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Obare LM, Temu T, Mallal SA, Wanjalla CN. Inflammation in HIV and Its Impact on Atherosclerotic Cardiovascular Disease. Circ Res 2024; 134:1515-1545. [PMID: 38781301 PMCID: PMC11122788 DOI: 10.1161/circresaha.124.323891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
People living with HIV have a 1.5- to 2-fold increased risk of developing cardiovascular disease. Despite treatment with highly effective antiretroviral therapy, people living with HIV have chronic inflammation that makes them susceptible to multiple comorbidities. Several factors, including the HIV reservoir, coinfections, clonal hematopoiesis of indeterminate potential (CHIP), microbial translocation, and antiretroviral therapy, may contribute to the chronic state of inflammation. Within the innate immune system, macrophages harbor latent HIV and are among the prominent immune cells present in atheroma during the progression of atherosclerosis. They secrete inflammatory cytokines such as IL (interleukin)-6 and tumor necrosis-α that stimulate the expression of adhesion molecules on the endothelium. This leads to the recruitment of other immune cells, including cluster of differentiation (CD)8+ and CD4+ T cells, also present in early and late atheroma. As such, cells of the innate and adaptive immune systems contribute to both systemic inflammation and vascular inflammation. On a molecular level, HIV-1 primes the NLRP3 (NLR family pyrin domain containing 3) inflammasome, leading to an increased expression of IL-1β, which is important for cardiovascular outcomes. Moreover, activation of TLRs (toll-like receptors) by HIV, gut microbes, and substance abuse further activates the NLRP3 inflammasome pathway. Finally, HIV proteins such as Nef (negative regulatory factor) can inhibit cholesterol efflux in monocytes and macrophages through direct action on the cholesterol transporter ABCA1 (ATP-binding cassette transporter A1), which promotes the formation of foam cells and the progression of atherosclerotic plaque. Here, we summarize the stages of atherosclerosis in the context of HIV, highlighting the effects of HIV, coinfections, and antiretroviral therapy on cells of the innate and adaptive immune system and describe current and future interventions to reduce residual inflammation and improve cardiovascular outcomes among people living with HIV.
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Affiliation(s)
- Laventa M. Obare
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN (L.M.O., S.A.M., C.N.W.)
| | - Tecla Temu
- Department of Pathology, Harvard Medical School, Boston, MA (T.T.)
| | - Simon A. Mallal
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN (L.M.O., S.A.M., C.N.W.)
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN (S.A.M.)
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN (S.A.M.)
- Institute for Immunology and Infectious Diseases, Murdoch University, WA, Western Australia (S.A.M.)
| | - Celestine N. Wanjalla
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN (L.M.O., S.A.M., C.N.W.)
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Kulkarni S, Endsley JJ, Lai Z, Bradley T, Sharan R. Single-Cell Transcriptomics of Mtb/HIV Co-Infection. Cells 2023; 12:2295. [PMID: 37759517 PMCID: PMC10529032 DOI: 10.3390/cells12182295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/17/2023] [Accepted: 09/11/2023] [Indexed: 09/29/2023] Open
Abstract
Tuberculosis (TB) and Human Immunodeficiency Virus (HIV) co-infection continues to pose a significant healthcare burden. HIV co-infection during TB predisposes the host to the reactivation of latent TB infection (LTBI), worsening disease conditions and mortality. There is a lack of biomarkers of LTBI reactivation and/or immune-related transcriptional signatures to distinguish active TB from LTBI and predict TB reactivation upon HIV co-infection. Characterizing individual cells using next-generation sequencing-based technologies has facilitated novel biological discoveries about infectious diseases, including TB and HIV pathogenesis. Compared to the more conventional sequencing techniques that provide a bulk assessment, single-cell RNA sequencing (scRNA-seq) can reveal complex and new cell types and identify more high-resolution cellular heterogeneity. This review will summarize the progress made in defining the immune atlas of TB and HIV infections using scRNA-seq, including host-pathogen interactions, heterogeneity in HIV pathogenesis, and the animal models employed to model disease. This review will also address the tools needed to bridge the gap between disease outcomes in single infection vs. co-infection. Finally, it will elaborate on the translational benefits of single-cell sequencing in TB/HIV diagnosis in humans.
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Affiliation(s)
- Smita Kulkarni
- Texas Biomedical Research Institute, San Antonio, TX 78227, USA
| | - Janice J. Endsley
- Departments of Microbiology & Immunology and Pathology, The University of Texas Medical Branch, Galveston, TX 77555, USA;
| | - Zhao Lai
- Greehey Children’s Cancer Research Institute, The University of Texas Health San Antonio, San Antonio, TX 78229, USA;
| | - Todd Bradley
- Genomic Medicine Center, Children’s Mercy Research Institute, Children’s Mercy Kansas City, Kansas City, MO 64108, USA;
- Departments of Pediatrics and Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, MO 66160, USA
- Department of Pediatrics, UMKC School of Medicine, Kansas City, MO 64108, USA
| | - Riti Sharan
- Texas Biomedical Research Institute, San Antonio, TX 78227, USA
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Temu TM, Polyak SJ, Wanjalla CN, Mandela NA, Dabee S, Mogaka JN, Masyuko S, Longernecker C, Shakil S, Chohan B, Page ST, Lacourse SM, Gitura B, Crothers K, Oyugi J, Jaspan H, Farquhar C, Zifodya JS. Latent tuberculosis is associated with heightened levels of pro-and anti-inflammatory cytokines among Kenyan men and women living with HIV on long-term antiretroviral therapy. AIDS 2023; 37:1065-1075. [PMID: 36928263 PMCID: PMC10155699 DOI: 10.1097/qad.0000000000003523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/24/2023] [Accepted: 02/09/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Persons with HIV (PWH) on antiretroviral therapy (ART) have persistent immune activation associated with increased risk for non-AIDS related diseases. Latent tuberculosis infection (LTBI), endemic in Africa, may contribute to this immune dysregulation. We evaluated the impact of HIV and TB co-infection on plasma pro- and anti-inflammatory cytokines among Kenyan adults. METHODS We compared data from 221 PWH on long-term ART and 177 HIV-negative adults examining biomarkers of pro-[sCD14, interleukin (IL)-2, IL-6, interferon gamma (IFN-γ), tumor necrosis factor alpha (TNF-α), IL-12p70, IL-17A] and anti(IL-4, IL-5, IL-13) inflammatory cytokines, by HIV/LTBI status (HIV+LTBI+, HIV+LTBI-, HIV-LTBI+, HIV-LTBI-). LTBI was diagnosed based on a positive QuantiFERON TB Gold-Plus test in the absence of active TB symptoms. Linear regression was used to evaluate the associations of HIV, LTBI, and HIV/LTBI status with biomarkers adjusting for clinical factors including HIV-specific factors. RESULTS Half of the participants were women and 52% had LTBI. HIV was independently associated with higher sCD14, IL-15, IL-6, IL-4, IL-5. LTBI was independently associated with higher TNF-α, IL-12p70, IL-17A, IL-4, IL-13 in adjusted models ( P < 0.05). LTBI status was associated with higher IL-4 and IL-12p70 only among PWH, but not HIV-negative participants ( P < 0.05 for interactions). In multivariate analysis, only HIV+LTBI+ demonstrated elevated levels of TNF-α, IL-6, IL-12p70, IL-15, IL-17A, IL4, IL-5, IL-13 in comparison to the HIV-LTBI- ( P < 0.05 for all). The effect of LTBI on cytokines among PWH was independent of CD4 + T-cell count and ART duration. CONCLUSIONS Despite viral suppression, persons with HIV and LTBI exhibit abnormal cytokine production accompanied by high concentrations of pro- and anti-inflammatory cytokines.
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Affiliation(s)
- Tecla M. Temu
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | - Stephen J. Polyak
- Department of Laboratory Medicine & Pathology, University of Washington, Seattle, Washington
| | | | | | - Smritee Dabee
- Center for Infectious Disease Research, Seattle Biomedical Research Institute
| | - Jerusha N. Mogaka
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | | | - Chris Longernecker
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Medicine, University of Washington
| | - Saate Shakil
- Department of Medicine, University of Washington
| | - Bhavna Chohan
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | | | - Sylvia M. Lacourse
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Medicine, University of Washington
| | | | | | - Julius Oyugi
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | - Heather Jaspan
- Center for Infectious Disease Research, Seattle Biomedical Research Institute
| | - Carey Farquhar
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Medicine, University of Washington
- Veterans Affairs Puget Sound Healthcare System, Seattle, Washington
| | - Jerry S. Zifodya
- Department of Medicine, Tulane University School of Medicine, New Orleans, Lousiana, USA
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Walles J, Otero LG, Tesfaye F, Abera A, Jansson M, Balcha TT, Sturegård E, Winqvist N, Hansson SR, Björkman P. Tuberculosis infection and stillbirth in Ethiopia—A prospective cohort study. PLoS One 2022; 17:e0261972. [PMID: 35404930 PMCID: PMC9000061 DOI: 10.1371/journal.pone.0261972] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 12/14/2021] [Indexed: 11/23/2022] Open
Abstract
Background Tuberculosis is among the leading causes of death among infectious diseases. Regions with a high incidence of tuberculosis, such as sub-Saharan Africa, are disproportionately burdened by stillbirth and other pregnancy complications. Active tuberculosis increases the risk of pregnancy complications, but the association between latent tuberculosis infection (LTBI) and pregnancy outcomes is unknown. We explored the effect of latent tuberculosis infection on the risk of stillbirth in women attending antenatal care clinics in Ethiopia, a country with >170 000 annual cases of active tuberculosis. Method Pregnant women were enrolled from antenatal care at three health facilities in Adama, Ethiopia, during 2015–2018, with assessment for previous and current active tuberculosis and testing for LTBI using QuantiFERON-TB-GOLD-PLUS. Proportions of stillbirth (≥ 20 weeks of gestation) and neonatal death (< 29 days of birth) were compared with respect to categories of maternal tuberculosis infection (tuberculosis-uninfected, LTBI, previous-, and current active tuberculosis). Multivariable logistic regression was performed for stillbirth. Results Among 1463 participants enrolled, the median age was 25 years, 10.2% were HIV-positive, 34.6% were primigravidae, and the median gestational age at inclusion was 18 weeks. Four (0.3%) were diagnosed with active tuberculosis during pregnancy, 68 (4.6%) reported previous treatment for active tuberculosis, 470 (32.1%) had LTBI, and 921 (63.0%) were tuberculosis-uninfected. Stillbirth was more frequent in participants with LTBI compared to tuberculosis-uninfected participants, although not reaching statistical significance (19/470, 4.0% vs 25/921, 2.7%, adjusted [for age, gravidity and HIV serostatus] odds ratio 1.38, 95% confidence interval 0.73–2.57, p = 0.30). Rates of neonatal death (5/470, 1.1% vs 10/921, 1.1%) were similar between these categories. Conclusion Latent tuberculosis infection was not significantly associated with stillbirth or neonatal death in this cohort. Studies based on larger cohorts and with details on causes of stillbirth, as well as other pregnancy outcomes, are needed to further investigate this issue.
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Affiliation(s)
- John Walles
- Clinical Infection Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden
- Department of Infectious Diseases, Central Hospital, Kristianstad, Sweden
- * E-mail:
| | - Laura García Otero
- Fetal Medicine Research Center, BCNatal—Barcelona Center for Maternal-Fetal and Neonatal Medicine, University of Barcelona, Barcelona, Spain
- Institut Clinic de Ginecologia, Obstetricia i Neonatologia (ICGON), Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
- Universitat de Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), University of Barcelona, Barcelona, Spain
| | - Fregenet Tesfaye
- Clinical Infection Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Asmamaw Abera
- Ethiopia Institute of Water Resources, Addis Ababa University, Addis Ababa, Ethiopia
| | - Marianne Jansson
- Medical Microbiology, Department of Laboratory Medicine, Lund University, Lund, Sweden
| | - Taye Tolera Balcha
- Clinical Infection Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Erik Sturegård
- Clinical Infection Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden
- Clinical Microbiology, Division of Laboratory Medicine, Lund, Sweden
| | - Niclas Winqvist
- Skåne Regional Office for Infectious Disease Control and Prevention, Malmö, Sweden
| | - Stefan R. Hansson
- Division of Obstetrics and Gynecology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Skåne University Hospital, Lund, Sweden
| | - Per Björkman
- Clinical Infection Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden
- Department of Infectious Diseases, Skåne University Hospital, Malmö, Sweden
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Diaz MM, Zacarías MG, Sotolongo P, Sanes MF, Franklin DJ, Marquine MJ, Cherner M, Cárcamo C, Ellis RJ, Lanata S, García PJ. Characterization of HIV-Associated Neurocognitive Impairment in Middle-Aged and Older Persons With HIV in Lima, Peru. Front Neurol 2021; 12:629257. [PMID: 34220665 PMCID: PMC8248346 DOI: 10.3389/fneur.2021.629257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 04/21/2021] [Indexed: 12/12/2022] Open
Abstract
Background: With widespread use of antiretroviral medications, people living with HIV (PWH) are living longer worldwide, increasing their risk of developing neurocognitive impairment (NCI). The proportion of Peruvians over age 60 is expected to increase to 25% of the population by 2050, including PWH. Therefore, the problem of aging and NCI, especially in the setting of HIV infection, is uniquely pressing. We sought to study the rates of and risk factors associated with NCI among middle-aged and older PWH in Lima, Peru. Materials and Methods: Sociodemographic, medical (infectious and non-infectious), and psychiatric comorbidity and laboratory data were collected. We administered a brief neuropsychological battery evaluating seven cognitive domains affected in HIV-associated NCI and a depression screening. Cognitive test raw scores were converted to T-scores that were demographically adjusted. Descriptive statistics were performed together with regression (unadjusted and adjusted) analyses to determine potential risk factors for NCI among PWH. Results: This was a cross-sectional study in which 144 PWH aged ≥40 years attending a large HIV clinic in Lima, Peru, were recruited from September 2019 to March 2020. Mean age was 51.6 ± 7.7 years, and mean years of education were 14.0 ± 3.1 with 15% females. Median [interquartile range (IQR)] current CD4 and nadir CD4 were 554 (371, 723) and 179 (83, 291), respectively, and 10% currently had AIDS. The prevalence of NCI was 28.5%, and many demonstrated difficulty with attention and working memory (70%). One-quarter of PWH had mild depression or worse on Patient Health Questionnaire 9 (PHQ-9 ≥ 5). In bivariate analyses, neither a depression history nor a higher PHQ-9 score correlated with NCI. No other non-communicable medical or psychiatric comorbidity nor HIV characteristic was predictive of NCI. Having a positive lifetime history of hepatitis B infection, pulmonary tuberculosis, or syphilis increased risk of NCI (PR 1.72; 95% CI 1.04-2.86) in unadjusted analyses, but not in adjusted analyses. Conclusions: NCI among older Peruvians with HIV was found to be highly prevalent with levels consistent with prior reports of HIV-associated NCI worldwide. Common latent HIV-associated co-infections, including latent syphilis, hepatitis B infection, or pulmonary tuberculosis, may increase the risk of NCI among middle-aged and older PWH in Peru.
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Affiliation(s)
- Monica M. Diaz
- Department of Medicine, University of California, San Diego, San Diego, CA, United States
- University of California Global Health Institute, San Diego, CA, United States
- Facultad de Salud Pública, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Marcela Gil Zacarías
- Facultad de Medicina Alberto Hurtado, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Patricia Sotolongo
- Department of Psychology, Jackson Memorial Hospital, Miami, FL, United States
| | - María F. Sanes
- Facultad de Medicina Alberto Hurtado, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Donald J. Franklin
- Human Immunodeficiency Virus (HIV) Neurobehavioral Research Center, University of California, San Diego, San Diego, CA, United States
- Department of Psychiatry, University of California, San Diego, San Diego, CA, United States
| | - María J. Marquine
- Human Immunodeficiency Virus (HIV) Neurobehavioral Research Center, University of California, San Diego, San Diego, CA, United States
- Department of Psychiatry, University of California, San Diego, San Diego, CA, United States
| | - Mariana Cherner
- Human Immunodeficiency Virus (HIV) Neurobehavioral Research Center, University of California, San Diego, San Diego, CA, United States
- Department of Psychiatry, University of California, San Diego, San Diego, CA, United States
| | - Cesar Cárcamo
- Facultad de Salud Pública, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Ronald J. Ellis
- Human Immunodeficiency Virus (HIV) Neurobehavioral Research Center, University of California, San Diego, San Diego, CA, United States
- Department of Neurosciences, University of California, San Diego, San Diego, CA, United States
| | - Serggio Lanata
- Weill Institute for Neurosciences, Memory and Aging Center, University of California, San Francisco, San Francisco, CA, United States
- Global Brain Health Institute, University of California, San Francisco, San Francisco, CA, United States
| | - Patricia J. García
- Facultad de Salud Pública, Universidad Peruana Cayetano Heredia, Lima, Peru
- School of Public Health, University of Washington, Seattle, WA, United States
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Naik S, Alexander M, Kumar P, Kulkarni V, Deshpande P, Yadana S, Leu CS, Araújo-Pereira M, Andrade BB, Bhosale R, Babu S, Gupta A, Mathad JS, Shivakoti R. Systemic Inflammation in Pregnant Women With Latent Tuberculosis Infection. Front Immunol 2021; 11:587617. [PMID: 33584652 PMCID: PMC7873478 DOI: 10.3389/fimmu.2020.587617] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 12/09/2020] [Indexed: 11/17/2022] Open
Abstract
Background Recent studies in adults have characterized differences in systemic inflammation between adults with and without latent tuberculosis infection (LTBI+ vs. LTBI−). Potential differences in systemic inflammation by LTBI status has not been assess in pregnant women. Methods We conducted a cohort study of 155 LTBI+ and 65 LTBI− pregnant women, stratified by HIV status, attending an antenatal clinic in Pune, India. LTBI status was assessed by interferon gamma release assay. Plasma was used to measure systemic inflammation markers using immunoassays: IFNβ, CRP, AGP, I-FABP, IFNγ, IL-1β, soluble CD14 (sCD14), sCD163, TNF, IL-6, IL-17a and IL-13. Linear regression models were fit to test the association of LTBI status with each inflammation marker. We also conducted an exploratory analysis using logistic regression to test the association of inflammatory markers with TB progression. Results Study population was a median age of 23 (Interquartile range: 21–27), 28% undernourished (mid-upper arm circumference (MUAC) <23 cm), 12% were vegetarian, 10% with gestational diabetes and 32% with HIV. In multivariable models, LTBI+ women had significantly lower levels of third trimester AGP, IL1β, sCD163, IL-6 and IL-17a. Interestingly, in exploratory analysis, LTBI+ TB progressors had significantly higher levels of IL1β, IL-6 and IL-13 in multivariable models compared to LTBI+ non-progressors. Conclusions Our data shows a distinct systemic immune profile in LTBI+ pregnant women compared to LTBI− women. Data from our exploratory analysis suggest that LTBI+ TB progressors do not have this immune profile, suggesting negative association of this profile with TB progression. If other studies confirm these differences by LTBI status and show a causal relationship with TB progression, this immune profile could identify subsets of LTBI+ pregnant women at high risk for TB progression and who can be targeted for preventative therapy.
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Affiliation(s)
- Shilpa Naik
- Byramjee-Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India.,Department of Obstetrics and Gynecology, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Mallika Alexander
- Byramjee-Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - Pavan Kumar
- International Center for Excellence in Research, National Institutes of Health, National Institute for Research in Tuberculosis, Chennai, India
| | - Vandana Kulkarni
- Byramjee-Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - Prasad Deshpande
- Byramjee-Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - Su Yadana
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, United States
| | - Cheng-Shiun Leu
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY, United States
| | - Mariana Araújo-Pereira
- Instituto Goncalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research, Fundação José Silveira, New York, NY, Brazil.,Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil
| | - Bruno B Andrade
- Instituto Goncalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research, Fundação José Silveira, New York, NY, Brazil.,Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil.,Curso de Medicina, Faculdade de Tecnologia e Ciências, Salvador, Brazil.,Escola de Medicina, Universidade Salvador (UNIFACS), Laureate International Universities, Salvador, Brazil.,Curso de Medicina, Escola Bahiana de Medicina e Saúde Pública (EBMSP), Salvador, Brazil
| | - Ramesh Bhosale
- Byramjee-Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India.,Department of Obstetrics and Gynecology, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Subash Babu
- International Center for Excellence in Research, National Institutes of Health, National Institute for Research in Tuberculosis, Chennai, India
| | - Amita Gupta
- Byramjee-Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India.,Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jyoti S Mathad
- Department of Medicine, Weill Cornell Medical College, New York, NY, United States
| | - Rupak Shivakoti
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, United States
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