the following characteristics: a median follow-up time of 1.6 years, a median age of 34 years, and a median CD4 cell count at ART initiation of 107 cells/μL. All patients with suppressed HIV-RNA at M12 had a continuous increase in CD4 cell count up to 18 months after treatment initiation. By contrast, any degree of HIV-RNA replication both at M6 and M12 was associated with a flat or a decreasing CD4 cell count slope. Multivariable analysis using HIV-RNA thresholds of 10,000 and 5,000 copies confirmed the significant effect of HIV-RNA on CD4 cell counts both at M6 and M12. Conclusion In routinely monitored patients on an NNRTI-based first-line ART, on-going low-level HIV-RNA replication was associated with a poor immune outcome in patients who had detectable levels of the virus after one year of ART.
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Chao C, Tang B, Towner W, Silverberg MJ, Hurley L, Horberg M. Short-term clinical outcomes among treatment-experienced HIV-positive patients with early low level viremia. AIDS Patient Care STDS 2012; 26:253-5. [PMID: 22424146 DOI: 10.1089/apc.2012.0035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Chun Chao
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Beth Tang
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - William Towner
- Los Angeles Medical Center, Kaiser Permanente Southern California, Los Angeles, California
| | | | - Leo Hurley
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Michael Horberg
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, Maryland
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Balkundi S, Nowacek AS, Veerubhotla RS, Chen H, Martinez-Skinner A, Roy U, Mosley RL, Kanmogne G, Liu X, Kabanov AV, Bronich T, McMillan J, Gendelman HE. Comparative manufacture and cell-based delivery of antiretroviral nanoformulations. Int J Nanomedicine 2011; 6:3393-404. [PMID: 22267924 PMCID: PMC3260033 DOI: 10.2147/ijn.s27830] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Nanoformulations of crystalline indinavir, ritonavir, atazanavir, and efavirenz were manufactured by wet milling, homogenization or sonication with a variety of excipients. The chemical, biological, immune, virological, and toxicological properties of these formulations were compared using an established monocyte-derived macrophage scoring indicator system. Measurements of drug uptake, retention, release, and antiretroviral activity demonstrated differences amongst preparation methods. Interestingly, for drug cell targeting and antiretroviral responses the most significant difference among the particles was the drug itself. We posit that the choice of drug and formulation composition may ultimately affect clinical utility.
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Affiliation(s)
- Shantanu Balkundi
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE, USA
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Kanapathipillai R, McGuire M, Mogha R, Szumilin E, Heinzelmann A, Pujades-Rodríguez M. Benefit of viral load testing for confirmation of immunological failure in HIV patients treated in rural Malawi. Trop Med Int Health 2011; 16:1495-500. [PMID: 21883726 DOI: 10.1111/j.1365-3156.2011.02874.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Viral load testing is used in the HIV programme of Chiradzulu, Malawi, to confirm the diagnosis of immunological failure to prevent unnecessary switching to second-line therapy. Our objective was to quantify the benefit of this strategy for management of treatment failure in a large decentralized HIV programme in Africa. METHODS Retrospective analysis of monitoring data from adults treated with first-line antiretroviral regimens for >1 year and meeting the WHO immunological failure criteria in an HIV programme in rural Malawi. The positive predictive value of using immunological failure criteria to diagnose virological failure (viral load >5000 copies/ml) was estimated. RESULTS Of the 227 patients with immunological failure (185 confirmed with a repeat CD4 measurement), 155 (68.2%) had confirmatory viral load testing. Forty-four (28.4%) had viral load >5000 copies/ml and 57 (36.8%) >1000 copies/ml. Positive predictive value was 28.4% (95% CI 21.4-36.2%). Repeat CD4 count testing showed that 41% of patients initially diagnosed with immunological failure did no longer meet failure criteria. CONCLUSIONS Our results support the need for confirming all cases of immunological failure with viral load testing before switching to second-line ART to optimize the use of resources in developing countries.
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Evaluation of WHO Criteria for Viral Failure in Patients on Antiretroviral Treatment in Resource-Limited Settings. AIDS Res Treat 2011; 2011:736938. [PMID: 21541225 PMCID: PMC3085383 DOI: 10.1155/2011/736938] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Revised: 01/18/2011] [Accepted: 02/15/2011] [Indexed: 11/18/2022] Open
Abstract
Our objective was to evaluate outcomes in patients with sustained viral suppression compared to those with episodes of viremia. Methods. In a prospective cohort of patients started on ART in Uganda and followed for 48 months, patients were categorized according to viral load (VL): (1) sustained-suppression: (VL ≤1,000 copies/mL) (2) VL 1,001–10,000, or (3) VL >10,000. Results. Fifty-Three (11.2%) and 84 (17.8%) patients had a first episode of intermediate and high viremia, respectively. Patients with sustained suppression had better CD4+ T cell count increases over time compared to viremic patients (P < .001). The majority of patients with viremia achieved viral suppression when the measurement was repeated. Only 39.6% of patients with intermediate and 19.1% with high viremia eventually needed to be switched to second line (P = .008). Conclusions. The use of at least one repeat measurement rather than a single VL measurement could avert from 60% to 80% of unnecessary switches.
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Influences of Allocating HIV/AIDS Specialized Nurses on Clinical Outcomes in Japan. Asian Nurs Res (Korean Soc Nurs Sci) 2011; 5:11-8. [DOI: 10.1016/s1976-1317(11)60009-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Revised: 12/06/2010] [Accepted: 12/20/2010] [Indexed: 11/20/2022] Open
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Nowacek AS, McMillan J, Miller R, Anderson A, Rabinow B, Gendelman HE. Nanoformulated antiretroviral drug combinations extend drug release and antiretroviral responses in HIV-1-infected macrophages: implications for neuroAIDS therapeutics. J Neuroimmune Pharmacol 2010; 5:592-601. [PMID: 20237859 PMCID: PMC3401515 DOI: 10.1007/s11481-010-9198-7] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2010] [Accepted: 02/17/2010] [Indexed: 01/01/2023]
Abstract
We posit that improvements in pharmacokinetics and biodistributions of antiretroviral therapies (ART) for human immunodeficiency virus type one-infected people can be achieved through nanoformulationed drug delivery systems. To this end, we manufactured nanoparticles of atazanavir, efavirenz, and ritonavir (termed nanoART) and treated human monocyte-derived macrophages (MDM) in combination therapies to assess antiretroviral responses. This resulted in improved drug uptake, release, and antiretroviral efficacy over monotherapy. MDM rapidly, within minutes, ingested nanoART combinations, at equal or similar rates, as individual formulations. Combination nanoART ingested by MDM facilitated individual drug release from 15 to >20 days. These findings are noteworthy as a nanoART cell-mediated drug delivery provides a means to deliver therapeutics to viral sanctuaries, such as the central nervous system during progressive human immunodeficiency virus type one infection. The work brings us yet another step closer to realizing the utility of nanoART for virus-infected people.
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Affiliation(s)
- Ari S. Nowacek
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198-5880 USA
| | - JoEllyn McMillan
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198-5880 USA
| | | | - Alec Anderson
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198-5880 USA
| | | | - Howard E. Gendelman
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198-5880 USA
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Antiretroviral nanoparticles: an extended drug delivery modality. Ther Deliv 2010; 1:383-6. [PMID: 22816141 DOI: 10.4155/tde.10.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The antiretroviral nanoparticle formulation laboratory at Creighton University School of Pharmacy & Health Professions is lead by Chris Destache. Over the past 4 years, this laboratory has been investigating the use of antiretroviral nanoparticles as a sustained drug delivery method for HIV-1-infected patients.
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Saiyed ZM, Gandhi NH, Nair MPN. Magnetic nanoformulation of azidothymidine 5'-triphosphate for targeted delivery across the blood-brain barrier. Int J Nanomedicine 2010; 5:157-66. [PMID: 20463931 PMCID: PMC2865010 DOI: 10.2147/ijn.s8905] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2010] [Indexed: 12/19/2022] Open
Abstract
Despite significant advances in highly active antiretroviral therapy (HAART), the prevalence of neuroAIDS remains high. This is mainly attributed to inability of antiretroviral therapy (ART) to cross the blood–brain barrier (BBB), thus resulting in insufficient drug concentration within the brain. Therefore, development of an active drug targeting system is an attractive strategy to increase the efficacy and delivery of ART to the brain. We report herein development of magnetic azidothymidine 5′-triphosphate (AZTTP) liposomal nanoformulation and its ability to transmigrate across an in vitro BBB model by application of an external magnetic field. We hypothesize that this magnetically guided nanoformulation can transverse the BBB by direct transport or via monocyte-mediated transport. Magnetic AZTTP liposomes were prepared using a mixture of phosphatidyl choline and cholesterol. The average size of prepared liposomes was about 150 nm with maximum drug and magnetite loading efficiency of 54.5% and 45.3%, respectively. Further, magnetic AZTTP liposomes were checked for transmigration across an in vitro BBB model using direct or monocyte-mediated transport by application of an external magnetic field. The results show that apparent permeability of magnetic AZTTP liposomes was 3-fold higher than free AZTTP. Also, the magnetic AZTTP liposomes were efficiently taken up by monocytes and these magnetic monocytes showed enhanced transendothelial migration compared to normal/non-magnetic monocytes in presence of an external magnetic field. Thus, we anticipate that the developed magnetic nanoformulation can be used for targeting active nucleotide analog reverse transcriptase inhibitors to the brain by application of an external magnetic force and thereby eliminate the brain HIV reservoir and help to treat neuroAIDS.
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Affiliation(s)
- Zainulabedin M Saiyed
- Department of Immunology, College of Medicine, Florida International University, Miami, FL, USA
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Nowacek AS, Miller RL, McMillan J, Kanmogne G, Kanmogne M, Mosley RL, Ma Z, Graham S, Chaubal M, Werling J, Rabinow B, Dou H, Gendelman HE. NanoART synthesis, characterization, uptake, release and toxicology for human monocyte-macrophage drug delivery. Nanomedicine (Lond) 2010; 4:903-17. [PMID: 19958227 DOI: 10.2217/nnm.09.71] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Factors limiting the efficacy of conventional antiretroviral therapy for HIV-1 infection include treatment adherence, pharmacokinetics and penetration into viral sanctuaries. These affect the rate of viral mutation and drug resistance. In attempts to bypass such limitations, nanoparticles containing ritonavir, indinavir and efavirenz (described as nanoART) were manufactured to assess macrophage-based drug delivery. METHODS NanoART were made by high-pressure homogenization of crystalline drug with various surfactants. Size, charge and shape of the nanoparticles were assessed. Monocyte-derived macrophage nanoART uptake, drug release, migration and cytotoxicity were determined. Drug levels were measured by reverse-phase high-performance liquid chromatography. RESULTS Efficient monocyte-derived macrophage cytoplasmic vesicle uptake in less than 30 min based on size, charge and coating was observed. Antiretroviral drugs were released over 14 days and showed dose-dependent reduction in progeny virion production and HIV-1 p24 antigen. Cytotoxicities resulting from nanoART carriage were limited. CONCLUSION These results support the continued development of macrophage-mediated nanoART carriage for HIV-1 disease.
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Affiliation(s)
- Ari S Nowacek
- Department of Pharmacology & Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198-5880, USA
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Bartlett JA, Shao JF. Successes, challenges, and limitations of current antiretroviral therapy in low-income and middle-income countries. THE LANCET. INFECTIOUS DISEASES 2009; 9:637-49. [PMID: 19778766 DOI: 10.1016/s1473-3099(09)70227-0] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
As a result of the scale-up of antiretroviral treatment (ART) programmes and substantial financial support worldwide, an increasing number of HIV-infected individuals in low-income and middle-income countries (LIMCs) now have access to ART. Despite this progress, important questions remain on the best use of ART and how patients should be maintained on a successful regimen. This Review addresses some of the issues faced by those managing the epidemic in LMICs, including when to start treatment, choice of first-line ART, and when to switch regimens. Although the first priority must be continued expansion of access to ART, there should be a move towards starting ART earlier to treat individuals before they reach advanced stages of disease, to reduce early mortality, and to build support for improved monitoring of treatment failure. There is also a need for more randomised controlled studies to identify the long-term outcomes, cost-effectiveness of ART, and use of virological monitoring in LMICs.
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Affiliation(s)
- John A Bartlett
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, NC, USA.
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Abstract
A broad range of nanomedicines is being developed to improve drug delivery for CNS disorders. The structure of the blood-brain barrier (BBB), the presence of efflux pumps and the expression of metabolic enzymes pose hurdles for drug-brain entry. Nanoformulations can circumvent the BBB to improve CNS-directed drug delivery by affecting such pumps and enzymes. Alternatively, they can be optimized to affect their size, shape, and protein and lipid coatings to facilitate drug uptake, release and ingress across the barrier. This is important as the brain is a sanctuary for a broad range of pathogens including HIV-1. Improved drug delivery to the CNS would affect pharmacokinetic and drug biodistribution properties. This article focuses on how nanotechnology can serve to improve the delivery of antiretroviral medicines, termed nanoART, across the BBB and affect the biodistribution and clinical benefit for HIV-1 disease.
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Affiliation(s)
- Ari Nowacek
- Department of Pharmacology & Experimental Neuroscience, Center for Neurovirology & Neurodegenerative Disorders, University of Nebraska Medical Center, Omaha, NE 68198-5880, USA
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Wester CW, Bussmann H, Koethe J, Moffat C, Vermund S, Essex M, Marlink RG. Adult combination antiretroviral therapy in sub-Saharan Africa: lessons from Botswana and future challenges. HIV THERAPY 2009; 3:501-526. [PMID: 20161344 PMCID: PMC2774911 DOI: 10.2217/hiv.09.35] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Numerous national public initiatives offering first-line combination antiretroviral therapy (cART) for HIV infection have commenced in sub-Saharan Africa since 2002. Presently, 2.1 million of an estimated seven million Africans in need of cART are receiving treatment. Analyses from the region report favorable clinical/treatment outcomes and impressive declines in AIDS-related mortality among HIV-1-infected adults and children receiving cART. While immunologic recovery, virologic suppression and cART adherence rates are on par with resource-rich settings, loss to follow-up and high mortality rates, especially within the first 6 months of treatment, remain a significant problem. Over the next decade, cART coverage rates are expected to improve across the region, with attendant increases in healthcare utilization for HIV- and non-HIV-related complications and the need for expanded laboratory and clinical services. Planned and in-progress trials will evaluate the use of cART to prevent primary HIV-1 infection with so-called 'test and treat' expansions of coverage and treatment. Education and training programs as well as patient-retention strategies will need to be strengthened as national cART programs are expanded and more people require lifelong monitoring and care.
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Affiliation(s)
- C William Wester
- Botswana-Harvard School of Public Health AIDS Initiative Partnership for HIV Research & Education (BHP), Gaborone, Botswana
- Harvard School of Public Health, Department of Immunology & Infectious Diseases, Boston, MA, USA
- Vanderbilt University School of Medicine, Nashville, TN, USA
- Vanderbilt Institute of Global Health (VIGH), Vanderbilt University, Nashville, TN, USA
| | - Hermann Bussmann
- Botswana-Harvard School of Public Health AIDS Initiative Partnership for HIV Research & Education (BHP), Gaborone, Botswana
- Harvard School of Public Health, Department of Immunology & Infectious Diseases, Boston, MA, USA
| | - John Koethe
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Claire Moffat
- Botswana-Harvard School of Public Health AIDS Initiative Partnership for HIV Research & Education (BHP), Gaborone, Botswana
- Harvard School of Public Health, Department of Immunology & Infectious Diseases, Boston, MA, USA
| | - Sten Vermund
- Vanderbilt University School of Medicine, Nashville, TN, USA
- Vanderbilt Institute of Global Health (VIGH), Vanderbilt University, Nashville, TN, USA
| | - Max Essex
- Botswana-Harvard School of Public Health AIDS Initiative Partnership for HIV Research & Education (BHP), Gaborone, Botswana
- Harvard School of Public Health, Department of Immunology & Infectious Diseases, Boston, MA, USA
| | - Richard G Marlink
- Botswana-Harvard School of Public Health AIDS Initiative Partnership for HIV Research & Education (BHP), Gaborone, Botswana
- Harvard School of Public Health, Department of Immunology & Infectious Diseases, Boston, MA, USA
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de Mendoza C, Soriano V. Update on HIV viral-load assays: new technologies and testing in resource-limited settings. Future Virol 2009. [DOI: 10.2217/fvl.09.24] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Assessment of viral load is one of the best predictors of clinical progression, as well as the main parameter to assess treatment response in HIV-positive patients. Reproducible and sensitive assays based on real-time PCR technology have been developed to quantify HIV in the bloodstream of infected persons. Recent improvements have allowed reliable measurements of viremia in non-B subtypes. Testing of samples other than serum or plasma has been challenging, but is particularly important for developing countries.
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Affiliation(s)
- Carmen de Mendoza
- Department of Infectious Diseases, Hospital Carlos III, c/ Sinesio Delgado 10, 28029 Madrid, Spain
| | - Vincent Soriano
- Department of Infectious Diseases, Hospital Carlos III, c/ Sinesio Delgado 10, 28029 Madrid, Spain
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Comparative evaluation of the ExaVir Load version 3 reverse transcriptase assay for measurement of human immunodeficiency virus type 1 plasma load. J Clin Microbiol 2009; 47:3266-70. [PMID: 19656978 DOI: 10.1128/jcm.00715-09] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In resource-limited settings, the virological monitoring of antiretroviral therapy is limited by high cost and the lack of infrastructure. The Cavidi ExaVir Load assay employs a simple and inexpensive enzyme-linked immunosorbent assay format to measure human immunodeficiency virus (HIV) reverse transcriptase activity, which correlates with plasma RNA load. The version 3 assay has been described as having improved precision and sensitivity. There are limited data on its performance relative to those of current real-time assays. Our objective was to compare HIV type 1 (HIV-1) RNA load measurement in plasma by ExaVir Load version 3 (designated ExaVir), Abbott M2000sp/M2000rt RealTime HIV-1 assay (designated RealTime), and Roche COBAS Ampliprep/COBAS TaqMan HIV-1 version 1 assay (designated TaqMan). Plasma from 119 patients (34 with subtype B infection, 85 with non-subtype B infection [A-H, CRF01, CRF02, CRF06, CRF12, CRF14, and complex]; 48 subjects were treatment experienced, 71 were naive) and serial dilutions of the second international standard (IS) were tested. Assay relationship and agreement were determined by linear regression, correlation analysis, and the Bland-Altman method. The ExaVir assay quantified 77/83 (92.8%) samples with viral loads of >2.3 log10 copies/ml by the molecular assays. Results were linearly associated and strongly correlated with RealTime and TaqMan measurements (R of 0.94 and 0.92, respectively) for both subtype B (R of 0.97 and 0.95, respectively) and non-subtype B (R of 0.93 and 0.91, respectively) samples. Mean differences were 0.28 and 0.18 log10 copies/ml in favor of the two molecular assays; 7/119 (5.9%) and 5/119 (4.2%) samples were outside the 95% level of agreement. ExaVir underquantified the IS by a mean of 0.2 (range, 0.0 to 0.5) log10 copies/ml. The ExaVir assay showed excellent concordance with real-time molecular assays, offering a suitable option for virological monitoring in settings with limited infrastructure.
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Elema R, Mills C, Yun O, Lokuge K, Ssonko C, Nyirongo N, Mtonga V, Zulu H, Tu D, Verputten M, O'Brien DP. Outcomes of a Remote, Decentralized Health Center-Based HIV/AIDS Antiretroviral Program in Zambia, 2003 to 2007. ACTA ACUST UNITED AC 2009; 8:60-7. [DOI: 10.1177/1545109709331472] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A cross-sectional study of patients living with HIV/ AIDS treated during 2003 to 2007 in decentralized, rural health centers in Zambia was performed to measure virological outcomes after 12 months of antiretroviral therapy and identify factors associated with virological failure. Data from 228 patients who started antiretroviral therapy >12 months prior were analyzed. In all, 93% received stavudine + lamivudine + nevirapine regimens, and median antiretroviral therapy duration was 23.5 months (interquartile range 20-28). Of the 205 patients tested for viral load, 177 (86%) had viral load <1000 copies/mL. Probability of developing virological failure (viral load >1000 copies/mL) was 8.9% at 24 months and 19.6% at 32 months. Predictors for virological failure were <100% adherence, body mass index <18.5 kg/m2, and women <40 years old. Of those with virological failure who underwent 3 to 6 months of intensive adherence counseling, 45% obtained virological success. In a remote, resource-limited setting in decentralized health centers, virological and immunological assessments of patients on antiretroviral therapy >12 months showed that positive health outcomes are achievable.
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Affiliation(s)
- Riekje Elema
- Médecins Sans Frontières-Holland, Lusaka/Nchelenge,Zambia
| | - Clair Mills
- Médecins Sans Frontières-Holland, Amsterdam, Netherlands
| | | | | | - Charles Ssonko
- Médecins Sans Frontières-Holland, Lusaka/Nchelenge,Zambia
| | | | | | - Henry Zulu
- Ministry of Health, Lusaka/Nchelenge, Zambia
| | - David Tu
- Médecins Sans Frontières-Holland, Vancouver, Canada
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Correlation between human immunodeficiency virus type 1 (HIV-1) RNA measurements obtained with dried blood spots and those obtained with plasma by use of Nuclisens EasyQ HIV-1 and Abbott RealTime HIV load tests. J Clin Microbiol 2009; 47:1031-6. [PMID: 19193847 DOI: 10.1128/jcm.02099-08] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The plasma human immunodeficiency virus (HIV) RNA load is used in the clinical routine for the monitoring of HIV infection and the patient's response to antiretroviral therapy. Other body fluids or dried blood spots (DBS) can be used, however, to assess the level of viremia. The use of DBS may be especially helpful for the monitoring of HIV-infected patients in resource-poor settings, where access to adequate laboratory facilities is often difficult. However, the correlation between the HIV RNA levels in plasma and those in DBSs has not been well established. Paired plasma and DBS samples obtained from HIV type 1 (HIV-1)-infected patients were tested for HIV RNA copy numbers by using two different commercial assays, the Nuclisens EasyQ HIV-1 (version 1.1) test (the Nuclisens test; Biomerieux) and the m2000rt RealTime HIV test (the m2000rt test; Abbott). Nucleic acid extraction was performed manually by using either the Nuclisens isolation kit (which uses the Boom methodology) or the m2000rt sample preparation kit (an iron particle-based method). A total of 103 paired plasma and DBS samples were tested. Viral load results were obtained for 97 (94.2%) samples with the Nuclisens isolation kit and 81 (78.6%) samples with the m2000rt kit. The overall correlation between the RNA loads in plasma and DBS was good, although better results were obtained by the Nuclisens test (R(2) = 0.87, P < 0.001) than by the m2000rt test (R(2) = 0.70, P < 0.001). While the specificities were excellent and similar for both the Nuclisens and the m2000rt tests (97.1% and 100%, respectively), the sensitivity was greater by the Nuclisens test than by the m2000rt test (75.8% and 56.6%, respectively). Overall, the viral loads in DBS tended to be lower than those in plasma, with mean differences of 0.3 log unit (standard deviation, 0.5 log unit) and 0.76 log unit (standard deviation, 0.8 log unit) for the Nuclisens and the m2000rt tests, respectively. The levels of agreement between the measurements in plasma and DBS were assessed by using the Bland-Altman plot for each assay. The Nuclisens test gave results within its defined limits (-0.65 to 1.26) for 95.9% of the samples, while the m2000rt test gave results within its limits (-0.83 to 2.33) for 100% of the samples. In summary, the HIV-1 load can accurately be quantified by testing DBS by either the Nuclisens or the m2000rt test, although the Nuclisens test may outperform the m2000rt test when nucleic acids are extracted manually.
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Tenorio AR, Jiang H, Zheng Y, Bastow B, Kuritzkes DR, Bartlett JA, Deeks SG, Landay AL, Riddler SA. Delaying a treatment switch in antiretroviral-treated HIV type 1-infected patients with detectable drug-resistant viremia does not have a profound effect on immune parameters: AIDS Clinical Trials Group Study A5115. AIDS Res Hum Retroviruses 2009; 25:135-9. [PMID: 19239354 DOI: 10.1089/aid.2008.0200] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Some patients are unable to achieve and maintain an undetectable plasma HIV-1 RNA level with combination antiretroviral therapy (ART) and are therefore maintained on a partially suppressive regimen. To determine the immune consequences of continuing ART despite persistent viremia, we randomized 47 ART-treated individuals with low to moderate plasma HIV-1 RNA levels (200-9999 copies/ml) to either an immediate switch in therapy or a delayed switch (when plasma HIV-1 RNA became > or =10,000 copies/ml). After 48 weeks of follow-up, naive and memory CD4+ T cell percents were comparable in the two groups. The proportion of subjects with a lymphocyte proliferative response to Candida, Mycobacterium avium-intracellulare complex, or HIV-gag was also not significantly different at week 48. Delaying a treatment switch in patients with partial virologic suppression and stable CD4+ T cells does not have profound effects on immune parameters.
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Affiliation(s)
- Allan R. Tenorio
- Department of Medicine, Rush Medical College, Chicago, Illinois 60612
| | - Hongyu Jiang
- Department of Biostatistics, Statistical and Data Analysis Center, Harvard School of Public Health, Boston, Massachusetts 02319
| | - Yu Zheng
- Department of Biostatistics, Statistical and Data Analysis Center, Harvard School of Public Health, Boston, Massachusetts 02319
| | - Barbara Bastow
- Social & Scientific Systems, Inc., Silver Spring, Maryland 20910
| | - Daniel R. Kuritzkes
- Section of Retroviral Therapeutics, Brigham and Women's Hospital and Division of AIDS, Harvard Medical School, Boston, Massachusetts 02319
| | - John A. Bartlett
- Department of Medicine, Duke University Medical Center, Durham, North Carolina 27706
| | - Steven G. Deeks
- Department of Medicine, University of California–San Francisco and San Francisco General Hospital, San Francisco, California 94143
| | - Alan L. Landay
- Department Immunology and Microbiology, Rush Medical College, Chicago, Illinois 60612
| | - Sharon A. Riddler
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15260
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Rational use of antiretroviral therapy in low-income and middle-income countries: optimizing regimen sequencing and switching. AIDS 2008; 22:2053-67. [PMID: 18753937 DOI: 10.1097/qad.0b013e328309520d] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Abstract
OBJECTIVE To assess the performance of WHO clinical and CD4 cell count criteria for antiretroviral treatment (ART) failure among HIV-infected adults in a workplace HIV care programme in South Africa. DESIGN Cohort study. METHODS We included initially ART-naive participants who remained on first-line therapy and had an evaluable HIV viral load result at the 12-month visit. WHO-defined clinical and CD4 cell count criteria for ART failure were compared against a gold standard of virological failure. RESULTS Among 324 individuals (97.5% men, median age 40.2, median starting CD4 cell count and viral load 154 cells/mul and 47,503 copies/ml, respectively), 33 (10.2%) had definite or probable virological failure at 12 months, compared with 19 (6.0%) and 40 (12.5%) with WHO-defined CD4 and clinical failure, respectively. CD4 criteria had a sensitivity of 21.2% and a specificity of 95.8% in detecting virological failure, and clinical criteria had sensitivity of 15.2% and specificity of 88.1%. The positive predictive value of CD4 and clinical criteria in detecting virological failure were 36.8 and 12.8%, respectively. Exclusion of weight loss or tuberculosis failed to improve the performance of clinical criteria. CONCLUSION WHO clinical and CD4 criteria have poor sensitivity and specificity in detecting virological failure. The low specificities and positive predictive values mean that individuals with adequate virological suppression risk being incorrectly classified as having treatment failure and unnecessarily switched to second-line therapy. Virological failure should be confirmed before switching to second-line therapy.
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Moyle G, Gatell J, Perno CF, Ratanasuwan W, Schechter M, Tsoukas C. Potential for new antiretrovirals to address unmet needs in the management of HIV-1 infection. AIDS Patient Care STDS 2008; 22:459-71. [PMID: 18479200 DOI: 10.1089/apc.2007.0136] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Despite the myriad advances in antiretroviral therapy since the original highly active antiretroviral therapy regimens were developed, there remain numerous important and pressing unmet needs that, if addressed, would substantially improve the quality of life and longevity of HIV-infected patients. The most achievable goals of antiretroviral (ARV) therapy in the near future are likely to be continued reduction in HIV-related morbidity and mortality; improved quality of life; and restoration and preservation of immune function: all of which are most effectively achieved through sustained suppression of HIV-1 RNA. The ability to achieve long-term viral load reduction will require new ARVs with few, manageable toxicities, and medications that are convenient to adhere to, with few drug interactions. This is particularly true for the large number of highly treatment-experienced patients in whom HIV has developed resistance to one or more ARVs. Development of therapies that allow convenient dosing schedules, that do not necessitate strict adherence to meal-related timing restrictions, and that remain active in the face of resistance mutations is paramount, and remains a significant unmet need. Of the large number of ARVs currently in development, this article focuses on three agents recently approved that have shown particular promise in addressing some of these unmet needs: the novel non-nucleoside reverse transcriptase inhibitor etravirine; the CCR5 antagonist maraviroc; and the integrase inhibitor raltegravir.
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Affiliation(s)
- Graeme Moyle
- HIV Research Chelsea & Westminster Hospital, London, United Kingdom
| | - Jose Gatell
- Infectious Diseases & AIDS Unit, University of Barcelona, Barcelona, Spain
| | - Carlo-Federico Perno
- Department of Experimental Medicine, University of Rome, “Tor Vergata,” Rome, Italy
| | - Winai Ratanasuwan
- Department of Preventive and Social Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Mauro Schechter
- AIDS Research Laboratory, Hospital Universitario Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Christos Tsoukas
- Division of Clinical Immunology, Immune Deficiency Treatment Centre, McGill University, Montreal, Quebec, Canada
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Secor WE, Sundstrom JB. Below the belt: new insights into potential complications of HIV-1/schistosome coinfections. Curr Opin Infect Dis 2007; 20:519-23. [PMID: 17762787 DOI: 10.1097/qco.0b013e3282e9ac03] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW Areas of the world with high endemnicity for helminth parasites overlap with those regions that have a seemingly disproportionate prevalence of HIV/AIDS. This has fueled speculation that potential pathological interactions between these infectious agents may accelerate disease progression. The proximity of many helminth infections to gastrointestinal mucosal sites combined with the recent discovery that acute HIV-1 infection causes early and massive depletion of CD4+ T cells in the gut furthers the potential pathological significance of co-infection. In this review, the 'gut wrenching' consequences of schistosome infection on HIV disease progression that may ensue during coinfection are considered. RECENT FINDINGS Massive depletion of CD4+ T cells in the gut during acute HIV-1 infection suggests that in addition to the administration of highly active antiretroviral therapy, limiting viral infection of susceptible cells in the gut after initial exposure may offer the best opportunity for slowing disease progression. In addition to memory T cells, mast cells, which are present in the intestinal lamina propria and upregulated in the gut during schistosome infection, have been recently described as an inducible reservoir of persistent HIV-1 infection. SUMMARY Schistosome infections create immune environments that may accelerate HIV disease progression. Their impact on highly active antiretroviral therapy should be considered.
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Affiliation(s)
- W Evan Secor
- Division of Parasitic Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia 30341-3724, USA.
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Riddler SA, Jiang H, Tenorio A, Huang H, Kuritzkes DR, Acosta EP, Landay A, Bastow B, Haas DW, Tashima KT, Jain MK, Deeks SG, Bartlett JA. A randomized study of antiviral medication switch at lower- versus higher-switch thresholds: AIDS Clinical Trials Group Study A5115. Antivir Ther 2007; 12:531-41. [PMID: 17668562 DOI: 10.1177/135965350701200415] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Clinical stability has been observed with continued antiretroviral therapy (ART) in the setting of partial virological suppression. The optimal time to switch treatment in patients with low but detectable HIV-1 RNA is not known. METHODS Subjects on stable ART with HIV-1 RNA 200-10,000 copies/ml were randomized to an immediate treatment switch, or to a delayed switch when HIV-1 RNA increased to > or = 10,000 copies/ml or CD4+ T-cell count decreased by 20%. The primary outcome measures were immune activation (proportion of CD8+ T-cells expressing CD38 at week 48) and evolution of genotypic drug resistance. RESULTS The study failed to fully accrue the originally planned 108 subjects. Only 47 subjects were randomized to immediate- or delayed-switch arms. Of the subjects in the delayed-switch arm, 10/23 (43%) met the criteria for ART switch during the study (median follow-up 82 weeks). After 48 weeks of observation, the level of immune activation was comparable in the two arms. New resistance mutations were observed in 3/17 and 8/19 subjects in the immediate- and delayed-switch groups, respectively. The loss of future treatment options, however, was comparable in the delayed- and immediate-switch groups. CONCLUSIONS Individuals with partial viral suppression tend to remain immunologically stable, however, the accumulation of drug resistance mutations is an ongoing risk. Delayed switch in ART may be a reasonable short-term strategy for individuals with very limited treatment options.
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Affiliation(s)
- Sharon A Riddler
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
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Giambenedetto SD, Bracciale L, Colatigli M, Pannetti C, Bacarelli A, Prosperi M, Fadda G, Cauda R, De Luca A. Declining Prevalence of HIV-1 Drug Resistance in Treatment-Failing Patients: A Clinical Cohort Study. Antivir Ther 2007. [DOI: 10.1177/135965350701200516] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives A major barrier to successful viral suppression in HIV type 1 (HIV-1)-infected individuals is the emergence of virus resistant to antiretroviral drugs. We explored the evolution of genotypic drug resistance prevalence in treatment-failing patients from 1999 to 2005 in a clinical cohort. Patients and Methods Prevalence of major International AIDS Society-USA HIV-1 drug resistance mutations was measured over calendar years in a population with treatment failure and undergoing resistance testing. Predictors of the presence of resistance mutations were analysed by logistic regression. Results Significant reductions of the prevalence of resistance to all three drug classes examined were observed. This was accompanied by a reduction in the proportion of treatment-failing patients. Independent predictors of drug resistance were the earlier calendar year, prior use of suboptimal nucleoside analogue therapy, male sex and higher CD4 levels at testing. Conclusions In a single clinical cohort, we observed a decrease in the prevalence of resistance to all three examined antiretroviral drug classes over time. If this finding is confirmed in multicentre cohorts it may translate into reduced transmission of drug-resistant virus from treated patients.
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Affiliation(s)
| | - Laura Bracciale
- Institute of Clinical Infectious Diseases, Catholic University, Rome, Italy
| | - Manuela Colatigli
- Institute of Clinical Infectious Diseases, Catholic University, Rome, Italy
| | | | | | - Mattia Prosperi
- Department of Computer Science and Automation, University of Roma Tre, Rome, Italy
| | - Giovanni Fadda
- Institute of Microbiology, Catholic University, Rome, Italy
| | - Roberto Cauda
- Institute of Clinical Infectious Diseases, Catholic University, Rome, Italy
| | - Andrea De Luca
- Institute of Clinical Infectious Diseases, Catholic University, Rome, Italy
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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.
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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
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Abstract
An HIV patient’s chance for long-term treatment success is maximized when their first-line regimen produces an undetectable viral load. A persistently detectable viral load leads to the development of resistance and subsequent immunological and virological failure. It is important to select a regimen with excellent efficacy, tolerability and toxicity profile that is also easy to administer. Tenofovir/emtricitabine provides an effective and well-tolerated nucleoside analog reverse transcriptase inhibitor (NRTI) combination. Regimens with ritonavir-boosted protease inhibitors (PIs) and non-nucleoside reverse transcriptase inhibitors are superior to ritonavir-unboosted PIs and NRTIs in reducing viral load. Data suggest that regimens with lopinavir/ritonavir or efavirenz have the best long-term chance of producing an undetectable viral load.
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Affiliation(s)
- Jintanat Ananworanich
- South East Asia Research Collaboration with Hawaii (SEARCH), 104 Rajdumri Road, Pathumwan, Bangkok, 10330, Thailand
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Dou H, Morehead J, Destache CJ, Kingsley JD, Shlyakhtenko L, Zhou Y, Chaubal M, Werling J, Kipp J, Rabinow BE, Gendelman HE. Laboratory investigations for the morphologic, pharmacokinetic, and anti-retroviral properties of indinavir nanoparticles in human monocyte-derived macrophages. Virology 2007; 358:148-58. [PMID: 16997345 DOI: 10.1016/j.virol.2006.08.012] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2006] [Revised: 08/01/2006] [Accepted: 08/03/2006] [Indexed: 10/24/2022]
Abstract
The effectiveness of anti-retroviral therapies (ART) depends on its ultimate ability to clear reservoirs of continuous human immunodeficiency virus (HIV) infection. We reasoned that a principal vehicle for viral dissemination, the mononuclear phagocytes could also serve as an ART transporter and as such improve therapeutic indices. A nanoparticle-indinavir (NP-IDV) formulation was made and taken up into and released from vacuoles of human monocyte-derived macrophages (MDM). Following a single NP-IDV dose, drug levels within and outside MDM remained constant for 6 days without cytotoxicity. Administration of NP-IDV when compared to equal drug levels of free soluble IDV significantly blocked induction of multinucleated giant cells, production of reverse transcriptase activity in culture fluids and cell-associated HIV-1p24 antigens after HIV-1 infection. These data provide "proof of concept" for the use of macrophage-based NP delivery systems for human HIV-1 infections.
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Affiliation(s)
- Huanyu Dou
- Center for Neurovirology and Neurodegenerative Disorders, University of Nebraska Medical Center, Omaha, NE 68198-5880, USA
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Calmy A, Ford N, Hirschel B, Reynolds SJ, Lynen L, Goemaere E, Garcia de la Vega F, Perrin L, Rodriguez W. HIV viral load monitoring in resource-limited regions: optional or necessary? Clin Infect Dis 2006; 44:128-34. [PMID: 17143828 DOI: 10.1086/510073] [Citation(s) in RCA: 186] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2006] [Accepted: 08/30/2006] [Indexed: 11/04/2022] Open
Abstract
Although it is a standard practice in high-income countries, determination of the human immunodeficiency virus (HIV) load is not recommended in developing countries because of the costs and technical constraints. As more and more countries establish capacity to provide second-line therapy, and as costs and technological constraints associated with viral load testing decrease, the question of whether determination of the viral load is necessary deserves attention. Viral load testing could increase in importance as a guide for clinical decisions on when to switch to second-line treatment and on how to optimize the duration of the first-line treatment regimen. In addition, the viral load is a particularly useful tool for monitoring adherence to treatment, performing sentinel surveillance, and diagnosing HIV infection in children aged <18 months. Rather than considering viral load data to be an unaffordable luxury, efforts should be made to ensure that viral load testing becomes affordable, simple, and easy to use in resource-limited settings.
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Affiliation(s)
- Alexandra Calmy
- Medecins sans Frontieres, Access to Medicines Campaign, Geneva, 1211, Switzerland.
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Dou H, Destache CJ, Morehead JR, Mosley RL, Boska MD, Kingsley J, Gorantla S, Poluektova L, Nelson JA, Chaubal M, Werling J, Kipp J, Rabinow BE, Gendelman HE. Development of a macrophage-based nanoparticle platform for antiretroviral drug delivery. Blood 2006; 108:2827-35. [PMID: 16809617 PMCID: PMC1895582 DOI: 10.1182/blood-2006-03-012534] [Citation(s) in RCA: 203] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Complex dosing regimens, costs, side effects, biodistribution limitations, and variable drug pharmacokinetic patterns have affected the long-term efficacy of antiretroviral medicines. To address these problems, a nanoparticle indinavir (NP-IDV) formulation packaged into carrier bone marrow-derived macrophages (BMMs) was developed. Drug distribution and disease outcomes were assessed in immune-competent and human immunodeficiency virus type 1 (HIV-1)-infected humanized immune-deficient mice, respectively. In the former, NP-IDV formulation contained within BMMs was adoptively transferred. After a single administration, single-photon emission computed tomography, histology, and reverse-phase-high-performance liquid chromatography (RP-HPLC) demonstrated robust lung, liver, and spleen BMMs and drug distribution. Tissue and sera IDV levels were greater than or equal to 50 microM for 2 weeks. NP-IDV-BMMs administered to HIV-1-challenged humanized mice revealed reduced numbers of virus-infected cells in plasma, lymph nodes, spleen, liver, and lung, as well as, CD4(+) T-cell protection. We conclude that a single dose of NP-IDV, using BMMs as a carrier, is effective and warrants consideration for human testing.
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Affiliation(s)
- Huanyu Dou
- Department of Pharmacology and Experimental Neuroscience, Center for Neurovirology and Neurodegenerative Disorder, University of Nebraska Medical Center, 985880 Nebraska Medical Center, Omaha, NE 68198-5880, USA
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