Intraocular and plasma HIV-1 RNA loads and HIV uveitis

The Association of Intraocular Efavirenz Concentrations and HIV-1 Viral Load Among Persons With HIV

OBJECTIVE

Efavirenz (EFV) is commonly used in combination antiretroviral therapy. However, in our previous study, many persons living with HIV exhibited ocular complications despite undergoing effective combination antiretroviral therapy. Here, we aimed to determine the intraocular EFV concentrations in the vitreous and analyze the factors affecting viral load in the vitreous in patients with HIV-associated retinopathies.

DESIGN

Observational, retrospective study.

METHODS

Fourteen patients receiving EFV in combination with an antiretroviral therapy who underwent pars plana vitrectomy were enrolled between January 2019 and August 2022. The patients were divided into 2 groups based on presence or absence of retinal detachment (RD). Patient characteristics and HIV-1 RNA levels in plasma and vitreous were recorded during pars plana vitrectomy. Paired blood plasma and vitreous samples were obtained for EFV concentration analysis using ultra-high-performance liquid chromatography/tandem mass spectrometry.

RESULTS

The median age of the enrolled patients was 48 years (interquartile range, 32.25-53.25), including 12 men and 2 women. Median vitreous and plasma EFV concentrations were 141.5 (interquartile range, 69.63-323.75) and 2620 ng/mL (1680-4207.5), respectively. Median ratio of vitreous/plasma EFV concentrations in the paired samples among all participants was 0.053 (0.018-0.118). Median vitreous/plasma EFV concentrations significantly differed between the non-RD and RD groups (0.04 vs 0.12, P = 0.042).

CONCLUSIONS

The vitreous EFV concentrations were insufficient to inhibit viral replication in intraocular tissues, which may be because of poor penetration of the blood-retinal barrier. High vitreous EFV concentrations were associated with RD, indicating a correlation between the EFV concentration and the severity of blood-retinal barrier disruption. It implied that EFV was not a suitable antiviral drug to inhibit HIV-1 replication in ocular tissues.

Discordance of Aqueous/Plasma HIV Replication on ART

BACKGROUND

The study was conducted to analyze HIV dynamics across blood-retinal barrier (BRB) and the relevant risk factors for HIV-associated ocular complications.

METHODS

This study included a case series of 40 HIV-positive patients with ocular lesions, which were studied retrospectively. Clinical and laboratory examinations included plasma and intraocular viral load (VL).

RESULTS

HIV VL on paired aqueous/plasma samples was available for 40 patients. Aqueous VL was negatively associated with antiretroviral treatment (ART) duration (p = 0.02 and p < 0.05), and plasma VL was independent of ART duration (p = 0.53). An aqueous/plasma discordance was found in 19/40 (47.5%) patients, eight of whom (20%) had detectable aqueous VL despite a suppressed plasma VL (escape). There were significant differences in CD4+ T-lymphocyte levels (p = 0.011 and p < 0.05) and ART duration (p = 0.007 and p < 0.05) between the patients with HIV-associated ocular complications and the patients without.

CONCLUSION

This study provides a rationale for initiating ART early in the course of infection to reduce HIV VL in the aqueous humor, and raises the possibility of the ocular sanctuary where HIV replicates. Meanwhile, early and standard ART would be an optimal option to protect against ocular opportunistic infection.

Human Immunodeficiency Virus and Uveitis

Uveitis is one of the most common ocular complications in people living with the Human immunodeficiency virus (HIV) and can be classified into HIV-induced uveitis, co-infection related uveitis, immune recovery uveitis, and drug-induced uveitis. The introduction of antiretroviral therapy has considerably changed the incidence, diagnosis, and treatment of different types of HIV-related uveitis. Furthermore, the specific immune condition of patients infected with HIV makes diagnosing HIV-related uveitis difficult. Recent studies have focused on the growing prevalence of syphilis/tuberculosis co-infection in uveitis. Simultaneously, more studies have demonstrated that HIV can directly contribute to the incidence of uveitis. However, the detailed mechanism has not been studied. Immune recovery uveitis is diagnosed by exclusion, and recent studies have addressed the role of biomarkers in its diagnosis. This review highlights recent updates on HIV-related uveitis. Furthermore, it aims to draw the attention of infectious disease physicians and ophthalmologists to the ocular health of patients infected with HIV.

Viral anterior uveitis

Viral anterior uveitis (VAU) needs to be suspected in anterior uveitis (AU) associated with elevated intraocular pressure, corneal involvement, and iris atrophic changes. Common etiologies of VAU include herpes simplex, varicella-zoster, cytomegalovirus, and rubella virus. Clinical presentations can vary from granulomatous AU with corneal involvement, Posner-Schlossman syndrome, Fuchs uveitis syndrome, and endothelitis. Due to overlapping clinical manifestations between the different viruses, diagnostic tests like polymerase chain reaction and Goldmann-Witmer coefficient analysis on the aqueous humor may help in identifying etiology to plan and monitor treatment.

Real-time polymerase chain reaction for diagnosis and management of HIV-induced uveitis

Intraocular (IO) inflammation in patients with Human immune deficiency virus (HIV) infection can be due to opportunistic infections, immune recovery uveitis, drugs used in the management or a primary manifestation of HIV itself. We studied the role of RT-PCR for HIV RNA in confirming the diagnosis of HIV induced uveitis and its useful in the management and follow-up of these patients.

Polymerase Chain Reaction and Goldmann-Witmer Coefficient to Examine the Role of Epstein-Barr Virus in Uveitis

PURPOSE

To use polymerase chain reaction (PCR) and Goldmann-Witmer Coefficient (GWC) calculation to search for evidence that Epstein-Barr virus (EBV) causes uveitis.

METHODS

A prospective cross-sectional study where participants with positive multiplex EBV PCR results were further investigated by: 1) real-time PCR for EBV viral loads (VL) and 2) EBV GWC.

RESULTS

Eleven of 106 consecutive uveitis patients (10.4%) had positive multiplex PCR for EBV on aqueous humor sampling and 7/11 (63.6%) were HIV-positive. Only 4/10 (40%) cases had detectable intraocular EBV VLs which were always lower than the blood or plasma VL. EBV GWC was negative in all 10 cases tested. In 9/11 (81.8%) of these cases an alternative, more plausible cause of uveitis was identified.

CONCLUSION

We found no evidence of active intraocular replication or antibody production to prove that EBV caused uveitis in these cases. In most cases an alternative treatable cause of uveitis was identified.

Genetic analyses of HIV env associated with uveitis in antiretroviral-naive individuals

OBJECTIVE

To analyze and compare HIV-1 env sequences from the eye to those from the blood of individuals with uveitis attributed to HIV with the goal of gaining insight into the pathogenesis of HIV-associated eye disease.

DESIGN

A prospective case series of five HIV-infected antiretroviral-naive individuals with uveitis negative for other pathogens.

METHODS

RNA from blood plasma and ocular aqueous humor was reverse transcribed using random hexamers. HIV env C2-V5 (HXB2: 6990-7668) sequences were generated by single-genome amplification using nested polymerase chain reaction followed by bidirectional Sanger sequencing. Sequence analyses by Geneious, Geno2Pheno, N-GLYCOSITE, DIVEIN, and HyPhy evaluated relationships between HIV in plasma and aqueous humor.

RESULTS

A median of 20 (range: 13-22) plasma and 15 (range: 9-18) aqueous humor sequences were generated from each individual. The frequencies of sequences with predicted-N-linked-glycosylation sites and C-X-C chemokine receptor type 4 were comparable in aqueous humor and plasma of all five patients. Aqueous humor sequences had lower median genetic diversity compared with plasma across all patients, but similar divergence, in four of five patients. Aqueous humor HIV sequences were compartmentalized from plasma across subjects by Critchlow correlation coefficient, Slatkin and Maddison, nearest-neighbor statistic, and Fixation index.

CONCLUSION

Among antiretroviral-naive individuals with uveitis attributed to HIV, the universal compartmentalization and decreased diversity of eye compared with blood sequences suggests time-limited passage of a small subset of variants from each patient's viral population into the eye tissues, followed by limited immune selection despite the inflammatory uveitis.

Loss of amplitude of accommodation in pre-presbyopic HIV and AIDS patients under treatment with antiretrovirals

Background: The prevalence of HIV and AIDS is causing an enormous public health burden. Its manifestations spare no organ. Ocular complications are mainly attributed to various opportunistic infections which are directly or indirectly caused by immune deficiency.Purpose and aim: The purpose of this study was to determine the effect of HIV and AIDS on subjective amplitude of accommodation of patients under treatment with antiretrovirals and then to compare their results to those of control subjects.Methods: The study took place over a period of 10 months. A quantitative study was carried out on 58 subjects (29 ± 5.5 years) with HIV and AIDS and 35 (28.67 ± 4.6 years) controls of similar age. Amplitude of accommodation was measured using the subjective Royal Air Force push-up method. The influence of CD4+ cell count was also recorded.Results: People with HIV and AIDS had lower mean amplitude of accommodation (5.69 ± 0.88 D) compared to controls (8.53 ± 1.2 D). The decrease in amplitude of accommodation did not show any correlation with the CD4+ cell count. Lower amplitude of accommodation exists in people living with HIV and AIDS when compared with age-related healthy people.Conclusion: The results suggest that patients with HIV and AIDS on antiretroviral drugs (ARVs) have reduced amplitude of accommodation and might experience presbyopia earlier in life than participants without HIV and AIDS. The reduced amplitude of accommodation could be the initial presentation of HIV infection before the systemic manifestation. The possible causes could be the direct neuronal infection by HIV-1, ARVs use, pathological changes of the lens and ciliary muscle or the sensory component of the visual system. It is unknown whether the reduced amplitude of accommodation occurred prior to antiretroviral therapy or represents an ongoing injury to the eye and visual system by the HIV.

Ocular and Cerebrospinal Fluid Penetration of Antiretroviral Agents

PURPOSE

The ocular penetration of systemically administered antiretroviral drugs (ARVs), which is important in the clinical setting of HIV uveitis, is unknown. This study aimed to assess the ocular penetration of different antiretroviral drugs in an animal model.

METHODS

Twenty-five male New Zealand white rabbits were assigned to one of five treatment groups. Each group received a single oral dose of an antiretroviral drug (lamivudine, tenofovir, efavirenz, lopinavir, and raltegravir). These 5 drugs represent 4 different ARV drug classes [nucleoside reverse transcriptase inhibitors (NRTI), non-NRTI, protease inhibitors, and integrase inhibitors]. Serum, cerebrospinal fluid (CSF), and aqueous and vitreous humor samples were collected at the time of theoretical maximum serum concentration of each respective drug, for example, lamivudine 1 h, tenofovir 1 h, efavirenz 5 h, lopinavir 4 h, and raltegravir 3 h. The drug concentration in each sample was determined by means of high-performance liquid chromatography and mass spectrometry.

RESULTS

After a single oral dose, measurable levels of all five ARVs administered could be detected in all 4 body compartments. The limit of detection based on a signal-to-noise ratio of 1:3 for the antiretroviral agents was as follows: 1 part per billion (ppb) for lamivudine, tenofovir, and efavirenz and 0.1 ppb for lopinavir and raltegravir. The IC50 (inhibitory concentration where 50% of viral replication is inhibited by a drug) was reached for all drugs in the serum and CSF. In the aqueous humor, lopinavir failed to reach IC50 and in the vitreous humor, only efavirenz and lopinavir attained IC50 levels.

CONCLUSION

After a single oral dose, measurable levels of all 4 classes of ARVs could be detected in all 4 body compartments sampled. In the eye, IC50 levels were lower in the vitreous humor than in aqueous humor. IC50 levels in the serum were higher than in the CSF.

Neuroretinal Degeneration in HIV Patients Without Opportunistic Ocular Infections in the cART Era

Subtle structural and functional retinal abnormalities, termed 'HIV-associated Neuroretinal Disorder (HIV-NRD)', have been reported in HIV patients receiving combination antiretroviral therapy (cART), without infectious retinitis or any apparent fundus abnormalities otherwise. In this review, we provide an overview of studies investigating HIV-NRD in HIV patients without opportunistic ocular infections in the cART era, and try to elucidate underlying mechanisms and associated risk factors. Most studies focused on patients with severe immune-deficiency and demonstrated that patients with nadir CD4 counts<100 cells/μL are most at risk for neuroretinal damage, with a thinner retinal nerve fiber layer, subtle loss of color vision and/or contrast sensitivity, visual field deficits, and subnormal electrophysiological responses. In contrast, alterations in retinal vascular calibers and retinal blood flow were not associated with nadir CD4 counts, but instead with detectable viremia, suggesting a role for (chronic) inflammation in microvascular damage. Although the alterations in visual function are subtle, they can lead to difficulties in activities, such as reading or driving, thereby affecting quality of life. Since HIV has become a chronic disease, its long-term effects with respect to visual function loss become more important, as is recently emphasized by a longitudinal study, reporting that AIDS patients with HIV-NRD have higher risks of developing bilateral visual impairment and even blindness than patients without HIV-NRD. The question remains whether patients with high (>350 cells/μL) nadir CD4 counts and well-suppressed HIV infection on cART remain at risk for HIV-NRD, as this group constitutes a growing part of the aging HIV-infected population.

HIV-1 Tat-mediated apoptosis in human blood-retinal barrier-associated cells

HIV-1-associated ocular complications, such as microvasculopathies, can lead to the loss of vision in HIV-1-infected patients. Even in patients under highly active antiretroviral therapy, ocular lesions are unavoidable. Ocular complications have been demonstrated to be closely related to the breakdown of the blood-retinal-barrier (BRB); however, the underlying mechanism is not clear. The data from this study indicated that the HIV-1 Tat protein induced the apoptosis of human retinal microvascular endothelial cells (HRMECs) and retinal pigmen epithelium (RPE) cells, which compose the inner BRB and the outer BRB, respectively. In addition, this study found that the activation of N-methyl-D-aspartate receptors (NMDARs) was involved in the apoptosis of RPE cells, but it caused no changes in HRMECs. Furthermore, both cell types exhibited enhanced expression of Bak, Bax and Cytochrome c. The inhibition of Tat activity protected against the apoptosis induced by NMDAR activation and prevented the dysregulation of Bak, Bax and Cytochrome c, revealing an important role for the mitochondrial pathway in HIV-1 Tat-induced apoptosis. Together, these findings suggest a possible mechanism and may identify a potential therapeutic strategy for HIV-1-associated ocular complications.

Mechanism of blood-retinal barrier breakdown induced by HIV-1 (Review)

Human immunodeficiency virus (HIV)-1 has been detected in ocular tissues; however, the mechanism of entry has not been established. It has been hypothesized that the blood-retinal barrier (BRB), a critical guardian against microbial invasion of the eye, may be compromised in the presence of HIV-1 in the eye. In vivo and in vitro model systems have shown that the breach of tight junctions induced by HIV-1-associated factors contributes to the breakdown of the BRB. The present study reviews the mechanism of tight junction disruption, focusing on signaling pathways, the expression of enzymes, including metalloproteinases, and cytokines that affect inflammation. The studied pathways may be potential targets for the prevention of ocular HIV complications.

Corneal endothelial cells provide evidence of accelerated cellular senescence associated with HIV infection: a case-control study

Background

Cellular senescence may be a key factor in HIV-related premature biological aging. We assessed features of the corneal endothelium that are known to be associated with biological aging, and cellular senescence markers in HIV-infected adults.

Methods

Case-control study of 242 HIV-infected adults and 249 matched controls. Using specular microscopy, the corneal endothelium was assessed for features of aging (low endothelial cell density [ECD], high variation in cell size, and low hexagonality index). Data were analysed by multivariable regression. CDKN2A expression (a cell senescence mediator) was measured in peripheral blood leukocytes and 8-hydroxy-2′-deoxyguanosine (8-OHDG; an oxidative DNA damage marker) levels were measured in plasma.

Results

The median age of both groups was 40 years. Among HIV-infected adults, 88% were receiving antiretroviral therapy (ART); their median CD4 count was 468 cells/µL. HIV infection was associated with increased odds of variation in cell size (OR = 1.67; 95% CI: 1.00–2.78, p = 0.04). Among HIV-infected participants, low ECD was independently associated with current CD4 count <200 cells/µL (OR = 2.77; 95%CI: 1.12–6.81, p = 0.03). In participants on ART with undetectable viral load, CDKN2A expression and 8-OHDG levels were higher in those with accelerated aging, as reflected by lower ECD.

Conclusions

The corneal endothelium shows features consistent with HIV-related accelerated senescence, especially among those with poor immune recovery.

Clinical manifestations of human immunodeficiency virus-induced uveitis

PURPOSE

To describe the clinical manifestations of patients with human immunodeficiency virus (HIV)-induced uveitis in Thailand.

DESIGN

Prospective cohort study of 6 patients with HIV-induced uveitis.

PARTICIPANTS

Six patients (8 eyes) with HIV-induced uveitis who had an extremely high intraocular: plasma HIV-1 RNA ratio.

METHODS

The clinical manifestations and laboratory findings are reported of 6 consecutive patients with HIV-induced uveitis who had an extremely high intraocular-to-plasma HIV-1 RNA ratio and were diagnosed between July 2009 and May 2011.

MAIN OUTCOME MEASURES

Clinical manifestations and laboratory findings.

RESULTS

Human immunodeficiency virus-induced uveitis was diagnosed in 4 men and 2 women with an average age of 41 years at presentation. None of the patients were receiving highly active anti-retroviral therapy (HAART) or had clinical or laboratory evidence, or both, of opportunistic infections. The mean plasma load was 218 688 copies/ml (median, 137 500 copies/ml; range, 24 900-540 000 copies/ml), and the mean intraocular HIV load was 20 937 755 copies/ml (median, 7 499 000 copies/ml; range, 2 460 000-89 800 000 copies/ml). The average CD4 cell count was 192 cells/μl (median, 248 cells/μl; range, 5-342 cells/μl). All the patients had decreased vision, and none had conjunctival hyperemia. The anatomic location of uveitis was anterior in all patients, and associated vitreitis was present in 4 patients; none exhibited retinal lesions or scars. Anterior segment inflammation and keratic precipitates were observed in all patients, and none responded to topical corticosteroid therapy. After the administration of HAART, the intraocular inflammation disappeared entirely within several weeks in all of the patients and the intraocular and plasma HIV loads decreased.

CONCLUSIONS

Human immunodeficiency virus-induced uveitis should be suspected in HAART-naïve, HIV-positive patients or in those in whom this treatment fails and who have anterior uveitis without any retinal lesions and exhibit no response to topical corticosteroids. The concurrent determination of HIV load in the intraocular fluids and plasma may clarify the cause of HIV-associated uveitis.

Human immunodeficiency virus and its effects on the visual system

During the first 15 years of the AIDS epidemic patients experienced a high incidence of blindness due to cytomegalovirus (CMV) retinitis and other severe ocular opportunistic infections. Highly active anti-retroviral therapy, introduced in 1996, dramatically decreased the incidence of CMV retinitis. Though CMV retinitis still causes 40% of vision loss in AIDS patients, other conditions such as immune reconstitution uveitis, cataracts, and a significant othercategory -which most investigators believe is directly due to HIV - comprise the majority of cases. HIV causes vascular abnormalities of the conjunctiva and retina in the majority of AIDS patients, as well as retinitis, anterior and posterior uveitis and vasculitis. HIV frequently causes an optic neuropathy and is responsible for the majority of eye movement disorders among HIV patients. Physicians need to be aware that these problems may be the initial manifestation of HIV infections or a sign of highly active anti-retroviral therapy (HAART) failure. Therefore, patients with identifiable risk factors for AIDS who present with ophthalmologic conditions of unknown etiology should be considered for HIV testing. Finally, anti-retroviral therapy has been reported to cause asymptomatic deposits as well as degenerative conditions of both the anterior and posterior segments of the eye.

Risk of cataract surgery in HIV-infected individuals: a Danish Nationwide Population-based cohort study

BACKGROUND

Premature aging has been suggested a risk factor for early death in patients infected with human immunodeficiency virus (HIV). Therefore, the risk of age-related diseases, such as cataracts, should be increased in this population. In a nationwide, population-based cohort study we assessed the risk of cataract surgery in HIV-infected individuals compared with the general population.

METHODS

We identified 5315 HIV-infected individuals from a Danish national cohort of HIV-infected individuals and a population-based age- and sex-matched comparison cohort of 53,150 individuals. Data on cataract surgery were obtained from the Danish National Hospital registry. Cumulative incidence curves were constructed. Incidence rate ratios (IRRs) and impact of immunodeficiency, highly active antiretroviral therapy (HAART), and treatment with abacavir, tenofovir, protease inhibitors, and nonnucleoside analogue reverse-transcriptase inhibitors (NNRTIs) were estimated by Poisson regression analyses and adjusted for age, sex, and calendar year.

RESULTS

HIV-infected individuals had a higher risk of cataract surgery than the comparison cohort (adjusted IRR, 1.87; 95% confidence interval (CI): 1.50-2.33). The highest risk was found in patients with a CD4 cell count ≤ 200 cells/μL (adjusted IRR before HAART initiation, 3.11 [95% CI, 1.26-7.63]; adjusted IRR after HAART initiation, 4.74 [95% CI, 2.60-8.62]). In patients not receiving HAART and those receiving HAART with a CD4 cell count >200 cells/mL the adjusted IRRs were 0.60 (95% CI: 0.22-1.61) and 1.87 (95% CI: 1.46-2.39). Treatment with abacavir, tenofovir, protease inhibitors, or NNRTIs did not increase the risk substantially.

CONCLUSIONS

HIV-infected individuals have an increased risk of cataract surgery. The risk is mainly associated with immunodeficiency and HAART, but accelerated aging cannot be excluded as part of the possible explanation.

Detection of HIV-1 viruses in tears of patients even under long-term HAART

To determine whether HIV-1 viruses exist in tears of patients under HAART, a cross-sectional study was designed. All participants who underwent long-term HAART with undetectable plasma viral load had detectable HIV-1 viral load in tears (n = 16) and had no difference from the controls (n = 5). Our data suggested that the lacrimal gland and/or other tear-associated tissues could be new reservoirs for HIV-1 and precautions should be taken when doing eye examinations.