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IKUMI NM, MALABA TR, PILLAY K, COHEN MC, MADLALA HP, MATJILA M, ANUMBA D, MYER L, NEWELL ML, GRAY CM. Differential impact of antiretroviral therapy initiated before or during pregnancy on placenta pathology in HIV-positive women. AIDS 2021; 35:717-726. [PMID: 33724257 PMCID: PMC8630811 DOI: 10.1097/qad.0000000000002824] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To examine the association between timing of antiretroviral treatment (ART) initiation in HIV-infected women and placental histopathology. DESIGN A nested substudy in a larger cohort of HIV-infected women which examined the association between ART status and birth outcomes. METHODS Placentas (n = 130) were examined for histopathology from two ART groups: stable (n = 53), who initiated ART before conception and initiating (n = 77), who started ART during pregnancy [median (interquartile range) 15 weeks gestation (11-18)]. Using binomial regression we quantified associations between ART initiation timing with placental histopathology and pregnancy outcomes. RESULTS One-third of all placentas were less than 10th percentile weight-for-gestation and there was no significant difference between ART groups. Placental diameter, thickness, cord insertion position and foetal-placental weight ratio were also similar by group. However, placentas from the stable group showed increased maternal vascular malperfusion (MVM) (39.6 vs. 19.4%), and decreased weight (392 vs. 422 g, P = 0.09). MVM risk was twice as high [risk ratios 2.03 (95% confidence interval: 1.16-3.57); P = 0.01] in the stable group; the increased risk remaining significant when adjusting for maternal age [risk ratios 2.04 (95% confidence interval: 1.12-3.72); P = 0.02]. Furthermore, MVM was significantly associated with preterm delivery and low birth weight (P = 0.002 and <0.0001, respectively). CONCLUSION Preconception initiation of ART was associated with an increased MVM risk, and may contribute to placental dysfunction. The association between MVM with preterm delivery and low birth weight suggests that a placenta-mediated mechanism likely links the putative association between long-term use of ART and adverse birth outcomes.
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Affiliation(s)
- Nadia M IKUMI
- Division of Immunology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Thokozile R MALABA
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Komala PILLAY
- Division of Anatomical Pathology, Department of Pathology, University of Cape Town, Cape Town, South Africa
- National Health Laboratory Services, Groote Schuur Hospital, Cape Town, South Africa
| | - Marta C COHEN
- Department of Histopathology, Sheffield Children’s NHS Foundation Trust , Sheffield, UK
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK, Department of Obstetrics and Gynaecology, University of Cape Town, Cape Town South Africa
| | - Hlengiwe P MADLALA
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Mushi MATJILA
- Department of Obstetrics and Gynaecology, University of Cape Town, Cape Town South Africa
| | - Dilly ANUMBA
- Academic Unit of Reproductive and Developmental Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Landon MYER
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Marie-Louise NEWELL
- School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Clive M GRAY
- Division of Immunology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- National Health Laboratory Services, Groote Schuur Hospital, Cape Town, South Africa
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Nozulu N, Gaede BM. Antiretroviral initiation of pregnant women and antenatal care booking practices in eThekwini District, KwaZulu-Natal, South Africa. Afr J Prim Health Care Fam Med 2018; 10:e1-e9. [PMID: 29943591 PMCID: PMC6018727 DOI: 10.4102/phcfm.v10i1.1606] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 02/24/2018] [Accepted: 03/05/2018] [Indexed: 11/20/2022] Open
Abstract
Background The introduction of antiretroviral therapy (ART) in South Africa began as part of the prevention of mother-to-child transmission programme. For significant reduction of vertical transmission, early antenatal care booking and ART initiation are necessary. Aim This study aimed to evaluate ART initiation and booking practices of women attending antenatal care in eThekwini district during financial years (FY) 2010/2011 and 2013/2014. Methods An observational study used a retrospective chart review at four eThekwini district community health centres (CHC). From these CHCs, records of women that initiated ART in FY10/11 and FY13/14 were reviewed and compared for ART initiation delays and booking practices. Results A total of 2749 pregnant women who attended antenatal care (ANC) at the study sites were found eligible for ART; of these, 49% (n = 1334) attended ANC in FY10/11 while 51% (n = 1414) attended in FY13/14. In FY10/11, 46% (n = 610) and 60 % (n = 855) of the women were initiated on ART during pregnancy. The mean gestational age at booking for FY10/11 was 20.88 (standard deviation [s.d.] = 5.6) and 18.40 (s.d. = 6.2) in FY13/14. The mean gestational age at ART initiation for women who initiated ART in FY10/11 was 26.30 (s.d. = 6.02) and in FY13/14 it was 19.06 (s.d. = 6.86). Conclusion In FY13/14 ART initiations occurred within 4 days after booking. ANC booking before 20 weeks was found to have improved between the two years from 39% to 58%; however, on average, in both years women booked during the second trimester.
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Affiliation(s)
- Nomonde Nozulu
- Department of Family Medicine, School of Nursing and Public Health, University of KwaZulu-Natal.
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Mujugira A, Baeten J, Kidoguchi L, Haberer J, Celum C, Donnell D, Ngure K, Bukusi E, Mugo N, Asiimwe S, Odoyo J, Tindimwebwa E, Bulya N, Katabira E, Heffron R. High levels of viral suppression among East African HIV-infected women and men in serodiscordant partnerships initiating antiretroviral therapy with high CD4 counts and during pregnancy. AIDS Res Hum Retroviruses 2018; 34:140-147. [PMID: 28899162 PMCID: PMC5806074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2024] Open
Abstract
BACKGROUND People who are asymptomatic and feel healthy, including pregnant women, may be less motivated to initiate ART or achieve high adherence. We assessed whether ART initiation, and viral suppression 6, 12 and 24-months after ART initiation, were lower in HIV-infected members of serodiscordant couples who initiated during pregnancy or with higher CD4 counts. METHODS We used data from the Partners Demonstration Project, an open-label study of the delivery of integrated PrEP and ART (at any CD4 count) for HIV prevention among high-risk HIV serodiscordant couples in Kenya and Uganda. Differences in viral suppression (HIV RNA <400 copies/ml) among people initiating ART at different CD4 count levels (≤350, 351-500, and >500 cells/mm3) and during pregnancy were estimated using Poisson regression. RESULTS Of 865 HIV-infected participants retained after becoming eligible for ART during study follow-up, 95% initiated ART. Viral suppression 24-months after ART initiation was high overall (97%), and comparable among those initiating ART at CD4 counts >500, 351-500 and ≤350 cells/mm3 (96% vs 97% vs 97%; relative risk [RR] 0.98; 95% CI: 0.93-1.03 for CD4 >500 vs <350 and RR 0.99; 95% CI: (0.93-1.06) for CD4 351-500 vs ≤350). Viral suppression was as likely among women initiating ART primarily to prevent perinatal transmission as ART initiation for other reasons (p=0.9 at 6 months and p=0.5 at 12 months). CONCLUSIONS Nearly all HIV-infected partners initiating ART were virally suppressed by 24 months, irrespective of CD4 count or pregnancy status. These findings suggest that people initiating ART at high CD4 counts or due to pregnancy can adhere to ART as well as those starting treatment with symptomatic HIV disease or low CD4 counts.
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Affiliation(s)
- Andrew Mujugira
- University of Washington, Department of Global Health , 901 Boren Ave , Suite 1300 , Seattle, Washington, United States , 98104 ;
| | | | | | | | | | - Deborah Donnell
- Fred Hutchinson Cancer Research Center, SCHARP/VIDI/PHS , 1100 Fairview Ave N , Seattle, Washington, United States , 98109 ;
| | | | | | - Nelly Mugo
- Kenya Medical Research Institute, Nairobi, Kenya ;
| | | | | | | | | | - Elly Katabira
- Makerere University, Infectious Disease Institute, Kampala, Uganda ;
| | - Renee Heffron
- University of Washington, Department of Epidemiology, Seattle, United States ;
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Chetty T, Newell ML, Thorne C, Coutsoudis A. Viraemia before, during and after pregnancy in HIV-infected women on antiretroviral therapy in rural KwaZulu-Natal, South Africa, 2010-2015. Trop Med Int Health 2017; 23:79-91. [PMID: 29121445 DOI: 10.1111/tmi.13001] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Pregnancy and post-partum viral load suppression is critical to prevent mother-to-child HIV transmission and ensure maternal health. We measured viraemia risk before, during and after pregnancy in HIV-infected women. METHODS Between 2010 and 2015, 1425 HIV-infected pregnant women on lifelong antiretroviral therapy (ART) for at least six months pre-pregnancy were enrolled in a cohort study in rural KwaZulu-Natal, South Africa. Odds ratios were estimated in multilevel logistic regression, with pregnancy period time-varying. RESULTS Over half of 1425 women received tenofovir-based regimens (n = 791). Median pre-pregnancy ART duration was 2.1 years. Of 988 women (69.3%) with pre-pregnancy viral loads, 82.0%, 6.8% and 11.2% had VL <50, 50-999 and ≥1000 copies/ml, respectively. During pregnancy and at six, 12 and 24 months, viral load was ≥1000 copies/ml in 15.2%, 15.7%, 17.8% and 16.6% respectively; viral load <50 was 76.9%, 77%, 75.5% and 75.8%, respectively. Adjusting for age, clinical and pregnancy factors, viraemia risk (viral load ≥50 copies/ml) was not significantly associated with pregnancy [adjusted OR (aOR) 1.31; 95% CI 0.90-1.92], six months (aOR 1.30; 95% CI 0.83-2.04), 12 months (aOR 0.96; 95% CI 0.58-1.58) and 24 months (aOR 1.40; 95% CI 0.89-2.22) post-partum. Adjusting for ART duration-pregnancy period interaction, viraemia risk was 1.8 during pregnancy and twofold higher post-partum. CONCLUSIONS While undetectable viral load before pregnancy through post-partum was common, the UNAIDS goal to suppress viraemia in 90% of women was not met. Women on preconception ART remain vulnerable to viraemia; additional support is required to prevent mother-to-child HIV transmission and maintain maternal health.
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Affiliation(s)
- Terusha Chetty
- Africa Health Research Institute, KwaZulu-Natal, South Africa.,Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
| | - Marie-Louise Newell
- Faculty of Medicine, Institute for Developmental Sciences, University of Southampton, Southampton, UK
| | - Claire Thorne
- UCL Institute of Child Health, University College London, London, UK
| | - Anna Coutsoudis
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
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Mujugira A, Baeten JM, Kidoguchi L, Haberer J, Celum C, Donnell D, Ngure K, Bukusi EA, Mugo N, Asiimwe S, Odoyo J, Tindimwebwa E, Bulya N, Katabira E, Heffron R, for the Partners Demonstration Proj. High levels of viral suppression among East African HIV-infected women and men in serodiscordant partnerships initiating antiretroviral therapy with high CD4 counts and during pregnancy. AIDS Res Hum Retroviruses 2017. [PMID: 28899162 DOI: 10.1089/aid.2017.0020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND People who are asymptomatic and feel healthy, including pregnant women, may be less motivated to initiate ART or achieve high adherence. We assessed whether ART initiation, and viral suppression 6, 12 and 24-months after ART initiation, were lower in HIV-infected members of serodiscordant couples who initiated during pregnancy or with higher CD4 counts. METHODS We used data from the Partners Demonstration Project, an open-label study of the delivery of integrated PrEP and ART (at any CD4 count) for HIV prevention among high-risk HIV serodiscordant couples in Kenya and Uganda. Differences in viral suppression (HIV RNA <400 copies/ml) among people initiating ART at different CD4 count levels (≤350, 351-500, and >500 cells/mm3) and during pregnancy were estimated using Poisson regression. RESULTS Of 865 HIV-infected participants retained after becoming eligible for ART during study follow-up, 95% initiated ART. Viral suppression 24-months after ART initiation was high overall (97%), and comparable among those initiating ART at CD4 counts >500, 351-500 and ≤350 cells/mm3 (96% vs 97% vs 97%; relative risk [RR] 0.98; 95% CI: 0.93-1.03 for CD4 >500 vs <350 and RR 0.99; 95% CI: (0.93-1.06) for CD4 351-500 vs ≤350). Viral suppression was as likely among women initiating ART primarily to prevent perinatal transmission as ART initiation for other reasons (p=0.9 at 6 months and p=0.5 at 12 months). CONCLUSIONS Nearly all HIV-infected partners initiating ART were virally suppressed by 24 months, irrespective of CD4 count or pregnancy status. These findings suggest that people initiating ART at high CD4 counts or due to pregnancy can adhere to ART as well as those starting treatment with symptomatic HIV disease or low CD4 counts.
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Affiliation(s)
- Andrew Mujugira
- Department of Global Health, University of Washington, Seattle, Washington
| | - Jared M. Baeten
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
| | - Lara Kidoguchi
- Department of Global Health, University of Washington, Seattle, Washington
| | | | - Connie Celum
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
| | - Deborah Donnell
- Department of Global Health, University of Washington, Seattle, Washington
| | - Kenneth Ngure
- Department of Global Health, University of Washington, Seattle, Washington
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Juja, Kenya
| | - Elizabeth A. Bukusi
- Department of Global Health, University of Washington, Seattle, Washington
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Nelly Mugo
- Department of Global Health, University of Washington, Seattle, Washington
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Josephine Odoyo
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Nulu Bulya
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Elly Katabira
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Renee Heffron
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
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Abstract
BACKGROUND While most recent evidence does not support a role for pregnancy in accelerating HIV disease progression, very little information is available on the effects of incident pregnancy in response to antiretroviral therapy (ART). Hormonal, immune, and behavioral changes during pregnancy may influence response to ART. We sought to explore the effects of incident pregnancy (after ART initiation) on virologic, immunologic, and clinical response to ART. METHODS Data were collected from HIV-infected women participating in 3 prospective studies (Partners in Prevention Herpes simplex virus/HIV Transmission Study, Couples Observational Study, and Partners Preexposure Prophylaxis Study) from 7 countries in Africa from 2004 to 2012. Women were included in this analysis if they were ≤45 years of age, were started on ART during the study and were not pregnant at ART initiation. Pregnancy was treated as a time-dependent exposure variable covering the duration of pregnancy, including all pregnancies occurring after ART initiation. Virologic failure was defined as a viral load (VL) greater than 400 copies per milliliter ≥6 months after ART initiation and viral suppression was defined as VL ≤400 copies per milliliter. Multivariable Cox proportional hazards models were used to assess the association between pregnancy and time to viral suppression, virologic failure, World Health Organization clinical stage III/IV, and death. Linear mixed-effects models were used to assess the association between pregnancy and CD4 count and VL. All analyses were adjusted for confounders, including pre-ART CD4 count and plasma VL. RESULTS A total of 1041 women were followed, contributing 1196.1 person-years of follow-up. Median CD4 count before ART initiation was 276 cells per cubic millimeter (interquartile range, 209-375); median pre-ART VL was 17,511 copies per milliliter (interquartile range, 2480-69,286). One hundred ten women became pregnant after ART initiation. Pregnancy was not associated with time to viral suppression (adjusted hazard ratio [aHR], 1.20, 95% confidence interval [CI]: 0.82 to 1.77), time to virologic failure (aHR, 0.67, 95% CI: 0.37 to 1.22), time to World Health Organization clinical stage III or IV (aHR, 0.79, 95% CI: 0.19 to 3.30), or time to death (aHR, 2.04, 95% CI: 0.25 to 16.8). Incident pregnancy was associated with an adjusted mean decrease in CD4 T-cell count of 47.3 cells per cubic millimeter (P < 0.001), but not with difference in VL (P = 0.06). CONCLUSIONS For HIV-infected women on ART, incident pregnancy does not affect virologic control or clinical HIV disease progression. A modest decrease in CD4 T-cell count could be due to physiologic effects of pregnancy.
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Reyskens KMSE, Essop MF. HIV protease inhibitors and onset of cardiovascular diseases: a central role for oxidative stress and dysregulation of the ubiquitin-proteasome system. Biochim Biophys Acta Mol Basis Dis 2013; 1842:256-68. [PMID: 24275553 DOI: 10.1016/j.bbadis.2013.11.019] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 11/09/2013] [Accepted: 11/18/2013] [Indexed: 12/18/2022]
Abstract
The successful roll-out of highly active antiretroviral therapy (HAART) has extended life expectancy and enhanced the overall well-being of HIV-positive individuals. There are, however, increased concerns regarding HAART-mediated metabolic derangements and its potential risk for cardiovascular diseases (CVD) in the long-term. Here certain classes of antiretroviral drugs such as the HIV protease inhibitors (PIs) are strongly implicated in this process. This article largely focuses on the direct PI-linked development of cardio-metabolic complications, and reviews the inter-linked roles of oxidative stress and the ubiquitin-proteasome system (UPS) as key mediators driving this process. It is proposed that PIs trigger reactive oxygen species (ROS) production that leads to serious downstream consequences such as cell death, impaired mitochondrial function, and UPS dysregulation. Moreover, we advocate that HIV PIs may also directly lower myocardial UPS function. The attenuation of cardiac UPS can initiate transcriptional changes that contribute to perturbed lipid metabolism, thereby fueling a pro-atherogenic milieu. It may also directly alter ionic channels and interfere with electrical signaling in the myocardium. Therefore HIV PI-induced ROS together with a dysfunctional UPS elicit detrimental effects on the cardiovascular system that will eventually result in the onset of heart diseases. Thus while HIV PIs substantially improve life expectancy and quality of life in HIV-positive patients, its longer-term side-effects on the cardiovascular system should lead to a) greater clinical awareness regarding its benefit-harm paradigm, and b) the development and evaluation of novel co-treatment strategies.
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Affiliation(s)
- Kathleen M S E Reyskens
- Cardio-Metabolic Research Group (CMRG), Department of Physiological Sciences, Stellenbosch University, Stellenbosch 7600, South Africa
| | - M Faadiel Essop
- Cardio-Metabolic Research Group (CMRG), Department of Physiological Sciences, Stellenbosch University, Stellenbosch 7600, South Africa.
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Reyskens KMSE, Fisher TL, Schisler JC, O'Connor WG, Rogers AB, Willis MS, Planesse C, Boyer F, Rondeau P, Bourdon E, Essop MF. Cardio-metabolic effectsof HIV protease inhibitors (lopinavir/ritonavir). PLoS One 2013; 8:e73347. [PMID: 24098634 PMCID: PMC3787040 DOI: 10.1371/journal.pone.0073347] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 07/18/2013] [Indexed: 01/24/2023] Open
Abstract
Although antiretroviral treatment decreases HIV-AIDS morbidity/mortality, long-term side effects may include the onset of insulin resistance and cardiovascular diseases. However, the underlying molecular mechanisms responsible for highly active antiretroviral therapy (HAART)-induced cardio-metabolic effects are poorly understood. In light of this, we hypothesized that HIV protease inhibitor (PI) treatment (Lopinavir/Ritonavir) elevates myocardial oxidative stress and concomitantly inhibits the ubiquitin proteasome system (UPS), thereby attenuating cardiac function. Lopinavir/Ritonavir was dissolved in 1% ethanol (vehicle) and injected into mini-osmotic pumps that were surgically implanted into Wistar rats for 8 weeks vs. vehicle and sham controls. We subsequently evaluated metabolic parameters, gene/protein markers and heart function (ex vivo Langendorff perfusions). PI-treated rats exhibited increased serum LDL-cholesterol, higher tissue triglycerides (heart, liver), but no evidence of insulin resistance. In parallel, there was upregulation of hepatic gene expression, i.e. acetyl-CoA carboxylase β and 3-hydroxy-3-methylglutaryl-CoA-reductase, key regulators of fatty acid oxidation and cholesterol synthesis, respectively. PI-treated hearts displayed impaired cardiac contractile function together with attenuated UPS activity. However, there was no significant remodeling of hearts exposed to PIs, i.e. lack of ultrastructural changes, fibrosis, cardiac hypertrophic response, and oxidative stress. Western blot analysis of PI-treated hearts revealed that perturbed calcium handling may contribute to the PI-mediated contractile dysfunction. Here chronic PI administration led to elevated myocardial calcineurin, nuclear factor of activated T-cells 3 (NFAT3), connexin 43, and phosphorylated phospholamban, together with decreased calmodulin expression levels. This study demonstrates that early changes triggered by PI treatment include increased serum LDL-cholesterol levels together with attenuated cardiac function. Furthermore, PI exposure inhibits the myocardial UPS and leads to elevated calcineurin and connexin 43 expression that may be associated with the future onset of cardiac contractile dysfunction.
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Affiliation(s)
- Kathleen M. S. E. Reyskens
- Cardio-Metabolic Research Group (CMRG), Department of Physiological Sciences, Stellenbosch University, Stellenbosch 7600, South Africa
| | - Tarryn-Lee Fisher
- Cardio-Metabolic Research Group (CMRG), Department of Physiological Sciences, Stellenbosch University, Stellenbosch 7600, South Africa
| | - Jonathan C. Schisler
- McAllister Heart Institute, Department of Pathology & Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Wendi G. O'Connor
- McAllister Heart Institute, Department of Pathology & Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Arlin B. Rogers
- McAllister Heart Institute, Department of Pathology & Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Monte S. Willis
- McAllister Heart Institute, Department of Pathology & Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Cynthia Planesse
- Groupe d'Etude sur l'Inflammation Chronique et l'Obésité (GEICO), Plateforme CYROI, Université de La Réunion, Saint Denis de La Réunion, France
| | - Florence Boyer
- Groupe d'Etude sur l'Inflammation Chronique et l'Obésité (GEICO), Plateforme CYROI, Université de La Réunion, Saint Denis de La Réunion, France
| | - Philippe Rondeau
- Groupe d'Etude sur l'Inflammation Chronique et l'Obésité (GEICO), Plateforme CYROI, Université de La Réunion, Saint Denis de La Réunion, France
| | - Emmanuel Bourdon
- Groupe d'Etude sur l'Inflammation Chronique et l'Obésité (GEICO), Plateforme CYROI, Université de La Réunion, Saint Denis de La Réunion, France
| | - M. Faadiel Essop
- Cardio-Metabolic Research Group (CMRG), Department of Physiological Sciences, Stellenbosch University, Stellenbosch 7600, South Africa
- * E-mail:
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Patients' demographic and clinical characteristics and level of care associated with lost to follow-up and mortality in adult patients on first-line ART in Nigerian hospitals. J Int AIDS Soc 2012; 15:17424. [PMID: 23010378 PMCID: PMC3494164 DOI: 10.7448/ias.15.2.17424] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Revised: 06/25/2012] [Accepted: 08/20/2012] [Indexed: 01/03/2023] Open
Abstract
Introduction Clinical outcome is an important determinant of programme success. This study aims to evaluate patients’ baseline characteristics as well as level of care associated with lost to follow-up (LTFU) and mortality of patients on antiretroviral treatment (ART). Methods Retrospective cohort study using routine service data of adult patients initiated on ART in 2007 in 10 selected hospitals in Nigeria. We captured data using an electronic medical record system and analyzed using Stata. Outcome measures were probability of being alive and retained in care at 12, 24 and 36 months on ART. Potential predictors associated with time to mortality and time to LTFU were assessed using competing risks regression models. Results After 12 months on therapy, 85% of patients were alive and on ART. Survival decreased to 81.2% and 76.1% at 24 and 36 months, respectively. Median CD4 count for patients at ART start, 12, 18 and 24 months were 152 (interquartile range, IQR: 75 to 242), 312 (IQR: 194 to 450), 344 (IQR: 227 to 501) and 372 (IQR: 246 to 517) cells/µl, respectively. Competing risk regression showed that patients’ baseline characteristics significantly associated with LTFU were male (adjusted sub-hazard ratio, sHR=1.24 [95% CI: 1.08 to 1.42]), ambulatory functional status (adjusted sHR=1.25 [95% CI: 1.01 to 1.54]), World Health Organization (WHO) clinical Stage II (adjusted sHR=1.31 [95% CI: 1.08 to 1.59]) and care in a secondary site (adjusted sHR=0.76 [95% CI: 0.66 to 0.87]). Those associated with mortality include CD4 count <50 cells/µl (adjusted sHR=2.84 [95% CI: 1.20 to 6.71]), WHO clinical Stage III (adjusted sHR=2.67 [95% CI: 1.26 to 5.65]) and Stage IV (adjusted sHR=5.04 [95% CI: 1.93 to 13.16]) and care in a secondary site (adjusted sHR=2.21 [95% CI: 1.30 to 3.77]). Conclusions Mortality was associated with advanced HIV disease and care in secondary facilities. Earlier initiation of therapy and strengthening systems in secondary level facilities may improve retention and ultimately contribute to better clinical outcomes.
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Mills EJ, Bakanda C, Birungi J, Chan K, Hogg RS, Ford N, Nachega JB, Cooper CL. Male gender predicts mortality in a large cohort of patients receiving antiretroviral therapy in Uganda. J Int AIDS Soc 2011; 14:52. [PMID: 22050673 PMCID: PMC3220631 DOI: 10.1186/1758-2652-14-52] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2011] [Accepted: 11/03/2011] [Indexed: 12/20/2022] Open
Abstract
Background Because men in Africa are less likely to access HIV/AIDS care than women, we aimed to determine if men have differing outcomes from women across a nationally representative sample of adult patients receiving combination antiretroviral therapy in Uganda. Methods We estimated survival distributions for adult male and female patients using Kaplan-Meier, and constructed multivariable regressions to model associations of baseline variables with mortality. We assessed person-years of life lost up to age 55 by sex. To minimize the impact of patient attrition, we assumed a weighted 30% mortality rate among those lost to follow up. Results We included data from 22,315 adults receiving antiretroviral therapy. At baseline, men tended to be older, had lower CD4 baseline values, more advanced disease, had pulmonary tuberculosis and had received less treatment follow up (all at p < 0.001). Loss to follow up differed between men and women (7.5 versus 5.9%, p < 0.001). Over the period of study, men had a significantly increased risk of death compared with female patients (adjusted hazard ratio 1.43, 95% CI 1.31-1.57, p < 0.001). The crude mortality rate for males differed importantly from females (43.9, 95% CI 40.7-47.0/1000 person-years versus 26.9, 95% CI 25.4-28.5/1000 person years, p < 0.001). The probability of survival was 91.2% among males and 94.1% among females at 12 months. Person-years of life lost was lower for females than males (689.7 versus 995.9 per 1000 person-years, respectively). Conclusions In order to maximize the benefits of antiretroviral therapy, treatment programmes need to be gender sensitive to the specific needs of both women and men. Particular efforts are needed to enroll men earlier into care.
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Affiliation(s)
- Edward J Mills
- Faculty of Health Sciences, University of Ottawa, Ottawa, Canada.
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Koethe JR, Jenkins CA, Shepherd BE, Stinnette SE, Sterling TR. An optimal body mass index range associated with improved immune reconstitution among HIV-infected adults initiating antiretroviral therapy. Clin Infect Dis 2011; 53:952-60. [PMID: 21946189 DOI: 10.1093/cid/cir606] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Higher body mass index (BMI) was associated with slower human immunodeficiency virus (HIV) disease progression before the availability of effective antiretroviral therapy (ART), but the relationship between pretreatment BMI and CD4(+) lymphocyte recovery on ART is not well described. METHODS We conducted an observational cohort study of HIV-infected, ART-naive adults starting treatment at a clinic affiliated with Vanderbilt University in Nashville, Tennessee. We assessed the relationship between pretreatment BMI and CD4(+) lymphocyte count change from baseline to 12 months in all subjects, among those with plasma HIV-1 RNA levels <400 copies/mL for ≥ 6 months and those with <10% change in weight during follow-up. Linear regression models were adjusted for age, sex, race, protease inhibitor usage, year of ART initiation, and baseline CD4(+) lymphocyte count and HIV-1 RNA level. RESULTS A total of 915 patients met inclusion criteria; 78% were male, and their median age, BMI, and CD4(+) lymphocyte count were 39 years, 24 kg/m², and 171 cells/μL, respectively. The CD4(+) lymphocyte increase at 12 months was greatest among patients with a pretreatment BMI of ~25-30 kg/m² and diminished above and below this range (P = .03). Similar patterns were observed in the subgroup analyses. Among patients with a pretreatment CD4(+) lymphocyte count < 200 cells/μL, a BMI of ~25 kg/m² was associated with the highest odds of reaching a CD4(+) lymphocyte count > 350 cells/μL at 12 months (P = .05). CONCLUSIONS 12-month immune reconstitution on ART was highest among patients commonly classified as overweight, suggesting there may be an optimal BMI range for immune recovery on ART.
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Affiliation(s)
- John R Koethe
- Department of Medicine, Division of Infectious Diseases, Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
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Westreich D, Cole SR, Nagar S, Maskew M, van der Horst C, Sanne I. Pregnancy and virologic response to antiretroviral therapy in South Africa. PLoS One 2011; 6:e22778. [PMID: 21829650 PMCID: PMC3149058 DOI: 10.1371/journal.pone.0022778] [Citation(s) in RCA: 20] [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: 01/31/2011] [Accepted: 07/05/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Although women of reproductive age are the largest group of HIV-infected individuals in sub-Saharan Africa, little is known about the impact of pregnancy on response to highly active antiretroviral therapy (HAART) in that setting. We examined the effect of incident pregnancy after HAART initiation on virologic response to HAART. METHODS AND FINDINGS We evaluated a prospective clinical cohort of adult women who initiated HAART in Johannesburg, South Africa between 1 April 2004 and 30 September 2009, and followed up until an event, death, transfer, drop-out, or administrative end of follow-up on 31 March 2010. Women over age 45 and women who were pregnant at HAART initiation were excluded from the study; final sample size for analysis was 5,494 women. Main exposure was incident pregnancy, experienced by 541 women; main outcome was virologic failure, defined as a failure to suppress virus to ≤ 400 copies/ml by six months or virologic rebound >400 copies/ml thereafter. We calculated adjusted hazard ratios using marginal structural Cox proportional hazards models and weighted lifetable analysis to calculate adjusted five-year risk differences. The weighted hazard ratio for the effect of pregnancy on time to virologic failure was 1.34 (95% confidence limit [CL] 1.02, 1.78). Sensitivity analyses generally confirmed these main results. CONCLUSIONS Incident pregnancy after HAART initiation was associated with modest increases in both relative and absolute risks of virologic failure, although uncontrolled confounding cannot be ruled out. Nonetheless, these results reinforce that family planning is an essential part of care for HIV-positive women in sub-Saharan Africa. More work is needed to confirm these findings and to explore specific etiologic pathways by which such effects may operate.
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Affiliation(s)
- Daniel Westreich
- Department of Obstetrics and Gynecology, Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America.
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