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Prendergast AJ, Szubert AJ, Pimundu G, Berejena C, Pala P, Shonhai A, Hunter P, Arrigoni FIF, Musiime V, Bwakura-Dangarembizi M, Musoke P, Poulsom H, Kihembo M, Munderi P, Gibb DM, Spyer MJ, Walker AS, Klein N. The impact of viraemia on inflammatory biomarkers and CD4+ cell subpopulations in HIV-infected children in sub-Saharan Africa. AIDS 2021; 35:1537-1548. [PMID: 34270487 PMCID: PMC7611315 DOI: 10.1097/qad.0000000000002916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the impact of virological control on inflammation and cluster of differentiation 4 depletion among HIV-infected children initiating antiretroviral therapy (ART) in sub-Saharan Africa. DESIGN Longitudinal cohort study. METHODS In a sub-study of the ARROW trial (ISRCTN24791884), we measured longitudinal HIV viral loads, inflammatory biomarkers (C-reactive protein, tumour necrosis factor alpha, interleukin 6 (IL-6), soluble CD14) and (Uganda only) whole blood immunophenotype by flow cytometry in 311 Zimbabwean and Ugandan children followed for median 3.5 years on first-line ART. We classified each viral load measurement as consistent suppression, blip/post-blip, persistent low-level viral load or rebound. We used multi-level models to estimate rates of increase or decrease in laboratory markers, and Poisson regression to estimate the incidence of clinical events. RESULTS Overall, 42% children experienced viral blips, but these had no significant impact on immune reconstitution or inflammation. Persistent detectable viraemia occurred in one-third of children and prevented further immune reconstitution, but had little impact on inflammatory biomarkers. Virological rebound to ≥5000 copies/ml was associated with arrested immune reconstitution, rising IL-6 and increased risk of clinical disease progression. CONCLUSIONS As viral load testing becomes more available in sub-Saharan Africa, repeat testing algorithms will be required to identify those with virological rebound, who need switching to prevent disease progression, whilst preventing unnecessary second-line regimen initiation in the majority of children with detectable viraemia who remain at low risk of disease progression.
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Affiliation(s)
| | | | | | | | - Pietro Pala
- MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda
| | | | | | | | - Victor Musiime
- Joint Clinical Research Centre, Kampala, Uganda
- Makerere University College of Health Sciences
| | | | | | | | | | | | | | | | | | - Nigel Klein
- UCL Great Ormond Street Institute of Child Health
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Gough EK, Bourke CD, Berejena C, Shonhai A, Bwakura-Dangarembizi M, Prendergast AJ, Manges AR. Strain-level analysis of gut-resident pro-inflammatory viridans group Streptococci suppressed by long-term cotrimoxazole prophylaxis among HIV-positive children in Zimbabwe. Gut Microbes 2020; 11:1104-1115. [PMID: 32024435 PMCID: PMC7524282 DOI: 10.1080/19490976.2020.1717299] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Antimicrobials have become a mainstay of healthcare in the past century due to their activity against pathogens. More recently, it has become clear that they can also affect health via their impact on the microbiota and inflammation. This may explain some of their clinical benefits despite global increases in antimicrobial resistance (AMR) and reduced antimicrobial effectiveness. We showed in a randomized controlled trial of stopping versus continuing cotrimoxazole prophylaxis among HIV-positive Zimbabwean children taking antiretroviral therapy (ART), that continuation of cotrimoxazole persistently suppressed gut-resident viridans group streptococcal species (VGS) that were associated with intestinal inflammation. In this addendum, we provide a broader overview of how antibiotics can shape the microbiota and use high read-depth whole metagenome sequencing data from our published study to investigate whether (i) the impact of cotrimoxazole on gut VGS and (ii) VGS associated inflammation, is attributable to strain-level variability. We focus on S. salivarius, the VGS species that was most prevalent in the cohort and for which there was sufficient genome coverage to differentiate strains. We demonstrate that suppression of S. salivarius by cotrimoxazole is not strain specific, nor did stool concentration of the pro-inflammatory mediator myeloperoxidase vary by S. salivarius strain. We also show that gut-resident S. salivarius strains present in this study population are distinct from common oral strains. This is the first analysis of how cotrimoxazole prophylaxis used according to international treatment guidelines for children living with HIV influences the gut microbiome at the strain-level. We also provide a detailed review of the literature on the mechanisms by which suppression of VGS may act synergistically with cotrimoxazole's anti-inflammatory effects to reduce gut inflammation. A greater understanding of the sub-clinical effects of antibiotics offers new insights into their responsible clinical use.
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Affiliation(s)
- Ethan K. Gough
- Department of International Health, Division of Human Nutrition, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA,CONTACT Ethan K. Gough Department of International Health, Division of Human Nutrition, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Claire D. Bourke
- Blizard Institute, Queen Mary University of London, London, UK,Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Chipo Berejena
- College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Annie Shonhai
- College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | | | - Andrew J. Prendergast
- Blizard Institute, Queen Mary University of London, London, UK,Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe,MRC Clinical Trials Unit at University College London, London, UK
| | - Amee R. Manges
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
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Bourke CD, Gough EK, Pimundu G, Shonhai A, Berejena C, Terry L, Baumard L, Choudhry N, Karmali Y, Bwakura-Dangarembizi M, Musiime V, Lutaakome J, Kekitiinwa A, Mutasa K, Szubert AJ, Spyer MJ, Deayton JR, Glass M, Geum HM, Pardieu C, Gibb DM, Klein N, Edens TJ, Walker AS, Manges AR, Prendergast AJ. Cotrimoxazole reduces systemic inflammation in HIV infection by altering the gut microbiome and immune activation. Sci Transl Med 2020; 11:11/486/eaav0537. [PMID: 30944164 DOI: 10.1126/scitranslmed.aav0537] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 11/21/2018] [Accepted: 02/14/2019] [Indexed: 12/21/2022]
Abstract
Long-term cotrimoxazole prophylaxis reduces mortality and morbidity in HIV infection, but the mechanisms underlying these clinical benefits are unclear. Here, we investigate the impact of cotrimoxazole on systemic inflammation, an independent driver of HIV mortality. In HIV-positive Ugandan and Zimbabwean children receiving antiretroviral therapy, we show that plasma inflammatory markers were lower after randomization to continue (n = 144) versus stop (n = 149) cotrimoxazole. This was not explained by clinical illness, HIV progression, or nutritional status. Because subclinical enteropathogen carriage and enteropathy can drive systemic inflammation, we explored cotrimoxazole effects on the gut microbiome and intestinal inflammatory biomarkers. Although global microbiome composition was unchanged, viridans group Streptococci and streptococcal mevalonate pathway enzymes were lower among children continuing (n = 36) versus stopping (n = 36) cotrimoxazole. These changes were associated with lower fecal myeloperoxidase. To isolate direct effects of cotrimoxazole on immune activation from antibiotic effects, we established in vitro models of systemic and intestinal inflammation. In vitro cotrimoxazole had modest but consistent inhibitory effects on proinflammatory cytokine production by blood leukocytes from HIV-positive (n = 16) and HIV-negative (n = 8) UK adults and reduced IL-8 production by gut epithelial cell lines. Collectively we demonstrate that cotrimoxazole reduces systemic and intestinal inflammation both indirectly via antibiotic effects on the microbiome and directly by blunting immune and epithelial cell activation. Synergy between these pathways may explain the clinical benefits of cotrimoxazole despite high antimicrobial resistance, providing further rationale for extending coverage among people living with HIV in sub-Saharan Africa.
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Affiliation(s)
- Claire D Bourke
- Blizard Institute, Queen Mary University of London, London E1 2AT, UK.
| | - Ethan K Gough
- School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
| | | | - Annie Shonhai
- College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Chipo Berejena
- College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Louise Terry
- Royal London Hospital, Barts Health NHS Trust, London E1 1BB, UK
| | - Lucas Baumard
- Blizard Institute, Queen Mary University of London, London E1 2AT, UK
| | - Naheed Choudhry
- Blizard Institute, Queen Mary University of London, London E1 2AT, UK
| | - Yusuf Karmali
- Blizard Institute, Queen Mary University of London, London E1 2AT, UK
| | | | - Victor Musiime
- Joint Clinical Research Centre, Kampala, Uganda.,College of Health Sciences, Department of Paediatrics and Child Health, Makerere University, Kampala, Uganda
| | - Joseph Lutaakome
- Uganda Virus Research Institute/MRC Uganda Research Unit on AIDS, Entebbe, Uganda
| | - Adeodata Kekitiinwa
- Baylor College of Medicine Children's Foundation-Uganda, Mulago Hospital, Kampala, Uganda
| | - Kuda Mutasa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | | | - Moira J Spyer
- MRC Clinical Trials Unit at University College London, London WC1V 6LJ, UK
| | - Jane R Deayton
- Blizard Institute, Queen Mary University of London, London E1 2AT, UK.,Royal London Hospital, Barts Health NHS Trust, London E1 1BB, UK
| | - Magdalena Glass
- School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
| | - Hyun Min Geum
- School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
| | - Claire Pardieu
- Blizard Institute, Queen Mary University of London, London E1 2AT, UK
| | - Diana M Gibb
- MRC Clinical Trials Unit at University College London, London WC1V 6LJ, UK
| | - Nigel Klein
- UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
| | - Thaddeus J Edens
- Devil's Staircase Consulting, West Vancouver, British Columbia V7T 1V7, Canada
| | - A Sarah Walker
- MRC Clinical Trials Unit at University College London, London WC1V 6LJ, UK
| | - Amee R Manges
- School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
| | - Andrew J Prendergast
- Blizard Institute, Queen Mary University of London, London E1 2AT, UK.,Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe.,MRC Clinical Trials Unit at University College London, London WC1V 6LJ, UK
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Prendergast AJ, Szubert AJ, Berejena C, Pimundu G, Pala P, Shonhai A, Musiime V, Bwakura-Dangarembizi M, Poulsom H, Hunter P, Musoke P, Kihembo M, Munderi P, Gibb DM, Spyer M, Walker AS, Klein N. Baseline Inflammatory Biomarkers Identify Subgroups of HIV-Infected African Children With Differing Responses to Antiretroviral Therapy. J Infect Dis 2016; 214:226-36. [PMID: 27190179 PMCID: PMC4918830 DOI: 10.1093/infdis/jiw148] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 04/04/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Identifying determinants of morbidity and mortality may help target future interventions for human immunodeficiency virus (HIV)-infected children. METHODS CD4(+) T-cell count, HIV viral load, and levels of biomarkers (C-reactive protein, tumor necrosis factor α [TNF-α], interleukin 6 [IL-6], and soluble CD14) and interleukin 7 were measured at antiretroviral therapy (ART) initiation in the ARROW trial (case-cohort design). Cases were individuals who died, had new or recurrent World Health Organization clinical stage 4 events, or had poor immunological response to ART. RESULTS There were 115 cases (54 died, 45 had World Health Organization clinical stage 4 events, and 49 had poor immunological response) and 485 controls. Before ART initiation, the median ages of cases and controls were 8.2 years (interquartile range [IQR], 4.4-11.4 years) and 5.8 years (IQR, 2.3-9.3 years), respectively, and the median percentages of lymphocytes expressing CD4 were 4% (IQR, 1%-9%) and 13% (IQR, 8%-18%), respectively. In multivariable logistic regression, cases had lower age-associated CD4(+) T-cell count ratio (calculated as the ratio of the subject's CD4(+) T-cell count to the count expected in healthy individuals of the same age; P < .0001) and higher IL-6 level (P = .002) than controls. Clustering biomarkers and age-associated CD4(+) and CD8(+) T-cell count ratios identified 4 groups of children. Group 1 had the highest frequency of cases (41% cases; 16% died) and profound immunosuppression; group 2 had similar mortality (23% cases; 15% died), but children were younger, with less profound immunosuppression and high levels of inflammatory biomarkers and malnutrition; group 3 comprised young children with moderate immunosuppression, high TNF-α levels, and high age-associated CD8(+) T-cell count ratios but lower frequencies of events (12% cases; 7% died); and group 4 comprised older children with low inflammatory biomarker levels, lower HIV viral loads, and good clinical outcomes (11% cases; 5% died). CONCLUSIONS While immunosuppression is the major determinant of poor outcomes during ART, baseline inflammation is an additional important factor, identifying a subgroup of young children with similar mortality. Antiinflammatory interventions may help improve outcomes.
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Affiliation(s)
- Andrew J Prendergast
- Queen Mary University of London MRC Clinical Trials Unit at University College London
| | | | | | | | - Pietro Pala
- MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda
| | | | - Victor Musiime
- Joint Clinical Research Centre Makerere University College of Health Sciences
| | | | | | | | - Philippa Musoke
- Paediatric Infectious Diseases Clinic/Baylor-Uganda, Kampala
| | | | - Paula Munderi
- MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda
| | - Diana M Gibb
- MRC Clinical Trials Unit at University College London
| | - Moira Spyer
- MRC Clinical Trials Unit at University College London
| | | | - Nigel Klein
- Institute of Child Health, London, United Kingdom
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Chimhuya S, Manangazira P, Mukaratirwa A, Nziramasanga P, Berejena C, Shonhai A, Kamupota M, Gerede R, Munyoro M, Mangwanya D, Tapfumaneyi C, Byabamazima C, Shibeshi EM, Nathoo KJ. Trends of rubella incidence during a 5-year period of case based surveillance in Zimbabwe. BMC Public Health 2015; 15:294. [PMID: 25885586 PMCID: PMC4391168 DOI: 10.1186/s12889-015-1642-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 03/16/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Rubella is a disease of public health significance owing to its adverse effects during pregnancy and on pregnancy outcomes. Women who contract rubella virus during pregnancy may experience complications such as foetal death or give birth to babies born with congenital rubella syndrome. Vaccination against rubella is the most effective and economical approach to control the disease, and to avoid the long term effects and high costs of care for children with congenital rubella syndrome as well as to prevent death from complications. Zimbabwe commenced rubella surveillance in 1999, despite lacking a rubella vaccine in the national Expanded Programme on Immunization, as per the World Health Organization recommendation to establish a surveillance system to estimate the disease burden before introduction of a rubella vaccine. The purpose of this analysis is to describe the disease trends and population demographics of rubella cases that were identified through the Zimbabwe national measles and rubella case-based surveillance system during a 5-year period between 2007 and 2011. METHODS Data from the Zimbabwe National Measles Laboratory for the 5-year study period were analysed for age, sex, district of origin, seasonality, and rubella IgM serostatus. RESULTS A total of 3428 serum samples from cases of suspected measles in all administrative districts of the country were received by the laboratory during this period. Cases included 51% males and 49% females. Of these, 2999 were tested for measles IgM of which 697 (23.2%) were positive. Of the 2302 measles IgM-negative samples, 865 (37.6%) were rubella IgM-positive. Ninety-eight percent of confirmed rubella cases were children younger than 15 years of age. Most infections occurred during the dry season. CONCLUSIONS The national case-based surveillance revealed the disease burden and trends of rubella in Zimbabwe. These data add to the evidence for introducing rubella-containing vaccine into the national immunization programme.
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Affiliation(s)
- Simbarashe Chimhuya
- Department of Paediatrics and Child Health, University of Zimbabwe-College of Health Sciences, Mazoe Street, A178, Avondale, Harare, Zimbabwe.
| | - Portia Manangazira
- Epidemiology and Disease Control Directorate, Ministry of Health and Child Care, Harare, Zimbabwe.
| | - Arnold Mukaratirwa
- Medical Microbiology Department, University of Zimbabwe-College of Health Sciences, Mazoe Street, A178, Avondale, Harare, Zimbabwe.
| | - Pasipanodya Nziramasanga
- Medical Microbiology Department, University of Zimbabwe-College of Health Sciences, Mazoe Street, A178, Avondale, Harare, Zimbabwe.
| | - Chipo Berejena
- Medical Microbiology Department, University of Zimbabwe-College of Health Sciences, Mazoe Street, A178, Avondale, Harare, Zimbabwe.
| | - Annie Shonhai
- Medical Microbiology Department, University of Zimbabwe-College of Health Sciences, Mazoe Street, A178, Avondale, Harare, Zimbabwe.
| | - Mary Kamupota
- Expanded Programme of Immunization, Ministry of Health and Child Care, Harare, Zimbabwe.
| | - Regina Gerede
- Expanded Programme of Immunization, Ministry of Health and Child Care, Harare, Zimbabwe.
| | - Mary Munyoro
- Expanded Programme of Immunization, World Health Organization, Harare, Zimbabwe.
| | - Douglas Mangwanya
- Laboratory Services Directorate, Ministry of Health and Child Care, Harare, Zimbabwe.
| | | | - Charles Byabamazima
- Immunization and Vaccines Development, East and South Africa Inter-Country Support Team, World Health Organization, Harare, Zimbabwe.
| | - Eshetu Messeret Shibeshi
- Immunization and Vaccines Development, East and South Africa Inter-Country Support Team, World Health Organization, Harare, Zimbabwe.
| | - Kusum Jackison Nathoo
- Department of Paediatrics and Child Health, University of Zimbabwe-College of Health Sciences, Mazoe Street, A178, Avondale, Harare, Zimbabwe.
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Nyaga MM, Stucker KM, Esona MD, Jere KC, Mwinyi B, Shonhai A, Tsolenyanu E, Mulindwa A, Chibumbya JN, Adolfine H, Halpin RA, Roy S, Stockwell TB, Berejena C, Seheri ML, Mwenda JM, Steele AD, Wentworth DE, Mphahlele MJ. Whole-genome analyses of DS-1-like human G2P[4] and G8P[4] rotavirus strains from Eastern, Western and Southern Africa. Virus Genes 2014; 49:196-207. [PMID: 24952422 DOI: 10.1007/s11262-014-1091-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2014] [Accepted: 05/27/2014] [Indexed: 01/02/2023]
Abstract
Group A rotaviruses (RVAs) with distinct G and P genotype combinations have been reported globally. We report the genome composition and possible origin of seven G8P[4] and five G2P[4] human RVA strains based on the genetic evolution of all 11 genome segments at the nucleotide level. Twelve RVA ELISA positive stool samples collected in the representative countries of Eastern, Southern and West Africa during the 2007-2012 surveillance seasons were subjected to sequencing using the Ion Torrent PGM and Illumina MiSeq platforms. A reference-based assembly was performed using CLC Bio's clc_ref_assemble_long program, and full-genome consensus sequences were obtained. With the exception of the neutralising antigen, VP7, all study strains exhibited the DS-1-like genome constellation (P[4]-I2-R2-C2-M2-A2-N2-T2-E2-H2) and clustered phylogenetically with reference strains having a DS-1-like genetic backbone. Comparison of the nucleotide and amino acid sequences with selected global cognate genome segments revealed nucleotide and amino acid sequence identities of 81.7-100 % and 90.6-100 %, respectively, with NSP4 gene segment showing the most diversity among the strains. Bayesian analyses of all gene sequences to estimate the time of divergence of the lineage indicated that divergence times ranged from 16 to 44 years, except for the NSP4 gene where the lineage seemed to arise in the more distant past at an estimated 203 years ago. However, the long-term effects of changes found within the NSP4 genome segment should be further explored, and thus we recommend continued whole-genome analyses from larger sample sets to determine the evolutionary mechanisms of the DS-1-like strains collected in Africa.
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Affiliation(s)
- Martin M Nyaga
- South African Medical Research Council/UL Diarrhoeal Pathogens Research Unit (MRC/DPRU), Department of Virology, University of Limpopo (Medunsa Campus) and National Health Laboratory Service, PO Box 173, Medunsa, Pretoria, 0204, South Africa
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