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Singh AK, Kumar A, Arora S, Kumar R, Verma A, Khalilullah H, Jaremko M, Emwas AH, Kumar P. Current insights and molecular docking studies of HIV-1 reverse transcriptase inhibitors. Chem Biol Drug Des 2024; 103:e14372. [PMID: 37817296 DOI: 10.1111/cbdd.14372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 08/12/2023] [Accepted: 09/22/2023] [Indexed: 10/12/2023]
Abstract
Human immunodeficiency virus (HIV) causes acquired immunodeficiency syndrome (AIDS), a lethal disease that is prevalent worldwide. According to the Joint United Nations Programme on HIV/AIDS (UNAIDS) data, 38.4 million people worldwide were living with HIV in 2021. Viral reverse transcriptase (RT) is an excellent target for drug intervention. Nucleoside reverse transcriptase inhibitors (NRTIs) were the first class of approved antiretroviral drugs. Later, a new type of non-nucleoside reverse transcriptase inhibitors (NNRTIs) were approved as anti-HIV drugs. Zidovudine, didanosine, and stavudine are FDA-approved NRTIs, while nevirapine, efavirenz, and delavirdine are FDA-approved NNRTIs. Several agents are in clinical trials, including apricitabine, racivir, elvucitabine, doravirine, dapivirine, and elsulfavirine. This review addresses HIV-1 structure, replication cycle, reverse transcription, and HIV drug targets. This study focuses on NRTIs and NNRTIs, their binding sites, mechanisms of action, FDA-approved drugs and drugs in clinical trials, their resistance and adverse effects, their molecular docking studies, and highly active antiretroviral therapy (HAART).
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Affiliation(s)
- Ankit Kumar Singh
- Department of Pharmaceutical Sciences and Natural Products, Central University of Punjab, Bathinda, Punjab, India
| | - Adarsh Kumar
- Department of Pharmaceutical Sciences and Natural Products, Central University of Punjab, Bathinda, Punjab, India
| | - Sahil Arora
- Department of Pharmaceutical Sciences and Natural Products, Central University of Punjab, Bathinda, Punjab, India
| | - Raj Kumar
- Department of Pharmaceutical Sciences and Natural Products, Central University of Punjab, Bathinda, Punjab, India
| | - Amita Verma
- Department of Pharmaceutical Sciences, Bioorganic and Medicinal Chemistry Research Laboratory, Sam Higginbottom University of Agriculture, Technology and Sciences, Prayagraj, Uttar Pradesh, India
| | - Habibullah Khalilullah
- Department of Pharmaceutical Chemistry and Pharmacognosy, Unaizah College of Pharmacy, Qassim University, Unayzah, Saudi Arabia
| | - Mariusz Jaremko
- Smart-Health Initiative (SHI) and Red Sea Research Center (RSRC), Division of Biological and Environmental Sciences and Engineering (BESE), King Abdullah University of Science and Technology (KAUST), Thuwal, Saudi Arabia
| | - Abdul-Hamid Emwas
- Core Labs, King Abdullah University of Science and Technology (KAUST), Thuwal, Saudi Arabia
| | - Pradeep Kumar
- Department of Pharmaceutical Sciences and Natural Products, Central University of Punjab, Bathinda, Punjab, India
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Maggi P, Ricci ED, Martinelli CV, De Socio GV, Squillace N, Molteni C, Masiello A, Orofino G, Menzaghi B, Bellagamba R, Vichi F, Celesia BM, Madeddu G, Pellicanò GF, Carleo MA, Cascio A, Parisini A, Taramasso L, Valsecchi L, Calza L, Rusconi S, Sarchi E, Martini S, Bargiacchi O, Falasca K, Cenderello G, Ferrara S, Di Biagio A, Bonfanti P. Lipids and Transaminase in Antiretroviral-Treatment-Experienced People Living with HIV, Switching to a Doravirine-Based vs. a Rilpivirine-Based Regimen: Data from a Real-Life Setting. Viruses 2023; 15:1612. [PMID: 37515298 PMCID: PMC10383194 DOI: 10.3390/v15071612] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/19/2023] [Accepted: 07/21/2023] [Indexed: 07/30/2023] Open
Abstract
Doravirine (DOR) is a newly approved non-nucleoside reverse transcriptase inhibitor (NNRTI). We aimed to investigate, in a real-life setting, how switching to a DOR-based regimen rather than a rilpivirine (RPV)-based regimen impacted metabolic and hepatic safety. The analysis included 551 antiretroviral treatment (ART)-experienced people living with HIV (PLWH), starting RPV-based or DOR-based regimens with viral load < 200 copies/mL, baseline (T0), and at least one control visit (6-month visit, T1). We enrolled 295 PLWH in the RPV and 256 in the DOR cohort. At T1, total cholesterol (TC), low-density lipoprotein-C (LDL-C), and triglycerides significantly decreased in both DOR and RPV cohorts, while high-density lipoprotein-C (HDL-C) only decreased in RPV-treated people. Consistently, the TC/HDL-C ratio declined more markedly in the DOR (-0.36, p < 0.0001) than in the RPV cohort (-0.08, p = 0.25) (comparison p = 0.39). Similar trends were observed when excluding the PLWH on lipid-lowering treatment from the analysis. People with normal alanine aminotransferase (ALT) levels showed a slight ALT increase in both cohorts, and those with baseline ALT > 40 IU/L experienced a significant decline (-14 IU/L, p = 0.008) only in the DOR cohort. Lipid profile improved in both cohorts, and there was a significant reduction in ALT in PLWH with higher-than-normal baseline levels on DOR-based ART.
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Affiliation(s)
- Paolo Maggi
- Infectious Diseases Unit, AORN Sant'Anna e San Sebastiano, 81100 Caserta, Italy
| | | | | | | | - Nicola Squillace
- Infectious Diseases Unit, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
| | - Chiara Molteni
- Unit of Infectious Diseases, A. Manzoni Hospital, 23900 Lecco, Italy
| | - Addolorata Masiello
- Infectious Diseases Unit, AORN Sant'Anna e San Sebastiano, 81100 Caserta, Italy
| | - Giancarlo Orofino
- Division I of Infectious and Tropical Diseases, ASL Città di Torino, 10149 Torino, Italy
| | - Barbara Menzaghi
- Unit of Infectious Diseases, ASST della Valle Olona, 21052 Busto Arsizio, Italy
| | - Rita Bellagamba
- National Institute for Infectious Diseases Lazzaro Spallanzani Institute for Hospitalization and Care Scientific, Lazio, 00161 Roma, Italy
| | - Francesca Vichi
- SOC 1 USLCENTRO Firenze, Unit of Infectious Diseases, Santa Maria Annunziata Hospital, 50012 Florence, Italy
| | | | - Giordano Madeddu
- Unit of Infectious Diseases, Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy
| | - Giovanni Francesco Pellicanò
- Unit of Infectious Diseases, Department of Human Pathology of the Adult and the Developmental Age 'G. Barresi', University of Messina, 98125 Messina, Italy
| | - Maria Aurora Carleo
- Infectious Diseases and Gender Medicine Unit, Cotugno Hospital, AO dei Colli, 80131 Naples, Italy
| | - Antonio Cascio
- Unit of Infectious Diseases, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, 90127 Palermo, Italy
| | - Andrea Parisini
- Department of Infectious Diseases, Galliera Hospital, 16128 Genoa, Italy
| | - Lucia Taramasso
- Clinic of Infectious Diseases, IRCCS Policlinico San Martino Hospital, University of Genoa, 16132 Genoa, Italy
| | - Laura Valsecchi
- 1st Department of Infectious Diseases, ASST Fatebenefratelli Sacco, 20157 Milan, Italy
| | - Leonardo Calza
- Infectious Diseases Unit, IRCCS Policlinico Sant' Orsola, Department of Medical Surgical Science, University of Bologna, 40138 Bologna, Italy
| | - Stefano Rusconi
- Infectious Diseases Unit, Ospedale Civile di Legnano, ASST Ovest Milanese, and DIBIC Luigi Sacco, Università degli Studi di Milano, 20025 Legnano, Italy
| | - Eleonora Sarchi
- Infectious Diseases Unit, Santi Antonio e Biagio e Cesare Arrigo Hospital, 15121 Alessandria, Italy
| | - Salvatore Martini
- Infectious Disease Unit, University Hospital Luigi Vanvitelli, 80138 Naples, Italy
| | - Olivia Bargiacchi
- Unit of Infectious Diseases, Ospedale Maggiore della Carità, 28100 Novara, Italy
| | - Katia Falasca
- Clinic of Infectious Diseases, Department of Medicine and Science of Aging, G. D'Annunzio University, Chieti-Pescara, 66100 Chieti, Italy
| | | | - Sergio Ferrara
- Unit of Infectious Diseases, Department of Clinical and Experimental Medicine, University of Foggia, 71122 Foggia, Italy
| | - Antonio Di Biagio
- Clinic of Infectious Diseases, IRCCS Policlinico San Martino Hospital, University of Genoa, 16132 Genoa, Italy
| | - Paolo Bonfanti
- Infectious Diseases Unit, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
- School of Surgery and Medicine, University of Milano-Bicocca, 20126 Milan, Italy
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Maggi P, Ricci ED, Cicalini S, Pellicanò GF, Celesia BM, Vichi F, Cascio A, Sarchi E, Orofino G, Squillace N, Madeddu G, De Socio GV, Bargiacchi O, Molteni C, Masiello A, Saracino A, Menzaghi B, Falasca K, Taramasso L, Di Biagio A, Bonfanti P. Lipids and transaminase elevations in ARV-experienced PLWH switching to a doravirine-based regimen from rilpivirine or other regimens. BMC Infect Dis 2023; 23:227. [PMID: 37059996 PMCID: PMC10103465 DOI: 10.1186/s12879-023-08191-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 03/22/2023] [Indexed: 04/16/2023] Open
Abstract
BACKGROUND Doravirine (DOR) is a newly approved antiretroviral belonging to the class of non-nucleoside reverse transcriptase inhibitors (NNRTI), well tolerated and leading to an improved lipid profile in antiretroviral experienced people living with HIV (PLWH). We aimed at evaluating if the lipid-lowering effect is linked to the drug class, using real-life data from the SCOLTA cohort. METHODS We compared the lipid profile modifications in experienced PLWH switching to a DOR-based regimen from rilpivirine or another NNRTI-based regimen or from an integrase strand transferase (INSTI)-based regimen. T0 and T1 were defined as the baseline and 6-month follow-up respectively. Data were collected at baseline and prospectively every six months and changes from baseline were compared using a multivariable linear model. RESULTS In 107 PLWH, enrolled in the SCOLTA DOR cohort, with undetectable HIV-RNA at baseline, 32.7% switched from RPV-based regimens (DOR1), 29.9% from other NNRTI-including regimens (DOR2) and 37.4% switched from INSTI-including regimens (DOR3). At T1, TC significantly decreased in DOR2 (-15 mg/dL) and DOR3 (-23 mg/dL), and significantly more in DOR3 than in DOR1 (-6 mg/dL) (p = 0.016). HDL-C declined in DOR2 (-2 mg/dL) whereas it increased in DOR1 (+ 3 mg/dL) (p = 0.042) and remained stable in DOR3. LDL-C significantly decreased from baseline in DOR2 (-12 mg/dL) and DOR3 (-22 mg/dL) and was different between DOR1 (-8 mg/dL) and DOR3 (p = 0.022). TC/HDL ratio showed a significant decline in the DOR3 group (-0.45), although similar to DOR1 (-0.23, p = 0.315) and DOR2 (-0.19, p = 0.254). Triglycerides did not noticeably change. ALT significantly decreased in PLWH with a baseline level > 40 UI/mL. CONCLUSIONS PLWH on doravirine treatment showed different trends in blood lipids according to their previous regimen. In PLWH switching from RPV, minimal modifications were seen, whereas in those switching from other NNRTIs and from INSTI-including regimens, we observed an overall improvement in lipid profile, seemingly independent of the "statin effect" of TDF.
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Affiliation(s)
- Paolo Maggi
- Infectious Diseases Unit, AORN Sant'Anna e San Sebastiano, Caserta, Italy
| | | | - Stefania Cicalini
- National Institute for Infectious Diseases Lazzaro Spallanzani Institute for Hospitalization and Care Scientific, Roma, Lazio, Italy
| | - Giovanni Francesco Pellicanò
- Unit of Infectious Diseases, Department of Human Pathology of the Adult and the Developmental Age 'G. Barresi', University of Messina, Messina, Italy
| | | | - Francesca Vichi
- Unit of Infectious Diseases, USLCENTRO FIRENZE, Santa Maria Annunziata Hospital, Florence, Italy
| | - Antonio Cascio
- Unit of Infectious Diseases, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Eleonora Sarchi
- Infectious Diseases Unit, S.Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Giancarlo Orofino
- Division I of Infectious and Tropical Diseases, ASL Città di Torino, Torino, Italy
| | - Nicola Squillace
- Infectious Disease Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Giordano Madeddu
- Unit of Infectious Diseases, Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
| | | | - Olivia Bargiacchi
- Unit of Infectious Diseases, Ospedale Maggiore della Carità, Novara, Italy
| | - Chiara Molteni
- Unit of Infectious Diseases, A. Manzoni Hospital, Lecco, Italy
| | | | - Annalisa Saracino
- Department of Biomedical Sciences and Human Oncology, Clinic of Infectious Diseases, University of Bari Aldo Moro, Bari, Italy
| | - Barbara Menzaghi
- Unit of Infectious Diseases, ASST della Valle Olona - Busto Arsizio (VA), Busto Arsizio VA, Italy
| | - Katia Falasca
- Clinic of Infectious Diseases, Department of Medicine and Science of Aging, G. D'Annunzio University, Chieti-Pescara, Chieti, Italy
| | - Lucia Taramasso
- Infectious Diseases, San Martino Hospital Genoa, University of Genoa, Genoa, Italy
| | - Antonio Di Biagio
- Infectious Diseases, San Martino Hospital Genoa, University of Genoa, Genoa, Italy
| | - Paolo Bonfanti
- Infectious Disease Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza - University of Milano-Bicocca, Monza, Italy
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Rivera CG, Otto AO, Zeuli JD, Temesgen Z. Hepatotoxicity of contemporary antiretroviral drugs. Curr Opin HIV AIDS 2021; 16:279-285. [PMID: 34545037 DOI: 10.1097/coh.0000000000000706] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW To date, more than 30 antiretroviral drugs have been approved by the Food and Drug Administration for the treatment of HIV infection. As new drugs with better efficacy and safety profile become available for clinical practice, older drugs are either withdrawn from the market or become no longer actively prescribed. We review hepatotoxicity associated with contemporary antiretroviral drugs, with emphasis on data from the past 3 years. RECENT FINDINGS Although less robust data exists for side effects of contemporary antiretroviral medications recently approved for the management of HIV (i.e., doravirine, ibalizumab, fostemsavir, cabotegravir), the risks of substantial hepatotoxicity appears to be minimal with these agents. SUMMARY Although newer antiretroviral drugs are better tolerated than their earlier counterparts, they are not completely devoid of adverse drug reactions, including hepatotoxicity. Monitoring patients on antiretroviral therapy for treatment-emergent liver injury should continue to be part of routine clinical care.
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Affiliation(s)
| | | | | | - Zelalem Temesgen
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA
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Benedicto AM, Fuster-Martínez I, Tosca J, Esplugues JV, Blas-García A, Apostolova N. NNRTI and Liver Damage: Evidence of Their Association and the Mechanisms Involved. Cells 2021; 10:cells10071687. [PMID: 34359857 PMCID: PMC8303744 DOI: 10.3390/cells10071687] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/26/2021] [Accepted: 06/29/2021] [Indexed: 12/12/2022] Open
Abstract
Due to the improved effectiveness and safety of combined antiretroviral therapy, human immunodeficiency virus (HIV) infection has become a manageable, chronic condition rather than a mortal disease. However, HIV patients are at increased risk of experiencing non-AIDS-defining illnesses, with liver-related injury standing out as one of the leading causes of death among these patients. In addition to more HIV-specific processes, such as antiretroviral drug-related toxicity and direct injury to the liver by the virus itself, its pathogenesis is related to conditions that are also common in the general population, such as alcoholic and non-alcoholic fatty liver disease, viral hepatitis, and ageing. Non-nucleoside reverse transcriptase inhibitors (NNRTIs) are essential components of combined anti-HIV treatment due to their unique antiviral activity, high specificity, and acceptable toxicity. While first-generation NNRTIs (nevirapine and efavirenz) have been related largely to liver toxicity, those belonging to the second generation (etravirine, rilpivirine and doravirine) seem to be generally safe for the liver. Indeed, there is preclinical evidence of rilpivirine being hepatoprotective in different models of liver injury, independently of the presence of HIV. The present study aims to review the mechanisms by which currently available anti-HIV drugs belonging to the NNRTI family may participate in the development of liver disease.
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Affiliation(s)
- Ana M. Benedicto
- Department of Pharmacology, Faculty of Medicine, University of Valencia, 46010 Valencia, Spain; (A.M.B.); (I.F.-M.); (N.A.)
| | - Isabel Fuster-Martínez
- Department of Pharmacology, Faculty of Medicine, University of Valencia, 46010 Valencia, Spain; (A.M.B.); (I.F.-M.); (N.A.)
| | - Joan Tosca
- Digestive Medicine Department, University Clinical Hospital of Valencia, 46010 Valencia, Spain;
| | - Juan V. Esplugues
- Department of Pharmacology, Faculty of Medicine, University of Valencia, 46010 Valencia, Spain; (A.M.B.); (I.F.-M.); (N.A.)
- FISABIO–University Hospital Dr Peset, 46017 Valencia, Spain;
- Center for Biomedical Research Network–Hepatic and Digestive Diseases (CIBERehd), 46010 Valencia, Spain
- Correspondence: ; Tel.: +34-963-864-167; Fax: +34-963-983-879
| | - Ana Blas-García
- FISABIO–University Hospital Dr Peset, 46017 Valencia, Spain;
- Center for Biomedical Research Network–Hepatic and Digestive Diseases (CIBERehd), 46010 Valencia, Spain
- Department of Physiology, Faculty of Medicine, University of Valencia, 46010 Valencia, Spain
| | - Nadezda Apostolova
- Department of Pharmacology, Faculty of Medicine, University of Valencia, 46010 Valencia, Spain; (A.M.B.); (I.F.-M.); (N.A.)
- FISABIO–University Hospital Dr Peset, 46017 Valencia, Spain;
- Center for Biomedical Research Network–Hepatic and Digestive Diseases (CIBERehd), 46010 Valencia, Spain
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Hepatotoxicity of Contemporary Antiretroviral Drugs: A Review and Evaluation of Published Clinical Data. Cells 2021; 10:cells10051263. [PMID: 34065305 PMCID: PMC8160846 DOI: 10.3390/cells10051263] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/09/2021] [Accepted: 05/11/2021] [Indexed: 02/07/2023] Open
Abstract
Contemporary antiretroviral agents afford enhanced potency and safety for patients living with HIV. Newer antiretroviral drugs are often better tolerated than those initially approved in the early stages of the HIV epidemic. While the safety profile has improved, adverse drug reactions still occur. We have segregated the antiretroviral agents used in contemporary practice into class groupings based on their mechanism of antiviral activity (non-nucleoside reverse transcriptase inhibitors, nucleoside reverse transcriptase inhibitors, integrase inhibitors, protease inhibitors, and entry inhibitors) while providing a review and discussion of the hepatoxicity seen in the most relevant clinical literature published to date. Clinical literature for individual agents is discussed and agent comparisons afforded within each group in tabular format. Our review will provide a summative overview of the incidence and medications associated with hepatic adverse reactions linked to the use of contemporary antiretroviral drugs.
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Ogedengbe OO, Jegede AI, Onanuga IO, Offor U, Naidu EC, Peter AI, Azu OO. Coconut Oil Extract Mitigates Testicular Injury Following Adjuvant Treatment with Antiretroviral Drugs. Toxicol Res 2016; 32:317-325. [PMID: 27818734 PMCID: PMC5080853 DOI: 10.5487/tr.2016.32.4.317] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 06/26/2016] [Accepted: 07/18/2016] [Indexed: 12/12/2022] Open
Abstract
Increased access to highly active antiretroviral therapy (HAART) has made the management of drug toxicities an increasingly crucial component of HIV. This study investigated the effects of adjuvant use of coconut oil and HAART on testicular morphology and seminal parameters in Sprague- Dawley rats. Twelve adult male Sprague-Dawley rats, weighing 153~169 g were distributed into four groups (A–D) and treated as follows: A served as control (distilled water); B (HAART cocktail- Zidovudine, Lamivudine and Nevirapine); C (HAART + Virgin coconut oil 10 mL/kg) and D (Virgin coconut oil 10 mL/kg). After 56 days of treatment, animals were killed and laparotomy to exercise the epididymis for seminal fluid analyses done whilst testicular tissues were processed for histomorphometric studies. Result showed a significant decline in sperm motility (P < 0.05) and count (P < 0.0001) in HAART-treated animals while there was insignificant changes in other parameters in groups C and D except count that was reduced (P < 0.0001) when compared with controls. Histomorphological studies showed HAART caused disorders in seminiferous tubular architecture with significant (P < 0.01) decline in epithelial height closely mirrored by extensive reticulin framework and positive PAS cells. Adjuvant Virgin coconut oil + HAART resulted in significant decrease in seminiferous tubular diameter (P < 0.05), but other morphometric and histological parameters were similar to control or Virgin coconut oil alone (which showed normal histoarchitecture levels). While derangements in testicular and seminal fluid parameters occurred following HAART, adjuvant treatment with Virgin coconut oil restored the distortions emanating thereof.
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Affiliation(s)
- Oluwatosin O Ogedengbe
- Discipline of Clinical Anatomy, Nelson R. Mandela School of Medicine, University of Kwazulu-Natal, Durban, South Africa; Department of Anatomy, College of Medicine and Health Sciences, Afe Babalola University, Ado Ekiti, Nigeria
| | - Ayoola I Jegede
- Discipline of Clinical Anatomy, Nelson R. Mandela School of Medicine, University of Kwazulu-Natal, Durban, South Africa; Department of Anatomy, Faculty of Basic Medical Sciences, College of Health Sciences, Ladoke Akintola University of Technology, Ogbomoso, Nigeria
| | - Ismail O Onanuga
- Discipline of Clinical Anatomy, Nelson R. Mandela School of Medicine, University of Kwazulu-Natal, Durban, South Africa; Department of Anatomy, Faculty of Biomedical Sciences, Kampala International University, Western Campus, Ishaka, Uganda
| | - Ugochukwu Offor
- Discipline of Clinical Anatomy, Nelson R. Mandela School of Medicine, University of Kwazulu-Natal, Durban, South Africa
| | - Edwin Cs Naidu
- Discipline of Clinical Anatomy, Nelson R. Mandela School of Medicine, University of Kwazulu-Natal, Durban, South Africa
| | - Aniekan I Peter
- Discipline of Clinical Anatomy, Nelson R. Mandela School of Medicine, University of Kwazulu-Natal, Durban, South Africa; Department of Anatomy, Faculty of Basic Medical Sciences, University of Uyo-Nigeria, Uyo, Nigeria
| | - Onyemaechi O Azu
- Discipline of Clinical Anatomy, Nelson R. Mandela School of Medicine, University of Kwazulu-Natal, Durban, South Africa
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