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Rapiti N, Abdelatif N, Moosa MYS. Prognostic variables and 4-year survival outcomes in CD20 Positive AIDS-Related Lymphoma in the Anti-retroviral treatment era: A Retrospective Review from a Single Centre in KwaZulu-Natal, South Africa. PLoS One 2022; 17:e0272282. [PMID: 36048870 PMCID: PMC9436083 DOI: 10.1371/journal.pone.0272282] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 07/16/2022] [Indexed: 11/18/2022] Open
Abstract
Objective To describe 4-year survival outcomes and assess the value of established and additional relevant variables to predict complete response (CR), four-year progression-free survival (PFS) and overall survival (OS) of CD20 positive AIDS-Related Lymphoma (ARL) treated with standard combination chemotherapy. Method We performed a retrospective review of patients diagnosed with CD20 positive ARL between 2006 and 2016. All patients over 12 years of age who received at least one cycle of combination chemotherapy with curative intent were included in the analysis. Variables assessed included the International Prognostic Index (IPI), age-adjusted-IPI, age, gender, B symptoms, extent of disease, functional performance status, CD4 cell count, viral load, concurrent ART with chemotherapy, rituximab inclusion, and number of chemotherapy cycles used. Kaplan-Meier survival curves for OS and PFS at 4 years were compared for IPI and aaIPI using the log-rank test. A Cox proportional hazards model was used to investigate the effects of prognostic variables for patients achieving OS and PFS at 4 years and logistic regression for patients achieving CR. Results A total of 102 patients were included in the analysis. At year four of follow-up, the OS was 50% (n = 51) and PFS was 43% (n = 44). Attaining a CR and male gender were significantly associated with improved 4-year OS (p<0.001 and p = 0.028 respectively) and PFS (p<0.001 and 0.048 respectively). A viral load of < 50 copies/ml was associated with a higher complete response rate (aOR 6.10 [95% CI 1.15, 24.04], p = 0.01). Six or more cycles of chemotherapy was superior to fewer cycles for both PFS (aHR 0.17 [95% CI 0.10, 0.29]) and OS (aHR 0.12 [95% CI 0.07, 0.22]) with p-value < 0.001 for both PFS and OS. The Kaplan-Meier survival estimates demonstrated the prognostic utility of the IPI and aaIP for OS (p = 0.002 and 0.030 respectively) and the IPI for PFS (p = 0.002). Conclusion This study is a first from a high prevalence HIV area in KwaZulu-Natal, South Africa, and confirms the utility of the internationally accepted prognostic scoring systems in predicting survival in CD20 positive ARL in the local population.
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Affiliation(s)
- Nadine Rapiti
- Department of Haematology, NHLS/University of KwaZulu Natal/King Edward VIII Hospital, Durban, South Africa
- * E-mail:
| | - Nada Abdelatif
- Biostatistics Research Unit, South African Medical Research Council, Cape Town, South Africa
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Khan K, Karim F, Cele S, San JE, Lustig G, Tegally H, Rosenberg Y, Bernstein M, Ganga Y, Jule Z, Reedoy K, Ngcobo N, Mazibuko M, Mthabela N, Mhlane Z, Mbatha N, Miya Y, Giandhari J, Ramphal Y, Naidoo T, Manickchund N, Magula N, Abdool Karim SS, Gray G, Hanekom W, von Gottberg A, Milo R, Gosnell BI, Lessells RJ, Moore PL, de Oliveira T, Moosa MYS, Sigal A. Omicron infection of vaccinated individuals enhances neutralizing immunity against the Delta variant. medRxiv 2022:2021.12.27.21268439. [PMID: 34981076 PMCID: PMC8722619 DOI: 10.1101/2021.12.27.21268439 10.1038/s41586-021-04387-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Omicron variant (B.1.1.529) infections are rapidly expanding worldwide, often in settings where the Delta variant (B.1.617.2) was dominant. We investigated whether neutralizing immunity elicited by Omicron infection would also neutralize the Delta variant and the role of prior vaccination. We enrolled 23 South African participants infected with Omicron a median of 5 days post-symptoms onset (study baseline) with a last follow-up sample taken a median of 23 days post-symptoms onset. Ten participants were breakthrough cases vaccinated with Pfizer BNT162b2 or Johnson and Johnson Ad26.CoV2.S. In vaccinated participants, neutralization of Omicron increased from a geometric mean titer (GMT) FRNT50 of 28 to 378 (13.7-fold). Unvaccinated participants had similar Omicron neutralization at baseline but increased from 26 to only 113 (4.4-fold) at follow-up. Delta virus neutralization increased from 129 to 790, (6.1-fold) in vaccinated but only 18 to 46 (2.5-fold, not statistically significant) in unvaccinated participants. Therefore, in Omicron infected vaccinated individuals, Delta neutralization was 2.1-fold higher at follow-up relative to Omicron. In a separate group previously infected with Delta, neutralization of Delta was 22.5-fold higher than Omicron. Based on relative neutralization levels, Omicron re-infection would be expected to be more likely than Delta in Delta infected individuals, and in Omicron infected individuals who are vaccinated. This may give Omicron an advantage over Delta which may lead to decreasing Delta infections in regions with high infection frequencies and high vaccine coverage.
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Affiliation(s)
- Khadija Khan
- Africa Health Research Institute, Durban, South Africa
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Farina Karim
- Africa Health Research Institute, Durban, South Africa
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Sandile Cele
- Africa Health Research Institute, Durban, South Africa
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - James Emmanuel San
- KwaZulu-Natal Research Innovation and Sequencing Platform, Durban, South Africa
| | - Gila Lustig
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | - Houriiyah Tegally
- KwaZulu-Natal Research Innovation and Sequencing Platform, Durban, South Africa
- Centre for Epidemic Response and Innovation, School of Data Science and Computational Thinking, Stellenbosch University, Stellenbosch, South Africa
| | - Yuval Rosenberg
- Department of Plant and Environmental Sciences, Weizmann Institute of Science, Rehovot, Israel
| | | | - Yashica Ganga
- Africa Health Research Institute, Durban, South Africa
| | - Zesuliwe Jule
- Africa Health Research Institute, Durban, South Africa
| | - Kajal Reedoy
- Africa Health Research Institute, Durban, South Africa
| | | | | | | | - Zoey Mhlane
- Africa Health Research Institute, Durban, South Africa
| | - Nikiwe Mbatha
- Africa Health Research Institute, Durban, South Africa
| | - Yoliswa Miya
- Africa Health Research Institute, Durban, South Africa
| | - Jennifer Giandhari
- KwaZulu-Natal Research Innovation and Sequencing Platform, Durban, South Africa
| | - Yajna Ramphal
- KwaZulu-Natal Research Innovation and Sequencing Platform, Durban, South Africa
| | - Taryn Naidoo
- Africa Health Research Institute, Durban, South Africa
| | - Nithendra Manickchund
- Department of Infectious Diseases, Nelson R. Mandela School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Nombulelo Magula
- Department of Internal Medicine, Nelson R. Mandela School of Medicine. University of Kwa-Zulu Natal
| | - Salim S. Abdool Karim
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States
| | - Glenda Gray
- South African Medical Research Council, Cape Town, South Africa
| | - Willem Hanekom
- Africa Health Research Institute, Durban, South Africa
- Division of Infection and Immunity, University College London, London, UK
| | - Anne von Gottberg
- National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
- SAMRC Antibody Immunity Research Unit, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Ron Milo
- Department of Plant and Environmental Sciences, Weizmann Institute of Science, Rehovot, Israel
| | - Bernadett I. Gosnell
- Department of Infectious Diseases, Nelson R. Mandela School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Richard J. Lessells
- KwaZulu-Natal Research Innovation and Sequencing Platform, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | - Penny L. Moore
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
- National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
- SAMRC Antibody Immunity Research Unit, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Tulio de Oliveira
- KwaZulu-Natal Research Innovation and Sequencing Platform, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
- Centre for Epidemic Response and Innovation, School of Data Science and Computational Thinking, Stellenbosch University, Stellenbosch, South Africa
- Department of Global Health, University of Washington, Seattle, USA
| | - Mahomed-Yunus S. Moosa
- Department of Infectious Diseases, Nelson R. Mandela School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Alex Sigal
- Africa Health Research Institute, Durban, South Africa
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
- Max Planck Institute for Infection Biology, Berlin, Germany
- Corresponding author.
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Khan K, Karim F, Cele S, San JE, Lustig G, Tegally H, Rosenberg Y, Bernstein M, Ganga Y, Jule Z, Reedoy K, Ngcobo N, Mazibuko M, Mthabela N, Mhlane Z, Mbatha N, Miya Y, Giandhari J, Ramphal Y, Naidoo T, Manickchund N, Magula N, Abdool Karim SS, Gray G, Hanekom W, von Gottberg A, Milo R, Gosnell BI, Lessells RJ, Moore PL, de Oliveira T, Moosa MYS, Sigal A. Omicron infection of vaccinated individuals enhances neutralizing immunity against the Delta variant. medRxiv 2022:2021.12.27.21268439. [PMID: 34981076 PMCID: PMC8722619 DOI: 10.1101/2021.12.27.21268439] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Omicron variant (B.1.1.529) infections are rapidly expanding worldwide, often in settings where the Delta variant (B.1.617.2) was dominant. We investigated whether neutralizing immunity elicited by Omicron infection would also neutralize the Delta variant and the role of prior vaccination. We enrolled 23 South African participants infected with Omicron a median of 5 days post-symptoms onset (study baseline) with a last follow-up sample taken a median of 23 days post-symptoms onset. Ten participants were breakthrough cases vaccinated with Pfizer BNT162b2 or Johnson and Johnson Ad26.CoV2.S. In vaccinated participants, neutralization of Omicron increased from a geometric mean titer (GMT) FRNT50 of 28 to 378 (13.7-fold). Unvaccinated participants had similar Omicron neutralization at baseline but increased from 26 to only 113 (4.4-fold) at follow-up. Delta virus neutralization increased from 129 to 790, (6.1-fold) in vaccinated but only 18 to 46 (2.5-fold, not statistically significant) in unvaccinated participants. Therefore, in Omicron infected vaccinated individuals, Delta neutralization was 2.1-fold higher at follow-up relative to Omicron. In a separate group previously infected with Delta, neutralization of Delta was 22.5-fold higher than Omicron. Based on relative neutralization levels, Omicron re-infection would be expected to be more likely than Delta in Delta infected individuals, and in Omicron infected individuals who are vaccinated. This may give Omicron an advantage over Delta which may lead to decreasing Delta infections in regions with high infection frequencies and high vaccine coverage.
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Affiliation(s)
- Khadija Khan
- Africa Health Research Institute, Durban, South Africa
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Farina Karim
- Africa Health Research Institute, Durban, South Africa
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Sandile Cele
- Africa Health Research Institute, Durban, South Africa
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - James Emmanuel San
- KwaZulu-Natal Research Innovation and Sequencing Platform, Durban, South Africa
| | - Gila Lustig
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | - Houriiyah Tegally
- KwaZulu-Natal Research Innovation and Sequencing Platform, Durban, South Africa
- Centre for Epidemic Response and Innovation, School of Data Science and Computational Thinking, Stellenbosch University, Stellenbosch, South Africa
| | - Yuval Rosenberg
- Department of Plant and Environmental Sciences, Weizmann Institute of Science, Rehovot, Israel
| | | | - Yashica Ganga
- Africa Health Research Institute, Durban, South Africa
| | - Zesuliwe Jule
- Africa Health Research Institute, Durban, South Africa
| | - Kajal Reedoy
- Africa Health Research Institute, Durban, South Africa
| | | | | | | | - Zoey Mhlane
- Africa Health Research Institute, Durban, South Africa
| | - Nikiwe Mbatha
- Africa Health Research Institute, Durban, South Africa
| | - Yoliswa Miya
- Africa Health Research Institute, Durban, South Africa
| | - Jennifer Giandhari
- KwaZulu-Natal Research Innovation and Sequencing Platform, Durban, South Africa
| | - Yajna Ramphal
- KwaZulu-Natal Research Innovation and Sequencing Platform, Durban, South Africa
| | - Taryn Naidoo
- Africa Health Research Institute, Durban, South Africa
| | - Nithendra Manickchund
- Department of Infectious Diseases, Nelson R. Mandela School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Nombulelo Magula
- Department of Internal Medicine, Nelson R. Mandela School of Medicine. University of Kwa-Zulu Natal
| | - Salim S. Abdool Karim
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States
| | - Glenda Gray
- South African Medical Research Council, Cape Town, South Africa
| | - Willem Hanekom
- Africa Health Research Institute, Durban, South Africa
- Division of Infection and Immunity, University College London, London, UK
| | - Anne von Gottberg
- National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
- SAMRC Antibody Immunity Research Unit, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Ron Milo
- Department of Plant and Environmental Sciences, Weizmann Institute of Science, Rehovot, Israel
| | - Bernadett I. Gosnell
- Department of Infectious Diseases, Nelson R. Mandela School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Richard J. Lessells
- KwaZulu-Natal Research Innovation and Sequencing Platform, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | - Penny L. Moore
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
- National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
- SAMRC Antibody Immunity Research Unit, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Tulio de Oliveira
- KwaZulu-Natal Research Innovation and Sequencing Platform, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
- Centre for Epidemic Response and Innovation, School of Data Science and Computational Thinking, Stellenbosch University, Stellenbosch, South Africa
- Department of Global Health, University of Washington, Seattle, USA
| | - Mahomed-Yunus S. Moosa
- Department of Infectious Diseases, Nelson R. Mandela School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Alex Sigal
- Africa Health Research Institute, Durban, South Africa
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
- Max Planck Institute for Infection Biology, Berlin, Germany
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Feldman C, Dlamini S, Richards GA, Black J, Butler ILC, Cutland C, Hefer E, Hodkinson B, Kok A, Manga P, Meiring S, Molaudzi M, Moosa MYS, Parker S, Peter J, van Vuuren C, Verburgh E, Watermeyer G. A comprehensive overview of pneumococcal vaccination recommendations for adults in South Africa, 2022. J Thorac Dis 2022; 14:4150-4172. [DOI: 10.21037/jtd-22-287] [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] [Received: 03/03/2022] [Accepted: 07/28/2022] [Indexed: 11/06/2022]
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Walker NF, Karim F, Moosa MYS, Moodley S, Mazibuko M, Khan K, Sterling TR, van der Heijden YF, Grant AD, Elkington PT, Pym A, Leslie A. OUP accepted manuscript. J Infect Dis 2022; 226:928-932. [PMID: 35510939 PMCID: PMC9470104 DOI: 10.1093/infdis/jiac160] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 04/28/2022] [Indexed: 11/15/2022] Open
Abstract
Current methods for tuberculosis treatment monitoring are suboptimal. We evaluated plasma matrix metalloproteinase (MMP) and procollagen III N-terminal propeptide concentrations before and during tuberculosis treatment as biomarkers. Plasma MMP-1, MMP-8, and MMP-10 concentrations significantly decreased during treatment. Plasma MMP-8 was increased in sputum Mycobacterium tuberculosis culture–positive relative to culture-negative participants, before (median, 4993 pg/mL [interquartile range, 2542–9188] vs 698 [218–4060] pg/mL, respectively; P = .004) and after (3650 [1214–3888] vs 720 [551–1321] pg/mL; P = .008) 6 months of tuberculosis treatment. Consequently, plasma MMP-8 is a potential biomarker to enhance tuberculosis treatment monitoring and screen for possible culture positivity.
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Affiliation(s)
- N F Walker
- Correspondence: N. F. Walker, Senior Clinical Lecturer, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, United Kingdom ()
| | - F Karim
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - M Y S Moosa
- Department of Infectious Diseases, University of KwaZulu-Natal, Durban, South Africa
| | - S Moodley
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - M Mazibuko
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - K Khan
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - T R Sterling
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Y F van der Heijden
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- The Aurum Institute, Johannesburg, South Africa
| | - A D Grant
- TB Centre and Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- School of Laboratory Medicine and Medical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - P T Elkington
- NIHR Biomedical Research Centre, Clinical and Experimental Sciences, University of Southampton, Southampton, United Kingdom
| | - A Pym
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - A Leslie
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- School of Laboratory Medicine and Medical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- Division of Infection and Immunity, University College London, London, United Kingdom
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Cele S, Jackson L, Khoury DS, Khan K, Moyo-Gwete T, Tegally H, San JE, Cromer D, Scheepers C, Amoako D, Karim F, Bernstein M, Lustig G, Archary D, Smith M, Ganga Y, Jule Z, Reedoy K, Hwa SH, Giandhari J, Blackburn JM, Gosnell BI, Karim SSA, Hanekom W, Network for Genomic Surveillance in, COMMIT-KZN Team, von Gottberg A, Bhiman J, Lessells RJ, Moosa MYS, Davenport MP, de Oliveira T, Moore PL, Sigal A. Omicron extensively but incompletely escapes Pfizer BNT162b2 neutralization. Nature 2021. [DOI: 10.1038/d41586-021-03824-5] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Cele S, Karim F, Lustig G, San JE, Hermanus T, Tegally H, Snyman J, Moyo-Gwete T, Wilkinson E, Bernstein M, Khan K, Hwa SH, Tilles SW, Singh L, Giandhari J, Mthabela N, Mazibuko M, Ganga Y, Gosnell BI, Karim SA, Hanekom W, Van Voorhis WC, Ndung’u T, Lessells RJ, Moore PL, Moosa MYS, de Oliveira T, Sigal A. SARS-CoV-2 evolved during advanced HIV disease immunosuppression has Beta-like escape of vaccine and Delta infection elicited immunity. medRxiv 2021:2021.09.14.21263564. [PMID: 34909798 PMCID: PMC8669865 DOI: 10.1101/2021.09.14.21263564] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Characterizing SARS-CoV-2 evolution in specific geographies may help predict the properties of variants coming from these regions. We mapped neutralization of a SARS-CoV-2 strain that evolved over 6 months from the ancestral virus in a person with advanced HIV disease. Infection was before the emergence of the Beta variant first identified in South Africa, and the Delta variant. We compared early and late evolved virus to the ancestral, Beta, Alpha, and Delta viruses and tested against convalescent plasma from ancestral, Beta, and Delta infections. Early virus was similar to ancestral, whereas late virus was similar to Beta, exhibiting vaccine escape and, despite pre-dating Delta, strong escape of Delta-elicited neutralization. This example is consistent with the notion that variants arising in immune-compromised hosts, including those with advanced HIV disease, may evolve immune escape of vaccines and enhanced escape of Delta immunity, with implications for vaccine breakthrough and reinfections. HIGHLIGHTS A prolonged ancestral SARS-CoV-2 infection pre-dating the emergence of Beta and Delta resulted in evolution of a Beta-like serological phenotypeSerological phenotype includes strong escape from Delta infection elicited immunity, intermediate escape from ancestral virus immunity, and weak escape from Beta immunityEvolved virus showed substantial but incomplete escape from antibodies elicited by BNT162b2 vaccination. GRAPHICAL ABSTRACT
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Affiliation(s)
- Sandile Cele
- Africa Health Research Institute, Durban, South Africa
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Farina Karim
- Africa Health Research Institute, Durban, South Africa
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Gila Lustig
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | - James Emmanuel San
- KwaZulu-Natal Research Innovation and Sequencing Platform, Durban, South Africa
| | - Tandile Hermanus
- National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
- MRC Antibody Immunity Research Unit, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Houriiyah Tegally
- KwaZulu-Natal Research Innovation and Sequencing Platform, Durban, South Africa
| | - Jumari Snyman
- Africa Health Research Institute, Durban, South Africa
- Centre for Epidemic Response and Innovation, School of Data Science and Computational Thinking, Stellenbosch University, Stellenbosch, South Africa
| | | | - Eduan Wilkinson
- KwaZulu-Natal Research Innovation and Sequencing Platform, Durban, South Africa
- HIV Pathogenesis Programme, University of KwaZulu-Natal, Durban, South Africa
| | | | - Khadija Khan
- Africa Health Research Institute, Durban, South Africa
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Shi-Hsia Hwa
- Africa Health Research Institute, Durban, South Africa
- Division of Infection and Immunity, University College London, London, UK
| | - Sasha W. Tilles
- Center for Emerging and Re-emerging Infectious Diseases, University of Washington, Seattle, USA
| | - Lavanya Singh
- KwaZulu-Natal Research Innovation and Sequencing Platform, Durban, South Africa
| | - Jennifer Giandhari
- KwaZulu-Natal Research Innovation and Sequencing Platform, Durban, South Africa
| | | | | | - Yashica Ganga
- Africa Health Research Institute, Durban, South Africa
| | - Bernadett I. Gosnell
- Department of Infectious Diseases, Nelson R. Mandela School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Salim Abdool Karim
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | - Willem Hanekom
- Africa Health Research Institute, Durban, South Africa
- Division of Infection and Immunity, University College London, London, UK
| | - Wesley C. Van Voorhis
- Center for Emerging and Re-emerging Infectious Diseases, University of Washington, Seattle, USA
| | - Thumbi Ndung’u
- Africa Health Research Institute, Durban, South Africa
- Centre for Epidemic Response and Innovation, School of Data Science and Computational Thinking, Stellenbosch University, Stellenbosch, South Africa
| | | | - Richard J. Lessells
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
- KwaZulu-Natal Research Innovation and Sequencing Platform, Durban, South Africa
| | - Penny L. Moore
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
- National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
- MRC Antibody Immunity Research Unit, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mahomed-Yunus S. Moosa
- Department of Infectious Diseases, Nelson R. Mandela School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Tulio de Oliveira
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
- KwaZulu-Natal Research Innovation and Sequencing Platform, Durban, South Africa
- HIV Pathogenesis Programme, University of KwaZulu-Natal, Durban, South Africa
- Department of Global Health, University of Washington, Seattle, USA
| | - Alex Sigal
- Africa Health Research Institute, Durban, South Africa
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
- Max Planck Institute for Infection Biology, Berlin, Germany
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8
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Lustig G, Cele S, Karim F, Derache A, Ngoepe A, Khan K, Gosnell BI, Moosa MYS, Ntshuba N, Marais S, Jeena PM, Govender K, Adamson J, Kløverpris H, Gupta RK, Harrichandparsad R, Patel VB, Sigal A. T cell derived HIV-1 is present in the CSF in the face of suppressive antiretroviral therapy. PLoS Pathog 2021; 17:e1009871. [PMID: 34555123 PMCID: PMC8509856 DOI: 10.1371/journal.ppat.1009871] [Citation(s) in RCA: 18] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 10/12/2021] [Accepted: 08/06/2021] [Indexed: 12/14/2022] Open
Abstract
HIV cerebrospinal fluid (CSF) escape, where HIV is suppressed in blood but detectable in CSF, occurs when HIV persists in the CNS despite antiretroviral therapy (ART). To determine the virus producing cell type and whether lowered CSF ART levels are responsible for CSF escape, we collected blood and CSF from 156 neurosymptomatic participants from Durban, South Africa. We observed that 28% of participants with an undetectable HIV blood viral load showed CSF escape. We detected host cell surface markers on the HIV envelope to determine the cellular source of HIV in participants on the first line regimen of efavirenz, emtricitabine, and tenofovir. We confirmed CD26 as a marker which could differentiate between T cells and macrophages and microglia, and quantified CD26 levels on the virion surface, comparing the result to virus from in vitro infected T cells or macrophages. The measured CD26 level was consistent with the presence of T cell produced virus. We found no significant differences in ART concentrations between CSF escape and fully suppressed individuals in CSF or blood, and did not observe a clear association with drug resistance mutations in CSF virus which would allow HIV to replicate. Hence, CSF HIV in the face of ART may at least partly originate in CD4+ T cell populations.
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Affiliation(s)
- Gila Lustig
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | - Sandile Cele
- Africa Health Research Institute, Durban, South Africa
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Farina Karim
- Africa Health Research Institute, Durban, South Africa
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Anne Derache
- Africa Health Research Institute, Durban, South Africa
| | | | - Khadija Khan
- Africa Health Research Institute, Durban, South Africa
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Bernadett I. Gosnell
- Department of Infectious Diseases, University of KwaZulu-Natal, Durban, South Africa
| | | | | | - Suzaan Marais
- Department of Neurology, University of KwaZulu-Natal, Durban, South Africa
| | - Prakash M. Jeena
- Discipline of Pediatrics and Child Health, University of KwaZulu-Natal, Durban, South Africa
| | | | - John Adamson
- Africa Health Research Institute, Durban, South Africa
| | - Henrik Kløverpris
- Africa Health Research Institute, Durban, South Africa
- Division of Infection and Immunity, University College London, London, United Kingdom
- Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Ravindra K. Gupta
- Africa Health Research Institute, Durban, South Africa
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | | | - Vinod B. Patel
- Department of Neurology, University of KwaZulu-Natal, Durban, South Africa
| | - Alex Sigal
- Africa Health Research Institute, Durban, South Africa
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
- Max Planck Institute for Infection Biology, Berlin, Germany
- * E-mail:
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9
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Cele S, Gazy I, Jackson L, Hwa SH, Tegally H, Lustig G, Giandhari J, Pillay S, Wilkinson E, Naidoo Y, Karim F, Ganga Y, Khan K, Bernstein M, Balazs AB, Gosnell BI, Hanekom W, Moosa MYS, Lessells RJ, de Oliveira T, Sigal A. Escape of SARS-CoV-2 501Y.V2 from neutralization by convalescent plasma. Nature 2021; 593:142-146. [PMID: 33780970 PMCID: PMC9867906 DOI: 10.1038/s41586-021-03471-w] [Citation(s) in RCA: 423] [Impact Index Per Article: 141.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 03/18/2021] [Indexed: 02/02/2023]
Abstract
SARS-CoV-2 variants of concern (VOC) have arisen independently at multiple locations1,2 and may reduce the efficacy of current vaccines that target the spike glycoprotein of SARS-CoV-23. Here, using a live-virus neutralization assay, we compared the neutralization of a non-VOC variant with the 501Y.V2 VOC (also known as B.1.351) using plasma collected from adults who were hospitalized with COVID-19 during the two waves of infection in South Africa, the second wave of which was dominated by infections with the 501Y.V2 variant. Sequencing demonstrated that infections of plasma donors from the first wave were with viruses that did not contain the mutations associated with 501Y.V2, except for one infection that contained the E484K substitution in the receptor-binding domain. The 501Y.V2 virus variant was effectively neutralized by plasma from individuals who were infected during the second wave. The first-wave virus variant was effectively neutralized by plasma from first-wave infections. However, the 501Y.V2 variant was poorly cross-neutralized by plasma from individuals with first-wave infections; the efficacy was reduced by 15.1-fold relative to neutralization of 501Y.V2 by plasma from individuals infected in the second wave. By contrast, cross-neutralization of first-wave virus variants using plasma from individuals with second-wave infections was more effective, showing only a 2.3-fold decrease relative to neutralization of first-wave virus variants by plasma from individuals infected in the first wave. Although we tested only one plasma sample from an individual infected with a SARS-CoV-2 variant with only the E484K substitution, this plasma sample potently neutralized both variants. The observed effective neutralization of first-wave virus by plasma from individuals infected with 501Y.V2 provides preliminary evidence that vaccines based on VOC sequences could retain activity against other circulating SARS-CoV-2 lineages.
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Affiliation(s)
- Sandile Cele
- Africa Health Research Institute, Durban, South Africa.,School of Laboratory Medicine and Medical Sciences, University of KwaZulu–Natal, Durban, South Africa
| | - Inbal Gazy
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu–Natal, Durban, South Africa.,KwaZulu–Natal Research Innovation and Sequencing Platform (KRISP), School of Laboratory Medicine and Medical Sciences, University of KwaZulu–Natal, Durban, South Africa.,Department of Biochemistry and Molecular Biology, The Institute for Medical Research Israel–Canada, Hadassah Medical School, The Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Shi-Hsia Hwa
- Africa Health Research Institute, Durban, South Africa.,Division of Infection and Immunity, University College London, London, UK
| | - Houriiyah Tegally
- KwaZulu–Natal Research Innovation and Sequencing Platform (KRISP), School of Laboratory Medicine and Medical Sciences, University of KwaZulu–Natal, Durban, South Africa
| | - Gila Lustig
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - Jennifer Giandhari
- KwaZulu–Natal Research Innovation and Sequencing Platform (KRISP), School of Laboratory Medicine and Medical Sciences, University of KwaZulu–Natal, Durban, South Africa
| | - Sureshnee Pillay
- KwaZulu–Natal Research Innovation and Sequencing Platform (KRISP), School of Laboratory Medicine and Medical Sciences, University of KwaZulu–Natal, Durban, South Africa
| | - Eduan Wilkinson
- KwaZulu–Natal Research Innovation and Sequencing Platform (KRISP), School of Laboratory Medicine and Medical Sciences, University of KwaZulu–Natal, Durban, South Africa
| | - Yeshnee Naidoo
- KwaZulu–Natal Research Innovation and Sequencing Platform (KRISP), School of Laboratory Medicine and Medical Sciences, University of KwaZulu–Natal, Durban, South Africa
| | - Farina Karim
- Africa Health Research Institute, Durban, South Africa.,School of Laboratory Medicine and Medical Sciences, University of KwaZulu–Natal, Durban, South Africa
| | - Yashica Ganga
- Africa Health Research Institute, Durban, South Africa
| | - Khadija Khan
- Africa Health Research Institute, Durban, South Africa
| | | | | | - Bernadett I. Gosnell
- Department of Infectious Diseases, Nelson R. Mandela School of Clinical Medicine, University of KwaZulu–Natal, Durban, South Africa
| | - Willem Hanekom
- Africa Health Research Institute, Durban, South Africa.,Division of Infection and Immunity, University College London, London, UK
| | - Mahomed-Yunus S. Moosa
- Department of Infectious Diseases, Nelson R. Mandela School of Clinical Medicine, University of KwaZulu–Natal, Durban, South Africa
| | | | | | - Richard J. Lessells
- KwaZulu–Natal Research Innovation and Sequencing Platform (KRISP), School of Laboratory Medicine and Medical Sciences, University of KwaZulu–Natal, Durban, South Africa.,Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - Tulio de Oliveira
- KwaZulu–Natal Research Innovation and Sequencing Platform (KRISP), School of Laboratory Medicine and Medical Sciences, University of KwaZulu–Natal, Durban, South Africa.,Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa.,Department of Global Health, University of Washington, Seattle, WA, USA.,Correspondence and requests for materials should be addressed to T.d.O. or A.S. ;
| | - Alex Sigal
- Africa Health Research Institute, Durban, South Africa.,School of Laboratory Medicine and Medical Sciences, University of KwaZulu–Natal, Durban, South Africa.,Max Planck Institute for Infection Biology, Berlin, Germany.,Correspondence and requests for materials should be addressed to T.d.O. or A.S. ;
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10
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Brijkumar J, Johnson BA, Zhao Y, Edwards J, Moodley P, Pathan K, Pillay S, Castro KG, Sunpath H, Kuritzkes DR, Moosa MYS, Marconi VC. A packaged intervention to improve viral load monitoring within a deeply rural health district of South Africa. BMC Infect Dis 2020; 20:836. [PMID: 33176715 PMCID: PMC7659110 DOI: 10.1186/s12879-020-05576-5] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 11/03/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The KwaZulu-Natal (KZN) province of South Africa has the highest prevalence of HIV infection in the world. Viral load (VL) testing is a crucial tool for clinical and programmatic monitoring. Within uMkhanyakude district, VL suppression rates were 91% among patients with VL data; however, VL performance rates averaged only 38·7%. The objective of this study was to determine if enhanced clinic processes and community outreach could improve VL monitoring within this district. METHODS A packaged intervention was implemented at three rural clinics in the setting of the KZN HIV AIDS Drug Resistance Surveillance Study. This included file hygiene, outreach, a VL register and documentation revisions. Chart audits were used to assess fidelity. Outcome measures included percentage VL performed and suppressed. Each rural clinic was matched with a peri-urban clinic for comparison before and after the start of each phase of the intervention. Monthly sample proportions were modelled using quasi-likelihood regression methods for over-dispersed binomial data. RESULTS Mkuze and Jozini clinics increased VL performance overall from 33·9% and 35·3% to 75·8% and 72·4%, respectively which was significantly greater than the increases in the comparison clinics (RR 1·86 and 1·68, p < 0·01). VL suppression rates similarly increased overall by 39·3% and 36·2% (RR 1·84 and 1·70, p < 0·01). The Chart Intervention phase showed significant increases in fidelity 16 months after implementation. CONCLUSIONS The packaged intervention improved VL performance and suppression rates overall but was significant in Mkuze and Jozini. Larger sustained efforts will be needed to have a similar impact throughout the province.
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Affiliation(s)
- J Brijkumar
- University of KwaZulu Natal, Nelson R Mandela School of Medicine, Durban, South Africa
| | | | - Y Zhao
- Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - J Edwards
- Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - P Moodley
- School of Laboratory Medicine and Medical Sciences, National Health Laboratory Service, University of KwaZulu-Natal, Durban, South Africa
| | - K Pathan
- Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - S Pillay
- University of KwaZulu Natal, Nelson R Mandela School of Medicine, Durban, South Africa
| | - K G Castro
- Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - H Sunpath
- University of KwaZulu Natal, Nelson R Mandela School of Medicine, Durban, South Africa
| | - D R Kuritzkes
- Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - M Y S Moosa
- University of KwaZulu Natal, Nelson R Mandela School of Medicine, Durban, South Africa
| | - V C Marconi
- Emory University Rollins School of Public Health, Atlanta, GA, USA.
- Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA.
- Emory Vaccine Center, Atlanta, USA.
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11
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Sojane K, Kangethe RT, Chang CC, Moosa MYS, Lewin SR, French MA, Ndung'u T. Individuals with HIV-1 Subtype C Infection and Cryptococcal Meningitis Exhibit Viral Genetic Intermixing of HIV-1 Between Plasma and Cerebrospinal Fluid and a High Prevalence of CXCR4-Using Variants. AIDS Res Hum Retroviruses 2018; 34:607-620. [PMID: 29658309 DOI: 10.1089/aid.2017.0209] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The genotypic properties of human immunodeficiency virus type 1 (HIV-1) subtype C in individuals presenting with cryptococcal meningitis (CM) are not well established. Employing single-genome amplification as well as bulk PCR, cloning and sequencing strategies, we evaluated the genetic properties of HIV-1 subtype C env in 16 antiretroviral therapy-naive study participants with CM. Eleven of the 16 participants had matched blood plasma and cerebrospinal fluid (CSF) evaluated, with the rest having either a plasma or CSF sample evaluated. Before antiretroviral therapy initiation, matched plasma and CSF-derived env sequences of all 11 participants displayed genetic intermixing between the two compartments. Overall, 7 of the 16 (∼43.8%) participants harbored CXCR4-using variants in plasma and/or CSF, according to coreceptor usage prediction algorithms. This study suggests that HIV-1 subtype C genetic intermixing between peripheral blood and the central nervous system is common in individuals presenting with CM, and that CXCR4 usage is present in one or both compartments in approximately 44% of individuals.
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Affiliation(s)
- Katlego Sojane
- HIV Pathogenesis Programme, Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Richard T. Kangethe
- HIV Pathogenesis Programme, Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Christina C. Chang
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia
| | - Mahomed-Yunus S. Moosa
- Department of Infectious Diseases, King Edward VIII Hospital, University of KwaZulu-Natal, Durban, South Africa
| | - Sharon R. Lewin
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia
- The Peter Doherty Institute for Infection and Immunity, University of Melbourne and Royal Melbourne Hospital, Melbourne, Australia
| | - Martyn A. French
- Medical School and School of Biomedical Sciences, University of Western Australia, Perth, Australia
- Department of Clinical Immunology, Royal Perth Hospital and PathWest Laboratory Medicine, Perth, Australia
| | - Thumbi Ndung'u
- HIV Pathogenesis Programme, Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Africa Health Research Institute, Durban, South Africa
- Ragon Institute of MGH, MIT and Harvard University, Cambridge, Massachusetts
- Max Planck Institute for Infection Biology, Berlin, Germany
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12
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Dlamini SK, Madhi SA, Muloiwa R, Von Gottberg A, Moosa MYS, Meiring ST, Wiysonge CS, Hefer E, Mulaudzi MB, Nuttall J, Moorhouse M, Kagina BM. Guidelines for the vaccination of HIV-infected adolescents and adults in South Africa. South Afr J HIV Med 2018. [DOI: 10.4102/sajhivmed.v19i1.839] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
No abstract available.
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13
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Murphy RA, Hatlen TJ, Moosa MYS. High-Dose Fluconazole Consolidation Therapy for Cryptococcal Meningitis in Sub-Saharan Africa: Much to Gain, Little to Lose. AIDS Res Hum Retroviruses 2018; 34:399-403. [PMID: 29353491 DOI: 10.1089/aid.2017.0240] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Cryptococcal meningitis accounts for an estimated 25% of AIDS-associated mortality in sub-Saharan Africa. Accumulating animal and human evidence suggest that a higher, more fungicidal, dose of fluconazole during consolidation therapy could be more effective in controlling residual infection and may help significantly reduce posthospitalization mortality. Although the potential for toxicity is low, the use of fluconazole at a dose of 800 mg/day during consolidation therapy requires examination in a randomized clinical trial. In the interim, within countries where postdischarge mortality from cryptococcal meningitis is high and amphotericin-flucytosine combination therapy remains unavailable, the use of high-dose fluconazole consolidation therapy deserves serious consideration as a strategy with limited risk and the potential for considerable public health benefit.
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Affiliation(s)
- Richard A. Murphy
- Department of Medicine, Division of Infectious Diseases, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Timothy J. Hatlen
- Department of Medicine, Division of Infectious Diseases, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Mahomed-Yunus S. Moosa
- Department of Infectious Diseases, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
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14
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Luke CA, Moosa MYS, Esterhuizen TM, Knight SE, Saman S, Ross A. Lactic acidosis, risk factors and predictive laboratory markers: a nested case control study in South Africa. S Afr Fam Pract (2004) 2014. [DOI: 10.1080/20786204.2014.10844585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Affiliation(s)
- CA Luke
- Discipline of Family Medicine, University of KwaZulu-Natal, Durban
| | - MYS Moosa
- ,Department of Infectious Disease, University of KwaZulu-Natal, Durban
| | - TM Esterhuizen
- Program of Bio Research Ethics and Medical Law, Division of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban
| | - SE Knight
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban
| | - S Saman
- Port Shepstone Hospital, Port Shepstone
| | - A Ross
- Discipline of Family Medicine, University of KwaZulu-Natal, Durban
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15
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