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Marcus R, C P, Gill K, Smith P, Rouhani S, Mendelsohn A, Mendel E, Lince-Deroche N, Naidoo K, Ahmed N, Stirrup O, Roseleur J, Leuner R, Meyer-Rath G, Bekker LG. Acceptability, feasibility and cost of point of care testing for sexually transmitted infections among South African adolescents where syndromic management is standard of care. BMC Health Serv Res 2023; 23:1078. [PMID: 37817160 PMCID: PMC10566254 DOI: 10.1186/s12913-023-10068-8] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 09/25/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND Young people (YP) in southern Africa are at substantial risk of HIV and sexually transmitted infections (STIs). Despite the epidemiological and biological link between STIs and HIV transmission and acquisition, infections such as Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) remain widely undiagnosed. Syndromic STI management is the standard of care in low- and middle-income countries (LMICs) despite a high prevalence of asymptomatic infections. We conducted an observational study to explore the acceptability, feasibility, and cost of a STI test-and-treat service for YP in Cape Town. METHODS YP attending a mobile clinic (MC) and a youth centre clinic (YC) were offered STI screening. Urine testing for CT and NG using a 90-min molecular point-of-care (POC) test on the GeneXpert platform was conducted and treatment provided. Data were collated on demographics, sexual behaviour, presence of symptoms, uptake of same-day treatment, prevalence of CT/NG, and service acceptability. RESULTS Three hundred sixty six participants were enrolled (median age 20, 83% female).57% (209/366) of participants tested positive for either CT (126/366, 34%) or NG (57/366, 16%) or co-infection (26/366, 7%). Clinical symptoms were a poor predictor of GeneXpert diagnosed CT or NG, with a sensitivity of 46.8% and 54.0% for CT and NG respectively. Although half of participants initially chose to receive same day results and treatment, only a third waited for results on the day. The majority of participants (91%) rated the service highly via a post-visit acceptability questionnaire. CONCLUSION Curable STIs are highly prevalent in this population. STI screening using POC testing was feasible and acceptability was high. The study provides further impetus for moving policy beyond syndromic management of STIs in South Africa.
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Affiliation(s)
- Rebecca Marcus
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa.
- North Middlesex University Hospital, London, UK.
| | - Pike C
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - K Gill
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - P Smith
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - S Rouhani
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - A Mendelsohn
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - E Mendel
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - N Lince-Deroche
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa
| | - K Naidoo
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - N Ahmed
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
- Mortimer Market Centre, Central North West London NHS Trust, London, UK
| | - O Stirrup
- Institute for Global Health, University College London, London, UK
| | - J Roseleur
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa
| | - R Leuner
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa
| | - G Meyer-Rath
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, School of Public Health, Boston University, Massachusetts, USA
| | - L G Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
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Pike C, Coakley C, Ahmed N, Lee D, Little F, Padian N, Bekker LG. Goals for girls: a cluster-randomized trial to investigate a school-based sexual health programme amongst female learners in South Africa. Health Educ Res 2023; 38:375-391. [PMID: 37405698 PMCID: PMC10516375 DOI: 10.1093/her/cyad025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 06/22/2023] [Accepted: 06/26/2023] [Indexed: 07/06/2023]
Abstract
The delivery of comprehensive sexuality education to adolescents at school is recognized as a long-term strategy to support adolescent health. Suboptimal sexual and reproductive health (SRH) outcomes among South African adolescents necessitate the ongoing development and optimization of SRH education and promotion models. We conducted a cluster-randomized controlled trial amongst secondary schools (n = 38) in Cape Town, South Africa, to evaluate a sport-based, near-peer-led SRH curriculum, SKILLZ, amongst female learners (n = 2791). Biomedical (sexually transmitted infections [STIs], human immunodeficiency virus [HIV] and pregnancy) and socio-behavioural (social support, gender norms and self-concept) outcomes were assessed pre and post intervention. Attendance at SKILLZ was low and intervention participants did not show an improvement in SRH outcomes, with HIV and pregnancy incidence remaining stable and STI prevalence remaining high and increasing in both control and intervention arms. Although evidence of positive socio-behavioural measures was present at baseline, participants with high attendance showed further improvement in positive gender norms. SKILLZ did not demonstrate the capacity to significantly impact clinical SRH outcomes. Modest improvements in outcomes amongst high attenders suggest that the impact may be possible with improved attendance; however, in the absence of optimal attendance, alternative intervention strategies may be required to improve SRH outcomes amongst adolescents.
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Affiliation(s)
- C Pike
- Desmond Tutu HIV Centre, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town 7925, South Africa
| | - C Coakley
- Desmond Tutu HIV Centre, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town 7925, South Africa
- Centre for Social Science Research, Faculty of Humanities, University of Cape Town, Cape Town 7701, South Africa
| | - N Ahmed
- Desmond Tutu HIV Centre, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town 7925, South Africa
- Mortimer Market Centre, Central North West London NHS Trust, Off Caper Street, London WC1E 6 JB, UK
| | - D Lee
- Grassroot Soccer, 35 Jamieson Street, Cape Town 7784, South Africa
| | - F Little
- Department of Statistical Sciences, University of Cape Town, Private Bag X3, Rhodes Gift, Cape Town 7707, South Africa
| | - N Padian
- Grassroot Soccer, 35 Jamieson Street, Cape Town 7784, South Africa
- School of Medicine University of California San Francisco, San Francisco, CA 94143, USA
| | - L G Bekker
- Desmond Tutu HIV Centre, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town 7925, South Africa
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Gill K, Johnson L, Dietrich J, Myer L, Marcus R, Wallace M, Pidwell T, Mendel E, Fynn L, Jones K, Wiesner L, Slack C, Strode A, Spiegel H, Hosek S, Rooney J, Gray G, Bekker LG. Acceptability, safety, and patterns of use of oral tenofovir disoproxil fumarate and emtricitabine for HIV pre-exposure prophylaxis in South African adolescents: an open-label single-arm phase 2 trial. Lancet Child Adolesc Health 2020; 4:875-883. [PMID: 33222803 PMCID: PMC9832157 DOI: 10.1016/s2352-4642(20)30248-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/22/2020] [Accepted: 07/14/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND HIV incidence among adolescents in southern Africa remains unacceptably high. Pre-exposure prophylaxis (PrEP) is an effective HIV prevention intervention but there are few data on its implementation among adolescents. We aimed to investigate the safety, feasibility, and acceptability of PrEP with oral tenofovir disoproxil fumarate and emtricitabine as part of a comprehensive HIV prevention package in an adolescent population in South Africa. METHODS This open-label single-arm phase 2 study (PlusPills) was done in two research clinics in Cape Town and Johannesburg, South Africa. Adolescents aged 15-19 years were recruited into the study through recruitment events and outreach in the community. Potential participants were eligible for enrolment if they reported being sexually active. Exclusion criteria were a positive test for HIV or pregnancy at enrolment, breastfeeding, or any relevant co-morbidities. Participants were given oral tenofovir disoproxil fumarate and emtricitabine for PrEP to take daily for the first 12 weeks and were then given the choice to opt in or out of PrEP use at three monthly intervals during scheduled clinic visits. Participants were invited to monthly visits for adherence counselling and HIV testing during the study period. The primary outcomes were acceptability, use, and safety of PrEP. Acceptability was measured by the proportion of participants who reported willingness to take up PrEP and remain on PrEP at each study timepoint. Use was defined as the number of participants who continued to use PrEP after the initial 12-week period until the end of the study (week 48). Safety was measured by grade 2, 3, and 4 laboratory and clinical adverse events using the Division of AIDS table for grading the severity of adult and paediatric adverse events, version 1.0. Dried blood spot samples were collected at each study time-point to measure tenofovir diphosphate concentrations. This trial is registered with ClinicalTrials.gov, NCT02213328. FINDINGS Between April 28, 2015, and Nov 11, 2016, 244 participants were screened, and 148 participants were enrolled (median age was 18 years; 99 participants [67%] were female) and initiated PrEP. PrEP was stopped by 26 of the 148 (18%) participants at 12 weeks. Cumulative PrEP opt-out, from the total cohort, was 41% (60 of 148 participants) at week 24 and 43% (63 of 148 participants) at week 36. PrEP was well tolerated with only minor adverse events (grade 2) thought to be related to study drug, which included headache (n=4, 3%), gastrointestinal upset (n=8, 5%), and skin rash (n=2, 1%). Two participants (1%) experienced grade 3 weight loss, which was deemed related to the study drug and resolved fully when PrEP was discontinued. Tenofovir diphosphate concentrations were detectable (>16 fmol/punch) in dried blood spot samples in 108 (92%) of 118 participants who reported PrEP use at week 12, in 74 (74%) of 100 participants at week 24, and in 22 (59%) of 37 participants by the study end at week 48. INTERPRETATION In this cohort of self-selected South African adolescents at risk of HIV acquisition, PrEP appears safe and tolerable in those who continued use. PrEP use decreased throughout the course of the study as the number of planned study visits declined. Adolescents in southern Africa needs access to PrEP with tailored adherence support and possibly the option for more frequent and flexible visit schedules. FUNDING National Institute of Allergy and Infectious Diseases of the US National Institutes of Health.
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Affiliation(s)
- K Gill
- Desmond Tutu HIV Centre, University of Cape town, Observatory, Cape Town, South Africa
| | - L Johnson
- Centre for Infectious Diseases Epidemiology and Research, University of Cape Town, South Africa
| | - J Dietrich
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - L Myer
- Health Systems Research Unit, South African Medical Research Council, Western Cape, South Africa
| | - R Marcus
- Desmond Tutu HIV Centre, University of Cape town, Observatory, Cape Town, South Africa
| | - M Wallace
- Cancer Association of South Africa (CANSA)
| | - T Pidwell
- Desmond Tutu HIV Centre, University of Cape town, Observatory, Cape Town, South Africa
| | - E Mendel
- Desmond Tutu HIV Centre, University of Cape town, Observatory, Cape Town, South Africa
| | - L Fynn
- Desmond Tutu HIV Centre, University of Cape town, Observatory, Cape Town, South Africa
| | - K Jones
- Vagelos College of Physicians and Surgeons, Columbia University, New York, USA
| | - L Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
| | - C Slack
- HIV AIDS Vaccines Ethics Group, University of KwaZulu- Natal, South Africa
| | - A Strode
- School of Socio Legal Studies, School of Law, Pietermaritzburg, University of KwaZulu-Natal, Private Bag X01, Scottsville
| | - H Spiegel
- Kelly Government Solutions, Contractor to National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services, Rockville, USA
| | - S Hosek
- Stroger Hospital of Cook County, Chicago, USA
| | - J Rooney
- Gilead Sciences, 333 Lakeside Drive, Building 300, Foster City, USA
| | - G Gray
- Office of the President, South African Medical Research Council, Western Cape, South Africa
| | - LG Bekker
- Desmond Tutu HIV Centre, University of Cape town, Observatory, Cape Town, South Africa
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Dabee S, Barnabas SL, Jaspan HB, Jaumdally SZ, Gamieldien H, Masson L, Lewis D, Wallace M, Bennie T, Gray C, Williamson AL, Hope T, Chiodi F, Shattock R, Bekker LG, Passmore JS. P15.04 Genital tract cellular activation and inflammation associated with highly prevalent sexually transmitted infections and bacterial vaginosis in adolescent women at risk for hiv infection. Sex Transm Infect 2015. [DOI: 10.1136/sextrans-2015-052270.545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Barnabas S, Dabee S, Jaspan HB, Jaumdally SZ, Gamieldien H, Masson L, Lewis D, Wallace M, Bennie T, Gray C, Williamson AL, Hope T, Chiodi F, Shattock R, Bekker LG, Gray G, Dietrich J, Passmore JS. O18.3 Adolescents in south africa and assessment of hiv risk: knowing who we are trying to protect. Br J Vener Dis 2015. [DOI: 10.1136/sextrans-2015-052270.178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Bekker LG. The epidemiology and pathophysiology of HIV--as seen by a South African. Oral Dis 2002; 8 Suppl 2:15-6. [PMID: 12164649 DOI: 10.1034/j.1601-0825.2002.00004.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The HIV/AIDS epidemic is probably the greatest calamity to befall South Africa. Millions of South Africans and possibly a whole generation will be lost as a result. The health, socioeconomic and personal loss is difficult to quantify. In an attempt to bring this world-wide problem to a level that can be understood and assimilated, an imaginary town, Kalamatiefontein, has been created. The effects of HIV/AIDS as modelled for South Africa are extrapolated to this town. To illustrate the devastation that a diagnosis of HIV positivity brings to an individual, a young woman from this town is introduced and her story related. Her options in South Africa today are discussed and a general plea is made across the nation for solidarity on this issue.
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Affiliation(s)
- L G Bekker
- Infectious Disease Clinical Research Unit, UCT Lung Institute, Mowbray, South Africa.
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7
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Bekker LG, Wood R. Does antiretroviral therapy have a role to play in the control of tuberculosis in South Africa? S Afr Med J 2001; 91:650-1. [PMID: 11584777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023] Open
Affiliation(s)
- L G Bekker
- Infectious Disease Clinical Research Unit, University of Cape Town
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Maartens G, Bekker LG, Sanne I. Deciding when to institute terminal palliative care for AIDS patients--an evidence-based approach. S Afr Med J 2001; 91:559-60. [PMID: 11544966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023] Open
Affiliation(s)
- G Maartens
- Infectious Diseases Unit, University of Cape Town
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9
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Bekker LG, Freeman S, Murray PJ, Ryffel B, Kaplan G. TNF-α Controls Intracellular Mycobacterial Growth by Both Inducible Nitric Oxide Synthase-Dependent and Inducible Nitric Oxide Synthase-Independent Pathways. J Immunol 2001; 166:6728-34. [PMID: 11359829 DOI: 10.4049/jimmunol.166.11.6728] [Citation(s) in RCA: 113] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The role of TNF-alpha in the control of mycobacterial growth in murine macrophages was studied in vitro. Infection of macrophages from TNF-alpha gene disrupted (TNF-knockout (KO)) mice with recombinant Mycobacterium bovis bacillus Calmette Guérin (BCG) expressing the vector only (BCG-vector) resulted in logarithmic growth of the intracellular bacilli. Infection with BCG-secreting murine TNF-alpha (BCG-TNF) led to bacillary killing. Killing of BCG-TNF was associated with rapid accumulation of inducible NO synthase (iNOS) protein and the production of nitrite. The uncontrolled growth of BCG-vector was associated with low iNOS expression but no nitrite production. Thus, iNOS expression appears to be TNF-alpha independent but iNOS generation of NO requires TNF-alpha. In cultures of TNF-KO macrophages infected with BCG-TNF, inhibition of iNOS by aminoguanidine (AMG) abolished the killing of the bacilli. However, the growth of the organisms was still inhibited, suggesting an iNOS-independent TNF-alpha-mediated growth inhibition. To confirm this, macrophages from iNOS-KO mice were infected with either BCG-vector or BCG-TNF. As expected, no nitrite was detected in the culture medium. TNF-alpha was detected only when the cells were infected with BCG-TNF. In the iNOS-KO macrophages, the growth of BCG was inhibited only in the BCG-TNF infection. These results suggest that in the absence of iNOS activity, TNF-alpha stimulates macrophages to control the growth of intracellular BCG. Thus, there appears to be both a TNF-alpha-dependent-iNOS-dependent killing pathway as well as a TNF-alpha-dependent-iNOS-independent growth inhibitory pathway for the control of intracellular mycobacteria in murine macrophages.
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Affiliation(s)
- L G Bekker
- Laboratory of Cellular Physiology and Immunology, The Rockefeller University, 1230 York Avenue, New York, NY 10021, USA
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10
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Orrell C, Bekker LG, Wood R. Adherence to antiretroviral therapy--achievable in the South African context? S Afr Med J 2001; 91:483-4. [PMID: 11455708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023] Open
Affiliation(s)
- C Orrell
- Infectious Disease Clinical Research Unit, University of Cape Town
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11
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Bekker LG, Moreira AL, Bergtold A, Freeman S, Ryffel B, Kaplan G. Immunopathologic effects of tumor necrosis factor alpha in murine mycobacterial infection are dose dependent. Infect Immun 2000; 68:6954-61. [PMID: 11083819 PMCID: PMC97804 DOI: 10.1128/iai.68.12.6954-6961.2000] [Citation(s) in RCA: 143] [Impact Index Per Article: 6.0] [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] [Indexed: 11/20/2022] Open
Abstract
In experimental mycobacterial infection, tumor necrosis factor alpha (TNF-alpha) is required for control of bacillary growth and the protective granulomatous response, but may cause immunopathology. To directly examine the positive and detrimental effects of this cytokine, a murine model was used in which different amounts of TNF-alpha were delivered to the site of infection. Mice with a disruption in the TNF-alpha gene (TNF-KO) or wild-type mice were infected with low or high doses of recombinant Mycobacterium bovis BCG that secreted murine TNF-alpha (BCG-TNF). Infection of TNF-KO mice with BCG containing the vector (BCG-vector) at a low dose led to increased bacillary load in all organs and an extensive granulomatous response in the lungs and spleen. The mice succumbed to the infection by approximately 40 days. However, when TNF-KO mice were infected with low doses of BCG-TNF, bacillary growth was controlled, granulomas were small and well differentiated, the spleen was not enlarged, and the mice survived. Infection with high inocula of BCG-TNF resulted in bacterial clearance, but was accompanied by severe inflammation in the lungs and spleen and earlier death compared to the results from the mice infected with high inocula of BCG-vector. Wild-type mice controlled infection with either recombinant strain, but showed decreased survival following high-dose BCG-TNF infection. The effects of TNF-alpha required signaling through an intact receptor, since the differential effects were not observed when TNF-alpha receptor-deficient mice were infected. The results suggest that the relative amount of TNF-alpha at the site of infection determines whether the cytokine is protective or destructive.
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Affiliation(s)
- L G Bekker
- Laboratory of Cellular Physiology and Immunology, The Rockefeller University, New York, New York 10021, USA
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12
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DeBarber AE, Mdluli K, Bosman M, Bekker LG, Barry CE. Ethionamide activation and sensitivity in multidrug-resistant Mycobacterium tuberculosis. Proc Natl Acad Sci U S A 2000; 97:9677-82. [PMID: 10944230 PMCID: PMC16924 DOI: 10.1073/pnas.97.17.9677] [Citation(s) in RCA: 262] [Impact Index Per Article: 10.9] [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] [Indexed: 11/18/2022] Open
Abstract
Ethionamide (ETA) is an important component of second-line therapy for the treatment of multidrug-resistant tuberculosis. Synthesis of radiolabeled ETA and an examination of drug metabolites formed by whole cells of Mycobacterium tuberculosis (MTb) have allowed us to demonstrate that ETA is activated by S-oxidation before interacting with its cellular target. ETA is metabolized by MTb to a 4-pyridylmethanol product remarkably similar in structure to that formed by the activation of isoniazid by the catalase-peroxidase KatG. We have demonstrated that overproduction of Rv3855 (EtaR), a putative regulatory protein from MTb, confers ETA resistance whereas overproduction of an adjacent, clustered monooxygenase (Rv3854c, EtaA) confers ETA hypersensitivity. Production of EtaA appears to be negatively regulated by EtaR and correlates directly with [(14)C]ETA metabolism, suggesting that EtaA is the activating enzyme responsible for thioamide oxidation and subsequent toxicity. Coding sequence mutations in EtaA were found in 11 of 11 multidrug-resistant MTb patient isolates from Cape Town, South Africa. These isolates showed broad cross-resistance to thiocarbonyl containing drugs including ETA, thiacetazone, and thiocarlide.
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Affiliation(s)
- A E DeBarber
- Tuberculosis Research Section, Laboratory of Host Defenses, National Institutes of Allergy and Infectious Disease, National Institutes of Health, Rockville, MD 20852, USA
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13
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Schoeman JF, Springer P, Ravenscroft A, Donald PR, Bekker LG, van Rensburg AJ, Hanekom WA, Haslett PA, Kaplan G. Adjunctive thalidomide therapy of childhood tuberculous meningitis: possible anti-inflammatory role. J Child Neurol 2000; 15:497-503. [PMID: 10961786 DOI: 10.1177/088307380001500801] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The objective of this study was to determine the safety and tolerability of the immunomodulatory agent thalidomide as adjunct therapy in children with tuberculous meningitis. Children with stage 2 tuberculous meningitis received oral thalidomide for 28 days in a dose-escalating study, in addition to standard four-drug antituberculosis therapy, corticosteroids, and specific treatment of complications such as raised intracranial pressure. Clinical and laboratory evaluations were carried out. Fifteen patients (median age, 34 months) were enrolled. Thalidomide was administered via nasogastric tube in a dosage of 6 mg/kg/day, 12 mg/kg/day, or 24 mg/kg/day. The only adverse events possibly related to the study drug were transient skin rashes in two patients. Levels of tumor necrosis factor-alpha in the cerebrospinal fluid decreased markedly during thalidomide therapy. Clinical outcome and neurologic imaging showed greater improvement than that experienced with historical controls. Thalidomide appeared safe and well tolerated in children with stage 2 tuberculous meningitis and could have important anti-inflammatory effects. These promising results have led us to embark on a randomized, double-blind, placebo-controlled trial of the efficacy of thalidomide in tuberculous meningitis.
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Affiliation(s)
- J F Schoeman
- Department of Paediatrics and Child Health, University of Stellenbosch and Tygerberg Hospital, South Africa.
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14
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Jacobs M, Marino MW, Brown N, Abel B, Bekker LG, Quesniaux VJ, Fick L, Ryffel B. Correction of defective host response to Mycobacterium bovis BCG infection in TNF-deficient mice by bone marrow transplantation. J Transl Med 2000; 80:901-14. [PMID: 10879741 DOI: 10.1038/labinvest.3780094] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Tumour necrosis factor-alpha (TNF) plays a central role in the recruitment and activation of mononuclear cells in mycobacterial infection. In the absence of type 1 TNF receptor, Mycobacterium bovis Bacillus Calmette-Guerin (BCG) infection of mice is not contained, leading to fatal disease. Because type 1 TNF receptor binds both TNF and lymphotoxin-a, we used TNF-deficient mice to determine the specific role of TNF in the host resistance to BCG infection. The bacterial burden of the lungs of TNF-deficient mice was substantially increased and the mice succumbed to pneumonia between 8 and 12 weeks with a defective granuloma response. Atypical granulomas developed by 4 weeks expressing low levels of MHC class II, intracellular adhesion molecule (ICAM-1), CD11b and CD11c. Macrophages showed little signs of activation and had low levels of acid phosphatase activity and inducible nitric oxide synthase (INOS) expression. Despite the defective cellular recruitment, the chemokines, monocyte chemoattractant protein-1 (MCP-1) and macrophage inflammatory protein-1 (MIP-1alpha), were increased in broncho-alveolar lavage fluid of TNF-deficient mice. The defective host response was corrected by the transplantation of normal bone marrow cells into irradiated TNF-deficient mice. These results demonstrate that TNF derived from hemopoietic cells rather than from mesenchymal origin are essential for a normal host response to BCG infection. Furthermore, TNF dependent expression of adhesion molecules may be essential for the recruitment of mononuclear cells for the formation of bactericidal BCG granulomas.
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Affiliation(s)
- M Jacobs
- Department of Immunology, University of Cape Town, South Africa
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15
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Bekker LG, Haslett P, Maartens G, Steyn L, Kaplan G. Thalidomide-induced antigen-specific immune stimulation in patients with human immunodeficiency virus type 1 and tuberculosis. J Infect Dis 2000; 181:954-65. [PMID: 10720518 DOI: 10.1086/315328] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Thalidomide, which inhibits monocyte tumor necrosis factor (TNF)-alpha production and costimulates T cells, was tested for immune modulation in patients with human immunodeficiency virus (HIV) infection and tuberculosis (TB) in a placebo-controlled study. Thalidomide therapy resulted in increased levels of plasma interleukin (IL)-2 receptor, soluble CD8, interferon-gamma, and IL-12, indicating immune stimulation. TNF-alpha levels were not reduced. Thalidomide treatment increased CD4+ and CD8+ T cell counts and lymphocyte proliferation to purified protein derivative. Immune stimulation was not associated with an increase in plasma HIV levels. In vivo, a thalidomide dose-dependent costimulatory effect on T cell proliferation and HIV replication was observed after stimulation with antigens or anti-CD3, respectively. Thalidomide-induced increased viral replication in CD4+ T cells was abrogated by adding back autologous CD8+ T cells. Thus, in the presence of thalidomide, antigen-specific immune responses in vitro and in patients with HIV/TB were enhanced.
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Affiliation(s)
- L G Bekker
- Department of Medicine, University of Cape Town, South Africa
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Johnson B, Bekker LG, Ress S, Kaplan G. Recombinant interleukin 2 adjunctive therapy in multidrug-resistant tuberculosis. Novartis Found Symp 1999; 217:99-106; discussion 106-11. [PMID: 9949803 DOI: 10.1002/0470846526.ch7] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Multidrug-resistant tuberculosis patients respond poorly to antituberculosis therapy and therefore require new modalities of treatment to overcome the infection. Administration of low dose recombinant human interleukin 2 (rhuIL-2) in combination with chemotherapy to multidrug-resistant tuberculosis patients resulted in reduced or cleared sputum acid-fast bacilli in about 60% of the patients in association with enhanced activation of the immune system. Daily rhuIL-2 administration for 30 days induced increases in CD25+ and CD56+ cells in the blood. rhuIL-2 therapy also resulted in increased expression of gamma-interferon and IL-2 mRNA at the site of a delayed-type hypersensitivity (DTH) response to purified protein derivative of tuberculin. Differential display reverse transcriptase PCR revealed several genes expressed at the DTH skin test site that were up- or down-regulated during rhuIL-2 treatment. The differentially regulated genes included components of endocytic vacuoles, enzymes of the respiratory pathway and other regulators of cellular function. The physiological importance of the differential expression of these genes is under investigation to determine their roles in leukocyte activation and in the development of an antimycobacterial response.
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Affiliation(s)
- B Johnson
- Laboratory of Cellular Physiology and Immunology, Rockefeller University, New York, NY 10021-6399, USA
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Johnson BJ, Bekker LG, Rickman R, Brown S, Lesser M, Ress S, Willcox P, Steyn L, Kaplan G. rhuIL-2 adjunctive therapy in multidrug resistant tuberculosis: a comparison of two treatment regimens and placebo. Tuber Lung Dis 1998; 78:195-203. [PMID: 9713652 DOI: 10.1016/s0962-8479(97)90026-5] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
SETTING Low-dose recombinant human interleukin 2 (rhuIL-2) adjunctive immunotherapy in multidrug resistant tuberculosis (MDR-TB) patients. OBJECTIVE Evaluation of the effects of daily versus pulse-administered rhuIL-2 compared to placebo. DESIGN MDR-TB patients on best available antituberculous chemotherapy received rhuIL-2 for 30 consecutive days (daily therapy), or for 5 days followed by a 9-day 'rest', for three cycles (pulse therapy). Placebo control patients received diluent. The cumulative total dose of rhuIL-2 given to each patient in either rhuIL-2 treatment group was the same. Patient immunologic, microbiologic, and radiologic responses were compared. RESULTS The three treatment schedules induced different results. Immune activation was documented in patients receiving daily rhuIL-2 therapy. Numbers of CD25+ and CD56+ cells in the peripheral blood were increased in these patients, but not in patients receiving pulse rhuIL-2 or placebo. In addition, 5/8 (62%) patients receiving daily rhuIL-2 demonstrated reduced or cleared sputum bacterial load while only 2/7 (28%) pulse rhuIL-2 treated and 2/8 (25%) controls showed bacillary clearance. Chest radiographs of 7/12 (58%) patients receiving daily rhuIL-2 indicated significant improvement over 6 weeks. Only 2/9 (22%) pulse rhuIL-2-treated patients and 5/12(42%) placebo controls showed radiologic improvement. CONCLUSION Daily low dose rhuIL-2 adjunctive treatment stimulates immune activation and may enhance the antimicrobial response in MDR-TB.
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Affiliation(s)
- B J Johnson
- Laboratory of Cellular Psysiology and Immunology, Rockefeller University, New York, USA
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Bekker LG, Maartens G, Steyn L, Kaplan G. Selective increase in plasma tumor necrosis factor-alpha and concomitant clinical deterioration after initiating therapy in patients with severe tuberculosis. J Infect Dis 1998; 178:580-4. [PMID: 9697749 DOI: 10.1086/517479] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The initiation of antituberculosis treatment in patients with severe tuberculosis may be accompanied by clinical deterioration and even death before any improvement occurs. To investigate this phenomenon, newly diagnosed human immunodeficiency virus-negative adults with severe tuberculosis were followed for the first 42 days of standard short-course therapy. Clinical status, serum lactate, plasma cytokine, and plasma cytokine receptor levels were monitored on days 0, 3, and 7 and then weekly for up to 42 days. Following 7 days of antituberculosis therapy, a significant transient decrease in mean Karnofsky score (P < .001), a concomitant increase in serum lactate (P = .06), a decrease in patient weight (P = .02), and an increase in plasma tumor necrosis factor-alpha (TNF-alpha) concentrations (P = .04) were observed. Plasma levels of soluble interleukin-2 receptor, interferon-gamma, interleukin-6, and TNF-alpha receptor decreased over the 42-day study period. These observations suggest that increases in plasma TNF-alpha levels may be associated with clinical deterioration observed early in the treatment of severe tuberculosis.
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Affiliation(s)
- L G Bekker
- Department of Medicine, University of Cape Town, South Africa
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