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Mainou E, Berendam SJ, Obregon-Perko V, Uffman EA, Phan CT, Shaw GM, Bar KJ, Kumar MR, Fray EJ, Siliciano JM, Siliciano RF, Silvestri G, Permar SR, Fouda GG, McCarthy J, Chahroudi A, Chan C, Conway JM. Assessing the impact of autologous neutralizing antibodies on rebound dynamics in postnatally SHIV-infected ART-treated infant rhesus macaques. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.06.01.596971. [PMID: 38895223 PMCID: PMC11185557 DOI: 10.1101/2024.06.01.596971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
The presence of antibodies against HIV in infected children is associated with a greater capacity to control viremia in the absence of therapy. While the benefits of early antiretroviral treatment (ART) in infants are well documented, early ART may interfere with the development of antibody responses. In contrast to adults, early treated children lack detectable HIV-specific antibodies, suggesting a fundamental difference in HIV pathogenesis. Despite this potential adverse effect, early ART may decrease the size of the latent reservoir established early in infection in infants, which can be beneficial in viral control. Understanding the virologic and immunologic aspects of pediatric HIV is crucial to inform innovative targeted strategies for treating children living with HIV. In this study, we investigate how ART initiation time sets the stage for trade-offs in the latent reservoir establishment and the development of humoral immunity and how these, in turn, affect posttreatment dynamics. We also elucidate the biological function of antibodies in pediatric HIV. We employ mathematical modeling coupled with experimental data from an infant nonhuman primate Simian/Human Immunodeficiency Virus (SHIV) infection model. Infant Rhesus macaques (RMs) were orally challenged with SHIV.C.CH505 375H dCT four weeks after birth and started treatment at different times after infection. In addition to viral load measurements, antibody responses and latent reservoir sizes were measured. We estimate model parameters by fitting viral load measurements to the standard HIV viral dynamics model within a nonlinear fixed effects framework. This approach allows us to capture differences between rhesus macaques (RMs) that develop antibody responses or exhibit high latent reservoir sizes compared to those that do not. We find that neutralizing antibody responses are associated with increased viral clearance and decreased viral infectivity but decreased death rate of infected cells. In addition, the presence of detectable latent reservoir is associated with less robust immune responses. These results demonstrate that both immune response and latent reservoir dynamics are needed to understand post-rebound dynamics and point to the necessity of a comprehensive approach in tailoring personalized medical interventions.
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Affiliation(s)
- Ellie Mainou
- Department of Biology, Pennsylvania State University, University Park, PA, USA
| | | | | | - Emilie A Uffman
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC, USA
| | - Caroline T Phan
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC, USA
| | - George M Shaw
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Katharine J Bar
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mithra R Kumar
- Department of Pharmacology and Molecular Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Emily J Fray
- Department of Biochemistry and Molecular Biology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Janet M Siliciano
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert F Siliciano
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Guido Silvestri
- Yerkes National Primate Research Center, Emory University, Atlanta, Georgia, USA
| | - Sallie R Permar
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | | | - Janice McCarthy
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA
| | - Ann Chahroudi
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Cliburn Chan
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA
| | - Jessica M Conway
- Department of Mathematics, Pennsylvania State University, University Park, PA, USA
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Ka'e AC, Santoro MM, Nanfack A, Ngoufack Jagni Semengue E, Yagai B, Nka AD, Ambada G, Mpouel ML, Sagnia B, Kenou L, Sanhanfo M, Togna Pabo WLR, Takou D, Chenwi CA, Sonela N, Sosso SM, Nkenfou C, Colizzi V, Halle-Ekane GE, Ndjolo A, Ceccherini-Silberstein F, Perno CF, Lewin S, Tiemessen CT, Fokam J. Characterization of HIV-1 Reservoirs in Children and Adolescents: A Systematic Review and Meta-Analysis Toward Pediatric HIV Cure. J Pediatr 2024; 267:113919. [PMID: 38237889 DOI: 10.1016/j.jpeds.2024.113919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 12/23/2023] [Accepted: 01/10/2024] [Indexed: 02/17/2024]
Abstract
OBJECTIVE To conduct a comprehensive, systematic review of the profile of HIV-1 reservoirs in children and adolescents with perinatally acquired HIV infection. STUDY DESIGN Randomized and nonrandomized trials, cohort studies, and cross-sectional studies on HIV reservoirs in pediatric populations, published between 2002 and 2022, were included. Archived-drug resistance mutations (ADRMs) and the size of reservoirs were evaluated. Subgroup analyses were performed to characterize further the data, and the meta-analysis was done through random effect models. RESULTS Overall, 49 studies from 17 countries worldwide were included, encompassing 2356 perinatally infected participants (48.83% females). There are limited data on the quantitative characterization of viral reservoirs in sub-Saharan Africa, with sensitive methodologies such as droplet digital polymerase chain reaction rarely employed. The overall prevalence of ADRMs was 37.80% (95% CI 13.89-65.17), with 48.79% (95% CI 0-100) in Africa, 42.08% (95% CI 6.68-82.71) in America, 23.88% (95% CI 14.34-34.90) in Asia, and 20.00% (95% CI 10.72-31.17) in Europe, without any difference between infants and adolescents (P = .656). Starting antiretroviral therapy (ART) before 2 months of age limited the levels of HIV-1 DNA (P = .054). Participants with long-suppressed viremia (>5 years) had lower levels of HIV-1 DNA (P = .027). Pre- and post-ART CD4 ≤29% and pre-ART viremia ≥5Log were all found associated with greater levels of HIV-1 DNA (P = .038, P = .047, and P = .041, respectively). CONCLUSIONS The pooled prevalence of ADRMs is high in perinatally infected pediatric population, with larger proviral reservoir size driven by delayed ART initiation, a shorter period of viral suppression, and immunovirological failures. Thus, strategies for pediatric HIV functional cure should target children and adolescents with very early ART initiation, immunocompetence, and long-term viral suppression.
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Affiliation(s)
- Aude Christelle Ka'e
- Departments of Virology and Immunology, Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Yaounde, Cameroon; Department of Experimental Medicine, PhD Course in Microbiology, Immunology, Infectious Diseases and Transplants (MIMIT), University of Rome "Tor Vergata", Rome, Italy
| | | | - Aubin Nanfack
- Departments of Virology and Immunology, Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Yaounde, Cameroon; IAS Research Cure Academy, Geneva, Switzerland
| | - Ezechiel Ngoufack Jagni Semengue
- Departments of Virology and Immunology, Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Yaounde, Cameroon
| | - Bouba Yagai
- UniCamillus - Saint Camillus International University of Health Sciences, Rome, Italy
| | - Alex Durand Nka
- Departments of Virology and Immunology, Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Yaounde, Cameroon
| | - Georgia Ambada
- Departments of Virology and Immunology, Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Yaounde, Cameroon; Department of Animal Biology and Physiology, Faculty of Sciences, University of Yaoundé I, Yaounde, Cameroon
| | - Marie-Laure Mpouel
- Departments of Virology and Immunology, Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Yaounde, Cameroon
| | - Bertrand Sagnia
- Departments of Virology and Immunology, Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Yaounde, Cameroon
| | - Leslie Kenou
- Departments of Virology and Immunology, Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Yaounde, Cameroon
| | - Michelle Sanhanfo
- Departments of Virology and Immunology, Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Yaounde, Cameroon
| | - Willy Le Roi Togna Pabo
- Departments of Virology and Immunology, Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Yaounde, Cameroon; Faculty of Sciences, Department of Microbiology and Parasitology, University of Buea, Buea, Cameroon
| | - Desire Takou
- Departments of Virology and Immunology, Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Yaounde, Cameroon
| | - Collins Ambe Chenwi
- Departments of Virology and Immunology, Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Yaounde, Cameroon; Department of Experimental Medicine, PhD Course in Microbiology, Immunology, Infectious Diseases and Transplants (MIMIT), University of Rome "Tor Vergata", Rome, Italy
| | - Nelson Sonela
- Departments of Virology and Immunology, Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Yaounde, Cameroon
| | - Samuel Martin Sosso
- Departments of Virology and Immunology, Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Yaounde, Cameroon
| | - Celine Nkenfou
- Departments of Virology and Immunology, Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Yaounde, Cameroon
| | - Vittorio Colizzi
- Departments of Virology and Immunology, Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Yaounde, Cameroon; Chair of UNESCO, Department of Biotechnology, Immunology and Molecular Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Gregory Edie Halle-Ekane
- Faculty of Health Sciences, Department of Medical Laboratory Sciences, University of Buea, Buea, Cameroon
| | - Alexis Ndjolo
- Departments of Virology and Immunology, Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Yaounde, Cameroon
| | | | - Carlo-Federico Perno
- Laboratory of Microbiology and Virology, Bambino Gesu Pediatric Hospital, Rome, Italy
| | - Sharon Lewin
- Infectious Diseases, University of Melbourne, Melbourne, Australia
| | - Caroline T Tiemessen
- National Institute for Communicable Diseases and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Joseph Fokam
- Departments of Virology and Immunology, Chantal Biya International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), Yaounde, Cameroon; IAS Research Cure Academy, Geneva, Switzerland; Faculty of Health Sciences, Department of Medical Laboratory Sciences, University of Buea, Buea, Cameroon.
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3
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Hendricks CL, Mellet J, Durandt C, Brittain D, Pepper MS. Haematopoietic stem-cell transplantation in an HIV endemic area: time to consider donors exposed to or living with HIV. Lancet HIV 2023; 10:e742-e749. [PMID: 37837978 DOI: 10.1016/s2352-3018(23)00198-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 07/24/2023] [Accepted: 07/31/2023] [Indexed: 10/16/2023]
Abstract
South Africa has more than 8 million people living with HIV. However, the number of patients undergoing haematopoietic stem-cell transplantation (HSCT) in South Africa is far below the target number. Donor numbers are insufficient to meet demand. Both HSCT and solid organ transplantation have proved successful in people living with HIV. Solid organ transplantation also has good outcomes when both donors and recipients have HIV. This Personal View explores the possible inclusion of people living with HIV and umbilical cord blood from HIV-negative infants exposed to HIV as donor sources for HSCT. Beyond the risk of HIV transmission, additional complications must be considered, such as delayed or inadequate immune reconstitution and an increased risk of haematological abnormalities and malignancies. Interactions between antiretroviral drugs and drugs used in the conditioning regimen, as well as the need to maintain virological suppression when gastrointestinal absorption deteriorates, are additional complicating factors. The process also requires more stringent ethical processes to be in place to minimise physical and emotional harm. However, in an HIV endemic country, people living with HIV or donors exposed to HIV must be considered as part of a multidisciplinary collaborative effort to provide more patients with the opportunity to have a life-saving HSCT.
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Affiliation(s)
- Candice Laverne Hendricks
- Institute for Cellular and Molecular Medicine, Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa; SAMRC Extramural Unit for Stem Cell Research and Therapy, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Juanita Mellet
- Institute for Cellular and Molecular Medicine, Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa; SAMRC Extramural Unit for Stem Cell Research and Therapy, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Chrisna Durandt
- Institute for Cellular and Molecular Medicine, Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa; SAMRC Extramural Unit for Stem Cell Research and Therapy, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - David Brittain
- Alberts Cellular Therapy, Netcare Pretoria East Hospital, Pretoria, South Africa
| | - Michael Sean Pepper
- Institute for Cellular and Molecular Medicine, Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa; SAMRC Extramural Unit for Stem Cell Research and Therapy, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.
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Botha JC, Demirov D, Gordijn C, Katusiime MG, Bale MJ, Wu X, Wells D, Hughes SH, Cotton MF, Mellors JW, Kearney MF, van Zyl GU. The largest HIV-1-infected T cell clones in children on long-term combination antiretroviral therapy contain solo LTRs. mBio 2023; 14:e0111623. [PMID: 37530525 PMCID: PMC10470503 DOI: 10.1128/mbio.01116-23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 06/26/2023] [Indexed: 08/03/2023] Open
Abstract
Combination antiretroviral therapy (cART) suppresses viral replication but does not cure HIV infection because a reservoir of infectious (intact) HIV proviruses persists in long-lived CD4+T cells. However, a large majority (>95%) of HIV-infected cells that persist on effective cART carry defective (non-infectious) proviruses. Defective proviruses consisting of only a single LTR (solo long terminal repeat) are commonly found as endogenous retroviruses in many animal species, but the frequency of solo-LTR HIV proviruses has not been well defined. Here we show that, in five pediatric donors whose viremia was suppressed on cART for at least 5 years, the proviruses in the nine largest clones of HIV-infected cells were solo LTRs. The sizes of five of these clones were assayed longitudinally by integration site-specific quantitative PCR. Minor waxing and waning of the clones was observed, suggesting that these clones are generally stable over time. Our findings show that solo LTRs comprise a large fraction of the proviruses in infected cell clones that persist in children on long-term cART. IMPORTANCE This work highlights that severely deleted HIV-1 proviruses comprise a significant proportion of the proviral landscape and are often overlooked.
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Affiliation(s)
| | - Dimiter Demirov
- Cancer Research Technology Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | | | - Mary Grace Katusiime
- HIV Dynamics and Replication Program, National Cancer Institute, Frederick, Maryland, USA
| | - Michael J. Bale
- Laboratory of Epigenetics and Immunity, Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Xiaolin Wu
- HIV Dynamics and Replication Program, National Cancer Institute, Frederick, Maryland, USA
| | - Daria Wells
- HIV Dynamics and Replication Program, National Cancer Institute, Frederick, Maryland, USA
| | - Stephen H. Hughes
- HIV Dynamics and Replication Program, National Cancer Institute, Frederick, Maryland, USA
| | | | - John W. Mellors
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Mary F. Kearney
- HIV Dynamics and Replication Program, National Cancer Institute, Frederick, Maryland, USA
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Mahlakwane KL, Preiser W, Nkosi N, Naidoo N, van Zyl G. Delays in HIV-1 infant polymerase chain reaction testing may leave children without confirmed diagnoses in the Western Cape province, South Africa. Afr J Lab Med 2022; 11:1485. [PMID: 35811753 PMCID: PMC9257942 DOI: 10.4102/ajlm.v11i1.1485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 03/24/2022] [Indexed: 11/29/2022] Open
Abstract
Background Early diagnosis and confirmation of HIV infection in newborns is crucial for expedited initiation of antiretroviral therapy. Confirmatory testing must be done for all children with a reactive HIV PCR result. There is no comprehensive data on confirmatory testing and HIV PCR test request rejections at National Health Laboratory Service laboratories in South Africa. Objective This study assessed the metrics of routine infant HIV PCR testing at the Tygerberg Hospital Virology Laboratory, Cape Town, Western Cape, South Africa, including the proportion of rejected test requests, turn-around time (TAT), and rate of confirmatory testing. Methods We retrospectively reviewed laboratory-based data on all HIV PCR tests performed on children ≤ 24 months old (n = 43 346) and data on rejected HIV PCR requests (n = 1479) at the Tygerberg virology laboratory over two years (2017–2019). Data from sample collection to release of results were analysed to assess the TAT and follow-up patterns. Results The proportion of rejected HIV PCR requests was 3.3%; 83.9% of these were rejected for various pre-analytical reasons. Most of the test results (89.2%) met the required 96-h TAT. Of the reactive initial test results, 53.5% had a follow-up sample tested, of which 93.1% were positive. Of the initial indeterminate results, 74.7% were negative on follow-up testing. Conclusion A high proportion of HIV PCR requests were rejected for pre-analytical reasons. The high number of initial reactive tests without evidence of follow-up suggests that a shorter TAT is required to allow confirmatory testing before children are discharged.
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Affiliation(s)
- Kamela L Mahlakwane
- Division of Medical Virology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Medical Virology, Tygerberg Hospital, National Health Laboratory Service, Cape Town, South Africa
| | - Wolfgang Preiser
- Division of Medical Virology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Medical Virology, Tygerberg Hospital, National Health Laboratory Service, Cape Town, South Africa
| | - Nokwazi Nkosi
- Division of Medical Virology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Medical Virology, Tygerberg Hospital, National Health Laboratory Service, Cape Town, South Africa
| | - Nasheen Naidoo
- Division of Clinical Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Clinical Pathology, Tygerberg Hospital, National Health Laboratory Service, Cape Town, South Africa
| | - Gert van Zyl
- Division of Medical Virology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Medical Virology, Tygerberg Hospital, National Health Laboratory Service, Cape Town, South Africa
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Vieira VA, Herbert N, Cromhout G, Adland E, Goulder P. Role of Early Life Cytotoxic T Lymphocyte and Natural Killer Cell Immunity in Paediatric HIV Cure/Remission in the Anti-Retroviral Therapy Era. Front Immunol 2022; 13:886562. [PMID: 35634290 PMCID: PMC9130627 DOI: 10.3389/fimmu.2022.886562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 04/13/2022] [Indexed: 11/13/2022] Open
Abstract
Only three well-characterised cases of functional cure have been described in paediatric HIV infection over the past decade. This underlines the fact that early initiation of combination antiretroviral therapy (cART), whilst minimising the size of the viral reservoir, is insufficient to achieve cure, unless other factors contribute. In this review, we consider these additional factors that may facilitate functional cure in paediatric infection. Among the early life immune activity, these include HIV-specific cytotoxic T-lymphocyte (CTL) and natural killer (NK) cell responses. The former have less potent antiviral efficacy in paediatric compared with adult infection, and indeed, in early life, NK responses have greater impact in suppressing viral replication than CTL. This fact may contribute to a greater potential for functional cure to be achieved in paediatric versus adult infection, since post-treatment control in adults is associated less with highly potent CTL activity, and more with effective antiviral NK cell responses. Nonetheless, antiviral CTL responses can play an increasingly effective role through childhood, especially in individuals expressing then 'protective' HLA-I molecules HLA-B*27/57/58:01/8101. The role of the innate system on preventing infection, in shaping the particular viruses transmitted, and influencing outcome is discussed. The susceptibility of female fetuses to in utero mother-to-child transmission, especially in the setting of recent maternal infection, is a curiosity that also provides clues to mechanisms by which cure may be achieved, since initial findings are that viral rebound is less frequent among males who interrupt cART. The potential of broadly neutralising antibody therapy to facilitate cure in children who have received early cART is discussed. Finally, we draw attention to the impact of the changing face of the paediatric HIV epidemic on cure potential. The effect of cART is not limited to preventing AIDS and reducing the risk of transmission. cART also affects which mothers transmit. No longer are mothers who transmit those who carry genes associated with poor immune control of HIV. In the cART era, a high proportion (>70% in our South African study) of transmitting mothers are those who seroconvert in pregnancy or who for social reasons are diagnosed late in pregnancy. As a result, now, genes associated with poor immune control of HIV are not enriched in mothers who transmit HIV to their child. These changes will likely influence the effectiveness of HLA-associated immune responses and therefore cure potential among children.
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Affiliation(s)
- Vinicius A. Vieira
- Peter Medawar Building for Pathogen Research, Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Nicholas Herbert
- Africa Health Research Institute (AHRI), Nelson R Mandela School of Medicine, Durban, South Africa
| | - Gabriela Cromhout
- HIV Pathogenesis Programme, Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Emily Adland
- Peter Medawar Building for Pathogen Research, Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Philip Goulder
- Peter Medawar Building for Pathogen Research, Department of Paediatrics, University of Oxford, Oxford, United Kingdom,Africa Health Research Institute (AHRI), Nelson R Mandela School of Medicine, Durban, South Africa,HIV Pathogenesis Programme, Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa,*Correspondence: Philip Goulder,
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Payne H, Chan MK, Watters SA, Otwombe K, Hsiao NY, Babiker A, Violari A, Cotton MF, Gibb DM, Klein NJ. Early ART-initiation and longer ART duration reduces HIV-1 proviral DNA levels in children from the CHER trial. AIDS Res Ther 2021; 18:63. [PMID: 34587974 PMCID: PMC8482761 DOI: 10.1186/s12981-021-00389-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 09/16/2021] [Indexed: 11/21/2022] Open
Abstract
Background Reduction of the reservoir of latent HIV-infected cells might increase the possibility of long-term remission in individuals living with HIV. We investigated factors associated with HIV-1 proviral DNA levels in children receiving different antiretroviral therapy (ART) strategies in the children with HIV early antiretroviral therapy (CHER) trial. Methods Infants with HIV < 12 weeks old with CD4% ≥ 25% were randomized in the CHER trial to early limited ART for 40 or 96 weeks (ART-40 W, ART-96 W), or deferred ART (ART-Def). For ART-Def infants or following ART interruption in ART-40 W/ART-96 W, ART was started/re-started for clinical progression or CD4% < 25%. In 229 participants, HIV-1 proviral DNA was quantified by PCR from stored peripheral blood mononuclear cells from children who had received ≥ 24 weeks ART and two consecutive undetectable HIV-1 RNA 12–24 weeks apart. HIV-1 proviral DNA was compared between ART-Def and ART-96 W at week 96, and in all arms at week 248. Factors associated with HIV-1 proviral DNA levels were evaluated using linear regression. Findings Longer duration of ART was significantly associated with lower HIV-1 proviral DNA at both 96 (p = 0.0003) and 248 weeks (p = 0.0011). Higher total CD8 count at ART initiation was associated with lower HIV-1 proviral DNA at both 96 (p = 0.0225) and 248 weeks (p = 0.0398). Week 248 HIV-1 proviral DNA was significantly higher in those with positive HIV-1 serology at week 84 than those with negative serology (p = 0.0042). Intepretation Longer ART duration is key to HIV-1 proviral DNA reduction. Further understanding is needed of the effects of “immune-attenuation” through early HIV-1 exposure. Funding Wellcome Trust, National Institutes of Health, Medical Research Council.
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8
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Katusiime MG, Van Zyl GU, Cotton MF, Kearney MF. HIV-1 Persistence in Children during Suppressive ART. Viruses 2021; 13:v13061134. [PMID: 34204740 PMCID: PMC8231535 DOI: 10.3390/v13061134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/06/2021] [Accepted: 06/08/2021] [Indexed: 12/16/2022] Open
Abstract
There is a growing number of perinatally HIV-1-infected children worldwide who must maintain life-long ART. In early life, HIV-1 infection is established in an immunologically inexperienced environment in which maternal ART and immune dynamics during pregnancy play a role in reservoir establishment. Children that initiated early antiretroviral therapy (ART) and maintained long-term suppression of viremia have smaller and less diverse HIV reservoirs than adults, although their proviral landscape during ART is reported to be similar to that of adults. The ability of these early infected cells to persist long-term through clonal expansion poses a major barrier to finding a cure. Furthermore, the effects of life-long HIV persistence and ART are yet to be understood, but growing evidence suggests that these individuals are at an increased risk for developing non-AIDS-related comorbidities, which underscores the need for an HIV cure.
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Affiliation(s)
- Mary Grace Katusiime
- HIV Dynamics and Replication Program, CCR, National Cancer Institute, Frederick, MD 21702, USA;
- Correspondence:
| | - Gert U. Van Zyl
- Division of Medical Virology, Stellenbosch University and National Health Laboratory Service Tygerberg, Cape Town 8000, South Africa;
| | - Mark F. Cotton
- Department of Pediatrics and Child Health, Tygerberg Children’s Hospital and Family Center for Research with Ubuntu, Stellenbosch University, Cape Town 7505, South Africa;
| | - Mary F. Kearney
- HIV Dynamics and Replication Program, CCR, National Cancer Institute, Frederick, MD 21702, USA;
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Powell L, Dhummakupt A, Siems L, Singh D, Le Duff Y, Uprety P, Jennings C, Szewczyk J, Chen Y, Nastouli E, Persaud D. Clinical validation of a quantitative HIV-1 DNA droplet digital PCR assay: Applications for detecting occult HIV-1 infection and monitoring cell-associated HIV-1 dynamics across different subtypes in HIV-1 prevention and cure trials. J Clin Virol 2021; 139:104822. [PMID: 33930698 PMCID: PMC8212401 DOI: 10.1016/j.jcv.2021.104822] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 04/06/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND In HIV-1-exposed infants, nucleic acid testing (NAT) is required to diagnose infection since passively transferred maternal antibodies preclude antibody testing. The sensitivity of clinical NAT assays is lowered with infant antiretroviral prophylaxis and, with empiric very early antiretroviral treatment of high-risk infants, thereby impacting early infant diagnosis. Similarly, adult HIV-1 infections acquired under pre-exposure prophylaxis may occur at low levels, with undetectable plasma viremia and indeterminate antibody tests, for which HIV-1 DNA testing maybe a useful adjunct. Cell-associated HIV-1 DNA concentrations are also used to monitor HIV-1 persistence in viral reservoirs with relevance to HIV-1 cure therapeutics, particularly in perinatal infections. OBJECTIVES We clinically validated an HIV-1 DNA quantitative assay using droplet digital PCR (ddPCR), across different HIV-1 subtypes. STUDY DESIGN The analytical sensitivity and specificity of an HIV-1 DNA ddPCR assay was determined using serial dilutions of a plasmid containing HIV-1 LTR-gag spiked into peripheral blood mononuclear cells (PBMCs), with MOLT-4 cells or PBMCs infected with different HIV-1 subtypes (A, B and C), and U1 cells spiked into PBMCs. Inter- and intra-run variability were used to determine assay precision. RESULTS The HIV-1 LTR-gag ddPCR assay was reliable and reproducible, and exhibited high analytical specificity with sensitivity to near single copy level, across multiple HIV-1 subtypes, and a limit of detection of 4.09 copies/million PBMCs. CONCLUSIONS This assay has applications for detecting occult HIV-1-infection in the setting of combination and long-acting regimens used for HIV-1 prevention, across different HIV-1 subtypes, in infants and adults, and in HIV-1 cure interventions.
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Affiliation(s)
- Laura Powell
- Johns Hopkins University, School of Medicine, Department of Pediatrics, Division of Infectious Diseases, Baltimore, MD, United States
| | - Adit Dhummakupt
- Johns Hopkins University, School of Medicine, Department of Pediatrics, Division of Infectious Diseases, Baltimore, MD, United States
| | - Lilly Siems
- Johns Hopkins University, School of Medicine, Department of Pediatrics, Division of Infectious Diseases, Baltimore, MD, United States
| | - Dolly Singh
- Johns Hopkins University, School of Medicine, Department of Pediatrics, Division of Infectious Diseases, Baltimore, MD, United States
| | - Yann Le Duff
- Center for AIDS Reagents, National Institute for Biological Standards and Controls, England, UK
| | - Priyanka Uprety
- Department of Pathology and Laboratory Medicine, Robert Wood Johnson University Hospital, Rutgers University, New Brunswick, NJ, United States
| | - Cheryl Jennings
- Rush University Medical Center, Department of Molecular Pathogens and Immunity, Chicago, IL, United States
| | - Joseph Szewczyk
- Johns Hopkins University, School of Medicine, Department of Pediatrics, Division of Infectious Diseases, Baltimore, MD, United States
| | - Ya Chen
- Johns Hopkins University, School of Medicine, Department of Pediatrics, Division of Infectious Diseases, Baltimore, MD, United States
| | - Eleni Nastouli
- Department of Population, Policy and Practice, UCL Great Ormond Street Institute of Child Health and Francis Crick Institute, London, UK
| | - Deborah Persaud
- Johns Hopkins University, School of Medicine, Department of Pediatrics, Division of Infectious Diseases, Baltimore, MD, United States; Departments of Molecular Microbiology and Immunology and International Health, Johns Hopkins Bloomberg School of Public Health, United States.
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10
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Pediatric HIV: the Potential of Immune Therapeutics to Achieve Viral Remission and Functional Cure. Curr HIV/AIDS Rep 2020; 17:237-248. [PMID: 32356090 DOI: 10.1007/s11904-020-00495-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE OF REVIEW In the absence of antiretroviral therapy (ART), more than 50% of perinatally HIV-infected children die by 2 years of age. Early ART from infancy is therefore a global recommendation and significantly improves immune health, child survival, and disease outcome. However, even early treatment does not prevent or eradicate the latent reservoir necessitating life-long ART. Adherence to life-long ART is challenging for children and longstanding ART during chronic HIV infection led to higher risks of non-AIDS co-morbidities and virologic failure in infected children. Thus, HIV-infected children are an important population for consideration for immune-based interventions to achieve ART-free remission and functional cure. This review summarizes how the uniqueness of the early life immune system can be harnessed for the development of ART-free remission and functional cure, which means complete virus control in absence of ART. In addition, recent advances in therapeutics in the HIV cure field and their potential for the treatment of pediatric HIV infections are discussed. RECENT FINDINGS Preclinical studies and clinical trials demonstrated that immune-based interventions target HIV replication, limit size of virus reservoir, maintain virus suppression, and delay time to virus rebound. However, these studies have been performed so far only in carefully selected HIV-infected adults, highlighting the need to evaluate the efficacy of immune-based therapeutics in HIV-infected children and to design interventions tailored to the early life maturing immune system. Immune-based therapeutics alone or in combination with ART should be actively explored as potential strategies to achieve viral remission and functional cure in HIV-infected pediatric populations.
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11
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Negative Diagnostic PCR Tests in School-Aged, HIV-Infected Children on Antiretroviral Therapy Since Early Life in Johannesburg, South Africa. J Acquir Immune Defic Syndr 2020; 83:381-389. [PMID: 31913997 DOI: 10.1097/qai.0000000000002265] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Younger age at antiretroviral therapy (ART) initiation has been associated with smaller HIV reservoirs. We investigated whether younger age of ART initiation is associated with testing negative and weaker signal on a standard HIV diagnostic test in treated children. METHODS At exit from a longitudinal study at 2 sites in Johannesburg, South Africa, 316 school-aged, HIV-infected children on continuous ART started at a median age of 6.3 months, were tested with standard total nucleic acid PCR used for infant diagnosis. All negative results were repeated. Simultaneous viral load (VL) and CD4 T-cell counts/percentages, along with data collected over the prior 4 years, were used in multivariable regression to predict negative PCR results and higher cycle threshold (Ct) values (weaker signal). RESULTS Seven children (2.2%, 95% confidence interval: 0.6 to 3.8) in the full cohort had negative PCR results; all 7 were in a subset of 102 (6.9%, 95% confidence interval: 2.0 to 11.8) who had initiated ART at age 0-4 months and had VL <50 copies/mL at the time of PCR testing. Only one repeat tested as negative. Younger age at ART initiation, VL <50 copies/mL at time of test, sustained VL <400 copies/mL, lower CD4 T-cell counts, and ever treated with efavirenz were significant predictors of weaker signal on the diagnostic test. CONCLUSIONS In a small proportion of children who start ART in the first months of life and remain on continuous therapy, standard diagnostic HIV PCR tests may result as negative. Repeat testing may resolve uncertainty of diagnosis.
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12
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Preiser W, van Zyl GU. Pooled testing: A tool to increase efficiency of infant HIV diagnosis and virological monitoring. Afr J Lab Med 2020; 9:1035. [PMID: 32934914 PMCID: PMC7479369 DOI: 10.4102/ajlm.v9i2.1035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 04/15/2020] [Indexed: 01/04/2023] Open
Abstract
Background Pooled testing, or pooling, has been used for decades to efficiently diagnose relatively rare conditions, such as infection in blood donors. Programmes for the prevention of mother-to-child transmission of HIV and for antiretroviral therapy (ART) are being rolled out in much of Africa and are largely successful. This increases the need for early infant diagnosis (EID) of HIV using qualitative nucleic acid testing and for virological monitoring of patients on ART using viral load testing. While numbers of patients needing testing are increasing, infant HIV infections and ART failures are becoming rarer, opening an opportunity for pooled testing approaches. Aim This review highlights the need for universal EID and viral load coverage as well as the challenges faced. We introduce the concept of pooled testing and highlight some important considerations before giving an overview of studies exploring pooled testing for EID and virological monitoring. Results For ART monitoring, pooling has been shown to be accurate and efficient; for EID it has not been tried although modelling shows it to be promising. The final part attempts to place pooling into the context of current mother-to-child transmission of HIV and ART programmes and their expected trajectories over the next years. Conclusion Several points warrant consideration: pre-selection to exclude samples with an elevated pre-test probability of positivity from pooled testing, the use of dried blood or plasma spots, and choosing a pooling strategy that is both practically feasible and economical. Finally, novel ideas are suggested to make pooling even more attractive.
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Affiliation(s)
- Wolfgang Preiser
- Division of Medical Virology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,National Health Laboratory Service (NHLS) Tygerberg, Cape Town, South Africa
| | - Gert U van Zyl
- Division of Medical Virology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,National Health Laboratory Service (NHLS) Tygerberg, Cape Town, South Africa
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13
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Performance evaluation of the Aptima HIV-1 Quant Dx assay for detection of HIV in infants in Kenya. J Clin Virol 2020; 125:104289. [PMID: 32097889 DOI: 10.1016/j.jcv.2020.104289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 01/29/2020] [Accepted: 02/15/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Early infant diagnosis (EID) of HIV-1 exposed infants enables timely initiation of antiretroviral therapy (ART), thereby allowing early diagnosis and treatment to slow disease progression and reduce mortality. Turn-around time to results, partially caused by low to medium throughput technology, remains a hindrance to early treatment. A major solution to this challenge is to incorporate high throughput and accurate technologies in the testing process. The Hologic Aptima Quant Dx Assay (Aptima) is a CE marked Real-Time TMA assay running on the high throughput Panther system. OBJECTIVES The objective of this study was to evaluate the performance of Aptima for EID using dried blood spots. STUDY DESIGN This was a cross-sectional prospective study of 2,048 infants seeking HIV services from health facilities in Western Kenya, Africa. Capillary Dried Blood Spot samples DBS were collected from infants with the consent of their mothers. The qualitative performance of Aptima was compared with the Roche COBAS Ampliprep/ COBAS Taqman HIV-1 Qualitative Test v2.0 (CAP/CTM), using these DBS. Demographic information of the participants was also collected. RESULTS A total of 1,975 successful comparisons between the two platforms were included in the analysis. The overall agreement between the assays was 99.65 %. The sensitivity and specificity of Aptima was 95.24 % (95 % CI 88.40-98.19 %) and 99.84 % (95 % CI 99.49-99.92 %) respectively. CONCLUSIONS Aptima assay has performance characteristics that are comparable to those of the Roche CAP/CTM for qualitative testing on DBS taken from infants. The two assays can therefore be used interchangeably for Early Infant Diagnosis of HIV.
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14
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Katusiime MG, Halvas EK, Wright I, Joseph K, Bale MJ, Kirby-McCullough B, Engelbrecht S, Shao W, Hu WS, Cotton MF, Mellors JW, Kearney MF, van Zyl GU. Intact HIV Proviruses Persist in Children Seven to Nine Years after Initiation of Antiretroviral Therapy in the First Year of Life. J Virol 2020; 94:e01519-19. [PMID: 31776265 PMCID: PMC6997763 DOI: 10.1128/jvi.01519-19] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 11/05/2019] [Indexed: 12/31/2022] Open
Abstract
In adults starting antiretroviral therapy (ART) during acute infection, 2% of proviruses that persist on ART are genetically intact by sequence analysis. In contrast, a recent report in children treated early failed to detect sequence-intact proviruses. In another cohort of children treated early, we sought to detect and characterize proviral sequences after 6 to 9 years on suppressive ART. Peripheral blood mononuclear cells (PBMC) from perinatally infected children from the Children with HIV Early antiRetroviral (CHER) study were analyzed. Nearly full-length proviral amplification and sequencing (NFL-PAS) were performed at one time point after 6 to 9 years on ART. Amplicons with large internal deletions were excluded (<9 kb). All amplicons of ≥9 kb were sequenced and analyzed through a bioinformatic pipeline to detect indels, frameshifts, or hypermutations that would render them defective. In eight children who started ART at a median age of 5.4 months (range, 2.0 to 11.1 months), 733 single NFL-PAS amplicons were generated. Of these, 534 (72.9%) had large internal deletions, 174 (23.7%) had hypermutations, 15 (1.4%) had small internal deletions, 3 (1.0%) had deletions in the packaging signal/major splice donor site, and 7 (1.0%) were sequence intact. These 7 intact sequences were from three children who initiated ART after 2.3 months of age, one of whom had two identical intact sequences, suggestive of a cell clone harboring a replication-competent provirus. No intact proviruses were detected in four children who initiated ART before 2.3 months of age. Rare, intact proviruses can be detected in children who initiate ART after 2.3 months of age and are probably, as in adults, maintained by clonal expansion of cells infected before ART initiation.IMPORTANCE There are limited data about the proviral landscape in children exhibiting long-term suppression after early treatment, particularly in Sub-Saharan Africa where HIV-1 subtype C predominates. Investigating the sequence-intact reservoir could provide insight on the mechanisms by which intact proviruses persist and inform ongoing cure efforts. Through nearly full-length proviral amplification and sequencing (NFL-PAS), we generated 733 NFL-PAS amplicons from eight children. We showed that rare, genetically intact proviruses could be detected in children who initiated ART after 2.3 months of age. The frequency of intact proviruses was lower (P < 0.05) than that reported for HIV subtype B-infected adults treated during early HIV infection. We show that cells harboring genetically intact HIV proviruses are rare in children exhibiting long-term suppression after early treatment and may require the processing of a large number of cells to assess reservoir size. This points to the need for efficient methods to accurately quantify latent reservoirs, particularly in pediatric studies where sample availability is limited.
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Affiliation(s)
- Mary Grace Katusiime
- Division of Medical Virology, Stellenbosch University and National Health Laboratory Service Tygerberg, Cape Town, South Africa
| | - Elias K Halvas
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Imogen Wright
- South African National Bioinformatics Institute, University of the Western Cape, Cape Town, South Africa
| | - Kevin Joseph
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Michael J Bale
- HIV Dynamics and Replication Program, National Cancer Institute-Frederick, NIH, Frederick, Maryland, USA
| | - Bronwyn Kirby-McCullough
- Institute for Microbial Biotechnology and Metagenomics, University of Western Cape, Cape Town, South Africa
| | - Susan Engelbrecht
- Division of Medical Virology, Stellenbosch University and National Health Laboratory Service Tygerberg, Cape Town, South Africa
| | - Wei Shao
- HIV Dynamics and Replication Program, National Cancer Institute-Frederick, NIH, Frederick, Maryland, USA
- Leidos Biomedical Research, Frederick, Maryland, USA
| | - Wei-Shau Hu
- HIV Dynamics and Replication Program, National Cancer Institute-Frederick, NIH, Frederick, Maryland, USA
| | - Mark F Cotton
- Department of Pediatrics and Child Health, Tygerberg Children's Hospital and Family Clinical Research Unit, Stellenbosch University, Cape Town, South Africa
| | - John W Mellors
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Mary F Kearney
- HIV Dynamics and Replication Program, National Cancer Institute-Frederick, NIH, Frederick, Maryland, USA
| | - Gert U van Zyl
- Division of Medical Virology, Stellenbosch University and National Health Laboratory Service Tygerberg, Cape Town, South Africa
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15
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Laughton B, Naidoo S, Dobbels EF, Boivin MJ, van Rensburg AJ, Glashoff RH, van Zyl GU, Kruger M, Cotton MF. Neurodevelopment at 11 months after starting antiretroviral therapy within 3 weeks of life. South Afr J HIV Med 2019; 20:1008. [PMID: 31745434 PMCID: PMC6852492 DOI: 10.4102/sajhivmed.v20i1.1008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 08/18/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Antiretroviral therapy (ART) started between 7 and 12 weeks of age improves neurodevelopmental outcomes in HIV-infected (HIV+) infants, but the impact of even earlier initiation is not yet described. OBJECTIVES We assessed the early neurodevelopment of HIV+ infants who started ART within 21 days of life. METHOD Participants were enrolled from the public sector birth HIV-diagnosis programme. Inclusion criteria included the following: birth weight > 2000 g, infant commencing ART < 6 weeks and no infant cytomegalovirus disease. Antiretroviral therapy included Zidovudine/Lamivudine/Nevirapine for the first 2 weeks, the latter then replaced by Lopinavir/Ritonavir. Once body weight > 3 kg and gestational age > 44 weeks, Abacavir replaced Zidovudine. The Griffiths mental development scales (GMDS) were administered at 10-12 months. RESULTS Of 29 infants assessed, 23 (79%) were girls. Mean birth weight was 3002 ± 501 g. Twenty-four mothers (83%) received ART during pregnancy. Seven (24%) infants were diagnosed HIV+ within 48 h of birth. Median [interquartile range] viral load (VL) at diagnosis was 3904 [259-16 922] copies/mL, age starting ART was 6.0 [3-10] days and age at VL suppression was 19.1 [15-36] weeks. At the GMDS assessment, nine (31%) participants had detectable VL and 26 (90%) had World Health Organization (WHO) clinical stage I disease. The GMDS was performed at a mean age of 11.5 ± 0.8 months. Mean quotients were within the average range: Global Griffiths score was 103.6 ± 10.9 and mean quotients on the subscales ranged from lowest 95.9 ± 13.4 for locomotor to highest 112.8 ± 11.3 for hearing-and-language. CONCLUSION Preliminary findings in this small group suggest that early neurodevelopmental scores are within the normal range in infants with perinatal HIV infection who started ART at a median of 6 days.
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Affiliation(s)
- Barbara Laughton
- Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Shalena Naidoo
- Department of Pathology, Stellenbosch University, Cape Town, South Africa
| | - Els F.M.T. Dobbels
- Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Michael J. Boivin
- Department of Psychiatry, Michigan State University, East Lansing, United States
- Department of Neurology and Ophthalmology, Michigan State University, East Lansing, United States
| | | | - Richard H. Glashoff
- Department of Pathology, Stellenbosch University, Cape Town, South Africa
- National Laboratory Services, Cape Town, South Africa
| | - Gert U. van Zyl
- National Laboratory Services, Cape Town, South Africa
- Division of Virology, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
| | - Mariana Kruger
- Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Mark F. Cotton
- Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
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16
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Haeri Mazanderani A, Sherman GG. Evolving complexities of infant HIV diagnosis within Prevention of Mother-to-Child Transmission programs. F1000Res 2019; 8. [PMID: 31543952 PMCID: PMC6745762 DOI: 10.12688/f1000research.19637.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/11/2019] [Indexed: 11/20/2022] Open
Abstract
Early diagnosis of HIV infection among infants and children is critical as prompt initiation of antiretroviral therapy prevents morbidity and death. Yet despite advances in the accuracy and availability of infant HIV diagnostic testing, there are increasing challenges with making an early definitive diagnosis. These challenges relate primarily to advances in prevention of mother-to-child transmission (PMTCT) of HIV. Although PMTCT programs have proven to be highly effective in reducing infant HIV infection, infants who are HIV-infected may achieve virological suppression and loss of detectability of HIV nucleic acid prior to diagnosis because of antiretroviral drug exposure. Hence, false-negative and indeterminate HIV polymerase chain reaction (PCR) results can occur, especially among high-risk infants given multi-drug prophylactic regimens. However, the infant HIV diagnostic landscape is also complicated by the inevitable decline in the positive predictive value of early infant diagnosis (EID) assays. As PMTCT programs successfully reduce the mother-to-child transmission rate, the proportion of false-positive EID results will increase. Consequently, false-negative and false-positive HIV PCR results are increasingly likely despite highly accurate diagnostic assays. The problem is compounded by the seemingly intractable prevalence of maternal HIV within some settings, resulting in a considerable absolute burden of HIV-infected infants despite a low mother-to-child transmission rate.
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Affiliation(s)
- Ahmad Haeri Mazanderani
- Centre for HIV & STIs, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa.,Department of Medical Virology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Gayle G Sherman
- Centre for HIV & STIs, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa.,Department of Paediatrics & Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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17
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Levin B, Kuhn L, Leu CS, Tsai WY. Sequential tests of promise with discrete time-to-event data. Contemp Clin Trials 2019; 85:105818. [PMID: 31445172 DOI: 10.1016/j.cct.2019.105818] [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: 04/16/2019] [Revised: 07/25/2019] [Accepted: 08/04/2019] [Indexed: 11/24/2022]
Abstract
We introduce a family of sequential test procedures in the context of a futility study design, or as we prefer to call it, a formal test of promise, suitable for use with time-to-event data. The procedures are motivated by an actual trial that was undertaken to test the promise of very early antiretroviral therapy to achieve viral remission in infants with perinatally-acquired HIV. Important gains in efficiency are illustrated in terms of early stopping and statistical power compared with other methods such as Simon's two-stage design with binary outcomes. We show how to calculate the operating characteristics of the proposed sequential tests of promise and provide optimal or near-optimal boundaries for small or medium size samples which provide the typical context for the tests under consideration. The design features discussed in this article are also of immediate pertinence to trials designed to test disease cures which may require treatment interruption and small numbers of participants.
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Affiliation(s)
- Bruce Levin
- Department of Biostatistics, Columbia University, Mailman School of Public Health, 722 West 168(th) Street, New York, NY 10032, USA.
| | - Louise Kuhn
- Department of Epidemiology, Columbia University, Mailman School of Public Health, 722 West 168(th) Street, New York, NY 10032, USA.
| | - Cheng-Shiun Leu
- Department of Biostatistics, Columbia University, Mailman School of Public Health, 722 West 168(th) Street, New York, NY 10032, USA.
| | - Wei-Yann Tsai
- Department of Biostatistics, Columbia University, Mailman School of Public Health, 722 West 168(th) Street, New York, NY 10032, USA.
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18
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Millar JR, Mvo Z, Bengu N, Fillis R, Sprenger K, Matthews PC, Archary M, Ndung'u T, Adland E, Puertas MC, Martinez-Picado J, Goulder P. Increasing Diagnostic Uncertainties in Children With In Utero HIV Infection. Pediatr Infect Dis J 2019; 38:e166-e168. [PMID: 31033913 PMCID: PMC7612888 DOI: 10.1097/inf.0000000000002315] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We present a case of an in utero HIV-infected child, who on day 1 of life had a positive whole blood total nucleic acid test but viral load <20 RNA copies/mL. Dried blood spot total nucleic acid testing was negative on day 1, 10 and at 3 months, while on ART prophylaxis then positive at 5 months after prophylaxis ended. Retrospective peripheral blood mononuclear cells HIV DNA testing from day 1 of life was positive, confirming in utero infection.
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Affiliation(s)
- Jane R Millar
- Umkhuseli Innovation and Research Management, Pietermaritzburg, South Africa
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Zodumo Mvo
- Umkhuseli Innovation and Research Management, Pietermaritzburg, South Africa
| | - Nomonde Bengu
- Umkhuseli Innovation and Research Management, Pietermaritzburg, South Africa
| | - Rowena Fillis
- Umkhuseli Innovation and Research Management, Pietermaritzburg, South Africa
| | - Ken Sprenger
- Umkhuseli Innovation and Research Management, Pietermaritzburg, South Africa
| | | | - Moherndran Archary
- Department of Paediatrics, University of KwaZulu-Natal, Durban, South Africa
| | - Thumbi Ndung'u
- Ragon Institute of MGH, MIT and Havard, Cambridge, MA, USA
- Africa Health Research Institute, Durban, South Africa
- Max Planck Institute for Infection Biology, Berlin, Germany
| | - Emily Adland
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Maria C Puertas
- AIDS Research Institute IrsiCaixa, Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Badalona, Spain
| | - Javier Martinez-Picado
- AIDS Research Institute IrsiCaixa, Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Badalona, Spain
- University of Vic-Central University of Catalonia, Vic, Spain
- Institució Catalana de Recerca i Estudis Avançats, Barcelona, Spain
| | - Philip Goulder
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
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19
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Veldsman KA, Janse van Rensburg A, Isaacs S, Naidoo S, Laughton B, Lombard C, Cotton MF, Mellors JW, van Zyl GU. HIV-1 DNA decay is faster in children who initiate ART shortly after birth than later. J Int AIDS Soc 2019; 22:e25368. [PMID: 31441231 PMCID: PMC6868516 DOI: 10.1002/jia2.25368] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 07/15/2019] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION There is limited data in children on whether persistence of HIV-1 infected cells is affected by age at initiating antiretroviral therapy (ART), its duration or any subsequent ART interruption. We therefore investigated the effects of both age of ART initiation and duration of ART interruption on HIV-1 DNA decay in children. METHODS We investigated HIV-1 DNA decay in three groups of children on ART: Group-1 (n = 7) started uninterrupted ART within eight days of life; Group-2 (n = 8) started uninterrupted ART at a median of five months of age; and Group-3 (n = 23) started ART at a median age of 1.8 months for either 40 or 96 weeks, then interrupted ART (median of seven months), and restarted ART based on CD4 count and clinical criteria. Total HIV-1 DNA was assayed using a sensitive HIV-1 subtype C-adapted quantitative PCR for integrase. The duration of ART was square root transformed to fit the observed slowing of HIV-1 DNA decay rate. For each group, point estimates for decay rates were determined after six months of continuous suppressive ART in groups 1 and 2 or six months after restarting ART in Group-3. Groups-2 and 3 were combined using a mixed effect regression model to investigate covariates of HIV-1 DNA decay rate. RESULTS AND DISCUSSION At six months of continuous suppressive ART, the HIV-1 DNA t½ (95% CI) was shorter in Group-1 (n = 7): 2.7 months (2.1 to 3.8), than 9.2 months (7.4 to 12.1) in Group-2 (n = 8); and 9.6 months (7.6 to 12.6) in Group-3 (n = 23) (p < 0.01). In multivariable analyses, HIV-1 DNA before treatment (p < 0.001) and the change in HIV-1 DNA during interruption (p < 0.01) were independent predictors of slower HIV-1 DNA decay. CONCLUSIONS These data suggest that ART initiation within the first week of life can reduce the persistence of long-lived infected cells. Delaying ART is associated with slower decay of infected cells.
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Affiliation(s)
- Kirsten A Veldsman
- Division of Medical VirologyStellenbosch UniversityFaculty of Medicine and Health SciencesCape TownSouth Africa
| | - Anita Janse van Rensburg
- Department Pediatrics and Child HealthTygerberg Children's Hospital and Family Clinical Research UnitStellenbosch UniversityCape TownSouth Africa
| | - Shahieda Isaacs
- Division of Medical VirologyStellenbosch UniversityFaculty of Medicine and Health SciencesCape TownSouth Africa
| | - Shalena Naidoo
- Division of Medical VirologyStellenbosch UniversityFaculty of Medicine and Health SciencesCape TownSouth Africa
| | - Barbara Laughton
- Department Pediatrics and Child HealthTygerberg Children's Hospital and Family Clinical Research UnitStellenbosch UniversityCape TownSouth Africa
| | - Carl Lombard
- Division of Epidemiology and BiostatisticsDepartment of Global HealthFaculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
- Biostatistics UnitSouth African Medical Research CouncilCape TownSouth Africa
| | - Mark F Cotton
- Department Pediatrics and Child HealthTygerberg Children's Hospital and Family Clinical Research UnitStellenbosch UniversityCape TownSouth Africa
| | - John W Mellors
- Division of Infectious DiseasesDepartment of MedicineUniversity of PittsburghPittsburghPAUSA
| | - Gert U van Zyl
- Division of Medical VirologyStellenbosch UniversityFaculty of Medicine and Health SciencesCape TownSouth Africa
- National Health Laboratory ServiceCape TownSouth Africa
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20
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Facente SN, Busch MP, Grebe E, Pilcher CD, Welte A, Rice B, Murphy G. Challenges to the performance of current HIV diagnostic assays and the need for centralized specimen archives: a review of the Consortium for the Evaluation and Performance of HIV Incidence Assays (CEPHIA) repository. Gates Open Res 2019; 3:1511. [PMID: 31460496 PMCID: PMC6706958 DOI: 10.12688/gatesopenres.13048.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2019] [Indexed: 11/20/2022] Open
Abstract
Background: New challenges for diagnosis of HIV infection abound, including the impact on key viral and immunological markers of HIV vaccine studies, pre-exposure prophylaxis usage and breakthrough infections, and very early initiation of anti-retroviral treatment. These challenges impact the performance of current diagnostic assays, and require suitable specimens for development and evaluation. In this article we review and describe an archive developed by the Consortium for the Evaluation and Performance of HIV Incidence Assays (CEPHIA), in order to identify the critical features required to create a centralized specimen archive to support these current and future developments. Review and Findings: We review and describe the CEPHIA repository, a large, consolidated repository comprised of over 31,000 highly-selected plasma samples and other body fluid specimen types, with over 50 purposely designed specimen panels distributed to 19 groups since 2012. The CEPHIA repository provided financial return on investment, supported the standardization of HIV incidence assays, and informed guidance and standards set by the World Health Organization and UNAIDS. Unified data from extensively characterized specimens has allowed this resource to support biomarker discovery, assay optimization, and development of new strategies for estimating duration of HIV infection. Critical features of a high-value repository include 1) extensively-characterized samples, 2) high-quality clinical background data, 3) multiple collaborations facilitating ongoing sample replenishment, and 4) sustained history of high-level specimen utilization. Conclusion: With strong governance and leadership, a large consolidated archive of samples from multiple studies provides investigators and assay developers with easy access to diverse samples designed to address challenges associated with HIV diagnosis, helping to enable improvements to HIV diagnostic assays and ultimately elimination of HIV. Its creation and ongoing utilization should compel funders, institutions and researchers to address and improve upon current approaches to sharing specimens.
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Affiliation(s)
- Shelley N. Facente
- University of California, San Francisco, San Francisco, CA, 94110, USA
- Vitalant Research Institute (formerly Blood Systems Research Institute), San Francisco, CA, 94118, USA
- Facente Consulting, Richmond, CA, 94804, USA
| | - Michael P. Busch
- University of California, San Francisco, San Francisco, CA, 94110, USA
- Vitalant Research Institute (formerly Blood Systems Research Institute), San Francisco, CA, 94118, USA
| | - Eduard Grebe
- University of California, San Francisco, San Francisco, CA, 94110, USA
- Vitalant Research Institute (formerly Blood Systems Research Institute), San Francisco, CA, 94118, USA
- The South African DST-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | | | - Alex Welte
- The South African DST-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Brian Rice
- London School of Hygiene and Tropical Medicine, London, UK
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21
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Spooner E, Govender K, Reddy T, Ramjee G, Mbadi N, Singh S, Coutsoudis A. Point-of-care HIV testing best practice for early infant diagnosis: an implementation study. BMC Public Health 2019; 19:731. [PMID: 31185962 PMCID: PMC6560857 DOI: 10.1186/s12889-019-6990-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 05/15/2019] [Indexed: 01/05/2023] Open
Abstract
Background With Universal Health Coverage and Integrated People-centred Health Care, streamlined health-systems and respectful care are necessary. South Africa has made great strides in prevention of mother-to-child transmission (PMTCT) but with the great burden of HIV, a minimum of birth and 10-week HIV-PCR testing are required for the estimated 360,000 HIV-exposed infants born annually which presents many challenges including delayed results and loss to follow-up. Point-of-care (POC) HIV testing of infants addresses these challenges well and facilitates initiation of HIV-infected infants rapidly after diagnosis for best clinical outcomes. Methods Objectives were to determine accuracy, feasibility and acceptability of POC testing compared to standard-of-care (SOC) central-laboratory testing. HIV-exposed infants for birth PCR testing in hospital (n = 323) and follow-up at a primary health care clinic (n = 117) in Durban, South Africa were included. A baseline situational-analysis reviewed registers and phoned mothers of HIV-exposed infants prior to the intervention. An effectiveness-implementation study of the Alere™q HIV-1/2 Detect POC test (heel-prick specimen processed in 50 min) was compared with SOC with questionnaires to mothers and staff. Stata 14 was used for analysis. Results At baseline 2% of birth HIV tests were missed; only 40% of mothers could be contacted; 17% did not receive birth test result; 19% did not have a 10-week test; 39% had not received the 10-week results. There were 5(1.5%) HIV-infected and 318(98.5%) HIV-negative infants detected in hospital with all clinic babies negative. All positive infants commenced ART before discharge. Ultimately POC and SOC had perfect concordance but for 10 SOC tests researchers actively tracked-down results or repeated tests. Turn around times for SOC tests were on average 8-days (IQR 6-10 days) and for POC testing was 0-days. The POC error-rate was 9,6% with all giving a result when repeated. The majority of mothers (92%) preferred POC testing with 7% having no preference. No staff preferred SOC testing with 79% preferring POC and 21% having no preference. Conclusions Point-of-care HIV testing for EID is accurate, feasible and acceptable, with benefits of early ART for all positive infants at birth facilities. We recommend that it be considered best practice for EID. Trial registration ISRCTN38911104 registered 9 January 2018 – retrospectively registered. Electronic supplementary material The online version of this article (10.1186/s12889-019-6990-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Elizabeth Spooner
- Department of Paediatrics and Child Health, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa.
| | - Kerusha Govender
- Department of Virology, Inkosi Albert Luthuli Central Hospital, National Health Laboratory Service, Durban, KwaZulu-Natal, South Africa
| | - Tarylee Reddy
- South African Medical Research Council, Biostatistics Unit, Durban, South Africa
| | - Gita Ramjee
- South African Medical Research Council, HIV Prevention Research Unit, Durban, South Africa
| | - Noxolo Mbadi
- Department of Paediatrics, Addington Hospital, Durban, South Africa
| | - Swaran Singh
- Department of Paediatrics, Addington Hospital, Durban, South Africa
| | - Anna Coutsoudis
- Department of Paediatrics and Child Health, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
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22
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Zyl G, Maritz J, Newman H, Preiser W. Lessons in diagnostic virology: expected and unexpected sources of error. Rev Med Virol 2019; 29:e2052. [DOI: 10.1002/rmv.2052] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/05/2019] [Accepted: 04/14/2019] [Indexed: 11/07/2022]
Affiliation(s)
- Gert Zyl
- Division of Medical Virology, Department PathologyStellenbosch University, Faculty of Medicine and Health Sciences Parow South Africa
- National Health Laboratory Service South Africa
| | - Jean Maritz
- Division of Medical Virology, Department PathologyStellenbosch University, Faculty of Medicine and Health Sciences Parow South Africa
- PathCare Reference Laboratory Cape Town South Africa
| | - Howard Newman
- Division of Medical Virology, Department PathologyStellenbosch University, Faculty of Medicine and Health Sciences Parow South Africa
- National Health Laboratory Service South Africa
| | - Wolfgang Preiser
- Division of Medical Virology, Department PathologyStellenbosch University, Faculty of Medicine and Health Sciences Parow South Africa
- National Health Laboratory Service South Africa
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23
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Jagodzinski LL, Manak MM, Hack HR, Liu Y, Malia JA, Freeman J, Phanuphak N, de Souza M, Kroon ED, Colby DJ, Chomchey N, Lally MA, Michael NL, Ananworanich J, Peel SA. Impact of Early Antiretroviral Therapy on Detection of Cell-Associated HIV-1 Nucleic Acid in Blood by the Roche Cobas TaqMan Test. J Clin Microbiol 2019; 57:e01922-18. [PMID: 30842229 PMCID: PMC6498003 DOI: 10.1128/jcm.01922-18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 02/25/2019] [Indexed: 12/31/2022] Open
Abstract
The Roche Cobas AmpliPrep/Cobas TaqMan HIV-1 test, v2.0 (the CAP/CTM assay), was used to quantify cell-associated HIV-1 (CAH) nucleic acid in peripheral blood mononuclear cells (PBMC) from well-characterized clinical specimens from HIV-1-infected individuals on antiretroviral therapy (ART). Chronically infected individuals on ART with no detectable plasma HIV-1 RNA demonstrated average CAH burdens of 3.2 HIV-1 log10 copies/million cells. Assay sensitivity and specificity were 98.9% and 100%, respectively, with the positive and negative predictive values being 100% and 98.6%, respectively. The CAH burden was also measured at weeks 0, 1, 2, 8, and 60 in 37 participants (RV254/SEARCH010, Bangkok, Thailand) stratified by Fiebig stage (Fiebig stage I [FI] to FVI) at ART initiation. Prior to ART initiation, the average CAH burden was 1.4, 4.1, and 3.6 log10 copies/million PBMCs for individuals who initiated ART at FI, FII, and FIII to FVI, respectively. Initiation of ART resulted in a rapid decline of CAH in all individuals, with the greatest decrease being observed in individuals who initiated ART at FI to FIII. By week 60, 100% (FI), 71.8% (FII/FIII), and 20.5% (FIV to FVI) of samples from individuals initiating treatment were at or near the limit of quantitation. Residual CAH was detectable at 60 weeks in most individuals who initiated ART at later stages (FIV to FVI) and averaged 1.9 ± 0.7 log10 copies/million PBMCs. The modified Roche CAP/CTM assay provides a convenient, standardized approach to measure residual HIV in blood and may be useful for monitoring patients under therapy or those participating in HIV remission studies.
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Affiliation(s)
- Linda L Jagodzinski
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Mark M Manak
- U.S. Military HIV Research Program, Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Holly R Hack
- U.S. Military HIV Research Program, Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Ying Liu
- U.S. Military HIV Research Program, Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Jennifer A Malia
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Joanna Freeman
- U.S. Military HIV Research Program, Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | | | - Mark de Souza
- SEARCH, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Eugène D Kroon
- SEARCH, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Donn J Colby
- SEARCH, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Nitiya Chomchey
- SEARCH, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Michelle A Lally
- Miriam Hospital, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Nelson L Michael
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Jintanat Ananworanich
- U.S. Military HIV Research Program, Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
- SEARCH, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand
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