HIV viral suppression in the era of antiretroviral therapy

Metformin Treatment Leads to Increased HIV Transcription and Gene Expression through Increased CREB Phosphorylation and Recruitment to the HIV LTR Promoter

Antiretroviral therapy has effectively suppressed HIV infection and replication and prolonged the lifespan of HIV-infected individuals. In the meantime, various complications including type 2 diabetes associated with the long-term antiviral therapy have shown steady increases. Metformin has been the front-line anti-hyperglycemic drug of choice and the most widely prescribed medication for the treatment of type 2 diabetes. However, little is known about the effects of Metformin on HIV infection and replication. In this study, we showed that Metformin treatment enhanced HIV gene expression and transcription in HIV-transfected 293T and HIV-infected Jurkat and human PBMC. Moreover, we demonstrated that Metformin treatment resulted in increased CREB expression and phosphorylation, and TBP expression. Furthermore, we showed that Metformin treatment increased the recruitment of phosphorylated CREB and TBP to the HIV LTR promoter. Lastly, we showed that inhibition of CREB phosphorylation/activation significantly abrogated Metformin-enhanced HIV gene expression. Taken together, these results demonstrated that Metformin treatment increased HIV transcription, gene expression, and production through increased CREB phosphorylation and recruitment to the HIV LTR promoter. These findings may help design the clinical management plan and HIV cure strategy of using Metformin to treat type 2 diabetes, a comorbidity with an increasing prevalence, in people living with HIV.

Pathophysiology and Clinical Management of Dyslipidemia in People Living with HIV: Sailing through Rough Seas

Infections with human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) represent one of the greatest health burdens worldwide. The complex pathophysiological pathways that link highly active antiretroviral therapy (HAART) and HIV infection per se with dyslipidemia make the management of lipid disorders and the subsequent increase in cardiovascular risk essential for the treatment of people living with HIV (PLHIV). Amongst HAART regimens, darunavir and atazanavir, tenofovir disoproxil fumarate, nevirapine, rilpivirine, and especially integrase inhibitors have demonstrated the most favorable lipid profile, emerging as sustainable options in HAART substitution. To this day, statins remain the cornerstone pharmacotherapy for dyslipidemia in PLHIV, although important drug-drug interactions with different HAART agents should be taken into account upon treatment initiation. For those intolerant or not meeting therapeutic goals, the addition of ezetimibe, PCSK9, bempedoic acid, fibrates, or fish oils should also be considered. This review summarizes the current literature on the multifactorial etiology and intricate pathophysiology of hyperlipidemia in PLHIV, with an emphasis on the role of different HAART agents, while also providing valuable insights into potential switching strategies and therapeutic options.

A cross-sectional survey on mother-to-child transmission of HIV among the migrant population in Dongguan, China

Introduction

The migrant population, consisting of individuals who relocate from rural to urban areas, faces unique challenges that heighten their vulnerability to HIV infection. These challenges stem from a combination of sociodemographic factors and limited access to healthcare services. Understanding the dynamics of HIV transmission within this population is crucial for the development of effective prevention strategies.

Methods

To investigate the factors contributing to HIV vulnerability among migrants, we conducted a cross-sectional study at Dongguan People's Hospital from January 1, 2018, to December 31, 2021. Our study focused on pregnant women living with HIV and their infants, with a particular emphasis on sociodemographic characteristics, HIV testing and treatment profiles, and neonatal clinical data. Data were systematically collected using standardized forms.

Results

Analysis of data from 98 participants revealed noteworthy findings. No significant associations were observed between age, marital status, and educational background regarding HIV vulnerability. Similarly, factors such as the status of sexual partners, spousal therapy, and the number of children had no significant impact. However, our analysis highlighted the critical role of treatment strategies for HIV-positive women and the timing of antiretroviral therapy initiation for women with HIV, both of which were associated with HIV transmission (P < 0.05). Additionally, factors such as feeding type, neonatal antiretroviral prophylaxis, and preventive treatment strategies showed significant associations, while the preventive treatment program for neonates demonstrated no significant impact.

Discussion

These findings provide valuable insights into the specific risk factors and barriers to HIV prevention faced by the migrant population in Dongguan. They underscore the importance of targeted interventions and policies aimed at curtailing mother-to-child HIV transmission. By addressing the unique challenges experienced by migrant mothers and their infants, this study contributes significantly to broader efforts in controlling the spread of HIV, ultimately enhancing the health outcomes and well-being of Dongguan's migrant population. Furthermore, our research introduces a distinctive perspective within the extensively examined domain of Prevention of Mother-to-Child Transmission (PMTCT) programs, focusing on the internally migrant Chinese population, an understudied demographic group in this context. This study, conducted in Dongguan, China, represents one of the pioneering investigations into pregnant women with HIV and their infants within this migrant community.

Trajectories of Antiretroviral Therapy Adherence and Virologic Failure in Women With HIV in the United States

BACKGROUND

Women with HIV (WHIV) in the United States face many challenges with adherence to antiretroviral therapy (ART), and suboptimal adherence often leads to virologic failure. This study aimed to determine the association between ART adherence trajectories and the risk of virologic failure.

METHODS

We included WHIV (aged 18 years or older) enrolled in the Women's Interagency HIV Study in the United States from April 2014 to September 2019 who had at least 2 consecutive measurements of HIV RNA and ≥3 measurements of self-reported adherence. Group-based trajectory modeling was used to identify adherence trajectories. Cox proportional hazard ratios were used to measure the association.

MAIN OUTCOME MEASURE

Virologic failure was defined as HIV RNA ≥200 copies/mL at 2 consecutive visits.

RESULTS

We included 1437 WHIV (median age 49 years). Of all women, 173 (12.0%) experienced virologic failure. Four adherence trajectories were identified, namely "consistently high" (26.3%), "moderate increasing" (9.5%), "moderate decreasing" (30.6%), and "consistently low" (33.5%). Women in the consistently low adherence group consumed alcohol and experienced depression more than other groups. Compared with the "consistently high" trajectory, the risk of virologic failure was higher among women with "consistently low" [adjusted hazard ratio (aHR) 2.8; 95% confidence interval (CI): 1.6 to 4.9; P < 0.001] and "moderate decreasing" adherence trajectories (aHR 1.8; 95% CI: 1.0 to 3.2; P = 0.04), but it was similar to those with "moderate increasing" adherence trajectory (aHR 1.0; 95% CI: 0.4 to 2.5; P = 0.94).

CONCLUSIONS

Adherence to ART remains a challenge among WHIV. Multilevel behavioral interventions to address poor adherence, alcohol consumption, and depression are needed.

Targeting the PEDV 3CL protease for identification of small molecule inhibitors: an insight from virtual screening, ADMET prediction, molecular dynamics, free energy landscape, and binding energy calculations

BACKGROUND

The porcine epidemic diarrhea virus (PEDV) represents a major health issue for piglets worldwide and does significant damage to the pork industry. Thus, new therapeutic approaches are urgently needed to manage PEDV infections. Due to the current lack of a reliable remedy, this present study aims to identify novel compounds that inhibit the 3CL protease of the virus involved in replication and pathogenesis.

RESULTS

To identify potent antiviral compounds against the 3CL protease, a virtual screening of natural compounds (n = 97,999) was conducted. The top 10 compounds were selected based on the lowest binding energy and the protein-ligand interaction analyzed. Further, the top five compounds that demonstrated a strong binding affinity were subjected to drug-likeness analysis using the ADMET prediction, which was followed by molecular dynamics simulations (500 ns), free energy landscape, and binding free energy calculations using the MM-PBSA method. Based on these parameters, four putative lead (ZINC38167083, ZINC09517223, ZINC04339983, and ZINC09517238) compounds were identified that represent potentially effective inhibitors of the 3CL protease.

CONCLUSION

Therefore, these can be utilized for the development of novel antiviral drugs against PEDV. However, this requires further validation through in vitro and in vivo studies.

HIV-1C in-House RNA-Based Genotyping Assay for Detection of Drug Resistance Mutations in Samples with Low-Level Viral Loads

Purpose

Monitoring HIV-1 drug resistance mutations (DRM) in treated patients on combination antiretroviral therapy (cART) with a detectable HIV-1 viral load (VL) is important for the selection of appropriate cART. Currently, there is limited data on HIV DRM at low-level viremia (LLV) (VL 401-999 copies/mL) due to the use of a threshold of VL ≥1000 copies/mL for HIV DRM testing. We here assess the performance of an in-house HIV drug resistance genotyping assay using plasma for the detection of DRM at LLV.

Methods

We used a total of 96 HIV plasma samples from the population-based Botswana Combination Prevention Project (BCPP). The samples were stratified by VL groups: 50 samples had LLV, defined as 401-999 copies/mL, and 46 had ≥1000 copies/mL. HIV pol (PR and RT) region was amplified and sequenced using an in-house genotyping assay with BigDye sequencing chemistry. Known HIV DRMs were identified using the Stanford HIV Drug Resistance Database. Genotyping success rate between the two groups was estimated and compared using the comparison of proportions test.

Results

The overall genotyping success rate was 79% (76/96). For VL groups, the genotyping success was 72% (36/50) at LLV and 87% (40/46) at VL ≥1000 copies/mL. Among generated sequences, the overall prevalence of individuals with at least 1 major or intermediate-associated DRM was 24% (18/76). The proportions of NNRTI-, NRTI- and PI-associated resistance mutations were 28%, 24%, and 0%, respectively. The most predominant mutations detected were K103N (18%) and M184V (12%) in NNRTI- and NRTI-associated mutations, respectively. The prevalence of DRM was 17% (6/36) at LLV and 30% (12/40) at VL ≥1000 copies/mL.

Conclusion

The in-house HIV genotyping assay successfully genotyped 72% of LLV samples and was able to detect 17% of DRM amongst them. Our results highlight the possibility and clinical significance of genotyping HIV among individuals with LLV.

Development of optimized drug-like small molecule inhibitors of the SARS-CoV-2 3CL protease for treatment of COVID-19

The SARS-CoV-2 3CL protease is a critical drug target for small molecule COVID-19 therapy, given its likely druggability and essentiality in the viral maturation and replication cycle. Based on the conservation of 3CL protease substrate binding pockets across coronaviruses and using screening, we identified four structurally distinct lead compounds that inhibit SARS-CoV-2 3CL protease. After evaluation of their binding specificity, cellular antiviral potency, metabolic stability, and water solubility, we prioritized the GC376 scaffold as being optimal for optimization. We identified multiple drug-like compounds with <10 nM potency for inhibiting SARS-CoV-2 3CL and the ability to block SARS-CoV-2 replication in human cells, obtained co-crystal structures of the 3CL protease in complex with these compounds, and determined that they have pan-coronavirus activity. We selected one compound, termed coronastat, as an optimized lead and characterized it in pharmacokinetic and safety studies in vivo. Coronastat represents a new candidate for a small molecule protease inhibitor for the treatment of SARS-CoV-2 infection for eliminating pandemics involving coronaviruses.

Small molecule drugs promise to remain a valuable tool in controlling the ongoing COVID-19 pandemic. Here the authors describe optimized drug-like small molecule inhibitors of the SARS-CoV-2 3CL protease for potential treatment of COVID-19.

Trends and effects of antiretroviral therapy coverage during pregnancy on mother-to-child transmission of HIV in Sub-Saharan Africa. Evidence from panel data analysis

Background

Antiretroviral therapy for pregnant women infected with HIV has evolved significantly over time, from single dosage antiretroviral and zidovudine alone to lifelong combination of antiretroviral therapy, but the effect of the intervention on population-level child HIV infection has not been well studied in sub-Saharan Africa. Therefore, this study aimed to establish the trend and effect of ART coverage during pregnancy on mother-to-child HIV transmission in sub-Saharan Africa from 2010 to 2019.

Methods

Country-level longitudinal ecological study design was used. Forty-one sub-Saharan Africa countries were included using publicly available data from the United Nations Programme on HIV/AIDS, World Health Organization, and World Bank. We created a panel dataset of 410 observations for this study from the years 2010–2019. Linear fixed effects dummy variable regression models were conducted to measure the effect of ART coverage during pregnancy on MTCT rate. Regression coefficients with their 95% confidence intervals (CIs) were estimated for each variable from the fixed effects model.

Results

ART coverage during pregnancy increased from 32.98 to 69.46% between 2010 and 2019. Over the same period, the rate of HIV transmission from mother to child reduced from 27.18 to 16.90% in sub-Saharan Africa. A subgroup analysis found that in southern Africa and upper-middle-income groups, higher ART coverage, and lower MTCT rates were recorded. The fixed-effects model result showed that ART coverage during pregnancy (β = − 0.18, 95% CI − 0.19–− 0.16) (p < 0.001) and log-transformed HIV incidence-to-prevalence ratio (β = 5.41, 95% CI 2.18–8.65) (p < 0.001) were significantly associated with mother-to-child HIV transmission rate.

Conclusions

ART coverage for HIV positive pregnant women and HIV incidence-to-prevalence ratio were significantly associated with MTCT rate in sub-Saharan Africa. Based on these findings we suggest countries scale up ART coverage by implementing varieties of proven strategies and control the HIV epidemic to achieve the global target of eliminating MTCT of HIV in the region.

Predictors of Viral Non-Suppression among Patients Living with HIV under Dolutegravir in Bunia, Democratic Republic of Congo: A Prospective Cohort Study

The Democratic Republic of the Congo adopted the integrase inhibitor dolutegravir (DTG) as part of its preferred first-line HIV treatment regimen in 2019. This study aimed to identify predictors of viral non-suppression among HIV-infected patients under a DTG-based regimen in the context of ongoing armed conflict since 2017 in the city of Bunia in the DRC. We conducted a cohort study of 468 patients living with HIV under DTG in all health facilities in Bunia. We calculated the proportion of participants with an HIV RNA of below 50 copies per milliliter. About three in four patients (72.8%) in this cohort had a viral load (VL) of <50 copies/mL after 6–12 months. After controlling for the effect of other covariates, the likelihood of having non-suppression remained significantly lower among the 25–34 age group and self-reported naïve patients with a baseline VL of ≥50 copies/mL. The likelihood of having non-suppression remained significantly higher among those who were at advanced stages of the disease, those with abnormal serum creatinine, those with high baseline HIV viremia over 1000 copies/mL, and the Sudanese ethnic group compared to the reference groups. This study suggests that we should better evaluate adherence, especially among adolescents and economically vulnerable populations, such as the Sudanese ethnic group in the city of Bunia. This suggests that an awareness of the potential effects of DTG and tenofovir is important for providers who take care of HIV-positive patients using antiretroviral therapy (ART), especially those with abnormal serum creatinine levels before starting treatment.

Molecular neuroimaging of inflammation in HIV

People with HIV now have near-normal life expectancies due to the success of effective combination antiretroviral therapy (cART). Following cART initiation, immune recovery occurs, and opportunistic diseases become rare. Despite this, high rates of non-infectious comorbidities persist in treated people with HIV, hypothesized to be related to persistent immuno-activation. One such comorbidity is cognitive impairment, which may partly be driven by ongoing neuro-inflammation in otherwise effectively treated people with HIV. In order to develop therapeutic interventions to address neuro-inflammation in effectively treated people with HIV, a deeper understanding of the pathogenic mechanisms driving persistent neuro-inflammatory responses and the ability to better characterize and measure neuro-inflammation in the central nervous system is required. This review highlights recent advances in molecular neuroimaging techniques which have the potential to assess neuro-inflammatory responses within the central nervous system in HIV disease. Proton magnetic resonance spectroscopy (1H-MRS) has been utilized to assess neuro-inflammatory responses since early in the HIV pandemic and shows promise in recent studies assessing different antiretroviral regimens. 1H-MRS is widely available in both resource-rich and some resource-constrained settings and is relatively inexpensive. Brain positron emission tomography (PET) imaging using Translocator Protein (TSPO) radioligands is a rapidly evolving field; newer TSPO-radioligands have lower signal-to-noise ratio and have the potential to localize neuro-inflammation within the brain in people with HIV. As HIV therapeutics evolve, people with HIV continue to age and develop age-related comorbidities including cognitive disorders. The use of novel neuroimaging modalities in the field is likely to advance in order to rapidly assess novel therapeutic interventions and may play a role in future clinical assessments.

The clinical and demographic profile of women living with HIV admitted to the acute unit at Stikland Psychiatric Hospital

BACKGROUND

There is a paucity of research on the clinical profile of women living with human immunodeficiency virus (HIV) (WLWH) admitted with acute mental health illness. Existing studies are small and did not look at factors that could have an impact on medication adherence. As a first step to inform service delivery for this vulnerable population, a thorough understanding of the composition and needs of these patients should be identified.

OBJECTIVES

To describe the socio-demographic and clinical profile that could have an influence on the antiretroviral therapy (ART) adherence of WLWH at an inpatient psychiatric unit.

METHODS

In this retrospective audit, the medical records of all WLWH (18-59 years of age), discharged from the acute unit at Stikland Psychiatric Hospital, were reviewed over a 12-month period.

RESULTS

Of the 347 female patients discharged, 55 patients were positive for HIV (15.9%). The majority of them were unmarried (78.2%), unemployed (92.7%), had a secondary level of education (Grade 8-10) (58.2%), lived with a family member (83.6%) and had children (61.8%). The most common psychiatric diagnosis on discharge was substance use disorder with 78.2% of patients being categorised as substance users. Interpersonal violence was only reported by 5.5% of patients. Although most patients performed poorly on the Montreal Cognitive Assessment (MoCA) and International HIV Dementia Scale (IHDS), only 12% of patients received a diagnosis of HIV-associated neurocognitive disorder (HAND) upon discharge. Antiretroviral therapy (ART) was initiated in 21.8% of patients. Only eight patients had a viral load of < 200 copies/mL, indicating viral suppression.

CONCLUSION

Our findings may inform service planning and emphasise the need for targeted intervention strategies to improve treatment outcomes in this vulnerable group.

The far-reaching HAND of cART: cART effects on astrocytes

Following the introduction of combination antiretroviral therapy (cART), the morbidity and mortality from human immunodeficiency virus (HIV) infection has been drastically curtailed and HIV has now become a chronic manageable disease. Persons living with HIV (PLWH) are living longer and experiencing significant co-morbidities and conditions of aging. NeuroHIV, clinically defined as HIV-Associated Neurocognitive Disorders (HAND) and pathologically manifested by persistent inflammation in the CNS despite cART, is a significant co-morbid condition for PLWH. In the pre-cART era, HIV mediated much of the pathogenesis in the Central Nervous System (CNS); in the cART era, with low to undetectable viremia, other mechanisms may be contributing to persistent neuroinflammation. Emerging data point to the adverse effects at the cellular level of cART, independent of HIV. Astrocytes are the most abundant cells in the CNS, playing vital roles in maintaining CNS homeostasis (e.g. metabolic support to neurons, clearance of neurotransmitters, ion balance, modulation of synaptic functions and maintaining the structural integrity of the blood brain barrier (BBB). Therefore, any disruption of their function will have wide repercussions in the CNS. In this review, we will address current knowledge and gaps on the impact of antiretrovirals (ARVs) on astrocytes and physiologic consequences in the CNS. Understanding the status of this field, will provide a practical framework to elucidate the potential role of cART-mediated dysregulation of astrocytes in neuroHIV pathogenesis and inform therapeutic strategies that are "neuro-friendly". Graphical abstract CNS-penetrating cART have the potential to cause resting astrocytes to become activated into an A1 or neurotoxic phenotype. These cells can in turn secrete inflammatory cytokines that affect surrounding microglia macrophages, as well as neurotoxic factors that impact nearby neurons. In addition, impairment in the physiologic functions of astrocytes will result in altered BBB permeability and disrupted metabolic homeostasis. CNS=Central Nervous System; cART=combined antiretroviral therapy; BBB=blood brain barrier.

Individual and neighborhood predictors of retention in care and viral suppression among Florida youth (aged 13-24) living with HIV in 2015

Youth aged 13‒24 are less likely to be retained in HIV care and be virally suppressed than older age groups. This study aimed to assess predictors of retention in HIV care and viral suppression among a population-based cohort of youth (N = 2872) diagnosed with HIV between 1993 and 2014 in Florida. We used generalized estimating equations to estimate prevalence ratios (PRs). Retention in care was defined as evidence of engagement in care (at least one laboratory test, physician visit, or antiretroviral therapy prescription refill), two or more times, at least three months apart during 2015. Viral suppression was defined as having evidence of a viral load <200 copies/ml among those in care during 2015. Among the 2872 youth, 65.4% were retained in care, and among those in care, 65.0% were virally suppressed. Older youth (18‒24 years old) and non-Hispanic Blacks (NHBs) were less likely to be retained in care, whereas those men who have sex with men, perinatal HIV transmission, living in low socioeconomic neighborhoods, and those diagnosed with AIDS before 2016 were more likely to be retained in care. Those diagnosed with AIDS before 2016 and NHBs were less likely to be virally suppressed, whereas those men who have sex with men and foreign-born persons were more likely to be virally suppressed. Results suggest the need for targeted retention and viral suppression interventions for NHB youth and older youth (18‒24 years-age).

Determinants of viral load rebound on HIV/AIDS patients receiving antiretroviral therapy: results from South Africa

BACKGROUND

Antiretroviral therapy (ART) has become the standard of care for patients with HIV infection in South Africa and has led to the reduction in AIDS related morbidity and mortality. In developing countries, the nucleosides reverse transcriptase inhibitors (NRTIs) class are widely used because of their low production costs. However patients treated with NRTIs develop varying degree of toxicity after long-term therapy. For this study patients are administered with a triple therapy of two NRTIs and one non-nucleoside reverse transcriptase inhibitor (NNRTI).

METHOD

In this study the progression of HIV in vivo is divided into some viral load states and a continuous time-homogeneous model is fitted to assess the effects of covariates namely gender, age, CD4 baseline, viral load baseline, lactic acidosis, peripheral neuropathy, non-adherence and resistance to treatment on transition intensities between the states. Effects of different drug combinations on transition intensities are also assessed.

RESULTS

The results show no gender differences on transition intensities. The likelihood ratio test shows that the continuous time Markov model for the effects of the covariates including combination give a significantly better fit to the observed data. From almost all states, rates of viral suppression were higher than rates of viral rebound except for patients in state 2 (viral load between 50 and 10,000 copies/mL) where rates of viral rebound to state 3 (viral load between 10,000 and 100,000 copies/mL) were higher than rates of viral suppression to undetectable levels. For this transition, confidence intervals were very small. This was quite notable for patients who were administered with AZT-3TC-LPV/r and FTC-TDF-EFV. Although patients on d4T-3TC-EFV also had higher rates of viral rebound from state 2 than suppression, the difference was not significant.

CONCLUSION

From these findings, we can conclude that administering of any HIV drug regimen is better when based on the viral load level of an HIV+ patient. Before initiation of treatment, patients should be well equipped on how antiretroviral drugs operate including possibilities of toxicity in order to reduce chances of non-adherence to treatment. There should also be a good relationship between patient and health-care-giver to ensure proper adherence to treatment. Uptake of therapy by young patients should be closely monitored by adopting pill counting every time they come for review.

HIV continuum of care in Europe and Central Asia

OBJECTIVES

The European Centre for Disease Prevention and Control (ECDC) supports countries to monitor progress in their response to the HIV epidemic. In line with these monitoring responsibilities, we assess how, and to what extent, the continuum of care is being measured across countries.

METHODS

The ECDC sent out questionnaires to 55 countries in Europe and Central Asia in 2014. Nominated country representatives were questioned on how they defined and measured six elements of the continuum. We present our results using three previously described frameworks [breakpoints; Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets; diagnosis and treatment quadrant].

RESULTS

Forty countries provided data for at least one element of the continuum. Countries reported most frequently on the number of people diagnosed with HIV infection (37; 93%), and on the number in receipt of antiretroviral therapy (ART) (35; 88%). There was little consensus across countries in their approach to defining linkage to, and retention in, care. The most common breakpoint (>19% reduction between two adjacent elements) related to the estimated number of people living with HIV who were diagnosed (18 of 23; 78%).

CONCLUSIONS

We present continuum data from multiple countries that provide both a snapshot of care provision and a baseline against which changes over time in care provision across Europe and Central Asia may be measured. To better inform HIV testing and treatment programmes, standard data collection approaches and definitions across the HIV continuum of care are needed. If countries wish to ensure an unbroken HIV continuum of care, people living with HIV need to be diagnosed promptly, and ART needs to be offered to all those diagnosed.

Effectiveness of first-line antiretroviral therapy in HIV/AIDS patients: A 5-year longitudinal evaluation in Fujian Province, Southeast China

The aim of this study was to evaluate the long-term effectiveness of first-line antiretroviral therapy in HIV/AIDS patients in Southeast China. A total of 450 eligible patients were selected to initiate first-line antiretroviral therapy from February 2005 through August 2009. During the study period from 2009 through 2013, each subject received clinical and laboratory monitoring for effectiveness, safety and toxicity once every 3 months in the first year, and once every 6 months in the following years. The response to first-line antiretroviral therapy was evaluated through body weight gain and immunological and virological outcomes. During the mean follow-up period of 70.86 ± 28.9 months, the overall mortality was 14.2%. The mean body weight and CD4(+) counts increased significantly following antiretroviral therapy as compared to baselines across the follow-up period, and the rate of immunological effectiveness was over 85% in all subjects at 2 to 5 years of treatment. The rate of inhibition of HIV virus was 87.67%, 89.32%, 91.73%, 92.8% and 91.63% across the study period. In addition, significant differences were detected after treatment as compared to baselines, and Pearson correlation analysis revealed a positive correlation between immunological effectiveness and viral inhibition. Forty-eight percent of the subjects changed antiretroviral drugs once, and 16.22% twice, and 31 patients switched from first-line to second-line antiretroviral therapy. Long-term antiretroviral therapy remains effective for treatment of HIV/AIDS, resulting in higher mean body weight, effective viral inhibition and a higher CD4 count. Immunological effectiveness of antiretroviral therapy positively correlates with HIV viral inhibition.

Initial Therapy for Human Immunodeficiency Virus: Broadening the Options

The goal of investigation into new therapeutic options for HIV/AIDS is to further the achievements of highly active antiretroviral therapy by developing new drugs with improved efficacy. Although several therapies are currently available for initial therapy in HIV-infected patients, ongoing research focuses on additions to existing and novel drug classes that might have improved pharmacokinetic and tolerability profiles, as well as on new therapeutic combinations that might result in synergistic activity. To retain activity against resistant strains, novel drugs need to target the numerous critical points in the life cycle of HIV, inhibiting different enzyme subsites than those affected by antiretroviral agents currently in use. An improvement in patient adherence to therapy is another key objective of efforts in HIV treatment, as suboptimal drug levels are a main determinant of antiretroviral regimen failure. This article reviews the current classes of antiretroviral agents in development, describing the clinical data obtained to date. These agents may have potential use as initial therapy in HIV patients.

The HIV care cascade and antiretroviral therapy in female sex workers: implications for HIV prevention

To achieve viral suppression and fully benefit from antiretroviral therapy (ART), it is important that individuals with HIV know that they are HIV infected, link to and remain in HIV care, start and remain on ART and adhere to treatment. In HIV epidemics where female sex workers (FSWs) are key drivers of HIV transmission, the extent to which FSWs use ART and engage in the HIV care cascade could have a considerable impact on HIV transmission from FSWs to the wider population. In this article we review the spectrum of FSW engagement in the HIV care cascade, look at the impact of the HIV care cascade and ART use among FSWs on population-level HIV transmission and discuss HIV prevention for FSWs in the context of ART and the HIV care cascade.

Emerging trends of HIV drug resistance in Chinese HIV-infected patients receiving first-line highly active antiretroviral therapy: a systematic review and meta-analysis

BACKGROUND

Highly active antiretroviral therapy (HAART) has led to a dramatic decrease in AIDS-related morbidity and mortality through sustained suppression of human immunodeficiency virus (HIV) replication and reconstitution of the immune response. Settings like China that experienced rapid HAART rollout and relatively limited drug selection face considerable challenges in controlling HIV drug resistance (DR).

METHODS

We conducted a systematic review and meta-analysis to describe trends in emergent HIV DR to first-line HAART among Chinese HIV-infected patients, as reflected in the point prevalence of HIV DR at key points and fixed intervals after treatment initiation, using data from cohort studies and cross-sectional studies respectively.

RESULTS

Pooled prevalence of HIV DR from longitudinal cohorts studies was 10.79% (95% confidence interval [CI], 5.85%-19.07%) after 12 months of HAART and 80.58% (95% CI, 76.6%-84.02%) after 72 months of HAART. The HIV DR prevalence from cross-sectional studies was measured in treatment intervals; during the 0-12-month HAART treatment interval, the pooled prevalence of HIV DR was 11.1% (95% CI, 7.49%-16.14%), which increased to 22.92% at 61-72 months (95% CI, 9.45%-45.86%). Stratified analyses showed that patients receiving a didanosine-based regimen had higher HIV DR prevalence than those not taking didanosine (15.82% vs 4.97%). Patients infected through former plasma donation and those receiving AIDS treatment at village clinics had higher HIV DR prevalence than those infected through sexual transmission or treated at a county-level hospital.

CONCLUSIONS

Our findings indicate higher prevalence of HIV DR for patients with longer cumulative HAART exposure, highlighting important subgroups for future HIV DR surveillance and control.

An ecosystem-based intervention to reduce HIV transmission risk and increase medication adherence among inmates being released to the community

HIV+ inmates reentering their communities are at increased risk for poor health outcomes and for transmitting HIV. This article reports on a randomized trial comparing an ecosystem-based intervention and an individually focused intervention for reducing HIV transmission risk and improving medication adherence. Reincarceration was considered as a secondary variable. Both groups decreased sexual risk behavior over the 12-month follow-up period. Unexpectedly, the ecosystem intervention group was less likely to be taking medication or to be adherent and more likely to have been reincarcerated. Failure to demonstrate a significant advantage of the ecosystem intervention may have resulted from the difficulty of engaging family and other ecosystem members in the intervention. Implications for developing and applying interventions for this population are discussed.

Preclinical pharmacokinetics and tissue distribution of long-acting nanoformulated antiretroviral therapy

Long-acting injectable nanoformulated antiretroviral therapy (nanoART) was developed with the explicit goal of improving medicine compliance and for drug targeting of viral tissue reservoirs. Prior nanoART studies completed in humanized virus-infected mice demonstrated sustained antiretroviral responses. However, the pharmacokinetics (PK) and tissue distribution of nanoART were not characterized. To this end, the PK and tissue distribution of nanoformulated atazanavir (ATV) and ritonavir (RTV) injected subcutaneously or intramuscularly in mice and monkeys were evaluated. Fourteen days after injection, ATV and RTV levels were up to 13-, 41-, and 4,500-fold higher than those resulting from native-drug administration in plasma, tissues, and at the site of injection, respectively. At nanoART doses of 10, 50, 100, and 250 mg/kg of body weight, relationships of more- and less-than-proportional increases in plasma and tissue levels with dose increases were demonstrated with ATV and RTV. Multiple-dose regimens showed serum and tissue concentrations up to 270-fold higher than native-drug concentrations throughout 8 weeks of study. Importantly, nanoART was localized in nonlysosomal compartments in tissue macrophages, creating intracellular depot sites. Reflective data were obtained in representative rhesus macaque studies. We conclude that nanoART demonstrates blood and tissue antiretroviral drug levels that are enhanced compared to those of native drugs. The sustained and enhanced PK profile of nanoART is, at least in part, the result of the sustained release of ATV and RTV from tissue macrophases and at the site of injection.

An economic case for providing free access to antiretroviral therapy for HIV-positive people in South Australia

BACKGROUND

As financial constraints can be a barrier to accessing HIV antiretroviral therapy (ART), we argue for the removal of copayment requirements from HIV medications in South Australia.

METHODS

Using a simple mathematical model informed by available behavioural and biological data and reflecting the HIV epidemiology in South Australia, we calculated the expected number of new HIV transmissions caused by persons who are not currently on ART compared with transmissions for people on ART. The extra financial investment required to cover the copayments to prevent an HIV infection was compared with the treatment costs saved due to averting HIV infections.

RESULTS

It was estimated that one HIV infection is prevented per year for every 31.4 persons (median, 24.0-42.7 interquartile range (IQR)) who receive treatment. By considering the incremental change in costs and outcomes of a change in program from the current status quo, it would cost the health sector $17860 per infection averted (median, $13651-24287 IQR) if ART is provided as a three-dose, three-drug combination without requirements for user-pay copayments.

CONCLUSIONS

The costs of removing copayment fees for ART are less than the costs of treating extra HIV infections that would result under current conditions. Removing the copayment requirement for HIV medication would be cost-effective from a governmental perspective.

Switch from a ZDV/3TC-based regimen to a completely once daily (QD) regimen of emtricitabine/tenofovir DF fixed dose combination plus a third QD agent (SONETT)

Objectives

To assess the efficacy and safety of a treatment switch from a twice-daily (BID) regimen containing zidovudine (ZDV) and lamivudine (3TC) plus a third agent to a once daily (QD) regimen containing the fixed-dose combination of tenofovir DF/emtricitabine (TDF/FTC, Truvada^®) plus a divergent third QD agent in HIV-1 infected patients.

Methods

Prospective, 48-week, non-randomised, single-group, open-label, study. Fifty-one patients on stable ZDV/3TC-containing HAART, with HIV-1 RNA < 50 copies/ml and CD4+ T-cell count > 50 cells/μl, were switched to TDF/FTC plus a third agent. Plasma HIV-1 RNA, CD4+ and CD8+ T-cell counts were assessed at baseline and weeks 4, 12, 24, 36 and 48 post-switch.

Results

During the 48-week study, 10 patients discontinued prematurely, including three due to adverse events (AEs). At week 48, plasma HIV-1 RNA was < 50 copies/ml in 40 patients (78.4%). No patient experienced virological failure (defined as HIV-1 RNA ≥50 copies/ml at two consecutive post-baseline measurements) during the study. Immunologic control was maintained, with no significant changes in CD4+ or CD8+ T-cell counts. A statistically significant improvement from baseline in haemoglobin level was observed at week 48 (median change 0.8 g/dl; p < 0.001). There was also a statistically significant decrease in total cholesterol concentration at week 48 (-26.0 mg/dl; p = 0.001) in a subset of patients (n = 22) entering the study with elevated total cholesterol. Treatment was well tolerated and no treatment-related grade 3 or 4 AEs were seen.

Conclusions

Results from this study support switching from a ZDV/3TC-containing HAART regimen to a completely QD regimen of TDF/FTC plus a third agent. Virologic and immunologic control are maintained, with apparent benefits in haemoglobin.

Human susceptibility to viral infection: the search for HIV-protective alleles among Africans by means of genome-wide studies

Human immunodeficiency virus (HIV) infection represents a major global health problem, with HIV now recognized as the fourth leading cause of death on a worldwide basis. One approach to developing effective anti- HIV interventions is to identify and understand the molecular mechanisms by which natural genetic variations provide protection from infection or disease progression. This approach can be used to identify human gene alleles that confer resistance or increased susceptibility to HIV infection. To date, however, this approach has been underutilized in the African population and all HIV-resistance alleles that have been described have been identified by evaluating candidate genes. This limited approach is based upon a researcher's assumption that those genes that will provide the host with a benefit can be predicted, a priori, but it does not provide for a large scale systematic screen of all possible candidate genes. Nonetheless, this method has met with some success in identifying HIV-resistance genes, mostly among the white population. The lack of a comprehensive genetic approach, both in terms of the populations studied and the percentage of the genome investigated, likely explains why all of the HIV-restriction alleles identified to date fall within two gene families, and why no resistance genes have been identified among black Africans. It is likely, as with any complex trait, that most protective alleles will provide only partial HIV resistance. Thus, HIV resistance in most persons likely arises through a QTL (quantitative trait loci) mechanism meaning that protection is a polygenic trait. This feature coupled with interpopulation genetic heterogeneity makes the candidate gene mapping approach a daunting task. A comprehensive genome-wide case-control allelic association study in the African population will maximize our chances of identifying new targets for the development of new therapeutics that have the promise of benefiting all persons infected with HIV.

The BCR-ABL story: bench to bedside and back

The twenty-first century is beginning with a sharp turn in the field of cancer therapy. Molecular targeted therapies against specific oncogenic events are now possible. The BCR-ABL story represents a notable example of how research from the fields of cytogenetics, retroviral oncology, protein phosphorylation, and small molecule chemical inhibitors can lead to the development of a successful molecular targeted therapy. Imatinib mesylate (Gleevec, STI571, or CP57148B) is a direct inhibitor of ABL (ABL1), ARG (ABL2), KIT, and PDGFR tyrosine kinases. This drug has had a major impact on the treatment of chronic myelogenous leukemia (CML) as well as other blood neoplasias and solid tumors with etiologies based on activation of these tyrosine kinases. Analysis of CML patients resistant to BCR-ABL suppression by Imatinib mesylate coupled with the crystallographic structure of ABL complexed to this inhibitor have shown how structural mutations in ABL can circumvent an otherwise potent anticancer drug. The successes and limitations of Imatinib mesylate hold general lessons for the development of alternative molecular targeted therapies in oncology.

Treatment outcomes after highly active antiretroviral therapy: a meta-analysis of randomised controlled trials

This systematic review summarises the evidence for treatment efficacy and tolerability of highly active antiretroviral therapies containing two nucleoside reverse transcriptase inhibitors (NRTI) with a protease inhibitor (PI), compared with two NRTIs alone for the treatment of HIV-1 infection in randomised controlled trials. Three electronic databases (Medline, Embase, and the Cochrane Library) were searched up to December 2003. 16 randomised controlled trials met the inclusion criteria and were included in the analysis from 328 articles screened. The pooled analysis indicated that treatment with two NRTIs with a PI is more effective in achieving viral suppression than two NRTIs alone (relative risk [RR] 3.44, 95% confidence interval [CI] 2.43-4.87). However, the RR for discontinuation of treatment due to adverse events of treatment with two NRTIs with a PI compared with two NRTIs alone was 1.81 (95% CI 1.17-2.79). The benefits of treatment with two NRTIs and a PI are substantial among those who can tolerate the regimen in comparison with treatment with two NRTIs alone.